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FIRSTLINGS

i

PRACTICE of PHYSIC.

B Y

WILLIAM £ULLEN, M. D.

Profeflbr of the Practice of Phyffc in the Univcrfry r.f Edinburgh

Flrfc Phyilclan :o ln~ Majefly for Scotland ;

Fellow of the Royal College of Phyficians cf Edinburgh,

of the Royal Societies of London, of Edinburgh, &c. c<c.

A NEW EDITION, Corrected and Enlarged.

IN FOUR VOLUMES.

VOL. IV.

: G H :

1 TOT, Edis burgh ;

E D I N B

Printed for C. ELL And C. ELLIOT, T. KAY, & Co. at N° Dr CuUen's Head^ Stvand, L o n dox.

M,DCCfLX\'\Vl!T.

.

-

tr

Cv3uvoVo<-a

i

J-> OCT O R

^ANDREW WIESENTH.

CONTENTS. PART II. BOOK III.

Page

Sedt. III. Of the Spafniodic Affccliont in the

Natural Funclions - g

CHAP. VIII.

Of the Pyrosis, or -what is named in Scot- land the Water-Brash - 9

CHAP. IX. Of the Colic - - 18

CHAP. X.

Of the Cholera - 39

A 2 CHAP.

Medicw iv C i\S.

Page

CHAP. XL

O/^Diarrhoea, or Looseness 49

CHAP. XII.

Of the Diabetes 82

CHAP. XIII.

Of the Hysteria, or the Hysteric Disease - "93

CHAP. XIV.

Of Canine Madness and Hydro- phobia - - 107

BOOK IV.

Of VESANIiE, or of the Disor- ders of the Intellectual Functions - - 111

CHAP.

CONTENTS.

CHAP. I.

Of Ve s a n i m in general

CHAP. II.

O/MANiAyor Madness

CHAP. III.

v

Page

III

I44

(^Melancholy, and other forms of Infamty - - 168

PART III.

OF CACHEXIES

188

BOOK I.

Of EMACIATIONS - - 192

BOOK

vi .qO.NTENTS.

•
2
B O*	o JC	II.
	•	-	Page
Of INTUMESCENTUE, or	General
Swellings	-	-	216

CHAP, I.

Of Adipose Swellings - 219

CHAP. II. O/Tlatulent Swellings - 226

CHAP. III.

Of Watery Swellings, or Drop- sies - - - 249

Se<5t. I. Of Ana/ana - - 277

Sedt. II. Of the Hydrothorax^or Dropfy oftheBreq/i - - 308

Sea,

CONTENTS. vii

Tage

Sed. III. Of A/cites, or Dropfy of the Lower Belly — - 321

CHAP. IV.

^General Swellings, arifingfrom an increased bulk of the whole fubflance ^Particular Parts 331

Of Rachitis , or Rickets - 332

BOOK III.

Of the 1MPETIGINES, or depra- ved Habit, with Affections of the Skin - - 357

CHAP. I.

Of Scrophula, or the King's Evil 359

CHAP.

viii CONTENTS,

Page

C H A P. II.

O^Sipyhlis, or the Venereal Dis- ease - - 382

CHAP. III. O/ScuRvy - - 412

CHAP. IV.

^/Jaundice . - 437

FIRST LINES

O F T H E

PRACTICE of PHYSIC.

PART II.

BOOK III. SECT. III.

Of the SPASMODIC AFFECTIONS in the NATURAL FUNCTIONS.

C H A P.

VIII.

Of the Pyrosis, or what is named in Scotland the Water-Brash.

MCCCCXXV1I.

PHE painful fenfations referred to the

•*• ftomach, and which are probably

occafioned by real affections of this organ,

Vol. IV. B are

io PRACTICE

are of different kinds. Probably they pro- . ceed from affections of different natures, and fliould therefore be diftinguifhed by dif- ferent appellations ; but I muff own that the ucmoft precifion in this matter will be difficult. In my eflay towards a metho- dical Nofology, 1 have, however, attempt- ed it. For thofe pains that are either a- cute and pungent, or accompanied with a fenfe of diftention, or with a fenfe of con- flri&ion, if they are at the fame time not attended with any fenfe cf acrimony or heat, 1 employ the appellation of Gaftro- dynia. To exprefs thofe painful or unea- fy fenfations which feem to arife from a fenfe of acrimony irritating the part, or from fuch a fenfe of heat as the applica- tion of acrids, whether externally or in- ternally applied, often gives, I employ the term of Cardialgia ; and by this I particu- larly mean to denote thofe feelings which are exprefled by the term Heartburn in

the

O F P H Y S I C. u

the Englifh language. I think the term Soda has been commonly employed by practical writers to expreis an affection attended with feelings of the latter kind.

MCCCCXXVIII.

Befide the pains denoted by the terms Gaitrodynia, Periadynia, Cardialgia, and Soda, there is, I think, another painful fenfation different from all of thefe, which is named by MrSauvages Pyrofis Suecica ; and his account of it is taken from Lin- naeus, who names it Cardialgia Sputatoria. Under the title of Pyrofis Mr Sauvages has formed a genus, of which the whole of the fpecies, except the eighth, which he gives under the title of Pyrofis Suecica, are all of them fpecies of the Gaitrodynia or of the Cardialgia ; and if there is a genus to be formed under the title of Pyrofis, it can in my opinion comprehend only the fpecies I B 2 have

12 PRACTICE

have mentioned. In this cafe, indeed, I own that the term is not very proper ; but my averlion to introduce new names has made me continue to employ the term of Mr Sauvages.

MCCCCXXIX. i

The Gaftrodynia and Cardialgia I judge to be for the mod part fymptomatic af- fe&ions ; and therefore have given them no place in this work : but the Pyrofis, as an idiopathic difeafe, and never before treated of in any fyftem, I propofe to treat of here.

MCCCCXXX.

It is a difeafe frequent among people in lower life ; but occurs alfo, though more rarely, in people of better condition. Though frequent in Scotland, it is by no

means

O F P H Y S 1 C. 13

means Co frequent as Linnxus reports it to be in Lapland. It appears moft: com- monly in perfons under middle age, but feldom in any perfons before the age of puberty. When it has once taken place, it is ready to recur occafionally for a long time after ; but it feldom appears in per- fons confiderably advanced in life It af- fedls both fexes, but more frequently the female. It fometimes attacks pregnant women, and fome women only when they are in that condition. Of other women, it more frequently affects the unmarried ; and of the married, mod frequently the barren. I have had many inftances of its occurring in women labouring under a fluor albus.

MCCCCXXXI.

The fits of this difeafe ufually come on

in the morning and forenoon, when the

B 3 fto-

14 PRACTICE

ftomach is empty. The firft fympcom of it is a pain at the pit of the ftomach, with a fenfe of conftriction, as if the ftomach was drawn towards the back ; the pain is increafed by raifing the body into an erect pofture, and therefore the body is bended forward. This pain is often very fevere; and, after continuing for fome time, it brings on an erudiation of a thin watery fluid in confiderable quantity. This fluid has fometimes an acid tafte, but is very often abfolutely infipid. The eructation is for fome time frequently repeated ; and does not immediately give relief to the pain which preceded it, but does fo at length, and puts an end to the fit.

MCCCCXXXII.

The fits of this difeafe commonly come on, without any evident exciting caufe ; ar.d I have not found it fteadily connec- ted

OF PHYSIC, 15

ced with any particular diet. It attacks

perfons ufing animal food, but I think

more frequently thofe living on milk and

farinacea. It feems often to be excited by

cold applied to the lower extremities ; and

is readily excited by any considerable emo- *£** ^ y *^~*

tion of mind. It is often without any fymp- *— «,^«*~. v ~

toms of dyfpepfia. "

MCCCCXXXIII.

The nature of this affediion is not very obvious ; but I think it may be explained in this manner : It feems to begin by a fpafm of the mufcular fibres of the fto- mach ; which is afterwards, in a certain manner, communicated to the blood- vef- fels and exhalants, fo as to increafe the impetus of the fluids in thefe veflels, while a conftricftion takes place on their extre- mities. While therefore the increafed im- B 4 petus

16 PRACTICE

petus determines a greater quantity than ufual of fluids into thefe vefTels, the con- ftri&ion upon their extremities allows only the pure watery parts to be poured out, analogous, as I judge, in every re- fpecfl, to what happens in the diabetes hy- (lericus.

MCCCCXXX1V.

The pradlice in this difeafe is as diffi-* cult as the theory. The paroxyfm is only to be certainly relieved by opium. Other antifpafmodics, as vitriolic ether and vo- latile alkali, are fometimes of fervice, but not conftaiitly fo. Although opium and other antifpafmodics relieve the fits, they hue no effed in preventing their recur- rence. For this purpofe, the whole of the remedies of dyfpepfia have been em- ployed without fuccefs. Of the ufe of

the

O F P H Y S I C. 17

the mix vomica, mentioned as a reme- dy by Linnaeus, I have had no expe- rience.

CHAP.

PRACTICE 18

CHAP. IX.

Of The Colic,

MCCCCXXXV.

THE principal fymptom of this difeafe, is a pain felc in the lower belly. It is feldom fixed and pungent in one part, but is a painful diftention in focne mea- fure fpreading over the whole of the belly; and particularly with a fenfe of twifting or wringing round the navel. At the fame time, with this pain, the navel

and

O F P H Y S I C. 19

and teguments of the belly are frequently drawn inwards, and often the mufcles of the belly are fpafmodically contracted, and this in feparate portions, giving rhe ap- pearance of a bag full of round balls.

mccccxxxvl

Such pains, in a certain degree, fome- times occur in cafes of diarrhoea and cho- lera ; but thefe are lefs violent and more tranfitory, and are named Gripings. It is only when more violent and permanent, and attended with coftivenefs, that they conftitute colic. This is alfo commonly attended with vomiting, which in many cafes is frequently repeated, efpecially when any thing is taken down into the ftomach; and in fuch vomitings, not only the con- tents of the ftomach are thrown up, but alfo the contents of the duodenum, and therefore frequently a quantity of bile.

MCCCCXXXVII.

so PRACTICE

In fome cafes of colic, the periftaltic motion is inverted through the whole length of the alimentary canal, in fuch a manner that the contents of the great guts, and therefore ftercoraceous matter, is thrown up by vomiting ; and the fame inverfion appears (till more clearly from this, that what is thrown into the re&um by glyfter is again thrown out by the mouth. In thefe circumftances of inver- fion the difeafe has been named Ileus, or the Iliac Paffion ; and this has been fup- pofed to be a peculiar difeafe diftincft from colic ; but to me it appears that the two difeafes are owing to the fame proximate caufe, and have the fame fymptoms, only in different degree.

MCCCCXXXVIII.

O F P H Y S I C. it

MCCCCXXXVILI.

The colic is often without any pyrexia attending it. Sometimes, however, an in-* flammation comes upon the part of the inteftine efpecially afFecled ; and this in- flammation aggravates all the fymptoms of the difeafe, being probably what brings on the moft confiderable inverfion of the pe- riftakic motion ; and, as the ftercoraceous vomiting is what efpecially diftinguifhes the ileus, this has been confidered as al- ways depending on an inflammation of the inteftines. However, I can affirm, that as there are inflammations of the in- teftines without ftercoraceous vomiting, fo I have feen inftances of ftercoraceous vo- miting without inflammation ; and there is therefore no ground for diftinguifhing ileus from colic, but as a higher degree of the fame afFe&ion.

iMCCCCXXXIX.

22 PRACTICE

MCCCCXXXIX.

The fymptoms of the colic, and the dii- fe&ions of bodies dead of this difeafe, (how very clearly, that it depends upon a fpaf- modic conftridlion of a part of the intef- tines; and that this therefore is to be con- fidered as the proximate caufe of the dif- eafe. In fome of the difTe&ions of perfons ^/4^-WjAdead of this difeafe, an intus-fufception jaj/ „at has been remarked to have happened ; but

4^ *H-

2l

" whether this be conflantly the cafe in all

a

the appearances of ileus, is not certainly de* termined.

MCCCCXL.

The colic has commonly been coniider- ed as being of different fpecies, but I can- not follow the writers on this fubjedt in the diftin&ions they have eftablifhed. So far, however, Jfas a difference of the re- i mote

O F P H Y S I C. 23

mote caufe conflitutes a difference of fpe- cies, a diflin&ion may perhaps be admit- ted ; and accordingly in my Nofology I have marked feven different fpecies : but I am well perfuaded, that in all thefe diffe- rent fpecies the proximate caufe is the fame, that is, a fpafmodic conftri&ion of a part of the inteftines; and confequently, that in all thefe cafes the indication of cure is the fame, that is, to rempve the conftric- tion mentioned. Even in the feveral fpe- cies named Stercorea, Callofa, and CalculofaJ-*-"- **<^**.^ in which the difeafe depends upon anob-Z^^/2^-^ ftruaion of inteftine, 1 am perfuaded that^^^^L thefe obftrudions do not produce thefymp- /£ , 4

toms of colic, excepting in fo far as theyy /- '* \-/^, produce fpafmodic conftri&ions of the in- <*+ 3 -£>«*»*<* teftines ; and therefore, that the means of cure in thefe cafes, fo far as they admit of cure, muft be obtained by the fame means which the general indication above men- tioned fuggefts.

MCCCGXLL

24 PRACTICE

MCCCCXLI.

The cure, then, of the colic univerfally, is to be obtained by removing the fpafe rnodic conftri6tions of the inteftines ; and the remedies fuited to this purpofe may be referred to three general heads :

i. The taking off the fpafm by various antifpafmodic powers.

2. The exciting the a&ion of the intef- tines by purgatives.

3. The employing mechanical dilata- tion.

MCCCCXLII.

Before entering upon a more particular account of thefe remedies, it will be pro- per to obferve, that in all cafes of violent colic, it is advifable to pra&ife blood- letting; both as it may be ufeful in ob- viating the inflammation which is com-* 1 monly

Of PHYSIC. 25

monly to be apprehended, and even as ir. may be a means of relaxing the fpafm of the intefline. This remedy may perhaps be improper in perfons of a weak and lax habit, but: in all perfons of tolerable vi- gour it will be a fafe remedy; and in all cafes where there is the lead fufpicion of an inflammation actually coming on, it will be abfolutely necelfary. Nay, it will be even proper to repeat it perhaps feveral times, if, with a full and hard pulfe, the appearance of the blood drawn, and the relief obtained by the firft bleeding, (hall authorife fuch repetition.

MCCCCXLIII.

The antifpafmodic powers that may be employed, are, the application of heat in a dry or humid form, the application of blifters, the ufe of opium, and the ufe of mild oils.

Vol. IV. C The

26 PRACTICE

The application of heat, in a dry form* has been employed by applying to the belly of the patient a living animal, or bladders filled with warm water, or bags of fubftances which long retain their heat; and all thefe have fometimes been applied with fuccefs ; but none of them feem to me fo powerful as the application of heat in a humid form.

This may be employed either by the immerfion of a great part of the body in warm water, or by fomenting the belly with cloths wrung out of hot water. The immerfion has advantages from the appli- cation of it to a greater part of the body, and particularly to the lower extremities : but immerfion cannot always be conve- niently pradtifcd, and fomentation may have the advantage of being longer conti- nued j and it may have nearly all the be- nefit of immerfion, if it be at the fame time

ap-

OF PHYSIC, 27

applied both to the belly and to the lower extremities.

MCCCCXL1V.

From confidering that the teguments of the lower belly have fuch a connection with the inteftines, as at the fame time to be affected with fpafmodic contractions, we perceive that blifters applied to the belly may have the effecft of taking off the fpafms both from the mufcles of the belly and from the inteftines ; and accordingly^ bliftering has often been employed in the colic with advantage. Analogous to this,v^ m^o^^tju. rubefacients^applied to the belly have been'^^-" tj^jj^. frequently found ufefuh *0^*- 4+u #

<**.

MCCCCXLV.

The ufe of opium in colic may feein to

be an ambiguous remedy. Very certainly

C 2 it

28 PRACTICE

it may for fome time relieve the pain, which is often fo violent and urgent, that it is difficult to abflain from the ufeof fuch a remedy. At the fame time, the ufe of opium retards or fufpends the periftaltic motion fo much, as to allow the inteftines to fall into conftridlions ; and may there- fore, while it relieves the pain, render the caufe of the difeafe more obftinate. On this account, and further as opium pre^ vents the operation of purgatives fo often neceffary in this difeafe, many pra<5tition* ers are averfe to the ufe of it, and fome en- tirely reject the ufe of it as hurtful. There are, however, others who think they can employ opium in this difeafe with much advantage.

In all cafes where the colic comes on without any previous coftivenefr, and ari- fes from cold, from paflions of the mind, or other caufes which operate efpeciallyon the nervous fyftem, opium proves a fafe

and

OF PHYSIC. 29

and certain remedy ; but in cafes which have been preceded by long coftivenefs, or where the colic, though not preceded by coftivenefs, has however continued for fome days without a (tool, to that a ftagna- tion of faeces in the colon is to be fufpec- ted, the ufe of opium is of doubftul effect. In fuch cafes, unlefs a ftool has been firft procured by medicine, opium cannot be employed but with fome hazard of ag- gravating the difeafe. However, even in thofe circumftances of coftivenefs, when, without inflammation, the violence of the ipafm is to be fufpecled, 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 alfo as an antifpafmo- dic, neceffary to favour the operation of purgatives ; and may be fo employed, when, either at the fame time with the o- C 3 piate,

w PRACTICE

piate, or not long after it, a purgative can

be exhibited. ^ Is the hyofciamus^as often fhowing, a-

SfcJ^ . J <^*c Ion? with its narcotic, a purgative qua- ^•^ ^^Jity, better fuited to this difeafe than o- --**~ - pium ?

MCCCCXLVI.

It is feemingly on good grounds that fe- veral practitioners have recommended the large ufe of mild oils in this difeafe, both as antifpafmodics and as laxatives ; and, where the palate and ftomach could admit them, I have found them very ufeful. But as there are few Scottifh ftomachs that can admit a large ufe of oils, I have had few opportunities of employing them.

MCCCCXLVIL

The fecond fet of remedies adapted to

the

O F P H Y S I C. 31

the cure of colic, are purgatives ; which, by exciting the action of the inteftines, ci- ther above or below the obftrucled place, may remove the conftriction ; and there- fore thefe purgatives may be given either by the mouth, or thrown by glyfter into the anus. As the difeafe is often feated in the great guts; as glyflers, by having a more fudden operation, may give more im- mediate relief; and as purgatives given by the mouth are ready to be rejected by vo- miting ; fo it is common, and indeed pro- per, to attempt curing the colic in the firft place by glyflers. Thefe may at firft be of the mildeft kind, confiding of a large bulk of water, with fome quantity of a mild oil; and fuch are fometimes fuffi* ciently efficacious : however, they are not always fo ; and it is commonly neceflary to render them more powerfully ftimulant by the addition of neutral falts, of which ^/.^j^ the mod powerful is the common or ma* C 4 rine

32 PRACTICE

rine fait. If thefe faline glyflers, as fome- times happens, are rendered again too quickly, and on this account or otherwife are found ineffectual, it may be proper, in- ftead of thefe falts, to add to the glyfters an infufion of fenna, or of fome other pur- gative that can be extracted by water. The antimonial wine may be fometimes em- ployed in glyfters with advantage. Hardly any glyfters are more effedlual than thofe l*& made of turpentine properly prepared.* \Zt^ f^ When all other injedlions are found inef- yfedual, recourfe is to be had to the injec-

^A-i' tion of tobacco-fmoke : and, when evea ^2U-^ <*-£> this fails, recourfe is to be had to the me-

tsjji <r*±r*^ *"-

chanical dilatation to be mentioned here- after.

MCCCCXLV1II.

As glyfters often fail altogether in relie- ling this difeafe, and as even when they

give

OF P H Y S I C. 33

give fome relief they are often imperfedl in producing a complete cure; fo it is ge- nerally proper, and ofcen neceflary, to at* tempt a more entire and certain cure by purgatives given by the mouth. The more powerful of thefe, or, as they are called, the Draftic Purgatives, may be fometimes neceflary ; but their ufe is to be avoided, both becaufe they are apt to be rejected by vomiting, and becaufe when they do not fucceed in removing the obftru&ion they are ready to induce an inflammation. Upon this account it is ufual, and indeed proper, at leaft in the firft place, to employ the milder and lefs inflammatory purga- tives. None have fucceeded with me better than the cryftals of tartar, becaufe this medicine may be conveniently given, J in fmall but repeated dofes, to a confider- able quantity ; and under this manage- ment it is the purgative lead ready to be

rejected

34 PRACTICE

rejected by vomiting, and much lefs fo than the other neutral falts. If a ftronger purgative be required, jalap, properly pre- &2 Jz^A-^y *6~— pared* is lefs offenfive to the palate, and I i^^jLucS^^ better upon the ftomach, than raoft ^^f^'if^ other powerful purgatives. On many oc- cafions of colic, nothing is more effectually <f i^c purgative than a large dofe of calomel. ^

9^ Some practitioners have attempted to re-

move the obftrucflion of the inteftines by antimonial emetics exhibited in fmall dofes repeated at proper intervals ; and when thefe dofes are not entirely rejected by vomiting, they often prove effectual pur- gatives.

When every purgative has failed, the eft- J~^ acftion of the inteftines has been effectually

f^^ <■"*-■ excited by throwing cold water on the lower extremities.

MCCCCXLIX

O F P H Y S I C. 3$

MCCCCXL1X.

