J. G. AUNER, < BOOKSELLER AND STATIONER, l SS3 Market St, > 4 doors below Nintli St. I PHILADELPHIA. J 4iP^^mJ&^ LOCK k.U CASE THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID , tfT/l»Tat|atC Tats ib. XU. COMMENTARIES HISTORY AHD CUBE OF DISEASES. By WILLIAM HEBERDEN, M.D. FROM THE LAST LONDON EDIXrON. TtpetVi KAt K*[x.niv ouKiri Swttfxviog^ rouro to /S/Ca/ov «^g«t4et, aviret^Af Tats fcirci TToJiKne rgiCijs sv tak tw *v6g«5Tw vovote KATAKtxpBua-Ai (/.at TrtigAs. ALEX. TRALL, Lib. XIF. boston: FEINTED BY WELLS AND LILLY. 1818. WILLIAM HEBERDEN Was born in London in the year 1710, and received the early part of his education in that city. At the close of the year 1734 he was sent to Saint John's College in Cam- bridge, and six years after was elected a Fellow. From that time he directed his at- tention to the study of medicine, which he pursued partly at Cambridge and partly in London. Having taken his degree of Doc- tor of Physic he practised in the University for about ten years, and during that time read every year a course of lectures on the Materia Medica. In the year 1746 he be- came a Fellow of the Royal College of Phy- sicians, and two years afterwards, leaving Cambridge, he settled in London and was elected into the Royal Society. He very soon got into great business, which he fol- [ iv ] lowed with unremitting attention above thirty years, till it seemed prudent to with- draw a little from the fiitigues of his profes- sion. He therefore purchased a house at Windsor, to which he used ever afterwards to retire during some of the summer montlis ; but returned to London in the winter, and still continued to visit the sick for many years. In 1766 he recommended to the College of Physicians the first design of the Medi- cal Transactions, in which he proposed to collect together such observations as might have occurred to any of their body, and were likely to illustrate the history or cure of dis- eases. The plan was soon adopted, and three volumes have successively been laid before the public. In 1778 the Boyal So- ciety of Medicine in Paris chose him into the number of their Associates. Besides the observations contained in the present volume, Doctor Heberden was the author of several papers in the Medical Transac- tions, and of some in the Philosophical I V ] Transactions of the Royal Society. He de- clined all professional business several years before his death, which was mercifully post- poned till the year 1801, when he was ad- vancing to the age of ninety-one. From his early youth he had always en- tertained a deep sense of religion, a con- summate love of virtue, an ardent tliirst af- ter knowledge, and an earnest desire to pro- mote tlie welfare and happiness of all man- kind. By these qualities, accompanied with great sweetness of manners, he acquired the love and esteem of all good men, in a degree which perhaps very few liave expe- rienced ; and after passing an active life with the uniform testimony of a good con- science, he became an eminent example of its influence, in the cheerfulness and sere- nity of his latest age. FREFACIE. Plutarch says,^ that the life of a vestal vir- gin was divided into three portions ; in the first of which she learned the duties of her profession, in the second she practised them, and in the third she taught them to others. This is no bad model for the life of a physician : and as I have now passed through the two first of these times, I am willing to employ the remainder of my days in teaching what I know to any of my sons who may choose the profession of physic ; and to him I desire that these papers may be given. The notes, from which the following observa- tions were collected, were taken in the chambers of the sick from themselves, or from their atten- dants, where several things might occasion the omission of some material circumstances. These notes were read over every month, and such facts, as tended to throw any light upon the history of a distemper, or the effects of a remedy, were enter- ed under the title of the distemper in another book, from which were extracted all the particu- lars here given, relating to the nature and cure of * Plutarch in Numa, et « 7rt^a which I have ever seen used, have in too many cases proved of little or no avail. If the gene- rality of deafnesses be not incurable, a discovery 58 Commentaries on the of the proper remedies is one of the many desi- derata in the art of healing. CHAPTER 13. Of the Bath Waters. The difficulty of ascertaining the powers of medicines, and of distinguishing their real effects from the changes wrought in the body by other causes, must have been felt by every physician : and no aphorisai of Hippocrates holds truer to this day, than that in which he laments the length of time necessary to establish medical truths, and the danger, unless the utmost cau- tion be used, of our being misled even by expe- rience. This observation is fully verified in the uncertainty, under which we still remain in re- gard to the virtues of the waters of Bath. Few medicines have been more repeatedly tried under the inspection of such numerous and able judges ; and yet we have had in the present age a dis- pute between those who by their experience and sagacity were best qualified to decide this ques- tion, in which one side asserted that paralytic patients were cured, and the other that they were killed, by the use of these waters. Such con- trary decisions, so disreputable to physicians, and so perplexing to the sick, could never have hap- pened after so long a trial, if a very small part of those, whose practice had afforded them frequent 0{)portunities of observing the effects of Bath waters, had told the public what in their judg- History ami Chive of Diseases. 59 ment was to be hoped or feared from them. It is probable that in some cases it would have been almost unanimously determined they do good ; in others, that they do no harm, though it might be doubtful whether they be of much use : in a third sort they would be generally condemned : and in a fourth class of diseases, some might judge them to be beneficial, and others detrimen- tal. Wherever the generality of voices passed either of the two first sentences upon these waters, there the use of them might be advised, or per- mitted, without any hesitation ; and all should be cautioned against them, where a great majority agreed that they. were hurtful. It would be no great loss to avoid going to Bath, in cases where the weight of evidence was so equally divided, as to make it doubtful whether the waters were a remedy, or a poison : for the probability is, that in all such disorders they are in reality insignifi- cant, and that the patients who use them either recover by other medicines, or the strength of their constitutions, or else sink under the natural progress of their diseases. It is here taken for granted, that no chemical analysis can do much towards ascertaining the virtues of these mineral springs, but that almost all our useful knowledge of them, as medicines, must be gained from ex- perience. Their virtues may be considered either as they are used externally, or internally. Externally used, either by immersing the whole body, or by deriving a stream to some particular part, they appear to be serviceable against con- "Mmi eo Commmmms on the tractions and other spasmodic affections of the muscles. In slight cutaneous disorders, warm bathing will sometimes clear the skin for a little while, but can hardly be considered as a cure. It has been a doubt with me, whether any weak- nesses left by the rheumatism, gout, or palsy, have been sooner removed by bathing at Bath, than they would have been without it. In some patients these weaknesses have been manifestly increased after a course of bathing at Bath ; and, according to my experience, cold bathing in these cases is preferable. It is by no means clear to me, that the external use of Bath water is more beneficial than that of equally warm common wa- ter, or at all different from it. Internally, these springs are of singular use in remedying the morning sickness and vomiting, the loss of appetite, pains of the stomach, and other ill eflfects of hard drinking, where it has not been so long continued as to make the liver schirrous, or to bring on a dropsy ; for in both these cases they are so far from relieving, that they aggravate the patient's misery, and hasten his death. They are so generally beneficial in other disorders of the stomach and bowels, that the probability of considerable benefit will make them very well worth any one's trying, who is afflicted with indigestion, a chronical diarrhoea, hiccup, flatulency, vomiting, or any spasmodic affections, and weaknesses, and pains of these parts, provided the pulse be in a natural state. For if there be no signs of hectical feverishness, I never had reason to suspect that Bath was pre-f judicial in any of these complaints, though it History and Cure of Diseases. 61 may have sometimes failed of being a cure. But 1 have never yet been able to satisfy myself, amidst the endless variety of these ails, upon what particular circumstances it has depended, that in some it has not been attended with suc- cess. Many judicious and experienced physicians have a favourable opinion of the internal use of Bath water in flying pains and weaknesses of the limbs, in rheumatisms, and in the simple jaundice, where the liver is not diseased. From the cases of this sort which have fallen under my observa- tion, I should rather conclude it to be innocent in them, than of any great use. More perhaps ought to be said in its commendation in the colic of Poitou ; and yet it appears difficult to find a time in this cruel disorder when we would wish to apply to Bath. During the paroxysm, while the bowels are in torture, much stronger medi- cines are indispensably necessary to the ease and safety of the patient : after the fit is ended, if the limbs do not become paralytic, I suppose the pa- tient would remain well without any relapse, if the manner in which lead had been introduced into the body could be found out, and a stop be put to its ever being introduced again. For all my experience tends to make me believe with the learned and judicious Sir George Baker, that lead is the sole cause of this distemper, though it be difficult in many cases to trace its admission into the stomach. Some of the worst fits of this colic, from which I ever saw the patient recover, when the cause was known, and could be avoided, have, by keeping out of its ree^ch, never returned in 6S Commentaries 'on the many years ; from which it is probable there was no fomes rnorbi left. I have hkewise observed this happen in a more chronical kind of this colic, where the Hmbs were become semi-paralytic; the weakness of which gradually abated, and the pains never returned, after leaving off the use of white Lisbon wine, the drinking of a pint of which every day was conjectured to have brought on this malady. Now, if the manner in which this poison insinuates itself be undiscoverable, and so cannot be guarded against, there neither Bath nor any other known means would, in my opinion, prevent the return of these torments, nor hinder them from ending in a lingering death. But it may be supposed that a person has taken so much of this poisonous metal, as may be sufficient, with- out any repetition, to occasion frequent fits of the colic, and to bring on at last the paralytic weak- ness peculiar to it ; and tliat these bad effects may possibly be obviated by drinking the Bath waters, or that the weakness may be cured by them after it has been brought on. How much truth there is in these suppositions I know not, but I can easily allow them so much weight, as to be sufficient reasons for the use of the Bath wa- ters in these circumstances, as they are unques- tionably safe, and as I fear we are in want of oth- er remedies upon which we might with more cer- tainty depend. Besides, in all chronical illnesses, where these waters are innocent^ there will be a good reason for any one's taking a Bath journey, who can afford it, in the benefit which he may hope to receive from the change of water, and air, from the breaking of some unhealthful habits, and from that suspension of business and cares, History and Cure of Diseases. 63 in which the visiters of Bath indulge themselves ; all which circumstances make a place of this sort highly useful in establishing the general health. The Bath waters have always appeared to me unquestionably prejudicial in all schirrous and ul- cerous affections of the lungs, or of the abdominal viscera. They increase the hectical heat which usually attends such maladies, and speedily put an end to what little hopes might have been en- tertained of their cure. All patients therefore of this sort cannot be too earnestly warned against meddling with the Bath waters, if they would avoid making their condition utterly desperate ; which with the greatest care, and under the best management, is always dangerous. In extreme dejection of spirits, languor, lassi- tude, inattention, trembhngs, catchings, faintings, giddiness, confusion of the head, and palpitations without any other apparent distemper, which are usually called hypochondriac, hysteric, or ner- vous ; in all these whether the patients had used the water externally, or internally, I have observ- ed them return worse from Bath ; but I hardly ever knew them better, if we except only some lit- tle relief of the pains, and flatulence, and acidi- ties, which often accompany the before-mentioned symptoms. Nor does the vacancy of a Bath life suit complaints, which are more frequently caus- ed by too little, than too much application and employment. It will indeed sometimes happen, that some degree of these miserable sensations will be produced by a too great weight of busi- ness ; the vexations of which in some evil hour 64 Commentaries on the may entangle a man so much, as to disable him from extricating himself by his own struggles, un- less for a while he eases himself of the load by retiring to some such place as Bath, where the manner of living will effect the cure, though the reputation of it may be put to the account of the waters. The same often happens in that languor and weakness, which aie left by a long illness, and require only time and quiet for their remo- vaL CHAPTER 14. Of the Bristol Water. The water of Bristol is celebrated for its purir iy^ and for its virtues in consumptions, and seve- ral weaknesses. It has certainly no claim to be thought a pure water ; and as far as my expe- rience goes, it has as little just pretence to any of the medicinal virtues which it has been thought to possess. CHAPTER 15. Bronchocele, A SWELLING of the thyroidal gland is endemial in some parts of Derbyshire, Buckinghamshire, and Surry, and is sometimes seen in persons who live in other parts of England, where this disor- der is not commonly known. It chiefly affectis History and Cure of Diseases, 65 women, and the younger part of them ; and is probably the same with the Alpine swelled throat, which, though so old a distemper, has not yet been found to endanger the hfe, or disorder the health, or to be worth regarding on any other ac- count than that of its deformity: though I have seen some, who have complained of its giving them, in certain situations, a difficulty of fetching their breath. The cause of this malady is most probably to be found in the peculiar nature of the water in those places where it is common ; a judi- cious examination of which is greatly wanted. I never saw this swelling come to suppuration. A course of sea water, or of solutions of any of the neutral salts, a removal from the place, or the drinking only of the Malvern, or distilled water, appear to be the most useful means of reducing the swelling, or of preventing its return. CHAPTER 16. Calculus Urince,^ Women are much less subject to calculous con- cretions than men ; they do not so readily form them, and more easily get rid of them. There is some difficulty in ascertaining both the presence of a stone, and its place. A scir- * Calculi are formed in many other parts of the body. In a woman, after great pain which lasted ten days, a tumour between the mulares and tongue broke, and there came out a calculus as big as two peas. ^ 9 66 Commentaries on the rhoiis swelling of the prostrate gland may be so easily mistaken for it, that I have known a consul- tation of very able and experienced practitioners, where they were divided in their opinions between these two causes of the symptoms, after every kind of examination. For a stone may be in the bladder without being felt by the catheter ; of which I have seen some very remarkable instan- ces, and particularly in one who had repeatedly been examined by three or four of the most dex- trous and experienced surgeons without its ever being touched, in whose bladder, after death, a stone was found weighing 5ij 3iij ; and the swel- ling of the prostate may not be large enough to put its diseased state out of all doubt; especially as it is said to be always a little fuller where the neck of the bladder has been long and frequently molested with a stone. The scirrhus of this gland is attended with an irritation to make water, and consequently with a prseternatural quantity of mu- cus, for it always is in proportion to the degree of irritation : there are besides strangury and te- nesmus ; which symptoms it has in common with the stone. Bloody urine in a scirrhus of the prostate is but rarely seen ; the quantity is small, and is not increased by riding as in calculous complaints. Hard