The third means of overcoming the fpafm of the inteftines in this difeafe, is by employing a mechanical dilatation ; and it has been frequently fuppofed that quickfilver, given in large quantity, might operate in this manner. 1 have not, how- ever, found it fuccefsful ; and the theory of it is with me very doubtful. Some au- thors have mentioned the ufe of gold and fllver pills, or balls, fwallowed down ; but I have no experience of fuch practices, and I cannot fuppofe them a probable means of relief.

MCCCCL.

Another means of mechanical dilatation, and a more probable meafure, is by injec- ting a large quantity of warm water by a proper fyringe, which may throw it with

fome

36 PRACTICE

fome force, and in a continued ftream, in- to the redlum. Both from the experiments <& 6*j». *~<J reported by the late Mr De Haen, and from ^JM thofe I myfelf have had occafion to make, JL*~l X^*— / J judge this remedy to be one of the mod t£lfj*2, j/powerful and effedtual.

fain*. &*J

*3* MCCCCLI.

~^Z- £.<*£ - '- •

••^T/io I have now mentioned all the feveral ^~ means that may be employed for the cure

of the colic, confidered as a genus ; but before I quit this fubjecft, it may be ex- pected that I fhould take notice of fome of the fpecies which may feem to require a particular confideration. In this view it may be expedled that I fhould efpecially take notice of that fpecies named the Colic of Poitou, and particularly known in Eng- land by the name of the Devonfhire Co- lic.

MCCCCLIl

OF PHYSIC. 37

MCCCCLIT.

This fpccies of the difeafe is certainly a peculiar one, both in refpeft of its caufc and its efFe&s ; but, as to the firfl, it has been lately fo much the fubjedt of invefti- gation, and is fo well afcertained by the learned phyficians Sir George Baker and Dr Hardy, that it is unneceflary for me to fay any thing of it here.

With refped to the cure of it, fo far as it appears in the form of a colic, my want of experience concerning it does not allow me to fpeak with any confidence on the fubjeft ; but, fo far as I can learn from others, it appears to me, that it is to be treated by all the feveral means that I have propofed above for the cure of colic in ge- neral.

How far the peculiar effe&s of this dif- eafe are to be certainly forefeen and ob- viated, I have not properly learned ; and I

muft

38 PRACTICE

muft leave the matter to be determined by thofe who have had fufficient experience in it.

CHAP.

OF PHYSIC. 39

CHAP. X

Of the Cholera

MCCCCLIII.

IN this difeafe, a vomiting and purging concurring1 together, or frequently al- ternating with one another, are the chief fymptoms. The matter rejedled both up- wards and downwards appears manifeftly to confift chiefly of bile.

MCCCCLIV,

4o PRACTICE

MCCCCL1V.

From this laft circumftance I conclude, that the difeafe depends upon an increafed fecretion of bile, and its copious effuiion into the alimentary canal ; and, as in this it irritates and excites the motions above mentioned, I infer, that the bile thus ef- fufed in larger quantity is at the fame time alfo of a more acrid quality. This appears likewife from the violent and very painful gripings that attend the difeafe, and which we can impute only to the vio- lent fpafmodic contractions of the intef- tines that take place here. Thefe fpafms are commonly communicated to the ab- dominal mufcles, and very frequently to thofe of the extremities.

MCCCCLV.

In the manner now deicribed, the dif- i eafe

Of PHYSlC. 41

eafe frequently proceeds with great vio- lence, till the ftrength of the patient is greatly, and ofcen fuddenly, weakened ; while a coldnefs of the extremities, cold fweats, and faintings, coming on, an end is put to the patient's life, fometimes in the coiirfe of one day. In other cafes the difeafe is lefs violent, continues for a day or two, and then ceafes by degrees ; though fuch recoveries feldom happen without the afliftance of remedies*

MCCCCLVL

The attacks of this difeafe are feldom accompanied with any fymptoms of py- rexia ; and though, during the courfe of it, both the pulfe and refpiration are hurried and irregular, yet thefe fymp- toms are generally fo entirely removed by the remedies that quiet the fpaf- modic affections peculiar to the difeafe,

Vol. IV, D a*

4* PRACTICE

as to leave no ground for fuppofing that it Jiad been accompanied by any proper py- rexia*

MCCCCLVII.

This is a difeafe attending a very warm (late of the air ; and, in very warm cli- mates, it may perhaps appear at any time of the year : but even in fuch climates it is mod frequent during their warmeft fea- fons ; and in temperate climates, it ap- pears only in the warm feafons. Dr Sy- denham confidered the appearances of this difeafe in England to be confined to the month of Auguft ; but he himfelf ob- ferved it to appear fometimes towards the end of fummer, when the feafon was un- ufually warm ; and that, in proportion to the heat, the violence of the difeafe was greater. Others have obferved that it appeared more early in fummer, and al- ways

O F P H Y S I C. 43

ways fooner or later, according as the great heats fooner or later fet in.

MCCCCLVIII.

From all thefe circumftances, it is, I think, very evident that this difeafe is the effedl of a warm atmofphere, produ- cing fome change in the (late of the bile in the human body : and the change may confift, either in the matter of the bile being rendered more acrid, and thereby fitted to excite a more copious fecretion ; or, in the fame matter, its being prepa- red to pafs off in larger quantity than ufual.

MCCCCLIX,

It has been remarked, that in warm cli- mates and feafons, after extremely hot and dry weather, a fall of rain cooling the at- D 2 mofpbere

44 PRACTICE

mofphere feems efpecially to bring on this difeafe ; and it is very probable that an obftrudted perfpiration may have alfo a fhare in this, though it is alfo certain that the difeafe does appear when no change in the temperature of the air, nor any application of cold, has been obfer- ved.

MCCCCLX.

It is poflible, that, in fome cafes, the heat of the feafon may give only a predif- pofition, and that the difeafe may be ex- cited by certain ingefta or other caufes ; but it is equally certain, that the difeafe has occurred without any previous change or error, either in diet, or in the manner of life, that could be obferved.

MCCCCLXL

OF PHYSIC. 45

MCCCCLXI.

The Nofologifts have conftituted a Ge- nus under the title of Cholera, and under this have arranged as fpecies every affec- tion in which a vomiting and purging of any kind happened to concur. In many of thefe fpecies, however, the matter eva- cuated is not bilious ; nor does the eva- cuation proceed from any caufe in the ftate of the atmofphere. Further, in many of thefe fpecies alfo, the vomiting which occurs is not an effential, but merely an accidental, fymptom from the particular violence of the difeafe. The appellation of Cholera therefore fhould, in my opinion, be confined to the difeafe I have defcribed above ; which by its peculiar caufe, and perhaps alfo by its fympcoms, is very dif- ferent from all the other fpecies that have been affociated with it. I believe that all the other fpecies arranged under the title D3 of

46 PRACTICE

of Cholera by Sauyages or Sagar, may be properly enough referred to the genus of Diarrhoea ; which we are to treat of in the next chapter.

The diftin&ion I have endeavoured to eftablifh between the proper Cholera, and the other difeafes that have fometimes got the fame appellation, will, as I judge, fu- perfede the queftion, Whether the Chole- ra, in temperate climates, happens at any ' other feafon than that above afligned i

MCCCCLXII.

In the cafe of a genuine cholera, the cure of it has been long eftablifh^d by ex- perience.

In the beginning of the difeafe, the eva- cuation of the redundant bile is to be fa- , voured by the plentiful exhibition of mild ^folL'tffa*" ^diluents, both given by the mouth, and injefted by the anus \ and all evacuant

medi-

OF P H Y S I C. 47

medicines, employed in either way, are not only fuperfluous, but commonly hurt- ful.

MCCCCLX1H.

When the redundant bile appears to be fufficiently wafhed out, and even before that, if the fpafmodic affedlions of the ali- mentary canal become very violent, and are communicated in a confiderable de- gree to other parts of the body, or when a dangerous debility feems to be induced, the irritation is to be immediately obvia- ted by opiates, in fufficiently large dofes, but in fmall bulk, and given either by the mouth or by glyfter.

MCCCCLXIV.

Though the patient be in this manner

relieved, it frequently happens, that when

D 4 the

48 PRACTICE

the operation of the opium is over, the difeafe fhows a tendency to return ; and, for at leaft fome days after the firft attack, the irritability of the inteftines, and their difpofition to fall into painful fpafmodic contractions, feem to continue. In this fituation, the repetition of the opiates, for perhaps feveral days, may come to be ne- ceffary ; and as the debility commonly in- duced by the difeafe favours the difpofition to fpafmodic affecftions, it is often ufeful and neceflary, together with the opiates, to employ the tonic powers of the Peruvian bark.

CHAP-

OF PHYSIC. 49

CHAP. XI.

Of Diarrhoea oh Looseness,

MCCCCLXV.

THIS difeafe confifts in evacuations by (tool, more frequent and of more li- quid matter than ufual. This leading and charadlerift\c fymptom is fo diverfified in its degree, in its caufes, and in the variety of matter evacuated, that it is almoft im- poffible to give any general hiftory of the difeafe.

MCCCCLXVI.

5o PRACTICE

MCCCCLXVI.

It is to bediftinguifhed from dyfentery,

&^ „ **JzJ>l noc beIng contagious ; by being gene-

f,*^^-*£^X2\\y without fever ; and by being with

fl-J&~^~*~\}&t evacuation of the natural excrements,

C/~2fc~ - which are, at lead for fome time, retained

£j~fc*~j fo- |n dyfentery. The two difeafes have been

±- s~!y>*£A,^> commonly diftinguifhed by the gripings

a^Z, A being more violent in the dyfentery ; and

hf~ ^^^*they are commonly lefs violent and lefs

CtLjr-**^ frequent in diarrhoea; but as they fre-

;*~Uj«faJuj quently do occur in this alfo, and fome-

'^H£>^*^l- times to a confiderable degree, fo they do

not afford any proper diftin&ion.

MCCCCLXVII.

A diarrhoea is to be diftinguifhed from cholera chiefly by the difference of their caufes ; which, in cholera, is of one pecu- liar kind ; but in diarrhoea is prodigioufly

diver-

O F P H Y S I C. s*

diverfified,as we fliall fee prefcntly. It has been common to diftinguifh cholera by the evacuation downwards being of bilious matter, and by this being always accom- panied with a vomiting of the fame kind; but it does not univerfally apply, as a diarrhoea is fometimes attended with vo- miting, and even of bilious matter,

MCCCCLXVIII.

The difeafe of diarrhoea, thus diftin- guifhed, is very greatly diversified ; but in all cafes, the frequency of ftools is to be imputed to a preternatural increafe of the periftaltic motion in the whole, or at leafl in a confiderable portion, of the inteftinai canal. This increafed a&ion is in differ- ent degrees, is often convulfive and fpaf- modic, . and at any rate is a mot us abnor~ mis : for which reafon, in the Methodical Nofology, I havejreferred it to the order

of

52 PRACTICE

of Spafmi, and accordingly treat of it in this place.

MCCCCLX1X.

Upon the fame ground, as I confider the difeafe named Lientery to be an in- creafed periftaltic motion over the whole of the inteftinal canal, arifing from a pe- culiar irritability, I have confidered it as merely a fpecies of diarrhoea. The idea of a laxity of the inteftinal canal being the caufe either of lientery, or other fpecies of diarrhoea, appears to me to be without foundation, except in the fingle cafe of frequent liquid ftools from a palfy of the [phinEier ani,

MCCCCLXX.

The increafed a&ion of the periftaltic motion, I confider as always the chief part

of

O F P H Y S I C. 53

of the "proximate caufe of diarrhoea : but the difeafe is farther, and indeed chiefly, diverfified by the different caufes of this increafed a&ion ; which we are now to inquire into.

MCCCCLXXI.

The feveral caufes of the increafed ac- tion of the inteftines may be referred, I think, in the firft place, to two general heads.

The Jirjl is, of the difeafes of certain parts of the body which, either from a confent of the inteftines with thefe parts, or from the relation which the inteftines have to the whole fyftem, occafion an in- creafed acftion in the inteftines, without the transference of any ftimulant matter from the primary difeafed part to them.

The fecond head of the caufes of the in- creafed aftion of the inteftines is of the

ftimuli

S4 PRACTICfe

ftimuli of various kinds, which are applied dire&ly to the inteftines themfelves,

MCCCCLXXIL

That affe&ions of other parts of the fy ftem may affeft the inteftines without the transference or application of any ftimu- lant matter, we learn from hence, that the paflions of the mind do in fome perfons excite diarrhoea*

MCCCCLXXIII.

That difeafes in other parts may in like manner affedi the inteftines, appears from the dentition of infants frequently ex- citing diarrhoea. I believe that the gout often affords another inftance of the fame kind ; and probably there are others alfof though not well afcertained.

i MCCCCLXXIV.

O F P H Y S I C. 55

MCCCCLXXIV.

The ftimuli (MCCCCLXXIV which may be applied to the inteftines are of very various kinds ; and are either,

i. Matters introduced by the mouth.

2. Matters poured into the inteftines by the feveral excretories opening into them,

3. Matters poured from certain preter- natural openings made into them in cer- tain difeafes.

MCCCCLXXV.

Of thofe (MCCCCLXXlV.r) introdu- ced by the mouth, the firft to be mention* ed are the aliments commonly taken in. Too great a quantity of thefe taken in, often prevents their due digeflion in the ftomach j and by being thus fent in their crude, and probably acrid, ftate to the

in-

♦

I

56 PRACTICE

inteftines, they frequently excite diar-» rhoea.

The fame aliments, though in proper quantity, yet having too great a propor-* tion, as frequently happens, of faline of faccharine matter along with them, prove ftimulant to the inteftines, and excite diarrhoea.

But our aliments prove efpecially the caufes of diarrhoea, according as they^ from their own nature, or from the weak-* nefs of the ftomach, are difpofed to un- dergo an undue degree of fermentation there, and thereby become ftimulant to the inteftines. Thus acefcent aliments are ready to produce diarrhoea 5 but whether from their having any diredly purgative quality, or only as mixed in an over pro- portion with the bile, is not well determi- ned.

MCCCCLXXVI.

I ■

OF PHYSIC. 57

MCCCCLXXVL

Not only the acefcent, but alfo the pu- trefcent difpofition of the aliments, feems to occafion a diarrhoea; and it appears that even the effluvia of putrid bodies, taken in any way in large quantity, have the fame effed.

Are oils or fats, taken in as a part of our aliments, ever the caufe of diarrhoea ? and if fo, in what manner do they operate ?

MCCCCLXXVIL

The other matters introduced by the mouth, which may be caufes of diarrhoea, are thofe thrown in either as medicines, or poifons that have the faculty of ftimula- ting the alimentary canal. Thus, in the lift of the Materia Medica, we have a long catalogue of thofe named purgatives ; and in the lift of poifons, we have many pof-

Vol. IV. IL feffed

I

58 PRACTICE

fefled of the fame quality. The former, given in a certain quantity, occafion a temporary diarrhoea ; and given in very large dofes, may occafion it in excefs, and continue it longer than ufual, producing that fpecies of diarrhoea named a Hyper- catharfis.

MCCCCLXXVIII.

The matters (MCCCCLXXIV. 2 ) pour- ed into the cavity of the inteftines from the excretories opening into them, and which may occafion diarrhoea, are either thofe from the pancreatic or biliary du6l, or thofe from the excretories in the coats of the inteftines themfelves.

MCCCCLXXIX.

What changes may happen in the pan- creatic juice, I do not exa&ly know ; but I

fuppofe

•^

OF PHYSIC. S9

fuppofe that an acrid fluid may ifTue from the pancreas, even while (till entire in its ftru'fiure ; but more efpecially when in is in a fuppurated, fcirrhous, or cancerous ftate, that a very acrid matter may be poured out by the pancreatic du<£t, and oc-1 cafion diarrhoea.

MCCCCLXXX.

We know well, that from the biliary dudl the bile may be poured out in greater quantity than ufual ; and there is little doubt of its being alfo fometimes poured out of a more than ordinary acrid quality. It is very probable, that in both ways the bile is frequently a caufe of diarrhoea.

Though I have faid above that diarrhoea may be commonly diilinguifhed from cho- lera, I muft admit here, that as the caufes producing that (late of the bile which oc- cafions cholera, may occur in all the dif- E 2 ferent

6o PRACTICE

ferent poflible degrees of force, fo as, on one occafion, to produce the mod violent and diftin&ly marked cholera; but, upon another, to produce only the gentled diar- rhoea ; which, however, will be the fame difeafe, only varying in degree : So I think it probable, that in warm climates, and in warm feafons, a dlarrhcea biliofa of this kind may frequently occur, not to be always certainly diftinguifhed from cho- lera.

However this may be, it is fufficiently probable, that, in fome cafes, the bile, with- out having been acted upon by the heat of the climate or feafon, may be redundant and acrid, and prove therefore a particular caufe of diarrhoea.

MCCCCLXXXI.

Befide bile from the feveral caufes and in the conditions mentioned, the biliary

duft

OF PHYSIC. 61

dud may pour out pus, or other matter, from abfcefles in the liver, which may be the caufe of diarrhoea.

Pra&ical writers take notice of a diar- rhoea wherein a thin and bloody liquid is difcharged ; which they fuppofe to have proceeded from the liver, and have there- fore given the difeafe the name of Hepa- tirrhoea : but we have not met with any inftance of this kind; and therefore cannot properly fay any thing concerning it*

MCCCCLXXX1I.

A fecond fet of excretories, from which matter is poured into the cavity of the in- teftines, are thofe from the coats of the in- teftines themfelves ; and are either the ex- halants proceeding diredtly from the extre- mities of arteries, or the excretories from the mucous follicles: and both thefe four- ces occur in prodigious number over the E3 in-

62 PRACTICE

internal furface of the whole inteftinal canal. It is probable that it is chiefly the effufion from thefe fources which, in mod inftances, gives the matter of the liquid {tools occurring in diarrhoea.

MCCCCLXXXIII.

The matter from both fources may be poured out in larger quantity than ufual, merely by the increafed a&ion of the in- teftines, whether that be excited by the paflions of the mind (MCCCCXXIL), by difeafes in other parts of the fyfteni (MCCCCLXXI. t.), or by the various fti- mulants mentioned MCCCCLXXV. and following; or the quantity of matter pour- ed out may be increafed, not fo much by the increafed action of the inteftines, as by an increafed afflux of fluids from other parts of the fyftem.

Thus, cold applied to the furface of the

body,

OF PHYSIC.

63

body, and fuppreffing pevfpiration, may determine a greater quantity of fluids to the inteftines.

Thus, in the ifchuria renalls^ the urine ta- ken into the blood- veflels is fometimes de- termined to pafs off again by the inteftines.

la like manner, pus or ferum may be abforbed from the cavities in which they

have been ftagnant, and be again poured out into the inteftines, as frequently hap- pens, in particular with refpedl to the wa- ter of dropfies.

MCCCCLXXXIV.

It is to be obferved here, that a diar- rhoea may be excited not only by a copious afflux of fluids from other parts of the fy- (lem, but likewife by the mere determi- nation of various acrid matters from the mafs of blood into the cavity of the inte- ftines. Thus it is fuppofed that the mor- E 4 bific

64 PRACTICE

bifk matter of fevers is fometimes thrown out into the cavity of the inteftines, and gives a critical diarrhoea : and whether I do or do not admit the dodtrine of critical evacuations, I think it is probable that the morbific matter of the exanthemata is fre- quently thrown upon the inteftines, and occafions diarrhoea.

MCCCCLXXXV.

It is to me further probable, that the putrefcent matter difFufed over the mafs of blood in putrid difeafes, is frequently poured out by the exhalants into the inte- ftines, and proves there the caufe, at lead in part, of the diarrhoea fo commonly at- tending thefe difeafes.

MCCCCLXXXVL

Upon this fubjeft of the matters pout- ed

OF PHYSIC. 65

ed into the cavity of the interlines, I have chiefly confidered them as poured out in unufual quantity : but it is probable that, for the mod part, they are alfo changed in their quality, and become of a more acrid and ftimulant nature ; upon which account efpecially it is, that they excite, or at ieaft increafe, a diarrhoea.

MCCCCLXXXVII.

How far, and in what manner, the ex* halant fluid may be changed in its nature and quality, we do not certainly know : but with refpedl to the fluid from the mu- cous excretories, we know, that, when poured out in unufual quantity, it is com- monly, at the fame time, in a more liquid and acrid form ; and may prove, therefore, confiderably irritating.

MCCCCLXXXVIII.

66 PRACTICE

MCCCCLXXXV1II.

Though the copious effufion of a more liquid and acrid matter from the mucous excretories, be probably owing to the mat- ter being poured out immediately as it is fecreted from the blood into the mucous follicles, without being allowed to ftagnate in the latter, fo as to acquire that milder quality and thicker confidence we com- monly find in the mucus in its natural {late ; and although we might fuppofe chat the excretions of a thin and acrid fluid fhould always be the effe£t of every deter- mination to the mucous follicles, and of every ftimulant applied to them : yet it is certain, that the reverfe is fometimes the cafe; and that, from the mucous follicles, there is frequently an increafed excretion of a mucus, which appears in its proper form of a mild, vifcid, and thickifti matter. This commonly occurs in the cafe of dy- i fentery ;

or PHYSIC, 67

fentcry ; and it has been obferved to give a fpecies of diarrhoea, which has been pro- perly named the Diarrhea Mucofa.

MCCCCLXXXIX.

A third fource of matter poured into the cavity of the inteftines, and occafioning diarrhoea (MCCCCLXX1V. 3.), is from thofe preternatural openings produced by difeafes in the inteftines or neighbouring parts. Thus the blood- veflels on the in- ternal furface of the inteftines may be o- pened by erofion, rupture, or anaftomo- fis, and pour into the cavity their blood, which, either by its quantity or by its a- crimony, whether inherent, or acquired by ftagnation, may fometimes give a diarrhoea evacuating bloody matter. This is what I think happens in that difeafe which has been called the Melana or Morbus Niger*

MCCCCXC.

68 PRACTICE

MCCCCXC.

Another preternatural fource of matter poured into the cavity of the inteftines, is the rupture of abfceffes feated either in the coats of the inteftines themfelves, or in any of the contiguous vifcera, which, during an inflamed ftate, had formed an adhefion with fome part of the inteftines. The mat*- ter thus poured into their cavity may be various ; purulent, or famous, or both to^- gether, mixed at the fame time with more or lefs of blood; and in each of thefe Hates may be a caufe of diarrhoea.

MCCCCXCI.

Amongft the ftimuli that may be di- rectly applied to the inteftines, and which, by increafing their periftaltic motion, may occafion diarrhoea, I muft not omit to

men-

OF PHYSIC. 69

mention worms, as having frequently that effetf.

MCCCCXC1I.

I muft alfo mention here a ftate of the inteftines, wherein their periftaltic motion is preternaturally increafed, and a diar- rhoea produced ; and that is, when they are affe&ed with an erythematic inflam- mation, With refpedt to the exiftence of fuch a ftate, and its occafioning diarrhoea, fee what is faid above in CCCXCV11I. and following. Whether it is to be con- fidered as a particular and diftindt cafe of diarrhoea, or is always the fame with fome of thofe produced by one or other of the caufes above mentioned, I have not been able to determine.

MGCCCXCIIL

7o PRACTICE

MCCCCXCIII.

Laftly, by an accumulation of alimen- tary or of other matter poured into the ca- vity of the inteftines from feveral of the fources above-mentioned, a diarrhoea may be efpecially occafioned when the abforp- tion of the la&eals, or of other abforbents, is prevented, either by an obftrudUon of their orifices, or by an obftru&ion of the mefenteric glands, through which alone the abforbed fluids can be tranfmitted.

In one inftance of this kind, when the chyle prepared in the ftomach and duode- num is not abforbed in the courfe of the inteftines, but pafles off in confiderable quantity by the anus, the difeafe has been named Morbus Caliacus, or limply and more properly Codiaca; which accordingly 1 have confidered as a fpecies of diarrhoea.

MCCCCXCIV.

O F P H Y S I C. 7*

MCCCCXC1V.

I have thus endeavoured to point out the various fpecies of difeafe that may come under the general appellation of Diarrhoea ; and from that enumeration it will appear, that many, and indeed the greater part of the cafes of diarrhoea, are to be confidered as fympathetic affedions, and to be cured only by curing the pri- mary difeafe upon which they depend ; of which, however, I cannot properly treat here. From our enumeration it will alfo appear, that many of the cafes of diarrhoea which may be confidered as idiopathic, will not require my faying much of them here. In many inftances, the difeafe is af- certained, and alfo the caufe affigned, by the condition of the matter evacuated ; fo that what is neceflfary to corredl or remove it will be fufficiently obvious to practition- ers of any knowledge. In fhort, I do not

find

72 PRACTICE

find that I can offer any general plan for the cure of diarrhoea ; and all that I can propofe to do on this fubjetft, is to give fome general remarks on the practice that has been commonly followed in the cure' of this difeafe.

MCCCCXCV.

The pra&ice in this difeafe has chiefly proceeded upon the fuppofition of an acri- mony in the fluids, or of a laxity in the Ample and moving fibres of the intensities- and the remedies employed have accord- ingly been, Correctors of particular acri- mony, general demulcents, evacuants by vomiting or purging, aftringents, or opi- ates. Upon each of thefe kinds of remedy I fhall now offer fome remarks.

MCCCCXCVI.

O F P H Y S I C. ?3

Mccccxcvr.

An acid acrimony is, upon feveral occa- fions, the caufc of diarrhoea, particularly in children ; and in fuch cafes the abfor- bent earths have been very properly em- ployed. The common, however, and pro- mifcuous ufe of thefe, has been very inju- dicious ; and where there is any putref- cency, they mud be hurtful.

MCCCCXCVII.

The: cafes in which there is a putrid or putrefcent acrimony prevailing, have been, I think, too feldom taken notice of ; and, therefore, the ufe of acids too feldom ad- mitted. The acrimony to be fufpected in bilious cafes, is probably of the putrefcent kind.

Vol. IV. F MCCCCXCVIII,

74 PRACTICE

MCCCCXCVIII.

The general correctors of acrimony are the mild diluents and demulcents. The former have not been fo much employed in diarrhoea as they ought ; for, joined with demulcents, they very much increafc the efFedls of the latter : and although the demulcents, both mucilaginous and oily, may by themfelves be ufeful, yet without the afliftance of diluents they can hardly be introduced in fuch quantity as to an* fwer the purpofe.

MCCCCXCIX.

As indigeftion and crudities prefent in the ftomach, are fo often the caufe of diar- rhoea, vomiting mud therefore be fre- quently very ufeful in this difeafe.

In like manner, when the difeafe pro- ceeds, as it often does, from obftrudled per-

fpiration,

Of PHYSIC. 75

fpiration, and increafed afflux of fluids to the inteftines, vomiting is perhaps the moft effedual means of reftoring the determi- nation of the fluids to the furface of the body.

It is poflible alio, that vomiting may give fome inverfion of the periftaltic mo- tion, which is determined too much down- wards in diarrhoea ; fo that upon the whole it is a remedy which may be very gene- rally ufeful in this difeafe.

Mb:

Purging has been fuppofed to be mofe univerfally neceflary^ and has been more generally pradlifed. This, however, in my opinion, proceeds upon very miftaken no- tions with refpedt to the difeafe; and fuch a practice feems to me for the moft part fuper- fluous, and in many cafes very hurtful. It goes upon the fuppofition of an acrimony F 2 pre-*

76 PRACTICE

prefent in the inteftines, that ought to be carried out by purging : but, if that acri- mony has either been introduced by the mouth, or brought into the inteftines from other parts of the body, purging can neither be a means of correcting nor of exhauft- ing it ; and muft rather have the effedt of increafing its afflux, and of aggravating its effecfls. From whatever fource the acri- mony which can excite a diarrhoea pro- ceeds, it may be fuppofed fufficient to eva- cuate itfelf, fo far as that can be done by purging ; and as in cholera, fo in the fame kind of diarrhoea, it will be more proper to affift the evacuation by diluents and de- mulcents, than to increafe the irritation by purgatives.

MDI.

If, then, the ufe of purgatives in diar- rhoea may be confidered, even when an acrimony is prefent, as fuperfluous,

there

i

O F P H Y S I C. 77

there are many other cafes in which it may be extremely hurtful. If the irrita- bility of the inteftines (hall, from affec- tions in other parts of the fyftem, or other caufes, have been already very much in- creafed, purgatives mud neceflarily aggra- vate the difeafe. In the cafe of lientery, nobody thinks of giving a purgative ; and in many cafes of diarrhoea approaching to that, they mud be equally improper. I have already obferved, that when diar- rhoea proceeds from an afflux of fluids to the inteftines, whether in too great quan- tity, or of an acrid quality, purgatives may be hurtful ; and whoever, therefore, conflders the numerous and various four- ces from which acrid matter may be poured into the cavity of the inteftines, will readily perceive, that, in many cafes of diarrhoea, purgatives may be extremely pernicious.

There is one cafe in particular to be ta- F 3 ken

78 PRACTICE

ken notice of. When, from a general and acrid difTolution of the blood, the ferous fluids run off too copioufly into the cavity of the inteftines, and excite that diarrhoea which attends the advanced ftate of hedlic fever, and is properly called a Colliqua- tive Diarrhoea ; I have, in fuch cafes, often feen purgatives given with the mod bane- ful effe&s.

There is ftill another cafe of diarrhoea in which purgatives are pernicious ; and that is, when the difeafe depends, as we have alleged it fometimes may, upon an erythemathic inflammation of the inte- flines.

I need hardly add, that if there be a cafe of diarrhoea depending upon a laxity of the folids, purgatives cannot there be of any fervice, and may do much harm. Upon the whole, it will, I think, appear, that the ufe of purgatives in diarrhoea is very much limited ; and that the pro- mi f-

O F P H Y S I C. 79

jnifcuous ufe of them, which has been fo common, is injudicious, and often perni- cious. I believe the pra&ice has been chiefly owing to the ufe of purgatives in dyfenteric cafes, in which they are truly ufeful ; becaufe, contrary to the cafe of diarrhoea, there is in dyfentery a confide* rable conftri&ion of the inteftines.

MDII.

Another fet of remedies employed in diarrhoea are aftringents. There has been fome hefitation about the employment of thefe in recent cafes, upon the fuppofition that they might occafion the retention of an acrid matter that fhould be thrown out. I cannot, however, well underftand or af- fign the cafes in which fuch caution is neceflary ; and I think that the power of aftringents is feldom fo great as to render their ufe very dangerous. The only difH- F 4 culty

83 PRACTICE

culty which has occurred to me, with re- fpedt to their ufe, has been to judge of the circumftances to which they are efpecially adapted. It appears to me to be only in thofe where the irritability of the inte- {lines depends upon a lofs of tone : and this, I think, may occur either from the debility of the whole fyftem, or from cau- fes a&ing on the inteftines alone. All violent or long-continued fpafmodic and convulfive affections of the inteftinal canal necefTarily induce a debility there; and fuch caufes often take place, from violent irritation, in colic, dyfentery, cholera, and diarrhoea.

MDIIL

The lalt of the remedies of diarrhoea that remain to be mentioned are opiates. The fame obje&ions have been made to the ufe of thefe, in recent cafes of diar- rhoea,

D I iJ II Y S I C. ft

rhoea, as to that of aftringents; but on no good grounds: for the effed of opiates, as aftringent, is never very permanent ; and an evacuation depending upon irritation, though it may be for fome time fufpended by opiates, yet always returns very foon. It is only by taking off irritability that o- piates are ufeful in diarrhoea ; and there- fore, when the difeafe depends upon an increafe of irritability alone, or when,tho' proceeding from irritation, that irritation is corre&ed or exhaufted, opiates are the mod ufeful and certain remedy. And tho' opiates are not fuited to corredl or remove an irritation applied, they are often of great benefit in fufpending the effects of that ir- ritation whenever thefe are violent: andf upon the whole, it will appear, that opiates may be very frequently, and with great propriety, employed in the cure of diar- rhoea.

CHAP,

8a PRACTICE

CHAP. Xll

Op The Diabetes,

MDIV,

THIS difeafe confifts in the voiding of an unufually large quantity of urine.

As hardly any fecretion can be increafed without an increafed adion of the veflels "concerned in it, and as fome inftances of this difeafe are attended with affections manifeftly fpafmodic, I have had no doubt of arranging the diabetes under the order ofSpafmi.

' J&&J+- ^<S^~J~ir ■ MDV-

— tu~ 2~. **>-/* * - **> 'rt *:

PRACTICE 8j

MDV.

This difeafe is always accompanied with a great degree of thirft, and therefore with the taking in of a great quantity of drink. This in fome meafure accounts for the very extraordinary quantities of urine voided : but dill, independent of this, a peculiar difeafe certainly takes place; as the quantity of urine voided does almoft always exceed the whole of the liquids, and fometimes the whole of both folids and liquids, taken in.

MDVL

The urine voided in this difeafe is al- ways very clear, and at firft fight appears entirely without any colour ; but, viewed in a certain light, it generally appears to be flightly tinged with a yellowifh green, and in this refpedl has been very properly

conv?

84 PRACTICE

compared to a folution of honey in a large proportion of water.

Examined by the tafte, it is very gene- rally found to be more or lefs fweet; and many experiments that have now been made in different inftances of the difeafe, fhow clearly that fuch urine contains, in confiderable quantity, a faccharine matter which appears to be very exa&ly of the nature of common fugar.

MDVII.

Dodor Willis feems to me to have been the firft who took notice of the fweetnefs of the urine in diabetes, and almoft every phyfician of England has fince taken notice of the fame. It is to be doubted, indeed, if there is any cafe of idiopathic diabetes in which the urine is of a different kind. Though neither the ancients, nor, in the other countries of Europe, the moderns,

till

OF PHYSia 85

till the latter were directed to it by the Englifti, have taken notice of the fweetnefs of the urine, it does not perfuade me, that either in ancient or in modern times the urine in diabetes was of another kind. I myfelf, indeed, think I have met with one inftance of diabetes in which the urine was perfectly infipid ; and it would feem that a like obfervation had occurred to Dr Mar- tin Lifter. I am perfuaded, however, that fuch inftances are very rare ; and that the other is by much the more common, and perhaps the almoft univerfal occurrence. I judge, therefore, that the prefence of fuch a faccharine matter may be confidered as the principal circumftance in idiopathic diabetes; and it gives at leaft the only cafe of that difeafe that I can properly treat of here, for I am only certain that what 1 am further to mention relates to fuch a cafe.

MDVIIL

86

PRACTICE

MDVIII.

The antecedents of this difeafe, and con-4 fequently the remote caufes of it, have not been well afcertained. 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 perfons of a broken conftitution, or who, as we often exprefs it, are in a cachedlic date \ that it fometimes follows intermittent fevers ; and that it has often occurred from excefs in the drinking of mineral waters. But none of thefe caufes apply very generally to the cafes that occur : fuch cafes are not always, nor even frequently, followed by a dia- betes ; and there are many inftances of diabetes which could not be referred to any of them. In moft of the cafes of this difeafe which I have met with, I could not refer it to any particular caufe.

i MDIX

OF PHYSIC. 87

MDIX.

This difeafe commonly comes on flow- ly, and almoft imperceptibly, without any previous diforder. It often arifes to a con- fiderable degree, and fubfifts long without being accompanied with evident diforder in any particular part of the fyftem. The great thirft which always, and the vora- cious appetite which frequently, occurs in it, are often the only remarkable fymp- toms. Under the continuance of the dif- eafe, the body is often greatly emaciated ; and a great weaknefs alfo prevails. The pulfeis commonly frequent; and an obfcure fever is for the mod part prefent. "When the difeafe proves fatal, it generally ends with a fever, in many circumftances, par- ticularly thofe of emaciation and debility, refembling a he&ic.

MDX.

88 PRACTICE

MDX.

The proximate caufe of this difeafe is not certainly or clearly known. It feems to have been fometimes conne&ed with calculous affe&ions of the kidneys j and it is poflible, that an irritation applied there may increafe the fecretion of urine. It perhaps often does fo ; but how it fhould produce the Angular change that takes place in the ftate of the urine, is not to be eafily explained. It certainly often happens, that calculous matters are long prefent in the urinary paflages, without having any fuch effedt as that of producing diabetes in any fhape.

Some have fuppofed that the difeafe oc- curs from a relaxed ftate of the fecretory vefTels of the kidneys; and indeed the dif- fecflions of perfons who had died of this difeafe have (hown the kidneys in a very flaccid ftate. This, however, is probably i to

OF PHYSIC. 89

to be conlidered as rather the effect than the Caufe of the difeafe.

That no topical aiTecftion of the kidneys has a ihare in producing this difeafe, and that a fault in the aflimilation of the fluids is rather to be blamed, I conclude from hence, that even the folid food taken in, increafes the quantity of the urine voided, at the fame time with an increafe of the faccharine matter above-mentioned.

MDXI.

The diabetes has been fuppofed to be owing to a certain ftate of the bile; and it is true, that this difeafe has fometimes oc- curred in perfons who were at the fame time affe&ed with difeafes of the liver: but this concurrence does not often take place ; and the diabetes frequently occurs feparately from any affe&ion of the liver. In twenty inftances of diabetes which I

Vol. IV. G have

7

go PRACTICE

have feen, there was not in any one of them any evident affedlion of the liver.

The explanation that has been offered of the nature and operation of the bile, in producing diabetes, is very hypothetical, and nowife fatisfying.

MDXII.

As I have already faid, I think it pro- bable, that in moft cafes the proximate caufe of this difeafe is fome fault in the af- fimilatory powers, or in thofe employed in converting alimentary matters into the proper animal fluids. This I formerly hinted to Dr Dobfon, and it has been pro- fecated and publifhed by him ; but I mutt own, that it is a theory embarrafled with fome difficulties which I cannot at prefent very well remove.

MDXIH.

OF PHYSIC. 91

MDXIH.

The proximate caufe of diabetes being io little known or ascertained, 1 cannoc propoie any rational method of cure in the difeafe. From die teftimony of feveral au- thors, I believe that the difeafe has been cured: but I believe alfo, that this has fel- dom happened; and when the difeafe has been cured, I doubt much if it was effected by the feveral remedies to which thefe cures have been afcribed. In all the inftances of this difeafe which I myfelf have feen, and in feveral others of which I have been informed, no cure of it has ever been made in Scotland, though many inftances of it have occurred, and in mod of them the remedies recommended by authors have been diligently employed. I cannot, there- fore, with any advantage, enter into a de- tail of thefe remedies ; and as the difeafe, together with its feveral circumflances, G 2 when

92 PRACTICE

when they fhall hereafter occur, is likely to become the fubjedl of diligent invefti- gation, 1 avoid going farther at prefent, and judge it prudent to fufpend my opi- nion till I mall have more obfervations and experiments upon which I can form it more clearly.

CHAP.

OF PHYSIC. 93

CHAP. XIII.

Of the Hysteria, or the Hysteric Disease.

MDXIV.

THE many and various fymptoms which have been fuppofed to belong to a difeafe under this appellation, render it extremely difficult to give a general cha- racter or definition of it. It is, however, proper in all cafes to attempt fome general idea ; and therefore, by taking the mofl common form, and that concurrence of G 3 fymp-

94 PRACTICE

fymptoms by which ic is principally di- flinguifhed, 1 have formed a character in my fyftem of Methodical Nofology, and fliall here endeavour to illuftrate it by gi- ving a more full hiftory of the pheno- mena.

MDXV.

The difeafe attacks in paroxyfms or fits. Thefe commonly begin by fome pain and fulnefs felt in the left fide of the belly. From this a ball feems to move with a grumbling noife into the other parts of the belly; and, making as it were various convolutions there, feems to move into the ftomach ; and more diftindtly ftill rifes up to the top of the gullet, where it remains for fome time, and by its preffure upon the larynx gives a fenfe of fufFocation. By the time that the difeafe has proceeded thus far, the patient is affected with a ftu-

por

O F P II Y S I C. 95

por and infenfibility, while at the fame time the body is agitated with various con- vuliions. The trunk of the body is wreath- ed to and fro, and the limbs are varioufly agitated ; commonly the convulfive mo- tion of one arm and hand, is that of beat- ing, with the clofed fift, upon the bread very violently and repeatedly. This ftate continues for fome time, and has during that time fome remilfions and renewals of the convulfive motions; but they at length ceafe, leaving the patient in a ftupid and feemingly fleeping ftate. More or lefs fud- denly, and frequently with repeated figh- ing and fobbing, together with a murmur- ing noife in the belly, the patient returns to the exercife of fenfe and motion, but generally without any recollection of the *u

feveral circumftances that had taken place TV

during the fit, y ^— <~

a 4 mdxvi/ ■•"■

96 PRACTICE

MDXVI.

This is the form of what is called an byjleric paroxyfm, and is the mod common form ; but its paroxyfms are considerably varied in different perfons, and even in the fame perfon at different times. It differs, by having more or fewer of the circum- ftances above mentioned; by thefecircum- flances being more or lefs violent; and by the different duration of the whole fie.

Before the fit, there is fometimes a fud- den and unufually large flow of limpid urine. At the coming on of the fit, the ftomach is fometimes affected with vomit- ing, the lungs with considerable difficulty of breathing, and the heart with palpita- tions. During the fit, the whole of the belly, and particularly the navel, is drawn ftrongly inwards ; the Sphincter ani is fometimes fo firmly conftricled as not to ad- mit a fmall glyfter-pipe, and there is at the

fame

O F P H Y S 1 C. 97

fame time an entire fuppreflion of urine. .Such fits are, from time to time, ready to recur; and during the intervals, the pa- tients are liable to involuntary motions, to lies of laughing and crying, with fudden tranfition from the one to the other ; while fometimes falfe imaginations, and fome degree of delirium, alfo occur.

MDXVII.

Thefe affections have been fuppofed pe- culiar to the female fex ; and indeed they moft commonly appear in females : but they fometimes, though rarely, attack alfo the male fex ; never, however, that I have obferved, in the fame exquifite degree.

In the female fex, the difeafe occurs efpe- cially from the age of puberty to that of thirty-five years ; and though it does fome- times, yet very feldom appears before the former or after the latter of thefe periods.

At

98

PRACTICE

At all ages, the time at which it mod readily occurs is that of the menftrual pe- riod.

The difeafe more efpecially affedls the females of the moll exquifitely fanguine and plethoric habits, and frequently affe&s thofe of the mod robuft and mafculine conftitutions.

It affe&s the barren more than the breeding women, and therefore frequently young widows.

It occurs efpecially in thofe females who are liable to the Nymphomania ; and the Nofologifts have properly enough marked one of the varieties of this difeafe by the title of Hyjlcria Libidinofa.

In the perfons liable to the fits of this difeafe, it is readily excited by the paf- fions of the mind, and by every confider- able emotion, efpecially thofe brought on by furprife.

The perfons liable to this difeafe ao*

quire

O F P II Y S I C. 99

quire often fuch a degree of fenfibility, as to be ftrongly aflecled by every impreflior* that comes upon them by furprife.

MDXVIII.

In this hiftory, there appears to be a concurrence of fymptoms and circumftan- ces properly marking a very particular difeafe, which I think may be diftinguifh- ed from all others. It feems to me to have been improperly confidered by phy- ficians as the fame with fome other difea- fes, and particularly with hypochondria- lis. The two difeafes may have fome fymptoms in common, but for the mod part are considerably different.