faeces give pain as they pass, and the testicles are apt to swell ; which symp- toms are also peculiar to the diseases of the pros- tale. But perhaps the best criterion for distin- guishing these two maladies is the effect which a scirrhus has upon the g-eneral health : those af- flicted with it lose their appetite, their flesh, and their strength, and have irregular shiverings, with a pulse quicker than natural, and keep constantly History and Cure of Biseases, 67 growing worse, without any considerable appear- ances of amendment, or intervals of ease : where- as the calculous patient has long respites from his pains, and shews no sign of his general health be- ing at all affected when the fit is off: and these are also the best marks which distinguish ulcers of the kidney, or bladder, from stones. Bloody urine, without any signs of internal ulcers, espe- cially if brought on or increased by motion, al- most always denotes a stone somewhere in the urinary passages. I remember to have read in books of other causes of this appearance, which I imagine occur but seldom, because I do not re- collect that I ever yet met with them. After it is determined that there is a stone, a difficulty often remains of finding the part in which it is lodged : but this is a matter of not much importance in practice ; for, except what ease may possibly be sometimes given by the catheter in pushing the stone from the neck of the bladder, there is no peculiar solvent of the stone in the bladder different from that of the kidneys ; and as to present ease, nothing will pro- cure it in either case so well as opium. It very frequently happens that there is a stone both in the kidney and bladder at the same time; and in such cases there is no knowing to which of the causes the symptoms are to be referred. Coffee-coloured, or bloody water, without any pain, or with a dull pain, or a sharp pain, a little above either hip, most probably proceeds wholly from a stone wounding the kidnejs: vomiting sometimes accompanies a nephritic pain, but is 68 Commentaries on tli£ far from being constantly joined with it: a numb- ness in the thigh or leg, a difficulty of bending the body, a drawing up of the testicle of the af- fected side, and a pain at the extremity of the urethra, are still less constant symptoms. As far as I know, we are wholly in the dark about the particular circumstances which make the stone of the kidneys capable of exciting such torments in some, while others with kidneys to- tally plugged up with calculous matter are un- conscious of any thing being amiss. Possibly the different sensations of people, as well as the surface and position of the stone, must be taken into the account ; for some by their feeling can trace the passage of a stone from the kidney to the bladder through the whole length of the ure- ter, of which others know nothing. Stones are very apt to make some stops in passing the ure- ter; and wherever they do, there are made dila- tations in it, several of which are commonly seen in opening the bodies of calculous persons. When the kidney is in pain, or any of the neighbouring parts, there will necessarily be formed abundance of thick mucus, which is voided with the urine, and alarms some patients with vain apprehensions of an ulcer. A violent fit of the stone will occasion, as I have observed in dissections, a slight inflammation of the kidneys, which without any ulcer causes a purulent liquor to exude tVom its cavity; and this, by its cream- like appearance at the bottom of the urine, may give juster suspicions of an ulceration. The reali- ty of an ulcer may be principally concluded from History and Cure of Diseases, 69 the ^reat quantity, from the constant flow, and particularly from the fetidness of this hquor. Ulcers of this part, as there was reason to judge, have continued for several years, and the whole kidney has been at last wasted, just as it happens with the lungs. But an ulcer only in one of the kidneys, while there is no tendency to gan- grene or cancer, is far less dangerous to life than one in the lungs, and the recovery from it to tolerable health may more reasonably be hoped. The urine of a w^oman deposited a great quan- tity of fetid mucus, which stuck to the bottom of the vessel, for ten months. After that time streaks of blood were perceived in it, without any pain, or strangury, not even from riding in a carriage. In the mean time her general health was unimpaired. Two years after, when she was with child, there came with the urine black fetid lumps, and soon after the urine appeared wholly bloody; a hiccup came on, the woman miscarried, and died. The right kidney was filled with calculous matter, the pelvis was sphacelated and full of fetid pus ; the ureter was greatly en- larged through its whole length, and was thick- ened and hardened almost into a cartilage. The left kidney also contained a stone. There was no stone found in the bladder. Hence we may collect, 1st, that such tenacious mucus, even though fetid, may be found without an ulcer; for it probably appeared in this case before the kid- ney had suffered any other injury than must ne- cessarily attend its being filled with stony matter. 2dly, that a stone in the kidneys will sometimes occasion neither pain nor strangury. 70 Commentaries on the The signs of a stone in the bladder are, great and frequent irritations to make water, a stoppage in the middle of making it, and a pain with heat just after it is made ; a tenesmus, pain in the ex- tremity of the urethra, incontinence or suppres- sion of urine, together with a quiet pulse, and the health in no bad state : all which symptoms are most commonly aggravated chiefly by riding, but sometimes, though much more rarely, by walking, and bloody water will now and then be brought on by motion ; yet in some few persons it happens that their sufferings from stones in the bladder, though very great, have not been perceivably in- creased either by walking or riding. This I have observed in cases where the patients were afterwards cut, or opened after death, and the stones in the bladder were found to be the sole cause of their pains. The very same person will at different times be perfectly at ease in a coach, or find that the motion is intolerable. The tor- ment arising from the stone depends more upon its figure and position, than its size ; but there must be some certain situations of the largest and roughest stone, both in the kidneys and bladder, in which little or no inconvenience is felt from it. Were it otherwise, the life of a calculous patient must be one continued fit, without any intervals of ease ; which is never known to happen. It is too often seen that those, who have once shown a disposition to have the calculous matter formed in the urinary passages, continue subject to it during their whole lives ; and this disposition seems also to be hereditary. But still examples occur of those who have been cut for the stone in History and Cure of Diseases. 71 their childhood, and afterwards have shown no signs of forming any new concretions for above fifty years ; and 1 have known others who had felt several fits, and voided many small stones, yet, when they were opened after death, showed not the least appearance of any stony matter, or any other disorder in their kidneys or bladder. But it is suspicious, when any one has long voided small stones or sand with his urine, to have this appearance suddenly stopt for a year or two ; for in this time most usually a stone will be forming, and shew itself at last by its proper symptoms: in this state, it will be no superabundant caution to enter upon a course of such remedies as will be most effectual in hindering the urine from deposit- ing any fresh calculous matter. The largest stone that I remember having ever seen voided by a man with his urine, weighed eight-and-twenty grains ; but far larger have come from women. All motion should carefully be avoided when it brings on bloody water; for a little grume of blood often forms the nucleus of a stone. 1 saw a stone voided by a woman, of an oval form, whose larger circumference was six inches, and the less four inches. She was delivered of a child the next day with less pain than she had felt in parting with the stone. The remedies against calculous complaints are cither such as relieve the pain during what is called a fit of the stone, or those which dispose the urine to dissolve the stones, and so make a 7S Commentaries on the perfect cure. For the former purpose twenty drops of tlnctura ppii, or as much more as may be found necessary, mixed with four or hve ounces of warm water, or oil, and given in a clyster, are the most effectual means which I have ever used ; and much more to be depended upon than any oily draughts or emulsions with gum dissolved in them, which however may have their use. The uva ursi has lately been recommended for reliev- ing dysury of all kinds ; in my hands it has not very well answered its character ; the most re- markable effect which I ever observed from it was, that upon many repeated trials it constantly tinged one person's urine with a deep green colour ; I never could hear of its doing the same to any one else. Lime water has in many cases appeared to communicate a solvent power to the urine. I have known it used for several years as the only liquor, and by custom it became not an unplea- sant one. The person who took it, from not being able to walk across his room, could bear to be carried in a coach without springs for several miles over the old rough pavement of London without making any complaints ; his urine in a few days dissolved a fragment of a calculus im- mersed in it, which had before been steeped in the urine of two other persons for some months without losing any part of its weight. Soap leys perhaps communicate a stronger solvent power to the urine; but it must be owned, that neither of them do so much as is wanted ; their effect at best is very slow, and upon some stones they seem to have none at all ; lor immersed in the strongest undiluted soap leys they hardly seem to waste. But still if they hinder the growth of many stones, m History and Cure of Diseases. 73 and loosen the texture of those already formed, and dissolve, as is probable, their sharp points, which are the chief causes of pain, they must be considered as vahiable medicines. 1 knew a per- son who took half an ounce of soap leys almost daily for ten years, without the least groimd to surmise that it had any ill effect upon his general health. There was reason to believe that they had helped to break in pieces some of the stones in his bladder ; for he had voided some ounces of very large fragments convex on one side and con- cave on the other ; and, from being quite confined to his house, became able to bear a coach, and for the last years of his life had suffered very lit- tle pain, of which he used to have frequent and very tormenting fits. But yet this long course persevered in so steadily, did not crumble them all ; for after his death one kidney was found full of stone, and there were two stones in the blad- der, one of which weighed 3vi. Bii. gr. iv ; the smaller ^ij gr. xii. It appears doubtful whether either lime water or soap leys have any power over the stone in the kidneys. It may be ques- tioned whether it be necessary to suspend the use of these lithontriptics upon account of bloody^ urine or a fit of the stone ; for it is far from cer- tain that they can increase the irritation by any acrimony which they communicate to the urine. However, as the fits usually last but a \ery few days, and time must then be found for the taking other medicines, there can be no great loss, and may be some convenience, in interrupting the course of these remedies until the fit be over. Have not too strict rules been laid down about the wholly avoiding of acids in the diet of those 10 74 Commentaries on the who take lime water or soap leys ? The power of digestion is not so well understood as to ena- ble us to determine how long it will be before acids are changed by it so as to cease from hav- ing the eifect of neutralizing alkaline substances. It is not improbable that at the distance of a very few hours they may have wholly lost their former nature. The fixed air, of which there is so much not only in the primae viae, but in all the liquors of the body, seems at least as likely to defeat the efficacy of these solvents, by saturating them with air, and destroying their power of extricating the fixed air from the urinary calculi : and it is in- deed very mysterious how this can be prevented. CHAPTER 17. Capitis Dolor, The nature of head-achs is extremely obscure. Their manifest causes are very various, and often contrary to one another. They probably there- fore arise from different disorders, and some of their obscurity may be owing to their being affec- tions of a part, the functions of which are but lit- tle understood. For they appear to be seated in the brain itself: since this pain is peculiar to the head, and there is no sensation like it in any oth- er part of the body, but all the parts of the head except the brain are just the same with what the rest of the body consists of; dissections likewise have shown it to have arisen in some instances from diseases of the brain. The seat then of this History and Cure of JDiseases, 75 malady, together with its long continuance and frequency of return, might make us expect that the mischief done to the general health would be great and lasting. But the contrary to this hap- pens. The most violent head-achs will frequent- ly harass a person for the greatest part of his life, without shortening his days, or impairing his fa- culties, or unfitting him, when his pains are over, for any of the employments of active or contem- plative life. The slightest stroke of a palsy will often be more detrimental in these respects, than head-achs returning often and with great violence from childhood to the beginning of old age. In- stead of their ruining the constitution, nature seems in the contest to get the better of them. I have observed in numberless instances that th^y almost always become milder, and generally va- nish towards the decline of life. This considera- tion must supply the place of a remedy where every other fails ; for it is some consolation for a man to know, that if he cannot cure his distem- per, he will however have a good chance to out- live it. This is true likewise of tlfat head-ach mentioned among the diseases of the eyes, which begins with a mist before the sight. The hemicrania, or pain of one half of the head, was very early distinguished by medical writers from the other species of head-achs : but we have not yet advanced much in knowing how this differs from other pains of the head, except in the circumstance which the name denotes. It has happened that I have oftener heard of this oh the left side than on the right ; but I believe this to have been merely accidental. Like other 76 Commentaries on the head-achs, it will continue to return through a person's whole life : it will attend the gout, and not be relieved by it ; and it is what follows that mist before the eyes which makes a part of every object invisible. A still more narrowly limited pain than this is often complained of over the left eye, scarcely extended beyond a space which might be covered with the top of a finger. This will last a day or two, and return two or three times in a month. Is it not most common in wo- men, and often joined with hysteric symptoms ? Some pains seize upon the back, others upon the fore part only of the head. There may be other varieties of the place affected, which it is hardly worth while to remark, unless more use, than I know, could be made of them in discovering their nature, and directing us to the cure. 1 say no- thing of Venereal head-achs, which are distin- guishable by their being chiefly troublesome at night, and by being joined with other symptoms of this distemper, and by yielding to its proper re- medies. Spring or autumn, or both, are the times when some head-achs constantly return ; others are sure to be felt just after sleeping. A few are most troublesome in summer, but more in winter. Of far the greatest number of head-achs it is true that they are indifferent to all seasons ; and their returns are totally irregular, and not to be reduc- ed to any rule : and so is the duration of the pain, which may last a few hours, or a day, or a week, or not cease entirely for many years. Some great change in the constitution has removed a nead»ach which had continued frotp infancy. It History and Cure of Diseases. 77 has ceased upon the coming on of an asthma ; and there have been many instances of its leaving women during every pregnancy, who were hard- ly ever free from it at any other time. Disagreeable as this pain is, it is not the whole which is felt by all those who suffer it. Giddiness will in some precede a fit, but this has more fre- quently joined itself to an old head-ach. Confu- sion of vision, flashes of light, the darkening or colouring of objects, stupor, and tightness of the head, are the certain companions of many head- achs ; and so are all sorts of hysteric symptoms, such as shiverings, cold sweats, fainting, coldness of the feet, numbnesses, lethargic heaviness, noises in the head, loss of voice and sight for a short time, catchings, convulsions, light-headedness. The intenseness of the pain will sometimes leave a soreness of the head for a day. Great disorders also of the stomach are sometimes united with head-achs, such as flatulence, a sense of fulness, uneasiness, pain, heartburn, sickness, vomiting, diarrhoea, and worms : in very many patients these two parts suffer alternately ; whenever the head is well, the stomach is uneasy, and vice ver- sa. This view of the complaints which are often connected with head-achs, makes it probable that the head is not always primarily affected, but sometimes suffers by sympathy with the stomach, which is the original seat of the malady. The healing of old sores, and of other cutaneous dis- tempers, and the menstrual irregularity of wo- men, more frequently affect the stomach first, and the head perhaps chiefly from its consent with the stomach. 