Spafmodic affedions occur in both dif- eafes ; but neither fo frequently nor to fo great a degree, in hypochondriasis as in hyftcria.

Perfons liable to hyfteria are fometimes

afFecled

ioo PRACTICE

affected at the fame time with dyfpepfia. They are often, however, entirely free from it ; but I believe this never happens to perfons affedted with hypochondriafis.

Thefe different circumftances mark fome

difference in the two difeafes ; but they

are ftill more certainly diftinguifhed by

the temperament they attack, and by the

^ '-} time of life at which they appear to be

3i *<*<*+ t^y- moft exquifitely formed.

*jLJ(< fu <?— It has been generally fuppofed, that the

(%"kl L two difeafes differ only in refpecl of their

^>^^^>*^ppearing in different fexes. But this is

*&j£*- not well founded : for although the hy-

fteria appears mod commonly in females,

the male fex is not abfolutely free from it,

as I have obferved above; and although

the hypochondriafis may be moft frequent

in men, the inftances of it in the female

fex are very common,

MDXIX.

OF PHYSIC. lot

MDXIX.

From all thefe confiderations, it muft, I think, appear, that the hyfteria may be very well, and properly, diftinguifhed from hypochondriafis.

Further, it feems to me to have been with great impropriety, that almoft every degree of the irregular motions of the nervous fyftem has been referred to the one or other of thefe two difeafes. Both are marked by a peculiarity of tempera- ment, as well as by certain fymptoms commonly accompanying that ; but fome of thefe, and many others ufually marked by the name of nervous fymptoms, may, from various caufes, arife in tempera- ments different from that which is pecu- liar to either hyfteria or hypochondriafis, and without being joined with the pecu- liar fymptoms of either the one or the other difeafe : fo that the appellations of

Hyfteric

A

102 PRACTICE

Hyfteric and Hypochondriac are very in- accurately applied to them. Under what view thefe fymptoms are otherwife to be confidered, I am not ready to determine \ but muft remark, that the appellation of Nervous Difeafes is too vague and unde- fined to be of any ufeful application.

MDXX.

Having thus endeavoured to diftinguilli hyfteria from every other difeafe,I fhall now attempt its peculiar pathology. With re- fpe<fl to this, I think it will, in the flrft place, be obvious^ that its paroxyfms be- gin by a convuHive and fpafmodic affec- tion of the alimentary canal, which is af- terwards communicated to the brain, and to a great part of the nervous fyftem. Although the difeafe appears to begin in the alimentary canal, yet the conne&ion which the paroxyfms fo often have with i the

i

OF PHYSIC. 103

the menflrual flux, and with the difeafes

that depend on the ftate of the genitals,

fhows, that the phyficians have at all times

judged rightly in confidering this difeafe

as an affection of the uterus and other a

parts of the genital fyftem. U<t'<~ *f ;U tfa**,

MDXXI.

With regard to this, however, I can go no farther. In what manner the uterus, and in particular the ovaria, are afFedled in this difeafe; how the afFe&ion of thefe is communicated, with particular circum- ftances, to the alimentary canal ; or how the affe&ion of this, riiing upwards, af- fedls the brain, fo as to occafion the par- ticular convulfions which occur in this difeafe ; I cannot pretend to explain.

But although I cannot trace this difeafe to its firft caufes, or explain the whole of the phenomena ; I hope, that with refpecfl

to

i04

Practice

to the general nature of the difeafe, I may form fome general conclufions, which may ferve to direct our condudt in the cure of

it.

MDXXII.

Thus from a confideration of the pre- difponent and occafional caufes, it will, I think, appear, that the chief part of the proximate caufe is a mobility of the fy- ftem, depending generally upon its pletho- ric ftatc\

MDXXllt.

Whether this difeafe ever arifes from a mobility of the fyftem, independent of any plethoric ftate of it, I cannot pofitively determine ; but in many cafes that have fubfifted for fome time, it is evident that a fenfibility, and confequently a mobility,

are

i

OF PHYSIC. 105

are acquired, which often appear when neither a general plethora can be fuppofed to fubfift, nor an occafional turgefcerice to have happened. However, as we have fhown above, that a diftention of the vef- fels of the brain feems to occafion epilep- fy, and that a turgefcence of the blood in the veflels of the lungs feems to produce afthma ; fo analogy leads me to fuppofe, that a turgefcence of blood in the uterus, or in other parts of the genital fyftem, may occafion the fpafmodic and convul- five motions which appear in hyfleria. It will, at the fame time, be evident, that this affe&ion of the genitals muft efpe- cially occur in plethoric habits ; and eve- ry circumftance mentioned in the hiftory of the difeafe ferves to confirm this opinion with refpedt to its proximate caufe.

Vol. IV. H MDXXIV.

io6 PRACTICE

MDXXIV.

From this view of the fubject, the ana- logy of hyfteria and epilepfy will readily appear ; and why, therefore, I am to fay that the indications of cure are the fame in both.

As the indications, fo the feveral means of anfwering them are fo much the fame in both difeafes, that the fame obfervations and directions, with regard to the choice and employment of thefe remedies, that have been delivered above on the fubjecSi of epilepfy, will apply pretty exadlly to hyfteria ; and therefore need not be re- peated here.

CHAP,

O F P H Y S I C. 107

CHAP. IX.

Of CanineMadness and Hydrophobia

A^S R 'W'/*k/.

MDXXV.

THIS difeafe has been fo exadlly and fully defcribed in books that are in A everybody's hands, that it is on no ac-^^2 /; count neceflary for me to give any hiftory of it here ; and with refpecfl to the patho- logy of it, I find chat I can fay nothing fatisfying to myfelf, or that I can expedl to prove fo to others. I find alfo, with re- H 2 fpeft

io8- PRACTICE

fped to the cure of this difeafe, that there is no fubjedt in which the fallacy of expe- rience appears more ftrongly than in this. From the mod ancient to the prefent times, many remedies for preventing and curing this difeafe have been recommend- ed under the fandtion of pretended ex- perience, and have perhaps alfo kept their . V ~ credit for fome time : but fucceeding

^^^j^uume& have generally, upon the fame 4~~Jh ^~ ^^ ground of experience, deftroyed that cre- dit entirely ; and mod of the 'remedies formerly employed are now fallen into abfolute negledh In the prefent age, fome new remedies have been propofed, and have experience alleged to vouch for their efficacy ; but many doubts ftill remain with refpedl to this : and though I can- not determine in this matter from my own experience, I think it incumbent on me to give the beft judgment I can

form

O F P H Y S I C. 109

form with refpcft to the choice of the re- medies at prefent recommended.

MDXXVI.

I am, in the firft place, firmly perfua- ded, that the mod certain means of pre- venting the confequences of the bite, is to cut out, or otherwife deftroy, the part in which the bite has been made. In this every body agrees ; but with this differ- ence, that fome are of opinion that it can only be effectual when it is done very foon after the wound has been made, and they therefore negledl it when this opportunity is miffed. There have been, however, no experiments made proper to determine this matter : and there are many confidera- tions which lead me to think, that the poifon is not immediately communicated to the fyftem ; and therefore, that this meafure of deftroying the part may be

H3 praSifed- ^

no PRACTICE

pra&ifed with advantage, even many days tflf^CCS after the bite has been given.

4+^ Lfr-t-tA** A^iU^t

^J^U MDXXVII.

^2? ^Z2*"*' Wkilft t^ie ftate°f our experience, with

j*efpedl to feveral remedies now in ufe, is

uncertain, I cannot venture to afTert that

any of thefe is abfolutely ineffectual ; but

^ I can give it as my opinion, that the effi-

IH2L f ^^Jcacy of mercury, given very largely, and

jZTZd-l*^' perfifted in for a long time, both as a

SL— 7^^means °f preventing the difeafe, and of

~ *"*14L l>£~ c.ur*ng ll when it has actually come on, is

sJul W~~^~ better fupported by experience than that

*~ j^ dl^ of any other remedy now propofed or

fcU-&»~2jfts* commonv employed.

BOOK

BOOK IV.

O F

V E S A N I JE,

OR OF THE

DISORDERS of the INTELLECTUAL FUNCTIONS.

CHAP. I.

Of Vesani^e in General, f

MDXXVIII.

THE Nofologifts, Sauvages and Sagar,y,^y/v^^^y in a clafs of difeafes under the title ^ £~T^ ~~ of Vesani-e, have comprehended the two ££^pu~ H4 orders; JT *"S

' / < // ~

U2 PRACTICE

orders, of Hallucinationes or Falfe Percep- tions, and of Morofitates or Erroneous Ap- petites and Paflions ; and in like manner, Linnaeus in his clafs of Mentales, cor- refponding to the Vefaniae of Sauvages, has comprehended the two orders of Imagina- rii and Pathetici, nearly the fame with the Hallucinationes and Morofitates of that au- thor. This, however, from feveral con- fiderations, appears to me improper ; an$ I have therefore formed a clafs of Vefanias nearly the fame with the Paranoias of Vo- gel, excluding from it the Hallucinationes and Morofitates, which I have referred to the Morbi Locales. Mr Vogel has done the like, in feparating from the Paranoias the falfe perceptions and erroneous appetites ; and has thrown thefe into another clafs, to which he has given the title of Hype- raefthefes*

MDXXIXc

OF PHYSIC. ii J

MDXXIX.

It is indeed true, that certain hallucina- tions and morofitatcs are frequently com- bined with what I propofe to confider as ftriftly a vefania or an erroneous judge- ment ; and fometimes the hallucinationes feem to lay the foundation of, and to form almoft entirely, the vefania. But as moft part of the hallucinationes enumerated by theNofologifts are affecftions purely topical, and induce no other error of judgment be- fide that which relates to the fingle objecfl of the fenfe or particular organ affedled ; fo thefe are certainly to be feparated from the difeafes which confift in a more general affection of the judgment. Even when the hallucinationes conftantly accompany or feem to induce the vefania, yet being fuch as arife from internal caufes, and may be prefumed to arife from the fame caufe as the more general affeflion of the judgment,

they

ii4 PRACTICE

they are therefore to be confidered as fymptoms of this only.

In like manner I judge with refpedl to the morofitates, or erroneous paffions*, that accompany vefania; which, as confequen- ces of a falfe judgment, muft be confidered as arifing from the fame caufes, and as fymptoms only, of the more general affec- tion.

There is, indeed, one cafe of a morofitas which feems to induce a vefania, or more general affecftion of the judgment ; and this may lead us to confider the vefania, in this cafe, as a fymptom of an erroneous appetite, but will not afford any good reafon for com- prehending the morofitates in general under the vefania, confidered as primary difeafes.

The limitation, therefore, of the clafs of Vefaniae to the lefions of our judging fa- culty, feems from every confideration to be proper.

The particular difeafes to be compre- hended

OF P II Y S I C ii5

hendcd under this clafs, may be diflin- guiihed according as they aired perfons in the time of waking or ileeping. Thofe which affeit men awake, may again be confidered, as they confifl in an erroneous judgment, to which I fhall give the appel- lation of Delirium; or as they confift in a weaknefs or imperfedlion of judgment, which I (hall name Fatuity. I begin with the confideration of Delirium,

MDXXX.

As men differ greatly in the foundnefs and force of their judgment, fo it may be proper here to afcertain more precifely what error or imperfection of our judging faculty is to be confidered as morbid, and to admit of the appellations of Delirium and Fatuity. In doing this, I fhall firfl confider the morbid errors of judgment under the general appellation of Delirium,

which

n6 PRACTICE

which has been commonly employed to denote every mode of fuch error.

MDXXXI.

As our judgment is chiefly exercifed in difcerning and judging of the feveral rela- tions of things, I apprehend that delirium may be defined to be, — In a perfon a- wake, a falfe or miftaken judgment of thofe relations of things, which, as oc- curring moft frequently in life, are thofe about which the generality of men form the fame judgment ; and particularly when the judgment is very different from what the perfon himfelf had before ufually formed.

MDXXXII.

With this miftaken judgment of rela- tions there is frequently joined fome falfe

per-

OF PHYSIC. ri7

perception of external objects, without any evident fault in the organs of fenfe, and which feems therefore to depend upon an internal caufe; that is, upon the imagina- tion arifing from a condition in the brain prefenting objects which are not actually prefent. Such falfe perceptions mufl ne- ceflarily occafion a delirium, or an erro- neous judgment, which is to be confidered as the difeafe.

MDXXXIII.

Another circumftance, commonly at- tending delirium, is a very unufual aflb- ciation of ideas. As, with refpedl to moft of the affairs of common life, the ideas laid up in the memory are, in moft men, affociated in the fame manner ; fo a very unufual affociation, in any individual, mufl prevent his forming the ordinary judgment of thofe relations which are the 4 mod

n8 PRACTICE

moft common foundation of afTociation in the memory : and therefore this unu- fual and commonly hurried afTociation of ideas, ufually is, and may be confidered as, a part of delirium. In particular it may be confidered as a certain mark of a general morbid aflfe&ion of the intellec- tual organs, it being an interruption or perverfion of the ordinary operations of memory, the common and neceflary foundation of the exercife of judge- ment,

MDXXXIV.

A third circumftance attending delirium, is an emotion or paffion, fometimes of the angry, fometimes of the timid kind ; and from whatever caufe in the perception or judgment, it is not proportioned to fuch caufe, either in the manner formerly cuf- tomary to the perfon himfelf, or in the 4 manner

O 9 P II Y B I C. 119

manner ufaal with the generality of other men.

MDXXXV.

Delirium, then, may be more fhortly defined, — In a perfon awake, a falfe judge- ment arifing from perceptions of imagina- tion, or from falfe recollection, and com- monly producing difproportionate emo- tions.

Such delirium is of two kinds ; as it is combined with pyrexia and comatofe af- fections ; or, as it is entirely without any fuch combination. It is the latter cafe that we name Infanity ; and it is this kind of delirium only that I am to treat of here.

MDXXXVr.

Infanity may perhaps be properly con-

fidered

120 PRACTICE

/

fidered as a genus comprehending many different fpecies, each of which may de- ferve our attention ; but before proceeding to the confideration of particular fpecies, I think it proper to attempt an inveftigation of the caufe of infanity in general.

MDXXXVII.

In doing this, I fliall take it for granted, as demonftrated elfewhere, that although this difeafe feems to be chiefly, and fome- times folely, an affeiftion of the mind ; yet the conne&ion between the mind and bo- dy in this cafe is fuch, that thefe affedlions of the mind muft be confidered as de- pending upon a certain ftate of our corpo- real part. See Halleri Prim. Lin. Phyfio- log. § dlxx. See Boerhaavii Inft. Med.

§DLXXXI. DCXCVI,

MDXXXVIII.

OF PHYSIC. i2!

MDXXXV1II.

Admitting this propofition, I mud in the next place ailume another, which 1 like- wife fuppofe to be demonstrated elfewhere. This is, that the part of our body more immediately connected with the mind, and therefore more efpecially concerned in every affe&ion of the intellectual func- tions, is the common origin of the nerves ; which I fliall, in what follows, fpeak of under the appellation of the Brain.

MDXXXIX.

Here, however, in afluming this laft propofition, a very great difficulty imme- diately prefents itfelf. Although we cannot doubt that the operations of our intellect always depend upon certain motions ta- king place in the brain, (fee Gaub. Path. Med. § 523 ) ; yet thefe motions have ne-

Vol. IV. I ver

122 PRACTICE

ver been the objedls of our fenfes, nor haye we been able to perceive that any particu- lar part of the brain has more concern in the operations of our intellect than any o- ther. Neither have we attained any know- ledge of what fhare the feveral parts of the brain have in that operation; and there- fore, in this fituation of our fcience, it mull be a very difficult matter to difcover thofe ftates of the brain that may give oc- cailon to the various ftate of our intellec- tual functions.

MDXL.

It may be obferved, that the different ftate of the motion of the blood in the vef- fels of the brain has fome fhare in afte&ing the operations of the intellect; and phyfi- cians, in feeking for the caufes of the dif-

*/ /v— /**k<~

ferent ftates of our intelledual fundions, have hardly looked further than into the

ftate

O F P II Y S I C. 123

ftate of the motion of the blood, or into the condition of the blood itfclf : but it is evi- dent that the operations of the intellectual fun&ions ordinarily go on, and are often considerably varied, without our being able to perceive any difference either in the mo- tions or in the condition of the blood.

MDXLI.

Upon the other hand, it is very probable that the ftate of the intellectual functions depends chiefly upon the ftate and condi- tion of what is termed the Nervous Power, or, as we fuppofe, of a fubtile very move- able fluid, included or inherent, in a man- ner we do not clearly underftand, in e- \ery part of the medullary fubftance of the brain and nerves, and which in a living and healthy man is capable of being mo- ved from every one part to every other of the nervous fyftem.

I 2 MDXLII.

*

124 PRACTICE

MDXLII.

With refpecfl to this power, we have pretty clear proof that it frequently has a motion from the fentient extremities of the nerves towards the brain, and thereby pro- duces fenfation ; and we have the fame proof, that in confequence of volition the nervous power has a motion from the brain into the mufcles or organs of motion. Ac- cordingly, as fenfation excitfes our intellec- tual operations, and volition is the effedt of thefe, and as the conne&ion between fen- fation and volition is always by the inter- vention of the brain and of intellectual o- perations ; fo we can hardly doubt, that thefe latter depend upon certain motions, and the various modification of thefe mo tions, in the brain.

f

OF PHYSIC, i2£

MDXLIII.

To afcertain the different dates of thcfe motions may be very difficult; and phy- ficians have commonly confidered it to be fo very myfterious, that they have gene- rally defpaired of attaining any knowledge with regard to it : but I confider fuch ab- lolute defpair, and the negligence it in- ipires, to be always very blameable ; and I fliall now venture to go fome length in the inquiry, hoping that fome fteps made with tolerable firmnefs may enable us to go ftill further.

MDXLIV.

To this purpofe, I think it evident, that the nervous power, in the whole as well as in the feveral parts of the nervous fyftem, and particularly in the brain, is at diffe- rent times in different degrees of mobility 1 3 and

126 PRACTICE

and force. To thefe different ftates, I beg leave to apply the terms of Excitement and Collapfe. To that ftate in which the mo- bility and force are fufficient for the exer-r cife of the fun<flions, or when thefe dates are any way preternaturally increafed, I give the name of Excitement ; and to that ftate in which the mobility and force are not fufficient for the ordinary exercife of the fundlions, or when they are diminifh- ed from the ftate in which they had been before, I give the name of Collapfe. 1 beg, however, it may be obferved, that by thefe terms I mean to exprefs matters of fa<ft only ; and without intending, by thefe terms, to explain the circumftance or con- dition, mechanical or phyfical, of the ner- vous power or fluid in thefe different ftate?,

MDXLV

L

OF PHYSIC. 127

MDXLV.

That thefe different ftates of excitement and collapfe take place on different occa- sions, mull, 1 think, be manifeft from numberlefs phenomena of the animal oe- conomy: but it is cfpecially to our prefent purpofe to obferve, that the different ftates 01 excitement and collapfe, are in no in- ftance more remarkable, than in the dif- ferent ftates of waking and fleeping. In the latter, when quite complete, the mo- tion and^obility of the nervous power, with refpeft to the whole of what are call- ed the Animal Functions, entirely ceafe, or, as I would exprefs it, are in a ftate of collapfe; and are very different from the liate of waking, which in healthy perfons I would call a ftate of general and entire excitement.

I 4 MDXLVL

128 PRACTICE

MDXLVI.

This difference in the ftates of the ner- vous power in fleeping and waking being admitted, I muft in the next place ob- ferve, that when thefe dates are changed from the one into the other, as commonly happens every day, the change is hardly ever made inftantaneoufly, but almofl al- ways by degrees, and in fome length of time only : and this may be obferved with refpedl to both fenfe and motion. Thus when a perfon is falling afleep, the fenfibility is gradually diminifhed: fo that, although fome degree offleep has come on, flight impreilions will excite fenfation, and bring back excitement; which the fame, or even ftronger impreffions, will be inef- ficient to produce when the (late of fleep has continued longer, and is, as we- may fay, more complete. In like manner, the power of voluntary motion is gradually

di-

O F P H Y S I C. 129

diminiflicd. In fomc members it fails fooner than in others ; and it is fome time before it becomes general and considerable over the whole.

The fame gradual progrefs may be re- marked in a perfon's coming out of fleep: The ears in this cafe are often awake before the eyes are opened or fee clearly, and the fenfes are often awake before the power of voluntary motion is recovered ; and it is curious to obferve, that, in fome cafes, fen- fations may be excited without producing the ordinary affociation of ideas. See Mem, de Berlin, 1752.

MDXLVII.

From all this, I think it will clearly appear, that not only the different ftates of excitement and collapfe can take place in different degrees, but that they can take place in different parts of the brain,

or

i3o PRACTICE

or at leaft, with refped to the different functions, in different degrees.

As I prefume that almoft every perfon has perceived the gradual approach of fleeping and waking, 1 likewife fuppofe every per- fon has obferved, that, in fuch interme- diate ftate of unequal excitement, there al- moft always occurs more or lefs of deli- '^i^T T f^ ruim> or dreaming, if any body choofes to ^^— -^-call it fo. There are in this ftate falfe perceptions, falfe aflbciations, falfe judge- ments, and disproportionate emotions; in fhort, all the circumftances by which I have above defined delirium.

This clearly fhows that delirium may depend, and I fhall hereafter endeavour to prove that it commonly does depend, upon fome inequality in the excitement of the brain ; and that both thefe afTercions are founded on this, that, in order to the proper exercife of our intellectual func- tions, the excitement muft be complete,

an<

O F P H Y S I C. 131

and equal in every pare of the brain. For though we cannot fay that the veftiges of ideas are laid up in different parts of the brain, or that they are in fome meafure difFufed over the whole, it will follow up- on either fuppofition, that as our reafoning our intellectual operations always require the orderly and exadt rccolle&ion or me- mory of afTociated ideas; fo, if any part of the brain is not excited, or not excitable, that recollection cannot properly take place, while at the fame time other parts of the brain, more excited and excitable, may give falfe perceptions, afTociations, and judgments.

MDXLV1IL

It will ferve to illuftrate this, that the collapfe in fleep is more or lefs complete : or that the fleep, as we commonly fpeak, is more or lefs profound : and therefore, that in many cafes, though fleep takes place to a 3 con-

i32 PRACTICE

confiderable degree, yet certain impreflions do ftill take effect, and excite motions, or, if you will, fenfations in the brain; but which fenfations, upon account of the collapfed ft ate of fo great a part of the brain, are gene- rally of the delirious kind, or dreams, con- fifting of falfe perceptions, aflbciations, and judgments, that would have been corrected if the brain had been entirely excited.

Every one, I believe, has obferved, that the molt imperfedt fleeps are thofe chiefly attended with dreaming ; that dreams, therefore, moft commonly occur towards morning, when the complete ftate of fleep is paffing away; and further, that dreams are moft commonly excited by ftrong and un- eafy impreflions made upon the body.

I apprehend it may alfo be an illuftration of the fame thing, that, even in waking hours, we have an inftance of an unequal ftate of excitement in the brain producing delirium. Such, I think, occurs in the

cafe

OF PHYSIC. 133

cafe of fever. In this, it is manifeft, that the energy of the brain, or its excitement, is conliderably diminifhed with refpedt to the animal functions : and it is according- ly upon this ground that I have explained above, in XLV. the delirium which fo commonly attends fever. To what I have there faid I (hall here only add, that it may ferve to confirm my dodlrine, that the delirium in fever comes on at a cer- tain period of the difeafe only, and that we can commonly difcern its approach by a more than ufual degree of it appearing in the time of the patient's falling into or coming out of fleep. It appears, therefore, that delirium, when it firft comes on in fever, depends upon an inequality of ex- citement ; and it can hardly be doubted, that the delirium which comes at length to prevail in the entirely weakened ftate of fevers, depends upon the fame caufe pre- vailing in a more confiderable degree.

1 MDXLIX.

i34 PRACTICE

MDXL1X.

From what has been now delivered, I hope it will be fufficiently evident, that delirium may be, and frequently is, occa- sioned by an inequality in the excitement of the brain.

How the different portions of the brain may at the fame time be excited or collap- fed in different degrees, or how the ener- gy of the brain may be in different degrees of force, with refpect to the feveral animal, vital, and natural functions, I cannot pre- tend to explain ; but it is fufficiently evi- dent in fact, that the brain may be at one and the fame time in different conditions with refpe<ft to thefe functions. Thus in inflammatory difeafes, when by a ftimu- lus applied to the brain the force of the vital fun&ions is preternaturally increafed, that of the animal is either little changed, or confiderably diminilhed. On the con- trary,

O F P H Y S I C. 135

trary, in many cafes of mania, the force of the animal functions depending always on the brain, is prodigioufly increafed, while the ftate of the vital function in the heart is very little or not at all changed. I muft therefore fay again, that how dif- ficult foever it may be to explain the me- chanical or phyfical condition of the brain in fuch cafes, the fads are fufficient to fhow that there is fuch an inequality as may difturb our intellectual operations.

MDL.

I have thus endeavoured to explain the general caufe of Delirium : which is of two kinds ; according as it is with, or without, pyrexia. Of the firft I take no further no- tice here, having explained it as well as I could above in XLV.

I proceed now to confider that delirium which properly belongs to the clafs of Ve-

faniat,

i36 PRACTICE

fania?, and which I fhall treat of under the general title of Infanity.

MDLI.

In entering upon this fubject, it im- mediately occurs, that in many inftances of infanity, we find, upon difle&ion after death, that peculiar circumftances had ta- ken place in the general condicion of the brain. In many cafes, it has been found of a drier, harder, and firmer confidence, than what it is ufually of in perfons who had not been affected with that difeafe. In other cafes, it has been found in a more humid, foft, and flaccid ftate ; and in the obfervations of the late Mr Meckel *, it has been found confiderably changed in

its

* Memoir, de Berlin pour l'annce 1 764. It appeared in many inftances of infane perfons, that the medullary fubftance of the cerebrum was drier, and of a lefs fpe- cific gravity, than in perfons who had been always of a found judgment.

OF PHYSIC. 137

its denfity or fpecific gravity. Whether thefc different dates have been obferved to be uniformly the lame over the whole of the brain, I cannot certainly learn ; and I f uipecl the diffe&ors have not always accu- rately inquired into this circumftance: but in feveral inftances, it appears that thefe ftates had been different in different parts of the brain ; and inftances of this inequa- lity will afford a confirmation of our gene- ral doclrine.

The accurate Morgagni has obferved, that in maniacal perfons the medullary portion of the brain is unufually dry, hard, and firm : And this he had fo fre- quently obferved, that he was difpofed to confider it as generally the cafe. But in moft of the particular inftances which he has given, it appears, that, for the moft part, while the cerebrum was of an, unufually hard and firm confidence, the cerebellum was of its ufual foftnefs ; and

Vol IV. K in

i33 PRACTICE

in many of the cafes it was unufually fofc and flaccid. In fome other cafes, Mor- gagni obferves, that while a part of the cerebrum was harder and firmer than or- dinary, other parts of it were preternatu- rally foft.

MDL1I.

Thefe obfervations tend to confirm our generaldocflrine: and there are otherswhich I think will apply to the fame purpofe.

Upon the difledlion of the bodies of perfons who had laboured under infanity, various organic affe&ions have been dif- covered in particular parts of the brain • and it is fufficiently probable, that fuch or- ganic affedtions might have produced a dif- ferent degree of excitement in the free and affedted parts, and mud have interrupted in fome meafure the free communication between the feveral parts of the brain,

and

OF PHYSIC: 139

and in either way have occafioned infa- nity.

There have occurred fo many inftances of this kind, that I believe phyficians are generally difpofed to fufpecT: organic le- fions of the brain to exift in almofl every cafe of infanity,

MDLIII.

This, however, is probably a miftake i for we know that there have been many inftances of infanity from which the per- fons have entirely recovered ; and it is difficult to fuppofe that any organic le- fions of the brain had in fuch cafe taken place. Such tranfitory cafes, indeed, ren- der it probable, that a ftate of excitement, changeable by various caufes, had been the caufe of fuch inftances of infanity.

R 2 MDL1V,

140

PRACTICE

MDLIV.

It is indeed further averted, that in many inftances of infane perfons, their brain had been examined after death, with- out fhowing that any organic lefions had before fubfifted in the brain, or finding that any morbid ftate of the brain then appeared. This, no doubt, may ferve to fhow, that organic lefidns had not been the csufe of the difeafe; but it does not afTure us that no morbid change had taken place in the brain : for it is probable, that the difledlors were not always aware of its be- ing the general condition of hardnefs and denfity, as different in different parts of the brain, that was to be attended to, in order to difcover the caufe of the prece- ding difeafe ; and therefore many of them had not with this view examined the ftate of the brain, as Morgagni feems carefully to have done.

MDLV

OF i> II Y S I GJ 141

MDLV.

Having thus endeavoured to inveftigate the caufe of infanity in general, it were to be wifhed that 1 could apply the doc- trine to the diflinguiming the feveral fpecies of it, according as they depend upon the different ftate and circumftances of the brain, and thereby to the eftablifli- ing of a fcientific and accurately adapted method of cure. Thefe purpofes, how- ever, appear to me to be extremely diffi- cult to be attained ; and I cannot hope to execute them here. All I can do is to make fome attempts, and offer fome re- flections, which further obfervation, and greater fagacity, may hereafter render more ufefuh

MDLVI.

The ingenious Dr Arnold has been com- K 3 men-

i42 PRACTICE

mendably employed in diftinguifhing the different fpecies of infanity as they appear with refpeel to the mind ; and his labours may hereafter prove ufeful, when we (hall come to know fomething more of the dif- ferent ftates of the brain correfponding to thefe different ftates of the mind ; but at prefent I can make little application of his numerous diftinc\ions. It appears to me that he has chiefly pointed out and enu- merated diftindions, that are merely va- rieties, which can lead to little or no va- riety of practice : and I am efpecially led to form the latter conclufion, becaufe thefe varieties appear to me to be often combi- ned together, and to be often changed in- ■:o one another, in the fame perfon ; in whom we muft therefore fuppofe a gene- ral caufe of the difeafe, which, fo far as it can be known, muft eftablifh the pa- thology, and efpecially 'diredt the prac- tice*

MDLVII,

OF PHYSIC, i43

MDLV1I.

In my limited views of the different ftates of infanity, I mud go on to confi- der them under the two heads of Mania and Melancholia : and though I am fen- fible that thefe two genera do not com- prehend the whole of the fpecies of infa- nity, I am not clear in afligning the other fpecies which may not be comprehended under thofe titles. I fhall, however, en- deavour, on proper occafions as 1 go along, to point them out as well as I can.

K 4 CHAP.

i44 PRACTICE

CHAP. II.

Of Mania, or Madness.

MDLVI1L

THE circumftances which I have men- tioned above in MDXXXV. as confli- cting delirium in general, do more efpe- cially belong to that kind of it which 1 fhall treat of here under the title of Mania.

There is fomecimes a falfe perception or imagination of things prefent that are not; but this is not a conftant, nor even a fre- quent, attendant of the difeafe. The falfe judgment, is of relations long before laid up in the memory. It very often turns upon

one

O P P II Y S I C. 145

one iinglc fubjecl : but more commonly the mind rambles from one liibject to another, with an equally tulle judgment concerning the mod part of them; and as at the lame time there is commonly a falfe allociation, this increafes the confufion of ideas, and therefore the falfe judgments. What for the mod part more especially di- ftinguiilies the difeafe, is a hurry of mind, in purfuing any thing like a train of thought, and in running from one train of thought to another. Maniacal perfons are in general very irafcible ; but what more particularly produces their angry emotions is, that their falfe judgments lead to fome action which is always pufli- ed with impetuofity and violence ; when this is interrupted or reftrained, they break out into violent anger and furious vio- lence againft every perfon near them, and upon every thing that ftands in the way pf their impetuous will. The falfe judge- ment

146 PRACTICE

ment often turns upon a miftaken opini- on of fome injury fuppofed to have been formerly received, or now fuppofed to be intended; and it is remarkable, that fuch an opinion is often with refpedl to their former deareft friends and relations ; and therefore their refentment and anger are particularly directed towards thefe. And although this fhould not be the cafe, they commonly foon lofe that refpedl and re- gard which they formerly had for their friends and relations. With all thefe cir- cumftances, it will be readily perceived, that the difeafe mud be attended very con- ftantly with that incoherent and abfurd fpeech we call raving. Further, with the' circumftances mentioned, there is com- monly joined an unufual force in all the voluntary motions ; and an infenfibility or refinance of the force of all impref- fions, and particularly a refiftance of the powers of fleep, of cold, and even of hun-

3 ger;

O F 1' H Y S 1 C. 147

i;vr; though indeed in many inftances a voracious appetite takes place.

MDLIX.

It appears to me, that the whole of thefe circumftances and fymptoms point out a coniiderable and unufual excefs in the ex- citement of the brain, efpecially with re- fpeft to the animal functions ; and it ap- pears at the fame time to be manifeftly in fome meafure unequal, as it very often takes place with refpedl to thefe functions alone, while at the fame time the vital and natural are commonly very little changed from their ordinary healthy ftate.

MDLX.

How this excefs of excitement is produ- ced, it may be difficult to explain. In the various inftances of what Sauvages has

named

148 PRACTICE

named the Mania Metajlatica^ and in all the inftances I have mentioned in my No- fology under the title of the Mania Corpo- reay it may be fuppofed that a morbid or- ganic affection is produced in fome part of the brain ; and how that may produce an increafed or unequal excitement in certain parts of it, I have endeavoured to explain above in MDLII. But I muft at the fame time acknowledge, that fuch remote cau- fes of mania have very rarely occurred; and that therefore fome other caufes of the difeafe muft be fought for.

The efFe&s of violent emotions or paf- fions of the mind have more frequently occurred as the remote caufes of mania ; and it is fufficiently probable, that fuch violent emotions, as they do often imme- diately produce a temperory increafe of excitement, fo they may, upon fome oc- calions of their permanent inherence or frequent repetition, produce a more confir

derable

O F P H Y S I C. 149

derable and more permanent excitement, that is, a mania.

With refped: to thofe caufes of mania which ari(e in confequence of a melancho- lia which had previoufly long fubfifted ; whether we confider that melancholia as a partial infanity, or as a long perfifting at- tachment to one train of thinking, it will be readily perceived, that in either cafe fuch an increafe of excitement may take place in fo confiderable a degree, and in fo large a portion of the brain, as may give occafion to a complete mania.

MDLXI.

Thefe confiderations with regard to the remote caufes appear to me to confirm fufficiently our general do&rine 01 in- creafed and unequal excitement in the mania which I have defcribed above ; but I mufl own, that I have not exhaufted the

fub-

ISO

PRACTICE

fubjecT;, and that there arc cafes of mank of which I cannot aflign the remote caufes: but although I cannot in all cafes explain in what manner the mania is produced, I prefume, from the explanation given, and efpecially from the fymptoms enumerated above, to conclude, that the difeafe defcri- bed above depends upon an increafed ex- citement 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 leaft I think it will moil clearly explain the operation of thofe remedies, which, fo far as I can learn from my own experience and that of others, have proved the mod fuc- cefsfulin this difeafe; and, to illuftrate this, I now enter upon the confideration of thefe remedies, and to make fome remarks upon the proper manner of employing them.

MDLXIL

OF PHYSIC, 15I

MDLXU.

Retraining the anger and violence of madmen is always necefTary for prevent- ing their hurting themfelves or others: but this reftraint is alfo to be confidered as a remedy. Angry paffions are always rendered more violent by the indulgence of the impetuous motions they produce ; and even in madmen the feeling of re- ftraint will fometimes prevent the efforts which their paffion would otherwife occa- fion. Reftraint, therefore, is ufeful, and ought to be complete ; but it fhould be ex- ecuted in the eafieft manner poffible for the patient, and the (trait waiftcoat anfwers every purpofe better than any other that has yet been thought of. The retraining madmen by the force of other men, as oc- casioning a conftant ftruggle and violent agitation, is often hurtful. Although, on many occafions, it may not be fafe to al- low

V

I

152 PRACTICE

V

low maniacs to be upon their legs or to

walk about, it is never defirable to confine them to a horizontal fituation; and when- ever it can be admitted, they fhould be /J^ /*— #^niore or lefs in an eredl pofture.* Altho1 ^/^xthere may be no fymptoms of any preter- ^^^^>^/U^^natural fulnefs or increafed impetus of blood in the vends of the brain, a hori- zontal poflure always increafes the fulnefs and tenfion of thefe vefTels, and may there- by increafe the excitement of the brain.

MDLXIIL

The reftraint mentioned requires con- finement within doors, and it fhould be in a place which prefents as few objedls qf fight and hearing as poflible; and particu- larly, it fhould be removed from the obje&s that the patient was formerly acquainted with, as thefe would more readily call up ideas and their various affociations. It is 3 for

OF PHYSIC. 153

tor this rcaion that the confinement of madmen Qiould hardly ever be in their u-

iual habitation | or if they are, that their apartment fliould be (tripped of all its for- mer furniture. It is ai'fo for the moll part proper, that maniacs fliould be without the company of any of their former acquain- tance; the appearance of whom common- ly excites emotions that increafe the dif- eafe. Strangers may at firft be offenfive ; but in a little time they come to be objects either of indifference or of fear, and they fliould not be frequently changed.

MDLXIV.

Fear being a paflion that diminiflies ex- citement, may therefore be oppofed to the excefs of it ; and particularly to the angry and irafcible excitement of maniacs. Thefe being more fufceptible of fear than might be expected, it appears to me to have been commonly ufeful. In moft cafes it has

Vol. IV. L ap-

J

*54 PRACTICE

appeared to be neceffary to employ a very conftant impreffion of fear; and therefore to infpire them with the awe and dread of fome particular perfons, efpeciallyof thofe who are to be conftantly near them. This awe and dread is therefore, by one means or other, to be acquired ; in the flrft place, by their being the authors of all the re- ftraints that may be occafionally proper ; but fometimes.it may be neceffary to ac- quire it even by ftripes and blows. The former, although having the appearance of more feverity, are much fafer than ftrokes or blows about the head. Neither of them, however, mould be employed further than feems very neceffary, and mould be trufted only to thofe whofe difcretion can be de- pended upon. There is one cafe in which they are fuperfluous ; that is, when the maniacal rage is either not fufceptible of fear, or incapable of remembering the ob- jects of it; for in fuch inftances, ftripes

and

OF PHYSIC; tg$

and blows wouM be wanton barbarity. la many cafes of a moderate diieaie, it is of advantage that the perfons who are the au- thors of reftraiiit and punifhment fhculd be upon other occafions the beftowers of every indulgence and gratification that is admiflible; never, however, negle&ing td employ their awe when their indulgence, .<- ^ <*<',s> fhall have led to any abufe. ^/

/

MDLXV.

Although in mania, no particular irri- tation nor fulnefs of the fyftem feem to be prefent, it is plain, that the avoiding all irritation and means of fulnefs is proper ; and therefore, that a diet neither ftimu- lating nor nourifhing is commonly to be employed. As it may even be ufeful to di-» minim the fulnefs of the fyftem, fo both z low and a fpare diet is likely in mod cafes "o be of fervice.

I. 2 MDLXVJ,

ie6 PRACTICE

MDLXVI.

Upon the fame principle, although no unufual fulnefs of the body be prefent, it may be of advantage to diminifh even its ordinary fulnefs by different evacuations.

Blood-letting, in particular, might be fuppofed ufeful ; and in all recent cafes of mania it has been commonly pradlifed, and I think with advantage; but when the dif- eafe has fubfifted for fome time, I have feldom found blood-letting of fervice. In thofe inftances in which there is any fre- quency or fulnefs of pulfe, or any marks of an increafed impetus of the blood in the veffels of the head, blood-letting is a pro- per and even a neceffary remedy. Some practitioners, in fuch cafes, have preferred a particular manner of blood-letting, re- commending arteriotomy, fcarifying the hind-head, or opening the jugular vein; and where any fulnefs or inflammatory

dif-

OF PHYSIC. 157

difpofitton in the veflels of the brain, is to be fufpecled, the opening of the veflels nearelt to them is likely to be of the great- eft fervice. The opening, however, of either the temporal artery or the jugular vein in maniacal perfons is very often inconveni- ent; and it may generally be fufficient to open a vein in the arm, while the body is kept in fomewhat of an erect pofture, and fuch a quantity of blood drawn as nearly brings on a deliquium animi, which is al- ways a pretty certain mark of fome dimi- nution of the fulnefs and tenfion of the veflels of the brain.

MDLXVII.

For the fame purpofe of taking off the fulnefs and tenfion of thefe veflels of the brain, purging may be employed ; and I can in no other view underftand the ce- lebrated life of hellebore among the an- L 3 cients,

158 PRACTICE

cients. I cannot, however, fuppofe any ipecific power in hellebore; and can by no means find that, at lead the black helle- bore, is fo efficacious with us as it is faid to have been at Anticyra. As coftivenefs, however, is commonly a very conftant and hurtful attendant of mania, purgatives come to be fometimes very neceffary ; and I have known fome benefit obtained from the frequent ufe of pretty draftic purga- tives in this, however, 1 have been fre- quently difappointed ; and 1 have found more advantage from the frequent ufe of pooling purgatives, particularly thefoluble ^^f^kfJtt^^ tartar, than from more draftic medicines.

Jc^UL - MDLXVIIL

Vomiting has alfo been frequently em- ployed in mania ; and by determining powerfully to the furface of the body, it may poffibly diminifli the fulnefs and ten- sion

L

OF PHYSIC. 159

fion of the vcffels, and thereby the excite- ment of'the brain; but I have never car- lied the life of this remedy fo far as might enable me to judge properly of its effedls. Whether it may do harm by impelling the blood too forcibly into the veffels of the brain, or whether by its general agitation of the whole fyflem it may remove that in- equality of excitement which prevails in mania, 1 have not had experience enough to determine,

MDLXIX.

Frequent (having of the head has been found of fervice in mania, and by promo- ting perfpiration it probably takes off from the excitement of the internal parts. This, however, it is likely, may be more effec- tually done by bliftering, which more cer- tainly takes off the excitement of fubjacent parts* In recent cafes it has been found L 4 ufeful

160 PRACTICE

ufeful by inducing fleep ; and when it has that effect, the repetition of it may be pro- per: but in maniacal cafes that have lafted for fome time, blillering has not appeared to me to be of any fervice ; and in fuch cafes alfo 1 have not found perpetual blifters, or any other form of ilTue, prove ufeful.

MDLXX.