78 Commentaries on the Very few head-achs are attended with danger; but where there is any, it is found where the most and the strongest of these symptoms appear, (such as stupor, swelhng of the neck, dehriousness, and convulsions,) which belong to epilepsies, lethar- gies, palsies, and apoplexies, into which head-achs, though rarely, have been manifestly continued. But a head-ach is so common a distemper, and a palsy so far from being an uncommon one, and yet the one succeeds the other so seldom, that the same person who had been accustomed to the former, may happen to have the latter, without affording sufficient reason to convince us that they had any connexion with one another. Some of these fatal head-achs, as I have had opportunities of knowing, have been occasioned by unnatural collections of liquor, or imperfect suppurations, or morbid masses formed in the brain, which had first occasioned the pain, and afterwards by the increase of the compression upon the origin of the nerves, had at last made them incapable of performing any of their duties. Many similar cases may be found in authors, which I forbear to quote, as I propose to confine myself wholly to the mention of what has occurred in my own practice, that these remarks may have the merit of being copied immediately from nature, to make up for their other defects. Among the more tractable head-achs, the same means, for no obvious reason, have had such op- posite effects in relieving and exasperating similar pains, that it must be left to more enlightened posterity to lay down a certain method of cure ; it not being always easy at present to satisfy our- History and Cure of Uiseuses. 7fi selves in determining which is the most probable. Anxiety and perturbation of spirits, noise, fatigue of mind or body, too much light, the air of" a room heated by a crowd of people, indigestion, and the acts of sneezing and coughing, have almost a cer- tain and universal effect of making head-achs worse. Eruptions upon the skin, eating, sleep, the heat of a fire, summer, winter, a cold, or hot climate, a fit of the gout, and the outward air have had very different effects upon different pa- tients ; but the greatest number hath been bene- fited by sleep, warmth, summer, hot cHmates, the outward air, and eruptions appearing on the skin. If cold bathing, bleeding by leeches, or by open- ing a vein or artery, perpetual blisters, issues, and sneezing powders, have done no harm, (of which they have been suspected,) they have, how- ever, in many cases, undoubtedly been useless, and so have warm bathing, nervous medicines and opium. Though every known remedy for head- achs has at times failed, yet among those which have seldomest disappointed my expectations, I find a perpetual blister to the head, the taking away of six ounces of blood by cupping upon the shoulders once in six weeks, and pills made of one grain of aloes and either four grains of colum- bo-root, or half a scruple of pulv. myrrh, comp., taken every night. Emetics are often highly ser- viceable ; the strain to vomit aggravates the pain much less than might be feared, and they have been repeated every month with success ; nor is it unusual for a spontaneous vomiting to cure a head-ach. The pain of the head, so common in the beginning of fevers, is much relieved by it ; but for this particular head-ach, a blister between 80 Commentaries on the the shoulders may be recommended as a specific. Warm fomentations of the head, or feet, often give present ease; and tinctura opii has been use- tul for the same purpose. CHAPTER 18. Capitis Dolores intermittentes. The Peruvian bark affords a remedy which sel- dom fails of curing periodical fevers, in which the whole body seems to be affected ; but in periodi- cal pains which seize only some part, both this bark, and every other medicine that I know, often prove ineffectual. This is the more to be regret- ted, because when such a topical intermittent in- fests the head or face, as it often does, there is as exquisite an anguish sutJered, as from any distem- per to which the body is subject, if we may judge by the expressions of it, which are wrung from the most patient tempers. The seat of these pains will be the whole head, as in a common head-ach, or only the hind part, or the forehead ; very frequently they will be felt only on one side of the face ; and though I have known them on both sides, and in the same per- son in different fits, yet they have been much more frequently on the left. During the fit, the upper lip, the gums, the cheek, and temporal muscle, will be in such an agony, as to make it impossible to speak, to chew, or to swallow ; sometimes only one of these parts will be affect- History and Cure of Diseases. 81 ed. The mouth is filled with saliva, the eje wa- ters extremely, and cannot bear the light ; the eye-lids will be swelled and red, and I have twice seen them black and blue, from the violence of the pain in every fit. A heat of the face, and redness, with an unusual flow of spittle, have been its forerunners ; and in some it has been at- tended with vomiting, and little spasms, or tre- mors of the parts affected. The fits have end- ed in one hour, and have lasted several, and even two days, and have kept their periods as regular as any common quotidian or tertian : they have also returned every ten days, and once a month, or twice a year; but their is usually great irregu- larity in the times of their returning. In some unhappy subjects, this disorder, from being inter- mittent, becomes almost continual ; for the slight- est attempt to eat, or speak, the motion of a car- riage, or a blast of cold air, will bring on the pain, so that for a considerable number of years they are scarcely ever entirely free from it. Both sexes are subject to it, but women much the most so; and it has spared no age, from childhood to the eightieth year of life. Sometimes a stupor has hun«: on for some hours after the ceasinp- of the fit ; but in the intervals of the paroxysms the patients are most usually free from all complaints. In the attempts to cure this malady, evacuations have proved not only useless, but hurtful ; and bleeding in particular has been veiy detrimental. Cataplasms have not been well borne, and have rather added to the misery of the patients. The Peruvian bark has very often been tried in vain, and so have the root of valerian, the fetid gums, 11 8S Commentaries on the myrrh, musk, camphor, opium, extract of hem- lock, sneezing powders, blisters, deep caustics, electrifying, fomentations made of a decoction of hemlock, warm pediluvia, epithems of ether, ano- dyne balsam, sp. vini, linimentum, saponaceum, and oil of amber, opening the temporal artery, and drawing some of the teeth ; nor has a super- vening fit of the gout made any alteration in this obstinate ailment. But still the bark has now and then succeeded, and not so seldom but that it is advisable to recommend it in the first place ; an ounce of it, or not much less, should be given eve- ry day for a week. Blisters behind the ears have appeared to abate the violence of the fits ; and in- stances have not been wanting of the good effect of as much extract, cicutae given daily as could be borne without giddiness. In some cases, where every thing else had failed, a draught with one quarter of a grain of emetic tartar and forty drops of tincture of opium, taken at bed-time for six nights, has made a lasting cure. Cold bathing has also been used with benefit. If the patient be unable to swallow the bark, or very averse from taking it, six ounces of a strong decoction with a quarter of an ounce of the powder may be given in a clyster, to which, if there be occasion, tinct. opii may commodlously be added. CHAPTER 19. Carbuncle Is a large red tutnour, usually appearing in the back, with a spongy base, loaded with a pu- History and Cure of Diseases. 83 rulent liquor, oozing out plentifully at any cracks or openings which it finds. Soon after the tu- mour begins, there comes on a considerable de- gree of fever, with great inquietude, and loss of strength, of appetite, sleep, and flesh; so that it has many marks of being the cause or effect of some extraordinary derangement of the health. Old persons and shattered constitutions are the usual subjects of this malady. The notion of its being commonly attended with a diabetes, has by no means been confirmed by my experience. In some cases, I have remarked only the usual quan- tity of urine, and that generally with a sediment ; and in one there was a total suppression of it for two days before the patient's death. Among those carbuncles which I have seen, several have proved fatal. As much bark should be given as the patient can take without loathing ; and as m'lch of an opiate as the inquietude and want of sleep may require. CHAPTER 20. Chorea Sancti Viti* The subjects of St. Vitus's dance are chiefly children from the age of ten to fifteen years, it has come on so early as the sixth year, and so late as in the twentieth. Among the patients whom I have attended, there have been four times as many girls as boys. Their legs and arms are agitated involuntarily, but the arms more than the legs ; and it is in a very imperfect and awk- 84 Commentaries on the ward manner that they perform any spontaneous motion. One side usually suffers more than the other, as in the hemiplegia ; but the disease does not always keep constantly in the same person to the same side. Some weakness, and cramps, and such slight symptoms of it, have usually been ob- served for some little time, and they have been known to continue for several months before the distemper was fully formed : it has also been brought on suddenly by convulsions : in many it has been preceded by a stiffness and pains of the knees. The tongue is so much affected, that none of these patients can speak plainly : several can hardly speak intelligibly, and some wholly lose all power of speaking at all. A boy had his legs so violently agitated, that the involuntary motions overpowered all the weaker efforts of his will to move them ; but a stronger exertion of the power which excites spontaneous motions \vi.s able to controul his distempered agitations, so that he could run, but could not walk : the same is observable in men intoxicated to a certain de- gree with strong liquors. This singular species of convulsions is accom- panied with giddiness, numbnesses, uneasiness of the stomach, disturbed sleep, and wasting of the flesh, though without much loss of appetite ; and for a time the understanding and temper become more childish. This malady is hardly ever fatal to the patients ; but is seldom removed in less than a month, and often resists all remedies for two or three, and has been known to last a year. A relapse is uncommon ; yet in some few, after they have seemingly recovered from this disease, History and Cure of Diseases. 85 there has been felt a little tendency to it every spring and autumn for three or four years. A violent affection of the mind has also made some symptoms of it return, so that slight traces of the agitations have been perceived for ten years ; if they were not rather hysteric, or paralytic com-, plaints, to which St. Vitus's dance is nearly al- lied. Nor does it seem more allied to them by the appearance of its symptoms, than by the cure "which it requires. Bleeding, and pui'ging, and violent medicines, can hardly be judged proper for a distemper attended with no inflammation, nor heat, and particularly incident to a very ten- der age, and to the weaker sex ,• and which, if left entirely to itself, would, I believe, generally cease spontaneously, and leave the constitution unhurt. This reasoning appears to me to have been justi- fied by fact aud experience. Where they have been used, I never saw any good effects from them, and rather suspect that they have done mischief. Pulv. myrrhae comp. gr. v. pil. opii gr. ij. made into two pills to be taken at bed-time every night, eccoprotics used occasionally, so as just to prevent costiveness, and a cup of any mild bitter infusion taken once or twice a day, is the method which has succeeded best with me : to which, when the patients begin to recover, the cold bath may be advantageously joined, in order more expeditiously and perfectly to restore their strength. I have known it borne extremely well in the very worst state of this malady. 86 Commentaries on the CHAPTER 21. Coxce Morbus et Exulceratio. There is a disease near the hip very different from the sciatica, or rheumatism, of that part; and though less painful, it occasions greater lame- ness, and is far more dangerous. It is seated in the joint of the thigh, and is attended with a re- markable pain in the knee, but with scarcely any in the part affected, even after the swelling is be- come very great, and a fluctuation of matter is perceivable. The thigh wastes, and the foot of that side is unable to support any share of the weight of the body. The patients sometimes die hectic, and wasted, before the swelling either breaks or is opened, but more commonly the ul- cer of the joint makes a way for the purulent matter to discharge itself outwardly : yet this sel- dom saves their lives, and never prevents their lameness. This disease will in some go on increasing for three years before it becomes fatal. It is chiefly found from the sixth to the sixteenth year, during which time of life the joints and external parts of the body suffer most from scrofulous complaints ; w^hich, after this age, seem to be turned upon the lungs, or abdominal viscera. The hip-evil evi- dently belongs to the scrofula ; and other scrofu- lous appearances are often joined with it. The Peruvian bark, and cicuta, opium, and eccopro- tics, make up the whole of the medicines, which History and Cure of Diseases, 87 either aim at the cure, or can occasionally relieve this most difficult and dangerous distemper. CHAPTER 22. Crurum Dolor^ Tumor^ Inflammation et Ulcus, Beside rheumatic and arthritic pains, with con- sequent weakness, almost to a loss of their use, which the legs suflfer in common with other parts of the body, they are peculiarly subject to oede- matous swellings without any pain ; secondly to a sharp humour, which swells and thickens, and hardens the skin, with an intolerable itching; which sharp humour oozes out copiously through cracks, where the skin has either burst, or has been torn by rubbing and scratching to allay the violence of the itching : thirdly, to erysipelatous inflammations with great pain, which return upon some persons once or twice every year, being preceded by shiverings and a hot fit, like an ague. This inflammation continues troublesome for seve- ral days at least, and will often end in an obsti- nate and ill-conditioned ulcer, which no art can heal for many years. These disorders are not always owing to inter- nal causes, but have sometimes appeared in con- sequence of external hurts of the legs, by which they have been weakened, or otherwise injured. Women are far more subject to all these diseases of the legs than men (except perhaps that erysi- pelatous inflammation, which lasts only a few days 88 Commentaries on the or weeks.) Healthy young women will often have their legs swell oedeinatousiy, especially in hot weather, which never happens to the young and healthy of the other sex. Pregnancy rarely fails to occasion this sort of swelling. A redness of the whole leg, with the skin thickened and hardened, and itching insufferably, with a great discharge of a sharp water, is very common among women after their fortieth year, remaining incurable for several years ; with which com- plaints fewer men are molested ; and the same may be said of ulcers of the legs. If then these swellings and inflammations, and ulcers, be almost peculiar to the legs, and chiefly incident to those, who from their age, or sex, or accidental hurts, may reasonable be supposed to have less firmness either in the textures of their whole bodies, or of this particular part, it should seem a right practice to add an additional strength by bandages and straight stockings : and how safely this may be done appears from the total vanishing of the tumour by a horizontal posture, without any apparent injury to the health; and from the ready healing of the inflammations and ulcers in many cases, where they were probably occasioned by weakness. But it undoubtedly happens that the morbid quantity, or quality of the humours, are no uncom- mon causes of the swellings and sores, which therefore cannot safely be repelled by violent means. An asthma, probably arising froD) water in the breast, which threatened every moment to be fatal, has immediately taken a more favourable History and Cure of Diseases, 89 turn as soon as the lower parts of the body began to swell ; and a sense of internal heats, with ruany disorders of the stomach, and other parts, have found as great relief by the formation of an ulcer in the leg; on the other hand, the healing of an ulcer in this part, has been followed by head-achs, giddiness, numbnesses, shortness of breath, loss of appetite, and pains of the stomach and bowels. A due attention to the present habit of the pa- tient's body, and to his former state of health, will afford the best direction to the physician's judgment in deciding, whether it be safe to cure these disorders, or necessary to let the present evil remain, in order to prevent a greater. The Rochelle, or any other of the purging salts, given twice or three times a week, so as to purge not more than thrice; two scruples of the Peruvian bark taken every day at any convenient hour; and, if there be occasion for any thing fur- ther, a quarter or a third or part or half a grain of calcined mercury, with a scruple of crude anti- mony swallowed every night, or every other night, will perhaps answer all the purposes of evacuating and correcting the morbid humours. They may be continued, if they be so long want- ed, for two or three months. An issue above the knee has been judged to contribute sometimes to the cure or prevention of an ulcer in the leg; and in other cases it has been useless. 12 90 Commentaries on the CHAPTER 23. Cutis Vitia, There is a great variety of cutaneous disor- ders. The several discolourings of the skin, brown, yellovr, black, and blue, hardly deserve to be reckoned among its diseases, where they neither rise above the level of the other parts, nor are attended with any unusual sensations. It may however be worth the mentioning, that I have seen some children with little purple spots, like the purples in bad fevers, all over their bo- dies, except that in some places there were larger patches of them as broad as the palm of ^he hand, unaccompanied with fever or any other alteration of their health, which after a few days sponta- neously vanished.* In old people, blue spots, about a quarter of an inch broad, are not uncom- mon. Small pimples frequently rise, and soon die away without spreading ; but they sometimes spread into a branny, or scaly blotch, or turn to a thick crust, cracking in various places ; whence a water oozes out, with which the legs and face, and more rarely the whole body, are covered, with equal deformity and inconvenience. Erup- tions, or risings above the skin, are red, or of the same colour with the skin, moist or dry, watery or purulent, smarting or itching, and sometimes without either. The nails too will become rough * See chapter 78. History and Cure of Diseases, 91 and thick and scaly. Pustules will arise so large as to approach the size of biles, which they re- semble. A heap of small watery pimples, after they have broken, have been known to leave a speck of blood, like the point of a pin, with itch- ing and swelling. Several of the appearances here mentioned have been distinguished among the ancient physi- cians by peculiar names : there is great difficulty, though happily not much use, in ascertaining the appearances to which these names were appro- priated ; for this reason the ancient divisions and titles of cutaneous diseases are very little regard- ed by the moderns. Almost all affections of the skin, which have no other name, are vulgarly, with great impropriety, called the scurvy. Of the true scurvy and leprosy I can say nothing, as they have never occurred in my practice ; beside these, the itch, shingles, and scald-head, are per- haps the only chronical cutaneous ails, for which we have names, in which all are agreed. Several of these maladies are hereditary : and even where they are not derived from the parents, they may still be the effects of a general disorder of the body, rather than merely local, and belong- ing only to the skin. Cutaneous ails, brought by some children with them into the world, have continued with very little interruption to the end of a long life. After the measles and small pox, disorders of the skin will make their appearance in some, who never had any of them before : it remains a doubt, whether they have been formed by some mischief arising from these diseases, or 9S Commentaries on the whether they have ^nlj been excited from latent seeds pre-existing in the body ; or lastly, whether their appearance at that time be not wholly casu- al : since it happens more seldom, than it proba- bly would, if the small pox and measles had a na- tural tendency either to breed any diseases in the skin, or to nourish them. The spring of the year is the season in which they are most apt to appear, or to grow worse ; and next to this may be reckoned the autumn ; but this is by no means constant. There is still much greater uncertainty with regard to summer and wmter ; so that it is hard to say whether more diseases of the skin be exasperated, or re- lieved, by either of them. The warmth of a bed, and of a fire, has made some spots of the skin re- treat, which never failed to re-appear in propor- tion as the body was cooled ; the contrary to this has been experienced in several instances, and perhaps in more. A moisture behind the ears is common in chil- dren ; and this, whether from neglect of keeping the part clean, or from the abundance and sharp- ness of the humour, will sometimes spread all over the head and face. The branny scurf, which is often observed in several patches all over the body, is very apt to begin at the point of the elbow. A violent itching of the skin with- out any eruption is familiar to the jaundice, and adds sometimes to the discomforts of old age.* Several women have had a pimple appear on *See afterwards chapter 76. ii ^History and Cure of Diseases. 93 their noses, which has been succeeded by a thick scab, covering by degrees, the nose, face, and neck; and has for many years eluded every method of cure w^hich a variety of physicians was able to suggest. This appearance is much less common, though not altogether unknown, in the other sex. A branny scurf in various parts of the skin, and particularly in the head, has infested some through their whole lives. There seems to be very little if any contagion in cutaneous disorders, if we except the itch and scald head. A woman, who had for five years had broad branny eruptions, suckled a child whose skin remained perfectly clear from any disorder. The itch is well known to be very infectious ; but there is an appearance exactly like it, and which could be traced up to its having been received from an infected person, and yet differs from the true psora by being very little, if at all infectious, by its resisting all the usual remedies, and by its returning frequently for many years. While the ears are swelled and red with a great watery dis- charge from behind them, it is very common for the lymphatic glands to be swelled, as they often are for a few days after a considerable discharge has been procured from the neighbouring parts by a blister. Many morbid appearances of the skin are judg- ed to be proofs of a diseased constitution, rather than merely local disorders of the part which is afflicted with them ; yet in some instances a hurt of the skin by a bruise or a burn has been the cause of a general mischief; so that in consequence 94 Commentaries on the of such an accident a clear habit of body has in an advanced age of hfe shewn all the marks of what is vulgarij called a scorbutic or even stru- mous taint. There are also other instances where cutaneous maladies, instead of relieving, have al- ways hurt the general health, never failing to be accompanied with head-achs and languors, which increased and decreased with the eruptions. Such cases however are rare ; and the reverse is much oftener met with, where some general ail of the body throws itself off in blotches and deformities of the skin ; so that when these retreat of them- selves, or are repelled, the patient will complain of head-achs, giddiness, lowness of spirits, want of sleep, cough, want of appetite, heart-burn, fla- tulence, sickness, pains of the stomach, wandering pains, feverishness, and wasting of the flesh. It is a doubt, whether some asthmatic, consumptive, and paralytic complaints, have been the effect of cutaneous distempers ceasing to appear, or whe- ther both of them have been owing to some com- mon cause ; for it has been not improbable, that some fatal mischief arising from other causes had so weakened the powers of life, that nature was unable to free herself any longer from that in- cumbrance which she used to throw off upon the skin. The moistur;'^^ so common behind the ears of children, during the first four years of their lives, requires only to have the parts kept Clean with a little warm water, and to be hindered from grow- ing together by means of a fine rag smeared with any mild ointment ; but all further application should be avoided, as having been sometimes at- I History and Cure of Diseases. 95 tended with convulsive fits, shortness of breath, and other bad consequences ; whereas none need be feared from suffering the disorder to take its own course, and from trusting to its curing itself, as soon as it is for the patient's benefit that it should be cured. Where mischief has ensued from repelling these eruptions in children by vio- lent means, a slight anointing of the parts, which had been affected, with the blister ointment, will be an useful method of recalling them. In adults there is usually less danger, than dif- ficulty, in freeing the skin from the several ble- mishes to which it is liable. There are too many so deeply rooted in the constitution, as to elude all the known external and internal remedies ; and they are often supposed to be cured when they are not ; for it is hard to determine whether they have yielded to the remedies, or have spon- taneously retreated ; which they have been known to do, and to be latent for aJDove twenty years, after which they have returned with unabated vi- gour ; plainly shewing that the cause had been neither subdued nor weakened. Where the per- spiration is great, and confined, as in the groin, under the breasts of women, and in the necks and other parts of very fat children, it is apt to grow acrid, and to fret the parts on which it lies ; the frequent washing of them, and the use of any soft ointment to prevent their rubbing against one an- other, will prove effectual remedies. During pregnancy many obstinate cutaneous maladies have been known to disappear spontaneously, which had long resisted all the usual medicines; ^ but after delivery they have returned in their for- ,96 Commentaries on the mer manner. There has been reason to believe that issues and blisters have in several instances proved useful drains to those morbid humours which made the skin foul and unsightly; but in others no benefit has seemed to arise from them. With regard to external applications, it is an useful general rule to employ acrid washes and unguents, where the diseased skin is accompanied with itching ; but where it is attended with sore- ness and pain, to use such mild ones as may miti- gate rather than increase the smart; otherwise, troublesome and even dangerous inflammations might be brought on. Water is the gentlest oi all external remedies, whether it be made a cold or warm bath, or applied in fomentation and vapour. It dilutes and weakens any sharp moisture which, by fretting the skin, may increase the evil ; and by suppleing the scales and crusts, makes them more easily thrown off. Salt, sulphur, and vari- ous herbs, are sometimes added to improve its detersive powers ; hence the sea water, and many natural springs, are judged more efficacious than plain water. Preparations of lead, though void of all acrimony, are in such general esteem as ex- ternal cutaneous remedies, that they are not only used to the disorders attended with heat and some degree of pain, but also to such as only itch, or are perfectly indolent. Extracts of lead made with vinegar, ceruse, and sugar of lead, formed into washes, ointments, and plaisters, are all in frequent use ; and it is not easy, from any experi- ence which I have had of them, to say which of these preparations is preferable to the others. The tar ointment may likewise be applied not^ History and Cure of Diseases. 97 only to such blotches as itch, but even to those where there are cracks and moist sores, without any fear of increasing the pain in most cases ; but in a few instances it has been known to dry, and create pain. Sulphur has a specific virtue in cur- ing one distemper of the skin, and there are few others in which it has not been tried externally and internally. The success, whatever it may have been, has by no means been so great as to hinder our doubting whether it have any, except in curing the itch. Tiie seeds of staves-acre, and the root of white hellebore, are both extreme- ly acrid, and require so much caution and accura- cy in the dose, that they have very rarely been ventured upon as internal medicines ; but when applied outwardly, they are safe and effectual in a degree, which may make it probable that, be- sides their acrimony, they have some specific powers in clearing the skin from foulnesses. One grain of white hellebore may be safely given in- ternally, but I know nothing of the internal use of staves-acre : half an ounce of the seeds of staves-acre, powdered, may be infused in half a pint of boiling water, to which, after it is cold, should be added as much brandy, and the parts affected are to be washed morning and night with the strained liquor. A lotion, applicable in the same manner, may be made by pouring twenty ounces of boiling water upon four or six drams of the powder of white hellebore root, and by ad- ding to the strained liquor four ounces of the tinc- ture of the same root. The only ill effects of I which I am aware from these lotions is the pain and constant inflammation which they may occa- sion ; this will easily be remedied by lowering I 98 Gomnientarles on the them with more water, till the heat and pain be- come moderate. There is such a difference of soundness and freshness in different parcels of these drugs, that there is no other way of exactly proportioning the quantity of water but by some help from trial ; not to mention the various de- grees of sensibility which is to be found in the skins of different persons. They may also be used in ointments, by mixing them with four times their quantity of simple ointment. Pepper, and many other acrimonious simples, have a place likewise among cutaneous remedies : upon this account cantharides in ointments and plasters have been used to clear the skin from its diseases; but I have not been witness to their virtues for this purpose often enough to be sufficiently acquainted with them. Solutions of alum, and of vitriol, will allay a troublesome itching of the skin which comes without an eruption, and will also destroy the half-dead scales, and clear the skin from seve- ral blemishes. The strength of these solutions must be limited by the pain and inflammation which they occasion : while these are slight, they can never be too strong. The same rule holds with regard to all the otlier acrimonious remedie? for the skin. Quicksilver, besides the corrosiveness of its preparations, appears to have some peculiar pow- ers in destroying the causes of some cutaneous maladies. Crude quicksilver, which is perfectly mild to the touch, when divided with any tena- cious substance, and applied in ointments and plas- ters, has been found considerably efficacious in cleansing the skin from many foulnesses. The History and Cure of Diseases. 99 chemical preparations of it add greatl-y to its pow- ers, by tne degree of acrioiony which thej pos- sess. The neatest of all these, but at the same time the most violent, is the corrosive sublimate, because it perfectly dissolves in water, or spirits of wine, and has neither colour nor smell. The others, being indissoluble in water, must be appli- ed in unguents and plasters. It must always be remembered, that besides the caution necessary to prevent pain and inflammation from thtf more acrimonious preparations of mercury, there is an- other thing to be attended to in the use of all of them, which is, not to employ them in so large a quantity as to occasion their peculiar effect of sa- livating. One dram of corrosive sublimate will generally be sufficient for a pint of water ; half an ounce is much loo large a quantity ; and I have known great pain and swelling ensue from wash- ing a very small portion of the skin with so strong a mercurial lotion. The corrosive sublimate should be dissolved in pure water preferably to lime water, which only weakens it, and gives it a disagreeable yellow colour. With regard to the probability of exciting a salivation, there will be a great difference, arising from the largeness of the surface of the body to which the mercurial medi- cine is applied. A very weak preparation spread over a large portion of the body, would be much more likely to raise a salivation, than a much stronger which covered only a small part of it. The ungueutum hydrargyri nitrati has been anoint- ed over the whole face every day for many days together, without any complaints either of present pain, or consequent salivation. How innocent a mercurial ointment may be made with one dram 100 Commentaries on the of the calx hydrargyri alba and one ounce, or half an ounce, of simple ointment, may be judged from the free use which is safely made in surgery of that stronger preparation, mercurius nitratus ruber. Magistery of bismuth, and flowers of zinc, either sprinkled upon the skin, or formed into an ointment, are rather cosmetic, than reme- dies for any harm considerable enough to be call- ed a distemper. The internal medicines are either such as eva- cuate the diseased tumours or correct them. — • Strong purges are improper for the first of these purposes, and will sooner exhaust the patient's strength than expel the cause of the distemper. A long continuance of the gentler purgatives is best calculated t© suit the obstinate nature of the dis- eases of the skin. The experience of mankind seems to have settled in preferring the purging salts as the most safe and commodious medicines of this class. They neither pall the stomach, nor require confinement ; and are so far from impair- ing^ the strength, that weakly persons have grown fatter and stronger during a twelve-months daily use of sea water. Whether they are best taken in sea water, or the natural solutions of various springs, or the artificial solutions in common wa- ter, and which of the neutral purging salts is the most friendly to the body, and most powerful against the distemper, all this seems to remain undecided by any experience with which I am ac- quainted. They should n4&t be given in such a dose as to purge above twice, and during their use frequent attention should be given to the state of the patient's strength and flesh ; for if History and Cure of Diseases. 