As heat is the principal means of firffe exciting the nervous fyftem, and eftablifh- ing the nervous power and vital principle in animals; fo, in cafes of preternatural excitement, tne application of cold might be iuppofed a proper remedy : but there are many inftances of maniacs who have beea expofed for a great length of time to a con- fiderable degree of cold without having their fymptoms anywife relieved. This may render in general the application of cold a doubtful remedy; but it is at the

fame

O E P II Y S I C. i6i

fame time certain, that maniacs have often I : relieved, and fometimes entirely cu- red, by the ule of cold bathing^efpecially ^Jf.^V/ when admini tiered in a certain manner.^*^ >~y<y~ This feems to confift, in throwing the mad- man into the cold water by furprife ; by detaining him in it for fome length of time; and, pouring water frequently upon the head, while the whole of the body except the head is immerfed in the water ; and thus managing the whole procefs, fo as that, with the affiftance of fome fear, a re- frigerant effecT: may be produced. This, I can affirm, has been often ufeful ; and that the external application of cold may be of fervice, we know further, from the benefit which has been received in fome maniacal cafes from the application of ice and fnow to the naked head, and from the applica- tion of the noted Clay Cap.

Warm bathing alfo has been recommend- ed by fome pra&ical writers \ and in fome

rigid

162 PRACTICE

rigid melancholic habits it may poffibly be ufeful, or as employed in the manner pre- fcribed by fome, of immerfing the lower parts of the body in warm water, while cold water is poured upon the head and tipper parts. Of this practice, however, I have had no experience ; and in the com- mon manner of employing warm bathing I have found it rather hurtful to maniacs.

MDLXXI.

According to my fuppofition that the difeafe depends upon an increafed excite- ment of the brain, efpecially with refpedl to the animal fundions, opium fo com- monly powerful in inducing fleep, or a confiderable collapfe as to thefe fun&ions, fhould be a powerful remedy of mania. That it has truly proved fuch, 1 believe from the teftimony of Bernard Huet, whofe pra&ice is narrated at the end of

Wep-

O V P II Y S I C. 163

Wepferi Hifloria Apopleclicorum. I leave to my readers to Itudy this in the work I have referred to, where every part of the practice is fully, and, as it appears to me, very judicioufly delivered. I have never indeed carried the trial fo far as feems to be requifite to an entire cure : but I have frequently employed in fome maniacal cafes, large dofes of opium ; and when they had the effect of inducing fleep, it •was manifeftly with advantage. At the fame time, in fome cafes, from doubts, whether the difeafe might not depend up- on fome organic leflons of the brain, whea the opium would be fuperfluous ; and in other cafes, from doubts, whether there might not be fome inflammatory affection joined with the mania, when the opium would be hurtful ; I have never pufhed this remedy to the extent that might be neceffary to make an entire cure.

MDJ.XXIL

1 64 PRACTICE

MDLXXII.

$tL~* l^~ *^. Camphire has been recommended as a ^^/Zl^o remedy of mania, and there are inftances ^fvUz*J~^h alleged of its having performed an entire

u~. 0cSX£%l£mt* As ic aPPears from the experiments

> *

*y>^Pj~~^ of Beccaria that this fubftance is poflefled, £J*><~<^ ^^uof a fedative and narcotic virtue, thefe t^~.~+~ ~ ^rcures are not altogether improbable : but ^£^V^^*^Ajn feverai trials, and even in large dofes, I M^j^i^^Jy^}i^yc found no benefit from it; and except- 9~ ^Ti^ *nS thofe m the Philofophical Tranfadions, Ju^a^^VjL* N° 400. I have hardly met with any other ^/*TV ^Iteftimonies in its favour.

4b^/ y MDLXXI1I.

I have been informed that fome maniacs

have been cured by being compelled to

c#L^-/i/i*^ conftant and even hard labour; and as

(?c^^>J/^C^ a forced attention to the condudt of any

j£u ^^^^jodiiy exercife, is a very certain means of

■frL~*ji —> L^- fty *^~*i£-*c> to *^+->4-4~*j £-0 - divert-

O F P H Y S I C. 1C5

diverting the mind from purfuing any train of thought, it is highly probable that fuch cxercife may be ufeful in many cafes of mania.

1 mu ft conclude this fubjeft with obfer- ving, that even in feveral cafes of complete mania, I have known a cure take place in the courfe of a journey carried on for fome Ji~~ /^^^ length of time. / , j^. ^

MDLXXIV.

Thefe are the remedies which have been chiefly employed in the mania that has been above defcribed, and I believe they have been employed promifcuoufly without fup- pofing that the mania was to be diftin- guifhed into different fpecies. Indeed I am not ready to fay howT far it is to be fo diftinguifhed, but 1 mall offer one obfer- vation which may pombly merit attention. Ic appears to me that there are two dif- ferent

1 56 PRACTICE

ferent cafes of mania that are efpecially different according to the original tempe- rament of the perfons whom the difeafe affedts. It perhaps occurs mod frequently in perfons of a melancholic or atrabilarian temperament ; but it certainly does alfo often occur in perfons of that very oppo- fite temperament which phyficians have named the Sanguine. According as the difeafe happens to occur in perfons of the one or other of thefe temperaments, I ap- prehend it may be confidered as of a dif- ferent nature ; and I believe, that accurate obfervation, employed upon a fufficienc number of cafes, would difcern fome pretty Conftant difference, either of the fymptoms, or at leaft of the ftate of fymptoms, in the two cafes. I imagine that fal/e imagina- tions, particular averfions and refentments, are more fixed and fteady in the melan- cholic than in the fanguine ; and that fome what inflammatory is more common-

17

OF PHYSIC. 167

ly joined with mania in the fanguine than in the melancholic. If fuch difference, however, does truly take place, it will be obvious, that it may be proper to make fome difference alfo in the practice. I am of opinion, that in the mania of fan- guine perfons, blood-letting and other an- tiphlogiftic meafures are more proper, and have been more ufeful, than in the melan- cholic. I likewife apprehend that cold ba- thing is more ufeful in the fanguine than in the melancholic : but I have not had experience enough to afcertain thefe points with fufficient confidence.

I have only to add this other obferva- tion, that maniacs of the fanguine tempe- rament recover more frequently and more entirely than thofe of the melancholic.

CHAP.

1 68

PRACTICE

CHAP.

III.

Of Melancholy, and other Form; of Insanity*

MDLXXV.

Tk VIElancholy has been common!; •*-▼«*• confidered as a partial infanity and as fuch it is defined in my Nofology but I now entertain doubts if this be alto- gether proper. By a partial infanity, I un- derftand a falfe and miftaken judgment upon one particular fubjedt, and what r< lates to it ; whilft, on every other fubjedt, the perfon affedled judges as the genera- lity of other men do. Such cafes have i „ cei

OF PHYSIC.

169

certainly occurred ; but, I believe, few in which the partial infanity is ftri&ly limi- ted. In many cafes of general infanity, there is one fubjecl of anger or fear, upon which the falfe judgment more particu- larly turns, or which is at leaft more fre- quently than any other the prevailing ob- ject of delirium : and though, from the inconfiftency which this principal object of delirium muft produce, there is there- fore alfo a great deal of infanity with re- gard to mod other objects ; yet this laffc is in very different degrees, both in dif- ferent perfons, and in the fame perfon at different times. Thus perfons confidered as generally infane, will, however, at times, and in fome cafes, pretty conftantly judge properly enough of prefent circumftances and incidental occurrences; though, when thefe objects engaging attention are not prefented, the operations of imagination Vol. IV. M may

iyo

PRACTICE

may readily bring back a general confu- fion, or recall the particular objed of the delirium. From thefe confiderations, I am inclined to conclude, that the limits be- tween general and partial infanity cannot always be fo exadly affigned, as to deter- mine when the partial affe&ion is to be confidered as giving a peculiar fpecies of difeafe, different from a more general in- fanity,

MDLXXVI.

When infanity, neither ftridlly partial, nor entirely nor conftantly general, occurs in perfons of a fanguine temperament, and is attended with agreeable, rather than with angry or gloomy, emotions, I think fuch a difeafe mud be confidered as different from the Mania defcribed above ; ami alfo, though partial, muft be held as

dif-

OF PHYSIC. 171

different from the proper Melancholia to be mentioned hereafter.

MDLXXVII.

Such a difeafe, as different from thofe defcribed MDLIV. requires, in my opi- nion, a different adminiftration of reme- dies ; and it will be proper for me to take particular notice of this here.

Although it may be necefTary to re- ftrain fuch infane perfons as we have men- tioned MDLXXVI. from purfuing the ob- jects of their falfe imagination or judge- ment, it will hardly be requifite to employ the fame force of reftraint that is necefTary in the impetuous and angry mania. It will be generally fufEcient to acquire fome awe over them, that may be employed, and fometimes even be necefTary, to check the rambling of their imagination, and inco- herency of judgment.

M 2 MDLXXVIII.

i72 PRACTICE

MDLXXVIII.

The reftraint juft now mentioned as ne- ceffary will generally require the patient's being confined to one place, for the fake of excluding the objedls, and more parti- cularly the perfons, that might excite ideas conne<5led with the chief objeds of their delirium. At the fame time, however, if it can be perceived there are objedls or perfons that can call off their attention from the purfuit of their own difordered imagination, and can fix it a little upon fome others, thcfe laft may be frequently prefented to them : and for this reafon, a journey, both by its having the effedl of interrupting all train of thought, and by prefenting objedls engaging attention, may often be ufeful. In fuch cafes alio, when the infanity, though more efpecially fixed upon one miftaken fubjed, is not confined to this alone, but is further apt to i ramble

OF PHYSIC. 173

ramble over other fubjeds with incoherent ideas, I apprehend the confining or forcing fuch perfons to fome conftant uniform la- bour, may prove an ufeful remedy.

MDLXX1X.

When fuch cafes as in MDLXVI. oc- cur in fanguine temperaments, and may therefore approach more nearly to Phre- nitic Delirium ; fo, in proportion as the fymptoms of this tendency are more evi- dent and confiderable, blood letting and purging will be the more proper and ne- ceflary.

MDLXXX.

To this fpecies of infanity, when occur- ring in fanguine temperaments, whether it be more or lefs partial, I apprehend that cold bathing is particularly adapted; while, M 3 in

174

PRACTICE

in the partial infanity of melancholic per* fons, as I fhall fhow hereafter, it is hardly adiniffible.

MDLXXXI.

Having thus treated of a fpecies of infa- nity, different, in my apprehenfion, from both the Mania and Melancholia, I pro- ceed to confider what feems more proper- ly to belong to this laft.

MDLXXX1I.

The difeafe which I name Melancholia is very often a partial infanity only. But as in many inftances, though the falfe ima- gination or judgment feems to be with re- fpecfl to one fubjecfl only ; yet it feldom happens that this does not produce much inconfiftency in the other intelle&uai operations : And as, between a very ge- neral and a very partial infanity, there

are

OF PHYSIC. 175

are all the poflible intermediate degrees ; fo it will be often difficult, or perhaps im- proper, to diflinguifh melancholia by the character of Partial Infanity alone. If I miftake not, it mud be chiefly diftinguifh- ed by its occurring in perfons of a melan- cholic temperament, and by its being al- ways attended with fomefeemingly ground- lefs, but very anxious, fear,

MDLXXX1II.

To explain the caufe of this, I muft ob- ferve, that perfons of a melancholic tem- perament are for the moft part of a feri- ous thoughtful difpofition, and difpofed to fear and caution, rather than to hope and temerity. Perfons of this cafl are lefs move- able than others by any impreffions ; and are therefore capable of a clofer or more continued attention to one particular ob- ject, or train of thinking. Tkey are even M 4 ready

176

PRACTICE

ready to be engaged in a conftant applica-. tion to one fubjed ; and are remarkably tenacious of whatever emotions they hap- pen to be affe&ed with.

MDLXXX1V.

Thefe circumftances of the melancholic character, feem clearly to fhow, that per- fons flrongly affedted with it may be rea- dily feized with an anxious fear ; and that this, when much indulged, as is natural to fuch perfons, may eafily grow into a par- tial infanity.

MDLXXXV.

Fear and deje&ion of mind, or a timid and defponding difpofition, may arife in certain ftates, or upon certain occafions of mere debility : and it is upon this foot- ing, that I fuppofe it fometimes\o attend dyfpepfia. But in thefe cafes, I believe

the

OF PHYSIC. 177

the deipondent difpofition hardly ever ari- fes to a confiderable degree, or proves fo obftinately fixed as when it occurs in per- fons of a melancholic temperament. In thefe lad, although the fear proceed from the fame dyfpeptic feelings as in the other cafe, yet it will be obvious, that the emotion may rife to a more confiderable degree ; that it may be more anxious, more fixed, and more attentive; and therefore may ex- hibit all the various circumftances which I have mentioned in MCCXXII.to take place in the difeafe named Hypochondriasis.

MDLXXXVI.

In confidering this fubjedt formerly in diftinguifhing Dyfpepfia from Hyppchon- driafis, although the fymptoms affedling the body be very much the fame in both, and even thofe affe&ing the mind be fome- what fimilar, I found no difficulty in di-

ftin-

178 PRACTICE

ftinguifhing the latter difeafe, merely from its occurring in perfons of a melancholic temperament. But I muft now acknow- ledge, that I am at a lofs to determine how in all cafes hypochondriafis and melancho- lia may be diftinguifhed from one ano- ther, whilft the fame temperament is com- mon to both.

MDLXXXVII.

I apprehend, however, that the diftinc- tion may be generally afcertained in the following manner.

The hypochondriafis I would confider as being always attended with dyfpeptic fymptoms : and though there may be, at the fame time, an anxious melancholic fear arifingfrom the feeling of thefe fymptoms; yet while this fear is only a miftaken judge- ment with refpecft to the ftate of the per- fon's own health, and to the danger to be

from

O F P H Y S I C. 179

from thence apprehended, I would flill confider the difeafe as a hypochondriafis, and as dirtincft from the proper melancho- lia. But when an anxious fear and de- fpondency arifes from a miitaken judg- ment with refpedt to other circumttance:; than thofe of health, and more efpecially when the perfon is at the fame time with- out any dyfpeptic fymptoms, every one will readily allow this to be a difeafe wide- ly different from both dyfpepfia and hy- pochondriafis; and it is, what I would ftri&ly name Melancholia.

MDLXXXVIII.

In this there feems little difficulty : but as an exquifitely melancholic temperament may induce a torpor and flownefs in the adlion of the ftomach, fo it generally pro- duces fome dyfpeptic fymptoms; and from thence there may be fome difficulty in di-

ftinguifhing

x8<

PRACTICE

(linguifhing fuch a cafe from hypochon- driafis. But I would maintain, however, that when the characters of the tempera- ment are ftrongly marked ; and more par- ticularly when the falfe imagination turns upon other fubjedts than that of health, or when, though relative to the perfon's own body, it is of a groundlefs and abfurd kind ; then, notwithftanding the appear- ance of fome dyfpeptic fymptoms, the cafe is (till to be conlidered as that of a melan- cholia, rather than a hypochondriafis.

MPLXXXIX.

The difeafe of melancholia, therefore, manifeftly depends upon the general tem- perament of the body : and although, in many perfons, this temperament is not at- tended with any morbid affedlion either of mind or body ; yet when it becomes ex- quifitely formed, and is in a high degree,

it

O F P H Y S I C. 181

it may become a difeafe affe&ing both, and particularly the mind. It will therefore be proper to confider in what this melancho. lie temperament efpecially confifts; and to this purpofe, it may be obferved, that in it there is a degree of torpor in the motion of the nervous power, both with refpedt to fenfation and volition ; that there is a general rigidity of the fimple folids ; and that the balance of the fanguiferous fy- ftem is upon the fide of the veins. But all thefe circumftances are the diredly oppo- fite of thofe of the fanguine temperament; and mud therefore alfo produce an op- pofite ftate of mind.

MDXC.

It is this ftate of the mind, and the ftate of the brain correfponding to it, that is the chief objedt of our prefent confideration. But what that ftate of the brain is, will

be

182 PRACTICE

be fuppofed to be difficult to explain ; and it may perhaps feem raili in me to attempt it.

I will, however, venture to fay, that it is probable the melancholic temperament of mind depends upon a drier and firmer texture in the medullary fubftance of the brain; and that this perhaps proceeds from a certain want of fluid in that fubftance, which appears from its being of a lefler fpe- cific gravity than ufual. That this ftateof the brain in melancholia does actually ex- ift, I conclude, firjl^ from the general rigi- dity of the whole habit; zn&,fecondlyy from diffe&ions, mowing fuch a ftate 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 any wife difficult to fuppofe, that the fame ftate of the brain may in a moderate de- gree give melancholia; and in a higher, that mania which melancholia fo often

paffcs

O F P H Y S I C. 183

paflfes into ; efpecially if 1 ihall be allowed further to fuppofe, that either a greater degree of firmnefs in the fubftance of the brain may render it fufceptible of a higher degree of excitement, or that one portion of the brain may be liable to acquire a greater firmnefs than others, and confe- quently give occafion to that inequality of excitement upon which mania fo much depends.

MDXCI.

I have thus endeavoured to deliver what appears to me mod probable with refpedl to the proximate caufe of melancholia; and altho' the matter fhould in fome refpeds remain doubtful, I am well perfuaded that thefe obfervations may often be employed to direcfl our pra&ice in this difeafe, asJL (hall now endeavour to mow.

MD2&1I.

184 PRACTICE

MDXCII.

In moftof the inftances of melancholia^ the mind is to be managed very much in the fame manner as I have advifed above with regard to hypochondriafis ; but as in the cafe of proper melancholia, there is commonly a falfe imagination or judge- ment appearing as a partial infanity, it may be further necefTary in fuch cafes to employ fome artifices for correcting fuch imagination or judgment.

MDXC1II.

The various remedies for relieving the dyfpeptic fymptoms which always attend hypochondriafis, will feldom be either re- quifite or proper in melancholia.

There is only one of the dyfpeptic fymp- toms, which, though there fhould be no other, is very conftantly prefent in melan- cholia,

OF PHYSIC. ifr$

cholia, and that is coftivenefs. This it U always proper and even neceflary to re- move; and I believe it is-upon this account that the ufe of purgatives has been found fo often ufeful in melancholia. Whether there be any purgatives peculiarly proper in this cafe, I dare not pofitively determine; but with fefpeel to the choice of purga- tives in melancholia, 1 am of the fame o- pinion that I delivered above on this fame fubjedl with refpecT: to mania.

MDXCIV.

With refpe<fl to other remedies, I judge that blood-letting will more feldom be pro- per in melancholia than in mania ; but how far it may be in any cafe proper, muft be determined by the fame confiderations

as in the cafe of mania.

-

Vol. IV. N MBXCV-

t86 PRACTICE

MDXCV.

The cold bathing that I judged to be Co very ufeful in feveral cafes of infanity, is, I believe, in melancholia, hardly ever fit to be admitted; at lead while this is purely a partial aftedtion,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 ufeful.

MDXCVL

With refpedl to opiates which I have iuppofed might often be ufeful in cafes of mania, I believe they can feldom be pro- perly employed in the partial infanities of the melancholic, except in certain inftances

of violent excitement, when the melancho-

*

Ha approaches nearly to the ftate of mania.

MDXCVII.

OF PHYSIC 187

MDXCVII.

In fuch cafes of melancholia approach- ing to a (late of mania, a low diet may fometimes be neceflary ; but as the em- ploying a low diet almoft unavoidably leads to the ufe of vegetable food, and as this in every torpid ftate of the ftomach is ready to produce fome dyfpeptic fymp- toms, fuch vegetable food ought, in mode- rate cafes of melancholia, to be ufed with fome caution.

Though exercife, as a tonic power, is not proper either in hypochondriafis or melan- cholia; yet, with refpeft to Its effefts upon the mind, it may be extremely ufeful in both, and in melancholia is to be employ- ed in the fame manner that I have advifed above in the cafe of hypochondriafis.

N 2 MDXCV11I.

i88

PRACTICE

MDXCV1II.

Having now delivered my dodlrine tvith refpedt to the chief forms of infanity, I fhould in the next place proceed to con- sider the other genera of Amentia and O- neirodynia, which in the Nofology I have arranged under the order of Vefaniae: but as I cannot pretend to throw much light upon thefe fubjedls, and as they are feldom the ob]€<5ls of practice, I think it allowable for me to pafs them ever at prefent ; and the particular circumftances of this work in fome meafure requires that 1 flaould do fo.

PART

PART III.

O F

CACHEXIES.

MDXCIX.

UNDER this title I propofe to eflablifh a clafs of difeafefr, which confift in a depraved ftate of the whole, or of a con- fiderable part, of the habit of the body, without any primary pyrexia or neurofis combined with that ftate.

N 3 MDC,

rifl

190

PRACTICE

MDC.

The term Cachexy has been employed by Linnaeus and Vogel, as it had been for- merly by other authors, for the name of a particular difeafe : but the difeafe to which thefe authors have affixed it, comes more properly under another appellation ; and the term of Cachexy is more properly em- ployed by Sauvages and Sagar for the name of a clafs. In this I have followed the laft-mentioned nofologifts, though I find it difficult to give fuch a character of the clafs as will clearly apply to all the fpe- cies I have comprehended under it. This difficulty would be ftill greater, if, in the clafs I have eftablifhed under the title of Cachexies, I were to comprehend all the difeafes that thofe other nofologifts have done; but I am willing to be thought de- ficient rather than very incorredi. Thofe difficulties, however, which dill remain in

me-

OF PHYSIC. 191

methodical nofology, mud not affect us much in a treatife of practice. If I can here properly diftinguiih and defcribe the feveral fpecies that truly and mod com- monly exiit, I fhall be the lefs concerned about the accuracy of my general clarifi- cation: though at the fame time this, I think, is always to be attempted; and J fhall purfue it as well as 1 can.

N4 BOOK

\

BOOK I,

O *

EMACIATIONS.

MDCL

EMaciation, or a confiderable dimi- nution of the bulk or plumpnefs of the whole body, is for the moft part only a fymptom of difeafe, and very feldom to be confidered as a primary and idiopathic affedtion. Upon this account, accord- ing to my general plan, fuch a fymptom

might

Q F P H Y S I C. 193

might perhaps have been omitted in the Methodical Nofology : but both the uncer- tainty of concluding it to be always fymp- tomatic, and the confiftency of fyflem, made me introduce into the Nofology, as others had done, an order under the title of Marcores ; and this renders it requifite now to take fome notice of fuch difeafes.