101 these begin to be impaired, the purging ought to be laid aside. A great variety of internal remedies for cor- recting the unhealthy humours which shew them- selves upon the skin, are to be found in all prac- tical books of physic. Among all these the Pe- ruvian bark and mercurial preparations have ap- peared to me to do the most good. In the less urgent cases a dram of the powder of the bark must be taken once a day, or two scruples twice a day. for several months; and I know it may be taken for a very long time with great advantage to the general health, besides its virtues in clear- in^j the skin. There has been very great reason to believe that it has mended the appetite and di- gestion, and prevented catarrhs. In more violent disorders, a quarter of a grain of calcined mercu- ry has been given every day for three or four months with safety and benefit. A solution of corrosive sublimate, containing half a quarter of a grain, may be used in the same manner. This method of cure has, as far as I could judge, prov- ed the most successful ; but it will happen, I fear, to all the known methods, that they will be found too weak to subdue the obstinacy of some invete- rate cutaneous diseases. The herpes, or shingles, has begun with a pain which has lasted in some for two or three days before the eruption appeared. It consists of a heap of watery bladders, itching at first, of which there are sometimes so many as nearly to sur- round the body, whence it has its name of shin- gles, from cingulum. This eruption is now and iO^ Commentaries on the iben attended with a fever. The bladders should be opened, and the sharp serum let out, after which the parts may be covered with a soft ce- rate, to defend them from the rubbing of the clothes, for they are sometimes verj painful. It seldom happens that these little blisters turn to obstinate sores, though in old persons, and in bad constitutions, it will be several days before they are quite healed. But the greatest part of the misery is many times to come after they are per- fectly well, and the skin has recovered its natural appearance ; for I have known a most pungent burning pain left in the part, which has teazed the patient for several months, or even for two or three years ; nor have t found that any soothing or opiate application ever gave much relief. The uneasy sensation which succeeds the herpes has in some arisen only to a torpid feel. In one per- son, in whom the herpes had broken out near the collar bone and shoulder, such an exquisite ten- derness was left, that he dreaded to move his arm, and could hardly bear the application of any thing to the part, though made with the lightest feather : he was obliged to cover himself only with a loose gown, having, when I saw him, been una- ble for two or three years to put on a coat. However, this was the only instance in which I ever knew the pain rage with such extraordinary violence. In a woman more than fifty years old the her- pes appeared upon the right clavicle, together with fever, and pains throughout the whole right arm. The eruption and fever continued some weeks ; but the skin remained scaly for several History and Cure of Diseases. 103 months, and the whole arm became graduallj weaker, till it lost all power of spontaneous mo- tion ; and in this state it continued at least for three years, and probably for her whole life. The fingers were constantly in an involuntary tre- mour. The porrigo, or scald head, begins with little spots of a branny scurf, which itch and grow bald ; these gradually become larger and more numerous, till they cover the whole head, the skin of which will be sometimes so deeply affect- ed with the humour as to be full of moist sores or scabs. Children are more subject to this com- plaint than adults, and boys more than girls. Among grown persons, 1 have seen several wo- men labouring under this complaint, and but few men. It is an infectious distemper, and readily communicable where children use the same combs, or pillows, or put the same covering on their heads with the infected person, or hold their heads close to his ; but when all these circum- stances are cautiously avoided, I have known children live and play together in the same house, and yet one who had a scald head did not give it to the rest. In some constitutions it seems as if certain dis" eased humours were thrown out and appeared in the form of a scald head ; so that a cough has im- mediately ceased upon its coming on, and when it retreated the breathing has become short and la- borious. A species of this disorder has broken out during the infancy of some women, and ha» continued upon them to old age without yielding 104 Commentaries cm the to any medicines. There is no little difficulty in curing it, in children, though it may have been re- cently contracted ; and every one must have heard of such who have been under very skilful manage- ment for two or three years without the desired success. The best method, which I know, is to cut off the hair where the distemper has spread over a great part of the head, and to keep it anointed with- the tar ointment, covering it with a hog's bladder. If it heal by means of this application, as it often does, though it may be two or three months before it be well, I then recommend the head to be wetted morning and evening with the infusion of white hellebore root above mentioned, as long as any tendency to scurf is seen. If there should be any part of the head where the skin is more deeply diseased so as to form a sore, one dram of the calx hydrargyri alba mixed with half an ounce of a soft cerate makes an useful oint- ment, some of which spread upon a piece of thin leather may be applied, and renewed as often as it grows too dry to stick on any longer. Where a healthy person has manifestly contracted this distemper from others, I know of no want of any internal medicines. The scabies, psora, or itch, appears most com- monly like very small watery pimples, but some- times resembles the smaller variolous pustules, having a red base, and being filled with a yellow matter. Both these appearances are attended with excessive itching, and are found chiefly about the joints, and particularly between the fingers ; History and Cure of Diseases. 105 but very remarkably spare the face ; so that I am not sure that I ever saw the least marks of it there, though once or txvice I have been in doubt whether the face has not some httle share of it. No distemper is more infections than this : but it has before been mentioned, that there is a species of it, which was at first catched by infection, and thougli seemingly cured by the proper remedies, yet will continue to return once or twice every year, Without being contagious even to those who lie in the same bed, and without retreating at all the sooner from the application of any of the usu- al remedies. The itch has been imputed to certain animal- cules. I was told by that very dextrous experi- menter, and accurate observer, the late Mr. Can- ton, that he had looked for them, but had never been able to satisfy himself that there were any. I have heard the same from Mr. Henry Baker, whose well-known treatise upon the microscope shews that no one was better skilled in its use. It is observable, that of infectious distempers, some, like the small pox or measles, can be had but once ; or very seldom oftener, as the malignant sore throat, and hooping-cough ; or only in parti- cular circumstances, or certain constitutions of the air, as the dysentery, camp-fever, and plague ; but the itch and the Venereal distemper are very generally communicable at all times to all persons who come in the way of their contagion. It is not easy to say what would have been the state of mankind, if out of the three specifics with 14 10(1 Commentaines on the which Providence has blessed us, two of them had not opposed the universal infection with which these two disorders would otherwise have over- spread the whole world. There is a vulgar notion in some countries, that the itch is wholesome, and that there is dan- ger in curing it too soon : this is almost too ridicu- lous to be mentioned ; and yet I believe there is as much foundation for it, as for that more respec- table, because more general, notion of the whole- someness of the gout. The remedies for this dis- temper are in the first place sulphur, which has a specific or peculiar power of curing it, and is al- ways safe, and can never be applied too soon, and therefore is preferable to all others ; but it is often objected to on account of its smell, and of its be- ing less neat than other remedies. The most common way of using it is by mixing one part of flowers of sulphur with four parts of lard, and anointing the parts once every twenty-four hours, A cure is by these means usually eflfected in about ten days. A shirt being lightly sprinkled with the flowers of sulphur is said to be equally effec- tual ; and the late Mr. Cheselden told me, that the distemper would be cured if the feet only were anointed, without applying the ointment to any other parts of the body which have suffered from the itch. Crude quicksilver seems also to possess some specific powers ; for if it be divided by white of egg, or any tenacious substance, and soaked up by flannel, or if the unguentum hydrargyri be spread upon linen or leather, and worn round the I History and Cure of Biseases. 107 body in the form of a girdle, this application will frequently be successful. And jet, what is very extraordinary, it is not uncommon for persons to rise from a salivation, uncured of the itch, not- withstanding their having been constantly daubed with the mercurial ointment for a month or six weeks. It is doubtful whether the chemical pre- parations of mercury prove remedies on account of any specific virtue, or merely from their corro- siveness, which reduces these little foul sores to a state of healing, just as any other ill-conditioned ulcer is brought on to heal by similar means. The neatest of all these preparations is a solution of one dram, or at most two drams, of corrosive sublimate in one pint of pure water, with which the distempered parts may frequently be wetted. One dram of white precipitate mixed with four times its quantity of ointment, makes also a safe, and not an offensive medicine, which may be ap- plied every night. Some persons have complain- ed of lowness of spirits, pains of the bowels, and wandering pains, after being cured by the help of these girdles, washes, and ointments, which they laid to the charge of the mercurial ingredient. But since very few of those who have been cured by the same means have reason to suspect any thing of this kind, and since a much freer use is made of mercury upon several other occasions without any of these ill consequences, it is most probable that these patients were mistaken in as- signing this cause of their complaints. The root of white hellebore is preferred by some, as having no smell, being perfectly inno- cent, and seldom failing of success. Medicines m 108 Commentaries on the prepared from it should be made so strong as to occasion some smart, but no inflammation : this will coQimonlj be effected by one part of the powdered root and eight parts of ointment, used in the same manner as the sulphur ointment. The decoction or infusion of the same root, as mentioned above, will make a wash, which, used like the mercurial wash, will verj rarely disapr point the patient. CHAPTER 24. Destillatio, It was necessary that the throat, and mouth, and nose, and eyes, should all be kept in a slate of moisture ; for which purpose a liquid is secret- ed from certain glands and glandular membranes; and if this become incommodiously copious, it is called a catarrh or defluxion. This seems to arise sometimes from a too great weakness or re- laxation of the secreting organs ; and sometimes from an abundance of superfluous humour, which nature can more easily discharge by these out- lets ; or from the acririfiony of tlie liquid, which makes the ©yes tender, or irritates the nose to perpetual sneezing, or the trachea to coughing with hoarseness, creating a pungent sensation in the mouth, and making all the parts sore over which it flows. When the catarrh affects only the eyes, or nostrils, and the cavities which open into them, it is not attended with any cough ; but if its seat be in the glands of the throat, then History and Cure of Diseases. 409 there will not only be a cough in the day-time, but the defluxion will collect in such quantities during the first sound sleep before it wakes the person, that at last he starts up almost suffocated, and it is with great efforts that he clears the tra- chea so as to recover the po\ver of breathing with tolerable ease : possibly some may have died sud- denly, having been choked in this manner. A sudden sense of suffocation frequently attacks some persons, and it is with great and laborious efforts that they save themselves from being chok-* ed. Is not this affection a peculiar kind of con- vulsion ? and is not the thin froth which they ex- pectorate in their struggle for breath, rather the effect, than the cause of this disorder ? If such a catarrh lasts only a few days, it is called a cold in the head ; but in many it becomes a chronical disorder, and has lasted with no long intervals for several months, for four years, or every night for ten years ; or has returned peri- odically twice a month for several years, or once in three weeks. I have known it return in four or five persons annually in the months of April, May, June, or July, and last a month with great violence. In one a catarrh constantly visited him every summer; and in another this was the only part of the year in which it ceased to be trouble- some. The state of pregnancy has several times been attended with this complaint : and I remem- ber it to have once continued for four years after the pregnancy. Irregularities of the menstrua, among other disorders of the health, have also been accompanied with an excessive flow of sali- va ; and hysteric women have been infested with ilO Commentaries on the it for two or three months, in a degree not infe- riour to that of a moderate sahvation raised with quicksilver. A bad sore throat has in some per- sons been followed for a long time by a very troublesome degree of spitting. But the salivary glands are peculiarly affected, as is well known, by mercurial medicines ; after the use of which a considerable salivation has teazed some patients for many months, and in two or three it has con- tinued frequently to return for above three years. jEthiop's mineral has several times had a similar effect; and in one who had taken it forty days a great spitting ensued, which lasted three years. Many women have, within my observation, suffer- ed in this manner from mercurial preparations; but I hardly recollect an instance of it in the oth- er sex. Such extraordinary discharges of saliva have in a few instances evidently wasted the flesh, and weakened the body; but have been often borne for a long time without any manifest injury of the health. A weight and pains of the head have so frequently been relieved by a great catarrh, that in such cases it may be considered rather as a remedy, than a disease, and therefore violent means should not be employed to check it. These pains with feverishness and a slight defluxion are in some years epidemical, occasioning a remarka- ble languor, at least for some days, which has hung upon some patients, together with night sweats and loss of appetite, for a long time, and has ended at last in a fatal pulmonary consump- tion, after a gradual decline for two or three years. History and Cure of Diseases, i 11 An habitual catarrh has spontaneously ceased in the seventieth year of hfe, and also upon the coming on of a palsy ; but has been oftener known to end in an asthma. In many cases a variety of means has been used to stop it with very little ef- fect. A spontaneous discharge of thin lymph from both the outside and inside of the ears has been found to check a catarrh ; and so has an artificial one made by a blister. The pillulse ca- tarrhales of many dispensatories, consisting of aloes and opium, seem well calculated to divert the humour, and to sooth the irritation. The mu- cilage of quince seeds is very grateful, where the mouth is sore : where the glands are only weak