MDCII.

Upon this occafion, therefore, I hope it may be ufeful to inveftigate the feveral caufes of emaciation in all the different cafes of difeafe in which it appears. And this I attempt, as the fureft means of deter- mining how far it is a primary, or a fymp- tomatic affection only ; and even in the latter view, the inveftigation may be at- tended with fome advantage.

MDCIII,

194 PRACTICE

MDCIII.

The caufes of emaciation may, I appre- hend, be referred to two general heads ; that is, either to a general deficiency of fluid in the veflels of the body, or to the particular deficiency of the oil in the cel- lular texture of it. Thefe caufes are fre- quently combined together ; but it will be proper, in the firft place, to confider them

vu 4K^£>U^~t^ feparately.

r^.3 ^s^/r,

A~7~~. #* MDCIV.

As a great part of the body of animals is made up of veflels filled with fluids, the bulk of the whole muft depend very much on the fize of thefe veflels, and the quantity of fluids prefent in them : and it will therefore be fufEciently obvious, that a deficiency of the fluids in thefe vef- fels muft, according to its degree, occa- sion

O F PHYSIC. IS9

fion a proportionate diminution of the bulk of the whole body. This, however, will appear ftill more clearly, from confidering that in the living and found body the vef- fels every where feem to be preternatural- ly diflended by the quantity of fluids pre- lent in them ; but being at the fame time elaftic, and conftantly endeavouring to con- tract themfelves, they muft on the with- drawing of the diftending force, or, in o- ther words, upon a diminution of the quantity of fluids, be in proportion con- traded and diminifhed in their fize : And it may be further obferved, that as each part of the yafcular fyflem communicates with every other part of it ; fo every de- gree of diminution of the quantity of fluid, in any one part, muft in proportion dimi- nifh the bulk of the vafcular fyftem, and confequently of the whole body. Jft^Jl*^^

j96 PRACTICE

MDCV.

The diminution and deficiency of the fluids may be occafioned by different caufes : fuch as, firft, by a due quantity of aliments not being taken in ; or by the aliment taken in, not being of a fufficiently nutri- tious quality. Of the want of a due quan- tity of aliment not being taken into the body, there is an inftance in the Atrophia laBantium Sauvagefii, fpecies 3. and many other examples have occurred of emaciation from want of food, occafioned by poverty, and other accidental caufes.

With refpedl to the quality of food, I apprehend it arifes from the want of nu- tritious matter in the food employed, that perfons living very entirely on vegetables are feldom of a plump and fucculent ha* bit.

MDCVI,

O F P H Y S I C. 197

MDCVI.

A fecond caufe of the deficiency of fluids may be, the aliments taken in not being conveyed to the blood- veffels. This may occur from a perfon's being affe&ed with a frequent vomiting ; which, rejecting the food foon after it had been taken in, muft prevent the neceffary fupply of fluids to the blood-veffels.

Another caufe, frequently interrupting the conveyance of the alimentary matter in- to the blood- veflels, is an obftru&ion of the conglobate or lymphatic gkfids of the me- fentery, through which the chyle muft ne- ceflTaf ily pafs to the thoracic dudt. Many in- ftances of emaciation, feemingly depending upon this caufe, have been obferved by phyficians, in perfons of all ages, but efpe- cially in the young. It has alfo been re- marked, that fuch cafes have moft fre- quently occurred in fcrophulous perfons,

in

198 PRACTICE

in whom the mefenteric glands are com- monly affecled wich tumour or obftruc-

L tion, and in whom, generally at the fame

time, fcrophula appears externally. Hence the Tabes fcrophulofa Synop. Nofelog. vol. ii, p. 266.: And under thefe I have put as fynonimes Tabes glandularis, fp. 1 o. ; 7tf- bes mefenteric a, fp. 9. ; Scrophula mefen- terica, fp. 4. ; Atrophia infantilis, fp. 13.5 Atrophia rachitica, fp. 8. ; Tabes rachialgica^ fp. 16. At the fame time, I have fre- quently found the cafe occurring in per- fons who did not fhow any external ap* pearance of fcrophula, but in whom the mefenteric obftruction was afterwards dis- covered by diffe&ion. Such alfo I fuppofe to have been the cafe in the difeafe fre- quently mentioned by authors under the title of the Atrophia infantum. This has received its name from the time of life at which it generally appears ; but I have met with inftances of it at fourteen years

3 of

OF PHYSIC.

1 99

of age ascertained by difTedtion. In feve- ral fuch cafes which I have fcen, the pa- tients were without any ferophulous ap- pearances at the time, or at any period of their lives before.

In the cafe of phthifical perfons, I (hall hereafter mention another caufe of their emaciation ; but it is probable that an ob- ftruclion of the mefenteric glands, which fo frequently happens in fuch perfons, concurs very powerfully in producing the emaciation that takes place.

Although a ferophulous taint may be the mod frequent caufe of mefenteric ob- ftructions, it is fufficiently probable that other kinds of acrimony may produce the ^j^^ fame, and the emaciation that follows. /c*?T^i^^

It may perhaps be fuppofed, that the +^* r /**?*. 7£* interruption of the chyle's paffing into tfce * ^^JttZ' blood- veffels may be fometimes owing to^ ^-^^f,^L a fault of the abforbents on the internal *^w~0 - ^C furface of the inteflines. This, however. //^

cannot^— &^ /^^

2oo PRACTICE

cannot be readily afcertained : but the in- terruption of the chyle's palling into the blood* veffels may certainly be owing to a rupture of the thoracic dud ; which, when it does not prove foon fatal, by oc- cafioning a hydrothorax, mud in a (hon time produce a general emaciation.

MDCVIL

A third caufe of the deficiency of the fluids may be a fault in the organs of di- geftion, as not duly converting the aliment into a chyle fit to form in the blood- vefiels a proper nutritious matter. It is not, how- ever, eafy to afcertain the cafes of ema- ciation which are to be attributed to this caufe ; but I apprehend that the emaciation which attends long fubfifting cafes of dyf- pepfia, or of hypochondriafis, is to be ex- plained chiefly in this way It is this which 1 have placed in the Nofology under the 2 title

j

O F P H Y S I C. 2oi

title of the Atrophia Milium ; and of which the Atrophia ncrvo/a^ Sauv. fp. i. is a pro- per inltance, and therefore put there as a fynonime. Bat the other titles of Atrophia lateralis y Sauv. fp. 15. and Atrophia fen ills ^ Sauv. fp. 11. are not fo properly put there, as they muft be explained in a different manner.

MDCVIII.

A fourth caufe of a deficiency of the fluids in the body, may be exceflive eva- cuations made from it by different out- lets ; and Sauvages has properly enume- rated the following fpecies, which we have put as fynonimes under the title of Atro- phia inanitorum ; as, Tabes nutricum, fp. 4. Atrophia nutricum, fp. 5. Atrophia a leucor- rhcea, fp. 4. Atrophia ab alvi fluxu, fp 6. Atrophia a ptyalifmo, fp. 7. and laftly, the

Vol. IV. O "Tabes

aoz PRACTICE

Tabes a fanguijluxu ; which, ic is to be ob- ferved, may arife not only from fponta- neous hemorrhagies or accidental wounds, but alfo'from blood-letting in too large a quantity, and too frequently repeated,

Upon this fubje<5t it feems proper to obferve, that a meagre habit of body fre- quently depends upon a full perfpiration being conftantly kept up, though at the fame time a large quantity of nutritious aliment is regularly taken in.

MDCIX.

Befides this deficiency of fluids from evacuations by which they are carried entirely out of the body, there may be a deficiency of fluid and emaciation in a confiderable part of the body, by the fluids being drawn into one part, or colle&ed into one cavity ; and of this we have an

in-

O F P H Y S I C. 203

inftance in the Tubes H fydiope, Siiuv.

fP.5.

MDCX.

In the Methodical Nofology, among the other fynonimes of the Atrophia inanitc- ru?7iy I have fet down the Tabes dor/alls ; but whether properly or not, I at prefent very much doubt. In the evacuation con- fidered as the caufe of .this tabes, as the quantity evacuated is never fo great as to account for a general deficiency of fluids in the body, we muft feck for another ex- planation of it. And whether the effedls of the evacuation may be accounted for, either from the quality of the fluid evacuated, or from the Angularly enervating pleafure at- tending the evacuation, or from the eva- cuation's taking off the tenfion of parts, the tenfion of which has a Angular power in fupporting the tenfion and vigour of the O 2 wholr

204 PRACTICE

whole body, I cannot pofitively determine; but I apprehend that upon one or other of thefe fuppofitions the emaciation attending the tabes dorfalis muft be accounted for ; and therefore that it is to be confidered as an inftance of the Atrophia debilium, rather than of the Atrophia inanitorum.

MDCXI.

A fifth caufe 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 f mall veffels, either not admitting of fluids, or of the fame pro- portion as before ; and this feems to me to be the cafe in the Atrophia f emits, Sauv. Tp. 2. Or it may be a palfy of the larger trunks of the arteries rendering them unfit to propel the blood into the fmaller veffels ; as is frequently the cafe of para- lytic limbs, in which the arteries are af-

fefled

O V P H Y S I C. ioj

fected as well as the mufcles. The Atro- phia lis. Sauv. ip. 15. feems to be of this nature.

MDCXIL

A fecond general head of the caufes of emaciation I have mentioned in MDCII. to be a deficiency of oil. The extent and quantity of the cellular texture in every part of the body, and therefore how con- iiderable a part it makes in the bulk of the whole, is now well known. But this, fubftance, in different circumftances, is more or lefs filled with an oily matter ; and' therefore the balk of ir, and in a great meafure that of the whole body, mud be greater or lefs according as this fubltance is more or lefs filled in that man- ner. The deficiency of fluids, for a reafon to be immediately explained, is generally . accompanied with a deficiency of oil : but O 3 ph

io6 PRACTICE

phyficians have commonly attended more to the latter caufe of emaciation than to the other, that being ufually the moft evident; and 1 fhall now endeavour to aflign the fe- veral caufes of the deficiency of oil as it occurs upon different occafions.

MDCX1II.

The bufinefs of fecretion in the human body is in general little underftood, and in no inflance lefs fo than that of the fe- cretion of oil from blood which does not appear previoufly to have contained it. It is poflible, therefore, that our theory of the deficiency of oil may be in feveral re- fpedls imperfedt; but there are certain fads that may in the mean time apply to the prefent purpofe.

MDCXIV.

Firft, it is probable3 that a deficiency of

oil

OF PHYSIC. 207

oil may be owing to a ftate of the bipod in animal bodies lefs fitted to afford a fe- cretion of oil, and confequently to fupply thewafteof it that is conftantlymade. This ftate of the blood muft efpecially depend upon the ftate of the aliments taken in, as containing lefs of oil or oily matter. From many obfervations made, both with refpedl to the human body and to that of other * animals, it appears pretty clearly, that the aliments taken in by men and domeftic animals, according as they contain more of oil, are in general more nutritious, and in particular are better fitted to fill the cel- lular texture of their bodies with oil. I might illuftrate this, by a minute and par- ticular confideration of the difference of alimentary matters employed ; but it will be enough to give two instances. The one is, that the herbaceous part of vegetables, does not fatten animals, fo much as the O 4 feeds

to8

PRACTICE

feeds of vegetables, which manifeftly con- tain in any given weight a greater propor- tion of oil ; and a fecond inftance is, that in general vegetable aliments do not fat- ten men fo much as animal food, which generally contains a larger proportion of oil.

It will be obvious, that upon the fame principles a want of food, or a lefs nutri- tious food, may not only occafion a gene- ral deficiency of fluids (MDC1V.), but muft alfo afford lefs oil, to be poured intp the cellular texture. In fuch cafes, there- fore, the emaciation produced, is to be at- tributed to both thele general caufes.

MDCXV.

A fecond cafe of the deficiency of oil rnay be explained in this manner. It is pretty manifefl, that the oil of the blood is fecreted and depofited in the cellular tex- ture

OF PHYSIC. 209

ture in greater or lefler quantity, accord- ing as the circulation of the blood is fa- der or flower: and therfore that excrcife which haftens the circulation of the blood, is a frequent caule of emaciation. Exer- cile produces this effedl in two ways, ift, By increafing the perfpiration, and thereby carrying off a greater quantity of the nu- tritious matter, it leaves lefs of it to be de- pofited in the cellular texture; thereby not only preventing an accumulation of fluids, but, as 1 have faid above, cau- fing a general deficiency of thefe, which muft alfo caufe a deficiency of oil in the cellular texture. 2dly, It is well known, that the oil depofited in the cellular tex- ture is upon many occafions, and for va- rious purpofes of the oeconomy, again ab- forbed, and mixed or difFufed in the mafs of blood, to be from thence perhaps car- ried entirely out of the body by the feve- jral excretions. Now, among other pur- pofes

no PRACTICE

pofes of the accumulation and re-abforp- tion of oil, this feems to be one, that the oil is requifite to the proper action of the moving fibres in every part of the body ; and therefore that nature has provided for an abforption of oil to be made according as the a&ion of the moving fibres may de- mand it. It will thus be obvious, that the exercife of the mufcular and moving fibres every where, muft occafion an abforption of oil; and confequently that fuch exercife not only prevents the fecretion of oil, as has been already faid, but may alfo caufe a deficiency of it, by occafioning an ab- forption of what had been depofited ; and in this way, perhaps efpecially, does it produce emaciation.

MDCXVI.

A third cafe of the deficiency of oil may occur from the following caufe. It is

probable

OF PHYSIC. 2ij

probable, that one purpofe of the accumu- lation of oil in the cellular texture of ani- mals is, that it may, upon occafion, be a- gain abforbed from thence, and carried in- to the mafs of blood, for the purpofe of inveloping and correcting any unufual a- crimony arifing and exifting in the ftate of the fluids. Thus, in mod inftances ia which we can difcern an acrid ftate of tho fluids, as in fcurvy, cancer, fyphilis, poi- fons, and feveral other difeafes, we find at the fame time a deficiency of oil and an emaciation take place ; which, in my ap- prehenfion, muft be attributed to the ab- forption of oil, which the prefence of acri- mony in the body excites.

It is not unlikely that certain poifons in- troduced into the body, may fubfift there ; and, giving occafion to an abforption of oil, may lay a foundation for the Tabes a yenenoy Sauv. fp. 17.

MDCXVIL

its PRACTICE

MDCXV1I.

A fourth cafe of emaciation, and which I would attribute to a fudden and confider- able abforpcion of oil from the cellular tex- ture, is that of fever, which fo generally produces emaciation. This may perhaps be in part attributed to the increafed per- foration, and therefore to the general de- ficiency of fluids that may be fuppofed to take place : but whatever fhare that may have in producing the effedl, we can, from the evident fhrinking and diminution of the cellular fubftance, wherever it falls un- der our obfervation, certainly conclude, that there has been a very confiderable abforption of the oil which had been be- fore depofited in that fubftance. This ex- planation is rendered the more probable from this, that I fuppofe the abforption mentioned is necefTarily made for the pur- pofe of enveloping or correcfling an acri- mony,

OF PHYSIC. 213

mony, which manifettly does in many, and may be fafpedted to arife in all, cafes of fever. The molt remarkable inftance of emaciation occurring in fevers, is that which appears in the cafe of heclic fevers. Here the emaciation may be attributed to the profufe fweatings that commonly at- tend the difeafe: but there is much reafon to believe, that an acrimony alfo is prefent in the blood ; which, even in the begin- ning of the difeafe, prevents the fecretion and accumulation of oil ; and in the more advanced dates of it, muft occafion a more confiderable abforption of it ; which, from the flirinking of the cellular fubitance, feems to go farther than in almoit any o- ther inftance.

Upon the fubjecl of emaciations from a deficiency of fluids, it may be obferved, that every increafed evacuation excites an abforption from other parts, and particu- larly from the cellular texture ; and it is

there-

214 PRACT I«C E

therefore probable, that a deficiency of fluids, from incrcafed evacuations, produ- ces an emaciation, not only by the wade of the fluids in the vafcular fyftem, but alfo by occafioning a confiderable abforp- tion from the cellular texture.

MDCXVIII.

I have thus endeavoured to explain the feveral cafes andcaufes of emaciation; but I could not profecuce the confideration of thefe here in the order they are fet down in the Methodical Nofology. In that work I was engaged chiefly in arranging the fpecies of Sauvages; but it is my opinion now, that the arrangement there given is erroneous, in both combining and fepara- ting fpecies improperly : and it feems to me more proper here to take notice of difeafes, and put them together, according to the affinity of their nature, rather than 2 by

j

O F P H Y S I C. *!$

by that of their external appearances. I doubt, if even the dilHndion of the Tabes and Atrophia, attempted in the Nofology, will properly apply ; as 1 think there are .certain difeafes of the fame nature, which fometimes appear with, and fometimes without, fever.

MDCXIX.

After having confidered the various ca- fes of emaciations, I fhould perhaps treat of their cure : but it will readily appear, that the greater part of the cafes above- mentioned are purely fymptomatic, and confequently that the cure of them muft be that of the primary difeafes upon which they depend. Of thofe cafes that can any- wife be confidered as idiopathic, it will ap- pear that they are to be cured, entirely by removing the remote caufes; the means of accomplifhing which muft be fufficiently obvious.

BOOK

216 PRACTICE

BOOK II.

O F

INTUMESCENTI1

O R

GENERAL SWELLINGS,

MDCXX.

THE fwellings to be treated of in this place are thofe which extend over the whole or a great part of the body ; or fuch at lead, as, though of fmall extent, are however of the fame nature with thofe that are more generally extended.

3 The

OF PHYSIC. 217

The fwellings comprehended under this artificial order, are hardly to be- diftin- guiihed from one another otherwife than by the matter they contain or confift of: and in this view I have divided the order into four feclions, as the fwelling happens to contain, 1//, Oil ; 2^, Air ; 3^/, A watery fluid ; or, 4/^, As the increafed bulk de- pends upon the enlargement of the whole fubftance of certain parts, and particularly of one or more of the abdominal vifcera.

Vol. IV. P CHAP,

218 PRACTICE

CHAP. I.

Of Adipose Swellings.

MDCXXI.

THE only difeafe to be mentioned in this chapter, I have, with other No- fologifts, named Polyfarcia ; and in Englifh it may be named Corpulency, or, more ftridtly, Obefity; as it is placed here upon the common fuppofition of its depending chiefly upon the increafe of oil in the cellu- lar texture of the body. This corpulency, or obefity, is in very different degrees in

dif-

O F P H Y S I C. 219

different perfons, and is often confiderable without being coniidered as a difeafe. There is, however, a certain degree of it, which will be generally allowed to be a difeafe; as, for example, when it renders perfons, from a difficult refpiration, un- eafy in themfelves, and, from the inabi- lity of exercife, unfit for difcharging the duties of life to others : and for that rea- fon 1 have given fuch a difeafe a place here. Many phyficians have confidered it as an object of practice, and as giving, even in no very high degree, a difpofition to many difeafes ; I am of opinion that it fhould be an object of practice more frequently than it has been, and therefore that it merits our confideraticm here.

MDCXXII.

It may perhaps be alleged, that I have

not been fufficiently correct, in putting

the difeafe of corpulency as an intume-

P 2 fcentia

32o PRACTICE

fcentia pinguedinofa, and therefore im- plying its being an increafe of the bulk of the body from an accumulation of oil in the cellular texture only. I am aware of this objection : and as I have already faid, that emaciation (MDCII.) depends ei- ther upon a general deficiency of fluids in the vafcular fyftem, or upon a deficiency of oil in the cellular texture ; fo I mould perhaps have obferved farther, that the corpulency, or general fulnefs of the body, may depend upon the fulnefs of the vaf- cular fyftem as well as upon that of the cellular texture. This is true ; and for the fame reafons I ought, perhaps, after Linnaeus and Sagar, to have fet down ple- thora as a particular difeafe, and as an in- ftance of morbid intumefcence. I have, however, avoided this, as Sauvages and Vogel have done ; becaufe I apprehend that plethora is to be confidered as a flate of temperament only, which may indeed difpofe to difeafe ; but not as a

dif-

OF PHYSIC. 221

difeafe in itfelf, unlcfs, in the language of the Stahlians, it be a plethora com- mota, when it produces a difeafe accom- panied with particular fymptoms, which give occafion to its being diflinguifhcd by a different appellation. Further, it appears to me, that the fymptoms which Linnxus, and more particularly thofe which Sagar employs in the character of plethora, never do occur but when the intumefcentia pinguedinofa has a great mare in producing them. It is, however, very neceffary to obferve here, that ple- thora and obefity are generally combined together ; and that in fome cafes of cor- pulency it may be difficult to determine which of the caufes has the greateft (hare in producing it. It is indeed very poffible that a plethora may occur without great: obefity; but I apprehend that obefity never happens to a confiderable degree without producing a plethora ad fpatium in a great P 3 part

J

222

PRACTICE

part of the fyftem of the aorta, and there- fore a plethora ad mokm in the lungs, and in the veflels of the brain.

MDCXXIIT.

In attempting the cure of polyfarcia, I am of opinion that the conjunction of plethora and obefity, in the manner juft now mentioned, fliould be conftantly at- tended to ; and when the morbid effects of the plethoric habit are threatened, either in the head or lungs, that blood-letting is to be pradtifed : but at the fame time it is to be obferved, that perfons of much obe- fity do not bear blood-letting well ; and when the circumftances 1 have mentioned do not immediately require it, the prac- tice upon account of obefity alone, is hardly ever to be employed. The fame remark is to be made with refpect to any other evacuations that may be propofed

for

OF PHYSIC. 223

for the cure of corpulency : for without the other means I am to mention, they can give but a very imperfeft relief; and, in fo far as they either empty or weaken the fyftem, they may favour the return of ple- thora, and the increafe of obefity.