and relaxed, the astringent decoctions of oak- bark, with alum dissolved in them, may have their use. A fit of the gout has supervened a catarrh, without affording any relief. Two persons, for other purposes, took at least a dram of the Peru- vian bark every day for many months, during all which time they were free from that sort of ca- tarrh which is commonly called a cold in the head, to which they had both of them been re- markably subject. CHAPTER 25. Devoratio, A CHILD two years and a half old swallowed two round pieces of copper money : the diameter of one was one inch and one tenth of an inch : the 11^ dommentaries on the other was a little less. She seemed very ill lor the first week after, and was unwilling to take down any food ; which might be owing to the soreness of the throat, which these pieces had oc- casioned in passing. After this time she frequent- ly took a little castor-oil, and enjoyed her usual health, complaining of nothing. Twenty-nine days after she had swallowed these pieces, tliey were both voided by stool, and did not show any sign of rust or corrosion. The power of swallowing is weakened, and sometimes wholly lost, from various causes. In hysteric fits it is not uncommon to be unable to get any thing down ; and a difficulty of doing it has constantly attended some women every time of their pregnancy. It is often seen that spasms, from whatever cause they arise, will come on in the middle of eating, stopping for a little while the descent of any thing into the stomach, and occasioning great efforts to clear the oesophagus, which force up much phlegm, but nothing of what had been before eaten. This has returned at very uncertain periods, once in ten days, or three or four times in a year, and has lasted in this manner for several years. The muscles serv- ing to deglutition are also liable to be seized with a paralytic weakness, rendering them incapable of performing their proper offices. A still more dangerous species of this disorder arises from a strumous swelling of the glands, which happens in all parts of the oesophagus from the fauces to the cardia ; in consequence of which the swallow- ing becomes gradually more and more difficult, till it be at last totally obstructed. I have known History and Cure of Diseases, 113 the same fatal mischief happen to the respiration froni the same cause. Besides these general incapacities of swallow- ing any thing, there are partial ones, which re- spect only particular things. Some have been able to swallow any food, except meai ; others have readily taken down liquids, but not solids ; and, what is more strange, in other cases solids have found a passage down into the stomach with much greater ease than liquids. Though I have had opportunities of frequently observing most of these complaints, yet I have not been able to sa- tisfy myself that any means which I have used have proved peculiarly serviceable, above the ge- neral method of treating those distempers to which the complaints appear to be related. The use of nourishing clysters is well known, by the assistance of which time may be gained ; and this in some of these disorders is of the utmost impor- tance. CHAPTER 26. Diabeies. The diabetes is a complaint which happily oc- curs but seldom ; and hence, 1 imagine, it has hap- pened, that the history of it in books is not very clear and precise ; nor has my own experience satisfied me in supplying their defects. I have scarcely had opportunities of observing twenty cases, where this was supposed to be the distem- 15 114 Commentaries on the per ; and some of these seemed not to deserve the name. In fevers, which proved fatal, 1 have once or twice known the symptom of a perpetual making of water, and in large quantities, with in- exringuisliable thirst. But the more usual man- ner in which this excess of urine shows itself, ranks it with chronical disorders. An unusual thirst is first taken notice of, with a tongue rough and furred, and a bad taste in the mouth; the ap- petite fails; the pulse is too quick; the strength and flesh waste ; the skin is in a burning heat, without the least tendency to sweat ; the thirst makes these patients drink immoderately, and of course they make water much more frequently than is common to them, and in much larger quantities, like hysterical persons. The urine should naturally be about four fifths of the drink; but even in health it will fall consi- derably short of this now and then for the space of a day, and will sometimes exceed the whole of what has been drunk ; and when it does, it will resemble common water more than urine, in its want of colour, taste, and smell. The urine in a diabetes is said to have a honey-like sweetness ; but in my judgment, formed upon the most per- fect cases of this distemper, it ought in most per- sons rather to be called insipid : in one, joined with a fever, I found it sweetish. An extraordi- nary flow of urine has been remarkable for some months ; and yet, when measured, has not been found to exceed the drink, which, on account of the thirst, is more than these patients are usually aware of However, towards the end of the dis- temper, the urine will considerably surpass the li- I History and Cure of Diseases, ii^ quor, so as to be double of what they have taken. This deviation of the urine from its natural state will continue sometimes more, and sometimes less, for three or four jears, and has returned af- ter seeming to be entirely gone. Though the excess of urine is the circumstance which has been chiefly attended to, yet, in every case of this kind which 1 have seen, the thirst has been first in time, and by far the most distressing, and what ought rather to have given name to the distemper; but, in truth, they seem both to be rather symptoms of the breaking up of a consti- tution, and have hardly ever been known but in very infirm and old people, in whom age or dis- temper had so far injured some of the parts ne- cessary to life, that death must soon have ensued, whether the patient made too much water, and was wasted in a diabetes, or made hardly any, and was bloated in a dropsy. It is not very im- probable, that some trivial circumstance deter- mined the body to take on one of these two dis- eases rather than the other, and that the remov- ing of either of them would do but little towards saving the patient's life. If the diabetes be, as I am inclined to think, the symptom of some other distemper, and not the disease of any of the organs which secrete the urine, the only useful remedies will be those which are directed to cure the principal malady, of which the diabetes is but an appendage. Ac- cordingly it has appeared to me, that little good was to be done with alum, the Peruvian bark, elixir of vitriol, Bristol water, lime water, a repe- 116 Commentaries on the titioii of emetics, or any other medicines, which were principally calculated to recover the kid- neys from their supposed relaxed state to their natural tone and firmness.* CHAPTER 27. Diarrhcea, A DIARRHCEA aHses from a variety of causes, most of which are void of all danger, and are ea- sily removed. It is often brought on by that power, which is exerted in every part of the body, of freeing itself from any thing painful and op- pressive. Not only the mischief from the noxious qualities, and improper quantities of what has been taken, and immediately offends the stomach, are carried off by means of a diarrhcea, but like- wise many disorders of remote parts, or of the whole body, (such as morbid impressions from the causes of epidemical coniplaints, and of fe- vers) are by the self-correcting powers of an ani- mal body determined to the bowels, and thence* discharged by a diarrhoea. The observation of this has given occasion to that useful caution of not being too hasty in stop- ping a recent spontaneous purging, it being fre- * A young man, who had laboured under a true diabetes for twelve monUis, was seized with an acute fever, and died. The body wliich was carefully examined, showed no marks of disease. The kidneys weve iujagined to-be rather fuller of blood than usu- al ; and the gall-bladder was perfectly empty. — E. History and Cure of Diseases. 117 quently useful to co-operate with nature in pro- moling this evacuation. For this purpose rhu- barb has been chiefly recommended, and deserv- edly; but instead of rhubarb I have many times given two or three drams of the neutral purging salts, and think they have always done as well, and in some cases better, by making a more speedy and complete evacuation of what had offended the bowels, and with less sickness. An emetic is also successfully used where the nausea is very great; but otherwise 1 think a vomit is unnecessary. Fifteen grains of powdered ipecacuanha, or even half a pint of carduus or camomile-flower tea, will jBufliciently answer this purpose. ^ After what had oppressed the bowels has been removed, a weak or two irritable a state of them may still continue : hence arise indigestions, flatu- lence, heartburn, frequent returns of the diar- rhoea, and a predominant acid in the stomach. The testaceous powders and chalk julep are the proper correctors of this too ready acescence of the humours; which therefore should be employ- ed : but they will not alone be of much avail in stopping a diarrhoea which is considerable enougji to require any medicines at all. Nutmeg, cinna- mon, pomegranate bark, and many other astrin- gent vegetable substances, are much more effica- cious, but yet often require to be joined with remedies which sooth the too great irritableness of the intestines, namely gum-arabic, starch, and opiates. Half a^lram of testaceous powder, fif- teen grains of pomegranate bark, and half a scru- ple of nutmeg, with three drops of tincture of opi- um, may be taken in any distilled, or common 118 Commentaries on the water, once or twice a day in the more chronical and habitual purgings, or once in six hours iu^the more recent and violent ones. Tinctura opii mix- ed in anj pleasant julep, so as to let the patient take as much as contains three or four drops after every pinging stool, is in many cases required : and besides this manner of giving the opium, it is often extremely serviceable to give from twenty to forty drops in a quarter of a pint of mucilage of quince seeds, or of starch, administered in a clyster. Gum-arabic dissolved in water, or in milk and water, may be taken to the quantity of one ounce in twenty-four hours : and, lastly, one large spoonful of clean mutton fat, mixed with a quarter of a pint of milk hot enough to melt the fat, and drunk twice a day, is not only a good re- medy, but nourishing food. This method has appeared to me the most ef- fectual, where the diarrhoea was curable and need- ed to be cured ; but there are instances of its be- ing habitual and harmless, at least for several years, and returning upon the slightest occasions for the greatest part of a person's life. I have seen an instance of a diarrhoea's continuing for three months at the rate of twenty times in a day without any apparent injury to the health. In such cases it is difficult, and perhaps hardly desi- rable, to effect a cure of what is not so much a distemper, as an inconvenience, which may be more than compensated by the benefit which it does to the general habit of me body. Where the appetite fails, and the flesh wastes, no time should be lost in checking the purging ; but if neither of these be affected, a cautious delay, and I History and Cure of Diseases. 119 gentle remedies, will prove the best means of re- storing the patient. Among the many causes of diarrhoeas, there are some, though few in proportion to the others, which are neither to be checked by the milder, nor subdued by the more vigorous methods of cure, but end only in the patient's death, after having been in vain opposed, as is usual in despe- rate cases, by a variety of regular and irregular practitioners. In some of these the glands of the mesentary and intestines have been found schir- rous ; in others, though they were opened, and all the parts examined by the most experienced and dexterous anatomists, the stomach and bow- els have appeared in a natural state, and no cause of the distemper could be discovered. 1 have not mentioned a sea voyage, nor the Bath, be- cause 1 have known them fail so often, that I have no encouragement to depend upon them ; and ra- ther think, where they have been supposed to be successful, that the success was in reality ow- ing to other causes. CHAPTER 28. Digitorum Nodi, Wh.\t are those little hard knobs, about the size of a small pea, which are frequently seen up- on the fingers, particularly a little below the top, near the joint ? They have no connexion with the gout, being found in persons who never had it ; ISO Commentmnes on the they continue for life ; and being hardly ever at- tended with pain, or disposed to become sores, are rather unsightl}^ than inconvenient, though they must be some little hindrance to the free use of the fingers. CHAPTER 29. Dolor, Pain is a symptom attending upon a variety of disorders, and is spmetimes itself the whole dis- temper. It is distinguished sometimes by being periodical ; sometimes it has a particular name from the part which is frequently its seat ; as head-ach, hemicrania, lumbago. All other parts of the body, which have any sense of feeling, are necessarily liable to pain, though they be not so frequently molested, as that the pain should be ranked as a distinct species with ^ particular name. Accordingly, there is no part of the body, or limbs, in which I have not observed a trouble- some and lasting pain without any discolouring, or swelling, or tendency to inflammation. It will remain fixed in the same place not only for months, but frequently from one to ten years ; and I have known such a pain complained of for fif- teen, sixteen, seventeen, twenty-four, and even thirty years. The more lasting of these pains are, as might be expected, moderate in degree : however, a few have continued for years, and yet at times have t History and Cure of Diseases, ISl raged with a veheraonce scarcely to be endured. Both sexes are subject to them, but women much ot'tener than men, and particularly the very young, and the iniirm, and the pregnant. The thorax and hypochondria are the parts which most fre- quently suffer from them ; and though some of these uneasy sensations gaay arise from internal disorders, yet in many instances there has been no reason to suspect that the hjngs, or liver, or any other of the viscera, had the least share in producing them. In most of these patients the pains could not be traced up to any certain cause ; but in several they have apparently arisen from terrour and grief, and anxiety, and have unques- tionably been recalled and exasperated by some disturbance of mind. In several instances no sort of relief has been obtained from the cold bath, fomentations, lini- ments with or without tinctura opii, warm plas- ters, blisters, cupping, vomiting, purging, sudori- fics : setons, and even a spontaneous abscess near the part affected has failed of doing good ; Bath, and sea voyages, have proved equally unsuccess- ful. It is probable that no great hurt is done to the seat of this pain, since it has continued so long without causing any swelling or change of colour ; and yet I have once or twice known such ill-con- ditioned biles, and such a tendency to a mortifica- ion, follow the use of a blister, as if the part was far from being in a perfectly sound state ; though there were no manifest signs of its being other- wise, except the pain. Tlie means which have the seldomest failed, and have in some cases evi- dently contributed to the cure, are cold-bathing, 16 1S2 Commentaries on the small perpetual blisters, or (if there be objections to blisters) emplastrum cymini worn for a long time. The most powerful internal medicine is tinctura opii, from ten drops to thirty given at night alone, or as many choose to give it, either in a spoonful of lac ammoniacura, or with a quar- ter of ^ grain of emetip tartar. The extract of hemlock has now and then appeared to weaken the cause of these obstinate ails. Cupping has sometimes succeeded ; hut all other bleeding, to- gether with emetics, and cathartics, have general- ly proved at least useless. Beside the pains which are either constantly felt, or rage at certain times, there are others which are regularly intermittent, the fits of which return as periodically as those of an ague : such I have known in the bowels, stomach, breast, loins, arms, and hips, though it be but seldom that these parts suffer in this manner ; but the head and face are frequently afflicted with a periodical pain, which by its violence and duration is not the least of the maladies which embitter human hfe ; of these some account will be found under the arti- cle Capitis Dolores inter mittentes. CHAPTER 30. Dolores vagi. Wandering pains are near akin to the rheuma- tism, but may be distinguished from it by their being accompanied neither with swelling, nor any Mstovy and Cure of Diseases. 