MDCXXIV.

Polyfarcia, or corpulency, whether it depend upon plethora or obefity, when- ever it either can be confidered as a dif- eafe, or threatens to induce one, is to be cured, or the effedls of it are to be obvia- ted, by diet and exercife. The diet muft be fparing ; or rather, what is more ad- miflible, it muft be fuch as affords little nutritious matter. It mult therefore be chiefly, or almoft only, of vegetable mat- ter, and at the very utmoft of milk. Such a diet mould be employed, and generally ought to precede exercife : for obefity does P 4 not

224 PRACTICE

not eafily admit of bodily exercife; which is, however, the only mode that can be very effectual. Such, indeed, in many cafes, may feem difficult to be admitted ; but I am of opinion, that even the mod corpulent may be brought to bear it, by at firft attempting it very moderately, and increafing it by degrees very flowly, but at the fame time perfifling in fuch attempts with great conflancy.

MDCXXV.

As thefe, though the only effe&ual mea*- fures, are often difficult to be admitted or carried into execution, fome other means have been thought of and employed for reducing corpulency. Thefe, if 1 miftake not, have all been certain methods of in- ducing a faline ftate in the mafs of blood ; for fuch I fuppofe to be the effecls of vi- negar and of foap, which have been prc-

pofed.

OF PHYSIC.

pofed. The latter, T believe, hardly paffes

into the blood- veffels, without being refol-

ved and formed into a neutral fait, with

the acid which it meets with in the fto-

mach. How well acrid and faline fub-

ftances are fitted to diminifh obefity, may

appear from what has been faid above in

MDCXV. What effects vinegar, ibap,7* or $:/h^^jtif

other fubftances employed, have had in o/^ rzz &***

reducing corpulency, there have not pro- fJ *-'j£j£.

per opportunities of obferving occurred

to me : but I am well perfuaded, that the

inducing a faline and acrid ftate of the

blood, may have worfe confequences than

the corpulency it was intended to correct;

and that no perfon fhould hazard thefe,

while he may have recourfe to the more

fafe and certain means of abftinence and

fxercife.

CHAP,

226

PRACTICE

CHAP.

II.

Of Flatulent Swellings.

MDCXXVI.

THE cellular texture of the human bo- dy very readily admits of air, and al- lows the fame to pafs from any one to eve- ry other part of it. Hence Emphyfemata have often appeared from air colleded in the cellular texture under the fkin, and in feveral other parts of the body. The fla- tulent fwellings under the fkin, have in- deed mod commonly appeared in confe-

quence

OF PHYSIC, 227

quenceof air imnu\li;u ' ioducedfrom without: hut in ces of flatulent

fvvellings, ef ... fc of the internal

parts nor communicating with the alimen- tary canal, fuch an introduction cannot be perceived or fuppofed; and therefore, in thefe cafes, fome other caufe of the pro- duction and collection of air muft be look- ed for, though it is often not to be clearly afcertained.

In every folid as well as every fluid fub- ftance which makes a part of the human body, there is a confiderable quantity of air in a fixed (late, which may be again re- ftored to its elaftic ftate, and feparated from thofe fubftances, by the power of heat, pu- trefaction, and perhaps other caufes : but which of thefe may have produced the fe- veral inftances of pneumatofis and flatu- lent fwellings that have been recorded by authors, I cannot pretend to afcertain. Indeed, upon account of thefe difficulties,

I

22S PRACTICE

I cannot proceed with any clearnefs on the general fubject of pneumatofis ; and, there- fore, with regard to flatulent fwellings, I find it necefiary to confine myfelf to the confideration of thofe of the abdominal region alone ; which I fliall now treat of under the general name of Tympa- nites.

MDCXXVIL

The tympanites is a fwelling of the ab- domen ; in which the teguments appear to be much ftretched by fome diftending power writhin, and equally ftretched in every pofture of the body. The fwelling does not readily yield to any prefTure; and in fo far as it does, very quickly re- covers its former ftate upon the prefTure being removed. Being (truck, it gives a found like a drum, or other ftretched ani- mal membranes. No fluctuation within

O F PHYSIC. 2:

is to be perceived: and the whole feels lef<i weighty than might be expected from its bulk. The uneafineis of the diftention is commonly relieved by the difcharge of air from the alimentary canal, either upwards or downwards.

MDCXXVIII.

Thefe are the chara&ers by which the tympanites may be diftinguifhed from the a 1 cites or phyfconia ; and many experi- ments mow, that the tympanites always depends upon a preternatural collection of air, fomewhere within 'the teguments of the abdomen : but the feat of the air is in different cafes fomewhat different ; and this produces the different fpecies of the difeafe.

One fpecies is, when the air collected is entirely confined within the cavity of the alimentary canal, and chiefly in that of the

inteftines,

23o PRACTICE

inteftines. This fpecies, therefore, is named the Tympanites intejlinalis, Sauv. fp. i. It is, of all others, the mod common; and to it efpecially belong the chara&ers given a- bove.

A fecond fpecies is, when the air collec- ted is not entirely confined to the cavity of the inteftines, but is alfo prefent between their coats; and fuch is that which is na- med by Sauvages Tympanites enteropbyfodes, Sauv. fp. 3. This has certainly been a rare occurrence; and has probably occur- red only in confequence of the tympanites intejlinalis^ by the air efcaping from the cavity of the inteftines into the interfaces of the coats. It is, however, poffible that an erofion of the internal coat of the inte- ftines may give occafion to the air, fo con- ftantly prefent in their cavity, to efcape into the interftices of their coats, though in the whole of their cavity there has been no previous accumulation.

1 A

O F P H Y S I C. aji

A third fpecies is, when the air is col- lected in the fac of the peritonaeum, or what is commonly called the cavity ot the abdomen, that is, the f'pace between the peritonaeum and vifcera; and then the dif- eafe is named Tympanites abJominalisy Sauv. fp. 2. The exigence of fuch a tympanites, without any tympanites intejlinalis, has been difputed; and it certainly has been a rare occurrence : but from feveral diflfcclions, it is unqueftionabie that fuch a difeafe has fometimes truly occurred.

A fourth fpecies of tympanites is, when the tympanites intejlinalis and abdominalis are joined together, or take place at the fame time. With refpedt to this, it is probable that the tympanites intejlinalis is the primary difeafe; and the other, only a confequence of the air efcaping, by an erofion or rupture of the coats of the in- teftines, from the cavity of thefe into that of the abdomen. It is indeed poflible, that

in

j32 PRACTICE

in confequence of erofion or rupture, the air which is fo conftantly prefent in the inteftinal canal, may efcape from thence in fuch quantity into the cavity of the ab- domen, as to give a tympanites abdominalis^ whilft there was no previous confiderable accumulation of air in the inteftinal cavity itfelf ; but I have not fads to afcertain this matter properly.

A fifth fpecies has alfo been enumerated. It is when a tympanites abdominalis happens to be joined with the hydrops af cites; and fuch a difeafe therefore is named by Sau- vages Tympanites afciticusy Sauv. fp. 4. In mod cafes of tympanites, indeed, fome quantity of ferum has, upon diffedtion, been found in the fac of the peritonaeum ; but that is not enough to conftitute the fpecies now mentioned'; and when the col- lection of ferum is more confiderable, it is commonly where, both from the caufes which have preceded, and likewife from 4 the

OF PHYSIC. ;33

the fymptoms which attend, the afcites may be considered as the primary difeafe ; and therefore that this combination does not exhibit a proper fpecies of the tympa- nites.

MDCXXIX,

As this lafl: is not a proper fpecies, and as fome of the others are not only extremely rare, but even, when occurring, are neither primary, nor to be eafily diftinguifhed, nor, as confidered in themfelves, admitting of any cure, I fhall here take no further notice of them; confining myfelf, in what follows, to the confideration of the mod frequent cafe, and almoft the only object of practice, the tympanites intejlinalis.

MDCXXX.

With refpect to this, I cannot perceive Vol. IV. Q^ that

234 PRACTICE

that it arifes in any peculiar temperament, or depends upon any predifpofition, which can be difcerned. It occurs in either fex, at every age, and frequently in young per- fons.

MDCXXXI.

Various remote caufes of it have been afligned: but many of thefehave not com- monly the effedt of producing this difeafe; and although fome of them have been truly antecedents of it, I can in few in- flances difcover the manner' in which they produce the difeafe, and therefore cannot certainly afcertain them to have been cau- fes of it.

MDCXXXII.

The phenomena of this difeafe in its fe- veral ftages are the following.

The

OF PHYSIC. 235

The tumour ot the belly fomctimes grows very quickly to a confiderable de- gree, and feldom in the flow manner the nfcites commonly comes on. In ibme ca- fe?, however, the tympanites comes on gra- dually, and is introduced by an unufual flatulency of the ftomach and inteftines, with frequent borborygmi, and an uncom- monly frequent expullion of air upwards and downwards. This ftate is alfo fre- quently attended with colic pains, efpe- cially felt about the navel, and upon the fides towards the back ; but generally as the difeafe advances, thefe pains become lefs confiderable. As the difeafe advances, there is a pretty conftant defire to dif- charge air,but it is accomplished with dif- ficulty : and when obtained, although it gives fome relief from the fenk of deten- tion, this relief is commonly tranfient and of ihort duration. While the difeafe is co- ming on, fome inequality of tumour and Qjz tenfion

2j6 PRACTICE

tendon may be perceived in different parts of the belly ; but the didention foon be- comes equal over the whole, and exhibits- the phenomena mentioned in the charac- ter. Upon the fird comming on of the difeafe, as well as during its progrefs, the belly is bound, and the fxces difcharged are commonly hard and dry. The urine, at the beginning, is ufually very little changed in quantity or quality from its natural ftate : but as the difeafe conti- nues, it is commonly changed in both re- fpe&s ; and at length fometimes a dran- gury, and even an ifchuria, comes on. The difeafe has feldom advanced far, be- fore the appetite is much impaired, and digeftion ill performed; and the whole body, except the belly, becomes confi- derably emaciated. Together with thefe fymptomsy a third and uneafy fenfe of heat at length comes on, and a confider- able frequency of pulfe occurs, which con- tinues

O F P II Y S I C. 237

tinues throughout the courfe of the dif- eafc. When the tumour of the belly ari- fes to a confiderable bulk, the breathing becomes very difficult, with a frequent dry cough. With all thefe fymptoms the ltrength of the patient declines ; and the febrile fymptoms daily increafing, death at length enfues, fometimes probably in confequence of a gangrene coming upon the inteftines.

MDCXXXIIL

The tympanites is commonly of fome duration, and to be reckoned a chronic difeafe. It is very feldom quickly fatal, except where fuch an affection fuddenly arifes in fevers. To this Sauvages has properly given a different appellation, that of Meteorifmus ; and I judge it may always be confidered as a fymptomatic affection, Q^ 3 en-

238 P R A C T I C L

entirely diftindl from the tympanites we are now confidering.

MDCXXX1V.

The tympanites is generally a fatal dif- eafe, feldom admitting of cure; but what may be attempted in this way, I fhall try to point out, after I (hail have endeavoured to explain the proximate caufe, which a- lone can lay the foundation of what may be rationally attempted towards its cure.

MDCXXXV.

To afcertain the proximate caufe of tympanites, is fomewhat difficult. It has been fuppofed in many cafes, to be merely an uncommon quantity of air prefent in the alimentary canal, owing to the extri- cation and detachment of a greater quan- tity

v

OF P H Y S I C. 239

tity of air than ufual from the alimentary

matters taken in. Our vegetable aliments, I believe, always undergo ibme degree of fer- mentation ; and in confequence, a quan- tity of air is extricated and detached from them in the ftomach and interlines : but it appears, that the mixture of the animal fluids which our aliments meet with in the alimentary canal, prevents the fame quantity of air from being detached from them that would have been in their fer- mentation without fuch mixture ; and it is probable that the fame mixture contri- butes alfo to the reabforption of the air that had been before in fome meafure de- tached. The extrication, therefore, of an unufual quantity of air from the aliments, may, in certain circumftances, be fuch, perhaps, as to produce a tympanites; io that this difeafe may depend upon a fault of the digeflive fluids, whereby they are unfit to prevent the too copious extrica- 0^4 tio:1

i+o PRACTICE

tion of air, and unfit: alfb to occafion that reabforption of air which in found per- fons commonly happens. An unufual quantity of air in the alimentary canal, whether owing to the nature of the ali- ments taken in, or to the fault of the di- geftive fluid, does certainly fometimes take place ; and may poffibly have, and in fome meafure certainly has, a fhare in producing certain flatulent diforders of the alimentary canal ; but cannot be fuppofed to produce the tympanites, which often occurs when no previous diforder had ap- peared in the fyftem. Even in thofe cafes of tympanites which are attended at their beginning with flatulent diforders in the whole of the alimentary canal, as we know that a firm tone of the inteflines both mo- derates the extrication of air, and contri- butes to its reabforption or ready expul- fion, fo the flatulent fympcoms which hap- pen to appear at the coming on of a

tym-

O F P II Y S I C. 241

tympanites, arc, in my opinion, to be re- ferred to a lofi of tone in the mufcular fibres of the inteftines, rather than to any fault in the digeftive iluids.

MDCXXXVI.

Thefc, and other confiderations, lead me to conclude, chat the chief part of the proximate caufe of tympanites, is a lofs of tone in the mufcular fibres of the inte- ftines. But further, as air of any kind accumulated in the cavity of the inteftines ihould, even by its own elaflicity, find its way either upwards or downwards, and fhould alfo, by the afliftance of infpira- tion, be entirely thrown out of the body ; fo, when neither the reabforption nor the expuliion takes place, and the air is accu- mulated fo as to produce tympanites, it is probable that the paflage of the air along the courfc of the inteftines is in fome

places

k

242

PRACTICE

places of thefe interrupted. This inter- ruption, however, can hardly be fuppofed to proceed from any other caufe than fpaf- modic conftridtions in certain parts of the canal ; and I conclude, therefore, that fuch conftridtions concur as part in the proxi- mate caufe of tympanites. Whether thefe fpafmodic conftridtions are to be attribu- ted to the remote caufe of the difeafe, or may be confidered as the confequence of fome degree of atony firft arifing, I cannot with certainty, and do not find it neceffary to determine.

MDCXXXVII.

Having thus endeavoured to afcertaii the proximate caufe of tympanites, I pro- ceed to treat of its cure ; which indee< has feldom fucceeded, and almoft nevei but in a recent difeafe. 1 muft, however, endeavour to fay what may be reafonabl; 3 at"

OF PHYSIC. 243

attempted ; what has commonly been at- tempted ; and what attempts have fome- tim:s fucceeded in the cure of this dif- safe.

MDCXXXV1II.

It mud be a firft indication to evacuate the air accumulated in the inteftines: and for this purpofe it is neceflary that thofe conftriclions, which had efpecially occa- fioned its accumulation, and continue to interrupt its paflage along the courfe of the inteftines, mould be removed. As thefe, however, can hardly be removed but by exciting the periftaltic motion in the ad- joining portions of the inteftines, purgatives have been commonly employed; but it is at the fame time agreed, that the more gentle laxatives only ought to be employed, as the more draftic, in the overftretched and

tenfe

244 PRACTICE

tenfe ftate of the inteftines, are in danger of bringing on inflammation.

It is for this reafon, alfo, that glyfters have been frequently employed ; and they are the more neceflary, as the feces col- lected are generally found to be in a hard and dry ftate. Not only upon account of this ftate of the faeces, but, farther, when glyfters produce a confiderable evacuation of air, and thus fhow that they have fome eflfed in relaxing the fpafms of the inte- ftines, they ought to be repeated very fre- quently.

MDCXXXIX.

In order to take off the conftri&ions

of the inteftines, and with fome view alfo

to the carminative effedls of the medicines,

y jl, c»~-*+-j^ J ■■„ .various antifpafmodics have been propo-

*/ fed, and commonly employed ; but their

efFeds are feldom confiderable, and it is

2 alleged

OF PHYSIC. 245

alleged that their heating and inflamma- tory powers have ibmetimes been hurtful. It is, however, always proper to join fome of the milder kinds with both the purga- tives and glyfters that are employed ; and it has been very properly advifed to give always the chief of antif pafinodics, that is, an opiate, after the operation of purgatives is finifhed.

MDCXL.

In confideration of the overflretched, tenfe, and dry ftate of the inteftines, and efpecially of the fpafmodic conftridtions that prevail, fomentations and warm ba- thing have been propofed as a remedy; and are faicj to have been employed with ad- vantage : but it has been remarked, that very warm baths have not been found fo fcfefal as tepid baths long continued.

MDCXLI.

246 PRACTICE

MDCXLI.

Upon the fuppofition that this difeafe depends efpecially upon an atony of the alimentary canal, tonic remedies feem to be properly indicated. Accordingly cha- lybeates, and various bitters, have been em- ployed ; and, if any atonic, the Peruvian bark might probably be ufeful.

MDCXLII.

But as no tonic remedy is more power- ful than cold applied to the furface of the body, and cold drink thrown into the fto- mach; fo fuch a remedy has been thought of in this difeafe. Cold drink has been conftantly prefcribed, and cold bathing has been employed with advantage ; and there have been feveral inftances of the dif- eafe being fuddenly and entirely cured by

the

O F P H Y S I C. 247

the repeated application of fnow to the lower belly.

MDCXLIIL

It is hardly neceffary to remark, that, in the diet of tympanitic perfons, all forts of food ready to become flatulent in the fto- mach are to be avoided ; and it is probable, that the foiTil acids and neutral falts, as antizymics, may be ufeful.

MDCXL1V.

In obftinate and defperate cafes of tym- panites, the operation of the paracentetic /, .^^ A^ has been propofed : but it is a very doubt- *KMM*e ful remedy, and there is hardly any tefti- mony of its having been pradlifed with fuccefs. It mud be obvious, that this ope- ration is a remedy fuited efpecially, and al- mo(t only, to the tympanites abdominalis ; the

exiftence

248

PRACTICE

exiftence of which, feparately from the in- tejlinalis, is very doubtful, at leaft not eafi- ly afcertained. Even if its exiftence could be afcertained, yet it is not very likely to be cured by this remedy : and how far the operation might be fafe in the tympanites inteftinales, is not yet determined by any proper experience*

CHAP.

OF PHYSIC. 249

CHAP. III.

Of Watery Swellings, or Dropsies.

A

MDCXLV.

Preternatural collection of fe- Jl+~~ - /~^~ rous or watery fluids, is often form— t. ^ulsz^L* v-

ed in different parts of the human body -9^1

and although the difeafe thence arifing be^>^y ^ <£- diftinguifhed according to the different^ u/a#u^+z> parts which it occupies, yet the whole of ^7 ^^ 9^^^'J- fuch collections come under the general ^ ^u^S^L^l Vol. IV. R ap-* ^/— -^.

25o PRACTICE

appellation of Dropfies. At the fame time, altho* the particular inftances of fuch col- lection are to be diftinguifhed from each other according to the parts they occupy, as well as by other circumftances attending them ; yet all of them feem to depend up- on fome general caufes, very much in common to the whole. Before proceeding, therefore, to confider the feveral fpecies, it may be proper to endeavour to affign the general caufes of dropfy.

MDCXLVI.

In perfons in health, a ferous or watery fluid feems to be conftantly poured out, or exhaled in vapour, into every cavity and interftice of the human body capable of receiving it ; and the fame fluid, without remaining long or being accumulated in thefe fpaces, feems conftantly to be foon again abforbed from thence by veffels ad- apted

OF PHYSIC. 251

apted to the purpofe. From this view of the animal oxonomy, it will be obvious^ t;hat if the quantity poured out into any fpace, happens to be greater than the ab- forbents can at the lame time take up, an unufual accumulation of ferous fluid will be made in fuch parts j or though the quantity poured out be not more than u- fual, yet if the abforption be anywiie in- terrupted or diminifhed, from this caufe alfo an unufual collection of fluids may be occafioned.

Thus, in general, dropfy may be imputed to an increafed effufion, or to a diminished abforption; and I therefore proceed to in*- quire into the feveral caufes of thefe.

MDCXLVII.

An increafed effufion may happen, ei- ther from a preternatural increafe of the R 2 ordi-

252 PRACTICE

ordinary exhalation, or from the rupture of vefTels carrying, or of facs containing, ferous or watery fluids.

MDCXLVIII.

The ordinary exhalation may be increa- fed by various caufes, and particularly by an interruption given to the free return of the venous blood from the extreme vefTels of the body to the right ventricle of the heart. This interruption feems to operate by refifling the free pafTage of the blood from the arteries into the veins, thereby increafing the force of the arterial fluids in the exhalants, and confequently the quan- tity of fluid which they pour out.

MDCXLIX.

The interruption of the free return of the venous blood from the extreme vefTels,

may

OF PHYSIC.

may be owing to certain circumllances af- fecting the courfe of the venous blood ; very frequently, to certain conditions in the right ventricle of the heart itfelf, pre- venting it from receiving the ufual quan- tity of blood from the vena cava; or to obftru&ions in the veflels of the lungs pre- venting the entire evacuation of the right ventricle, and thereby hindering its recei- ving the ufual quantity of blood from the cava. Thus, a polypus in the right ven- tricle of the heart, and the oflification of its valves, as well as all confiderable and permanent obftrucftions of the lungs, have been found'to be caufes of dropfy.

MDCL.