183 discolouring of the skin. Are they not chiefly suflfered by those, whose muscular fibres Rave been weakened, strained, or stiffened, by long ill- nesses, profuse bleedings, bruises, irregular living, hard working, or the advances of age ? They usu- ally continue for many years witFiout other ill con- sequences than becoming gradually a little more troublesome ; but, in a very few, the parts princi- pally affected have their power of motion more and more lessened, till at last it be quite lost. Time, and Warm bathing, and flannel, may contri- bute a little to the cure, or relief, or however to checking the progress of these Ails ; and there are scarcely any other helps to be given. CHAPTER 31. Dysenteria, The Dysentery is common in camps, but does not often infest those who live in healthy places with the conveniences of life about them, except at certain seasons, when it becomes epidemical,, particularly among children, old women, and in- firm men, and it is then fatal to many. The dis- tinguishing symptoms of it are frequent wants of going to stool, with excessive pain, and the void- ing without any relief a very little inodorous mu- cus, often tinged with blood, and sometimes pure blood ; a pain just under the navel, together with a fever, and great loss of appetite, sleep, and strength, and sometimes a vomiting. 134 Commentaries on the Since this distemper is commonly bred in camps by foul air, and is in some degree contagious (yet I have seldom seen two dysenteric persons in the same house,) too great care cannot be taken in regard to cleanliness and fresh air, both for the sake of the patient and his attendants. The usu- al methods of treating this malady with which I was acquainted, eften failed of procuring ease, and of preventing its ending fatally in a sphace- lus of the bowels. It appeared that in a dysente- ry some hurtful humours had been deposited in the intestines, which threw them into such disor- derly a<>Mtations as to hinder the expulsion of what had offended them. The readiness with which the neutral salts (especia|ly the cathartic salt) purge, their power of controlling and quiet- ing the irregular motions of the bowels, and their aptness to stay upon the stomach without being vomited up, made me conceive hopes that they Would make a valuable addition to the anti-dysen- teric medicines. At first I gave only one dram every six hours, which evidently soothed the pains very soon, and before it had any effect as a purge. In other cases larger quantities were given, and with the double good effect both of affording pre- sent ease, and afterwards of entirely removing, by effectual evacuations, the cause of the disor- der. After the danger of the distemper is past, the f)atient will still be teazed with a tenesmus as ong as any soreness or extraordinary tenderness of the rectum remains ; in which case a clyster of half a pint of fat mutton broth and twenty drops oi tinctura Thebaica scarcely ever fails of prov- History and Cure of Diseases, 125 in^ a cure ; and it is almost the onlj stage of the illness in which opium is either useful or safe : if it were given in the beginning to quiet the pain before any evacuation had been made, 1 appre- hend it would be very prejudicial. Where this distemper has ended fatally, it has been attended with a hiccup, and a fetid water voided by stool. CHAPTER 32. Ebrietas, The effects of hard drinking are, flatulence, loss of appetite, morning sickness, wasting of the flesh and strength, tremblings, pains of the sto- mach, cough, jaundice, dropsy, forgetfulness and inattention, giddiness, diarrhoea, broken sleep. If remedies be applied in time, and the habit of drinking can be broken, much may be hoped for in restoring the health. It is generally a favoura- ble circumstance to have an illness arise from an external cause, rather than from any internal fail- ing. Men of a strong constitution and high health are those who most usually indulge themselves in this excess; and these circumstances, which be- trayed them into their danger, will greatly assist in helping them out. Bath water seems specifically efficacious in cur- ing these complaints, if applied to in time, before the liver and stomach are too deeply hurt. Nor 1S6 Commentaries on the is Bath only a remedy against the mischief which has been already done ; but it is also singularly useful in preventing a relapse, by enabling the patients to correct the habit of drinking : for the nature of this water is so friendly in warming and comforting the stomach, as to relieve all that coldness and anxiety which almost irresistibly force a hard drinker to fly to strong liquors for ease under these insufferable sensations. Warm aperient medicines occasionally used so as to pre- vent costiveness, if there be a disposition that way, and bitters, are the whole of what is further ne- CGssarv to establish the health. CHAPTER 33. Epilepsia, The epilepsy may be called the reproach of physicians as well as the gout ; for it was well known before the writing of the most ancient me-r dical books, and yet no certain method of cure has been discovered. The number of remedies, which are to be found for it in books and vulgar tradition, afford a strong presumption that we have no effectual one. The difficulty of curing this disease, either by the cautious practice of such who have a character to lose, or the more hazardous attempts of men who have a character to get, is sufficiently evident from its having re- mained uncured in some who were enabled by their wealth and power^ and proiopted by their History and Cure of Diseases. credulity, impatience, or despair, to try all sorts of means for its removal. The good sense of the world has done more than medicine towards miti- gating this great evil, by lessening the imaginary part of it : for it is now generally considered in the same light with any other distemper, without adding to its malignity by the workings of fancy or superstition. It is no longer believed to be the immediate effect of some demon's malice ; nor is it regarded enough to let it dissolve public councils, and to put a stop to all business; neither is it detested with that degree of horrour by the ac- quaintance and friends, which must have shocked the miserable patient more than the cruellest at- tacks of the disease.* The fit makes the patient fall down senseless ; and without his will or consciousness presently every muscle is put in action, as if all the powers of the body were exerted to free itself from some great violence. In these strong and universal convulsions, the urine, excrements, and seed, are sometimes forced away, and the mouth is covered with foam, which will be bloody, when the tongue has been bitten, as it often is in the agony. This * Among the ancients, when any one happened to be seized with an epileptic fit, those who were present used to spit, and some- times into their own bosoms; either to show their abomination, or to avert the omen from themselves. Piautus calls this distem- per. Morbus qui spuiatur. Captiv. act. iii. seen. iv. v. 1&. and from what follows, it seems as if they used to spit upon the epi- leptics as a charm to relieve the convulsions. Eum morbum mihi cwfi, ut qui me opus sit iiisputarier. yer.2l. Multos iste morbus macerate quibus insputari salutifuit. v. 22. Hence it has been con- jectured, that St. Paul's thorn in thejlesh, 2 Cor. xii. 7. and infir- mity of the flesh, Gal. iv. 13. and temptation in the fleshy ver. 14. might be the epilepsy, and that the word «|e7r7y!raT8 isusedHterallj% and not in a metaphorical sense. 138 Commentaries on the wretched condition affords a picture of the great- est misery and distress even to a stranger ; to the friends and relations the horrour of such a sight is much greater; but happily the patients them- selves know nothing during the fit of what the body is enduring. Many suffer these attacks without the least previous notice ; others are sensible of their ap- proach; and the shock which this foreboding oc- casions is compensated by their being able to secure themselves from some of the mischiefs of a sudden unforeseen fall. It is not unusual to have a little warning of some of the first fits, and after- wards to have them come on without any previ- ous sign. The more common symptoms which are the remoter forerunners of a fit, are a general restlessness and uneasiness, a head ach, vertigo, and other disagreeable feels in the head, disorders of the stomach, and sleepiness ; these will in many persons hang upon them for two or three days before they fall. The most usual sensations im- mediately before the fit are a slight delirium, which will sometimes continue three or four hours, and a vapour rising up out of the stomach to the head, which in some few affects their palates and nostrils like musk. The less common warnings of the approach of the falling sickness are pains in the bowels, numbness of the hands and arms, a peculiar sensation in some of the extremities gra- dually diffusing itself all over the body, dimness of sight, a faltering, and difficulty, or a total loss of speech, a hiccup, a vomiting and purging, a pain in the back, a coldness of the extremities, a great defluxioii of phlegm, a blackness of the face, History and Cure of Diseases. 129 and shortness of breath ; lastly, a tendency to fainting will sometimes be followed by a fit, and sometimes the fit will seem to rise no higher than this, and the patient will escape for that time with feeling no more of it than this half fainting, joined perhaps with a forgetfulness or delirium for a few minutes. These are the shortest fits of all ; the more common ones will last from a quarter of an hour to three hours ; and in more eitraordinary cases the patient will lie senseless for two or three days, having during all this time frequent accesses of convulsions or fits. Giddiness, and dark spots dancing before the eyes, are the con- stant attendants on some epilepsies. All possible varieties are to be found in the re- turns of this distemper : many will have several of the slighter fits every day, or one in a day, or one in a week, or every month, or only two or three in a year. The epilepsy has Iain dormant for thirteen years, and then returned worse and oftener ; in others the respite has been still much longer, though with such threatenings of a re- lapse, as to put it out of all doubt that the cause still remained. After the convulsions have ceas- ed, and the patient begins to come to himself, he generally falls into a sound sleep, for one, or two, or even six hours. It is obvious to suppose that this sleep must prove a relief after the fatigue of the convulsions ; and I never knew but one in- stance in which it was found so detrimental, that the patient requested always to be roused from it, as he could never indulge it without being the worse. It must be owned that sleep seems to fa- vour the returns of these fits, just as it aggravates 17 130 Commentaries on the all the distempers attributed to the nerves ; the first attacks of the epilepsy being most usually in the night, just after the first sleep. Some epileptics feel themselves so little hurt oi altered by a fit, that, knowing nothing of what passes during the time of it, they can hardly be persuaded that they have had one. Others af- ter they have come to themselves have felt a hea- viness and numbness for three hours, or a head- ach, a sickness and vomiting, a languor and dull- ness, or have not perfectly recovered their under- standing and memory for two or three days : and these are the immediate effects of single fits> The more distant ones of repeated fits are, forget- fulness, stupidity, childishness, and a general de- bility of the body, or a palsy of some parts, or an apoplexy. These consequences appear very soon in some, while others continue a long time unhurt by these violent shocks ; so that some who began to labour under this malady very early in life, and had experienced many returns of it, have yet liv- ed to be promoted to some high offices in the state, merely on account of their extraordinary abilities. Julius Caesar is well known to have been a remarkable instance of this kind. Both sexes, and every age, are liable to this ill- ness ; children are much more so than adults, and much more easily get rid of it. One would like- wise expect that the weaker sex would, on ac- count of their weakness, be greater sufferers by epilepsies ; but it has appeared to me, that though boys and girls be equally subject to epileptic con- vulsions, yet fewer women are afflicted with them History and Cure of Diseases, lai than men. Convulsions are so common in chil- dren, from the day of their birth to their third or fourth year, as to make it probable that they may be occasioned by a variety of transient causes, such as worms, accidental indigestions, griping pains of the bowels, and many other sharp and sudden pains ; there is therefore always ground to hope that a child's convulsions may not pro- ceed from the same obstinate cause from which epilepsies arise in adults ; and accordingly many children under four or five years of age have had a few such fits, who have never afterwards expe- rienced a return. The true epilepsy most usual- ly shews itself in childhood or youth ; but there is hardly any time of life, from the first day of it to extreme old age, at which it has not been known to make its first- appearance. I have not- ed several who have begun to be epileptic at al- most every year between twenty and Mty ; a few have fallen into it at sixty ; and I saw one whosd first attack was in the seventy-fifth year of his life, and from that time he was often visited with it for at least six or sev^n years, and probably as long as he lived. It has been an old observation among physi- cians, that epilepsies beginning in childhood often terminate about the year of puberty ; which has by no means been Verified by any experience which has fallen in my way. On the contrary, this malady has appeared to me often to come on at that time o( life, but 1 have not remarked one instance of its yielding in either sex to the change made by puberty. Wherever it has lasted be- yond the fifth or sixth year, it has generally prov- 13S Commentaries on the ed a tedious distemper, and reached it beyond the beginning of maturity. If I could therefore sup- pose that in forty years practice a sufficient num- ber of epilepsies might occur upon which to form a judgment of this aphorism, I should be inclined to think that it was founded on theory, or in the hopes of the physician, rather than in fact. As there is no age at which this great affliction does not come on, so there is hardly any at which it has not finally left the patient.* But it must be owned that it is doubtful whether nature has not had more share in most cures than medicine, be- cause there is none which has not failed so often, that we cannot be confident of its having much merit where it has appeared to succeed. The epilepsy is in some degree hereditary; yet as there are several examples of its being cured, or spontaneously ceasing, in those whom it had frequently attacked, there is a stronger reason to hope that its powers may be often spent before it reaches the children ; and it is found in fact, that many pass their whole lives untainted with this part of the constitution of their parents. In the beginning of the epileptic fit care should be taken to loosen any bandage which might be about the neck ; for this part is apt to swell, and without this precaution might endanger suffoca- * Nicolaus Leonicenus a cunabulis ipsis ad trigesimum annum morbo comitiali adeo laborabat, ut pertaesus vitae pene sibi ma- nus afferret : sed post trigesimum annum plane eo malo defunc- tus, omnibus membrorum ac sensuum officiis integer, nnlla morbi suspieione ad quartum et Donagesimum annum perFcnit. — Jos Seal, ep. 19. History and Cure of Diseases. 133 tion : the patient should be placed upon a couch, or bed, and watched that he may not fall off, and that he may not throw his legs or arms about in such a manner as to hurt himself. All further officiousness will be prejudicial. To force liquids into the mouth, to hold pungent salts to the nose, to rub the temples, and to force open the hands, is certainly useless, and not quite innocent. To open a vein upon account of the fit is still worse, being a needless waste of blood, which may weak- en the patient, but not the disease. The interval of the fits is the only proper time in which any re- medies should be employed ; and in such cases as this, where the experience of mankind has not yet discovered any upon which we can have much de- pendence, there is the most good to be done by finding out the weak part of the patient's consti- tution, and directing such means as will keep him in the best general health, that he may have eve- ry assistance from the powers of life ; for they are so formed, that they are always ready to exert themselves in weakening and removing whatever distresses them ; and the stronger they are, the more vigorous and successful will their efforts be. No simple has had a greater reputation as an ante-epileptic than the wild valerian root, and it may have been beneficial in some cases ; but one ounce, and even fifteen drams, have been given every day with little or no advantage. The gout has come on without affording any relief, nor can I say much in favour of blisters, issues, setons, the cold bath, and chalybeate waters, except where they have been useful to the general health. Quicksilver I have known used both inwardly and d34 Commentaries on the outwardly ; and if it have seemed to do good in one case, it has certainly been useless in another. Two persons have imputed their cure to a total abstinence from all animal food ; but the same ab- stemious diet has failed in a third. Five ounces of a very strong infusion of wild valerian root, with one dram of musk, given as a clyster every eight hours for three days in a desperate case, had the credit, and perhaps justly, of saving the life of one who had lain senseless, with frequent returns of convulsions, for two or three days. Worms in children, or disordered bowels, have occasioned convulsive fits ; and gentle purgatives will generally cure them, by removing the cause : but purges should always be avoided in a just epilepsy, because the causes of it will be aggra- vated by purging. I knew a girl whose fits al- ways came on just after her having a stool. Vo- mits 1 have known to be equally hurtful, and like- wise bleeding. Sleep unquestionably disposes a fit to come on, and a too great indulgence in this article may probably contribute to fix the distem- per. All occasions of terrour should carefully be avoided ; for terrour will not only bring on a fit, but has been the original cause of the distemper. A life of debauchery, and particularly an intem- perate use of women, has a peculiar tendency to produce and strengthen this evil. My experience has furnished me with so little to say concerning the numerous anti-epileptic medicines to be found in all the practical writers, that I must let their merit rest on the characters of them which arc there to be found. History and Cure of Diseases. 135 CHAPTER 34. Erysipelas. St. Antony's fire shews itself in a redness ot' the part, with some degree of swelhng, heat, and pain ; and it is frequently beset with small watery blisters. It very rarely appears without a fever, the usual signs of which precede the appearance upon the skin for one, two, or three days. — The genuine erysipelas is oftenest seen in the face, head, neck, and shoulders ; yet many inflam- tions which are the forerunners of a suppuration, or sphacelus, in other parts, particularly the legs, have an erysipelatous appearance, and are called by that name. This disorder begins with a small red spot in one of the parts just mentioned, which gradually extends itself, and keeps moving from one part to another. The skin is sometimes so deeply hurt, as to have an ill-conditioned ulcer formed, which cannot be healed without much time and care. The little vesicles, if they be numerous, will, upon breaking, make the part so sore as to require some soft liniment spread upon linen, to defend it from the rubbing of the clotnes. Except in these two cases, it is better not to make use of external application to the parts affected. The height of the fever, which is almost always joined with this disorder, is much greater than might be expected from the quantity and degree of inflammation, and not seldom rises to light-headedness, and some- times is fatal ; where this happens, the erysipela- 136 Commentaries on the tous part becomes pale, and the distemper is said to be struck in. Some constitutions seem par- ticularly subject to this illness, and have frequent returns of it ; and whoever has once suffered it, seems much more liable to have it again. It has visited a person regularly once every year, and sometimes twice, for many years. The apparent- ly healthy, and young, are not entirely secure from it ; but it is much more common in those who are past the prime of life, and who have begun to find their health a little impaired. Instead of giving vent to any thing which injured the constitution, and carrying it off, St. Antony's fire has appeared to me at least to do no good, and I am inclined to think it does some harm. This distemper seems to partake of the nature of those which are called malignant, more than of the inflammatory ; by which I mean, that in gene- ral it does not require, nor bear, much evacuation. I have seen very dangerous symptoms follow not only bleeding, but even a gentle purge, though given after the patient had begun to recover. Notwithstanding this, the inflammation may some- times run so high, that it may be proper to take away a little blood, which has been done with success; and I have found a spontaneous bleeding at the nose to be advantageous. In this, as in alt other feversr it is necessary to check whatever troublesome symptoms may arise, by their proper remedies ; and besides these, I have only to re- comme«d two ounces of a decoction of bark, with thirty drops of tinctura opii camphorata, or two drops of tinctura opii, given every six or eight hours. History and Cure of I)isea8e8. 137 CHAPTER 35. Essera, or I^ettle-Rash, The nettle-rash is a distemper of the skin, which being attended with no danger, is mention- ed but seldom, and slightly in books ; though it be often so extremely troublesome, that physicians might justly have thought it important enough to have told us more of what they had learned from their experience relative to its cure. It has its English name from resembling in its appearance the effect of stinging-nettles upon the skin. Sydenham, in his chapter on the erysipelas, reckons it a species of that disease ; and Sennertus and others, describe it under the name of Essera^ supposing it to be the same dis- temper with that which is so called by the Arabi- an physicians. The little elevations upon the skin in the nettle- rash often appear instantaneously, especially if the skin be rubbed, or scratched, and seldom stay many hours in the same place, and sometimes not many minutes. There is no part of the body ex- empt from them. Where many of them rise to- gether, and continue an hour or two, there the parts affected are often considerably swelled ; which particularly happens in the face, arms, and hands. These eruptions will continue to infest the skin, sometimes in one place, and sometimes in another, for one or two hours at a time, two or three ti^nes ^yery day, or perhaps for the great- 138 Commentaries on the est part of the twenty-four hours. In some per- sons they last only a few days ; in others many months. I have known several complain of them for two years with very short intervals, and for seven, or even ten years. Males and females are equally liable to the es- sera, and I have observed it in all ages, from childhood to decrepit old age. Constitutions taint- ed with strumous, or harrassed with rheumatic and hysteric complaints, or broken down with in- temperance, palsies, and age, have all been, as far as 1 could judge, equally fitted for this disor- der ; but not more so than the soundest state of health, in the vigour of life, to which all other complaints were unknown. U some of the sufferers by this eruption have found themselves well whilst it appeared, and in- fested with pains of the head and stomach, and languors, upon its disappearing, others have com- plained of as much languor, and equal pains of the stomach, during the time of its appearance ; but far the greatest number experience no other evil from it besides the intolerable anguish arising from the itching, which will sometiuies make them fall away, by breaking their rest, and is often so tormenting as to make them almost weary of their lives. The external use of cantharides has been known to occasion this ail in several persons, and in some the internal use of the wild valerian root; but all who are affected with it find the itching and Uttle eminencies hardly ever fail to be brought on by any degree of of scratching or rubbing the History and Cure of Diseases, 139 skin. The seasons of the year have no constant effect either in alleviating or exasperating the dis- order ; and the same may be said of cold and lieat^ and particularly of the heat of a bed, which ap- pears to make some much better, and others much worse. Sea-bathing has seemed to occasion it in some, and to relieve it in others, but is perhaps in reality innocent and useless in all, as it certain- ly has been in several, as well as warm bathing, though continued for an unusual length of time. Mercurial and sulphureous ointments have been found ineffectual in curing it; and the powder, infusions, and decoctions of white hellebore root, in ointments and lotions, have only for a short time changed the itching into smarting. Oil, vinegar, and spirit of wine, applied to the skin, will sometimes mitigate the itching, and afford a little present relief. The appearance of this eruption was before said to resemble the sting of a nettle ; but, to- gether with such little risings in the skin, there are sometimes long wheals as if the part had been struck with a whip. Whatever be the shape of these eminences, they always appear solid, with- out having any cavity or head containing either water or any other liquor ; and this affords a use- ful mark by which this cutaneous affection is dis- tinguishable from the itch; for it often happens that the insufferable itching attending this erup- tion provokes the patient to scratch the parts so violently, as to rub off a small part of the cuticle on the top of these little tumours ; a little scab succeeds, and when the swelling has gone down. I there is left an appearance hardly to be distin- 1 140 Commentaries on the guished from the itch, but by the circumstance just now mentioned. It has been this exact re- semblance which has occasioned the appHcation of sulphureous and mercurial ointments in many persons whom I have seen, without producing either any good or bad effect. The essera fur- ther differs from the itch in not being infectious ; for though I have once suspected that a husband had catched it from his wife, yet my suspicion was probably not well founded in this instance, be- cause in many others I have known that this com- plaint shewed no signs of being communicable by contagion. I never saw a reason to suppose it had occa- sioned any such viciousness of the humours, as greatly to require, or to be much the better for internal alterative remedies : and if the itching could be certainly and expeditiously allayed, we might spare ourselves the pains of looking out for any other method of cure. CHAPTER 36. Expergefacti cum Clamore et Terrore. To wake in a violent hurry and agitation, and with loud exclamations, is a symptom sometimes observed in the gout, in palsies, and in hysteric complaints : it is a very common attendant upon pains of the bowels, worms, and convulsive fits in children ; and when they have started out of their sleep in this manner, they have been above an History and Cure of Diseases. 141 hour before they have perfectly come to them- selves. CHAPTER 37. Febris, A FEVER, or general languidness mih a quick pulse, is sometimes an attendant upon other dis- orders, and will retreat in proportion &s they are mitigated by their proper remedies. When it is itself the only distemper, it is still so various in its nature, that very different methods of cure must be employed for different fevers ; and some part of the treatment must be learned from knowing the patient's age, and constitution, and manner of living, as well as from a due attention to the sea- son of the year and the peculiar nature of the reigning disease. Where the fever is evidently inflammatory, as in the inflamed sore throat, peripneumonies, pleu- risies, and inflammations of the bowels, there no one can doubt of the necessity of bleeding ; and repeated bleedings are often required. The jail- fever, and others which resemble it, seldom ap- pear to stand in need of bleeding ; but it is often of great importance in the beginning of these fe- vers to clear the stomach and bowels, which is pointed out by the sickness which at that time teazes the patient. This may very properly be done by one scruple of ipecacuanha, joined with one grain of emetic tartar, which, beside vomit- 14S Commentaries on the ing, will generally occasion a few stools. The sickness is usually so perfectly renaoved by one dose of this medicine, that a second is very rarely wanted. A head-ach is a very distressing symp- tom in the beginning of fevers, for which a blister between the shoulders is an almost certain reme- dy. In the inflamed sore throat, pleurisies, and peripneumonies, blisters are likewise of great use in abating (perhaps by diverting) the inflamma- tion, and in all stages of low fevers, where they act as cordials, and stimulate the powers of life to exert themselves, and to shake off the languor with which they are oppressed. The strangury which they are apt to occasion is certainly cured by a clyster made of water and oil, each two oun- ces, and fifteen drops or more of tinctura opii. In the progress of the illness, if a purging should come on, the helps mentioned under the article of diarrhoea, must be employed to check it. The contrary state of too great costiveness will be best removed by a clyster of half an ounce of salt, and twelve ounces of water, with two ounces of oil. Restlessness and want of sleep, will often yield to fomenting the head and feet frequently with flannels wrung out of hot water ; or two or three drops of tinctura Thebaica may be given every six hours. Heat, and thirst, may be allay- ed with lemonade, or toast and water. Languor, and excessive lowness, may safely be treated with wine or cider mixed with water, or a spoonful of the camphor julep. Hiccups, and convulsive twitchings, and agitations, have appeared to be relieved by frequently taking a spoonful of the musk julep ; but though musk may have some virtue in quieting spasms, and camphor has in History and Cure of Diseases. 143 some cases procured sleep, jet their effects are neither great, nor constant. I have seen one scruple of camphor given every six hours, and, together with this, one scruple of musk as often in the intermediate hours : they w^ere both of them borne well by the stomach, but had no per- ceivable effect in abating the convulsive catchings, or composing the patient to rest. While the sick person is in his senses, his own inclination, and strength, will best determine whether he should sit up, or keep his bed, even in the eruptive fe<- vers, as well as in all others. A specific in continual fevers is, 1 fear, still one of the desiderata in physic, though it has been much sought after, particularly among the prepa- rations of antimony. In the beginning of fevers, the safe antimonial emetics and cathartics are un- questionably useful ; but 1 have never yet been able to satisfy myself that they do more good than would be done by any other equally strong purges and vomits. Many judicious physicians are persuaded that, in the succeeding stages of a fever, antimonial medicines, given in such a dose as just not to vomit or purge, are efficacious in abating the fever, either by bringing on a sweat, or by some specific power. In deference to their judgment, I have directed four grains of emetic tartar to be dissolved in four ounces of some sim- ple distilled water, of which solution I have given two drams, which contain a quarter of a grain, mixed with three spoonfuls of water, every six hours. This quantity is as much as an adult can usually bear without being sick ; and where it is more than the stomach qan be easy with, the 144 Commentaries on the draught may be divided into two parts, to be ta- ken at the distance of half an hour from one an- other, instead of the whole being taken at once. Of this medicine I have had considerable expe- rience ; but not enough to convince me that anti- mony possesses any specific virtue of curing con- tinual fevers. The Peruvian bark has been much dreaded, except in a clear and perfect intermission ; but the free use which has been made of it, notwithstand- ing the height of the fever, in mortifications, and in other cases, where a good suppuration was wanted, has taught us, that this dread is as ground- less as the many other fears which people have had of this valuable simple ; of which the more we know, the less danger we find of its doing any harm, and the more powers of doing good. Ac- cordingly it has been tried in high continual fe- vers, in which I am not so sure of its being useful, as I am of its being innocent, not only wnen two ounces of the decoction have been given every four hours, but when two scruples or a dram of the powdered bark have been directed to be ta- ken as often. In every fever it is of the utmost consequence to keep the air of the patient's chamber as pure as possible. No cordial is so reviving as fresh airl- and many persons have been stifled in their own putrid atmosphere by the injudicious, though well meaned, care of their attendants. The English seem to have a very extraordinary dread of a per- son's catching cold in fevers, and almost all other illnesses; the reason of which 1 could never right- History and Cure of Diseases, 145 V ]y comprehend. The sick do not appear to me to be particularly liable to catching cold ; nor do I know that a cold would be so detrimental, as not to make it worth while to run the risk of it for the sake of enjoying fresh air. I remember one, who, being dehrious at the eruption of the small pox, was so unmanageable, that by fre- quently throwing the clothes off, and being fre- quently naked, he catched a great cold, as ap- peared by all the common signs of one ; yet I could not observe that it had any ill effect in re- tarding the maturation, or heightening the fever, or preventing his recovery. It is often useful not only to keep the room well ventilated, but like- wise to correct the bad air, by pouring vinegar on a red-hot shovel, and making the room full of the acid vapour which arises from it. Very pale urine, unless the patient have drunk a great quantity of small liquors, is a bad sign in fevers, and it is very desirable to see it become thick, and deposit a sediment; but I know no oth- er use of it, than the giving us hope that the dis- temper is beginning to abate: nor am I aware that any important purpose can be answered by examining the faeces ; for I know no state of them which could direct us to employ, or to forbear, any particular method of cure. For the use of observing the pulse in fevers, see the Medical Transactions, vol. ii. art. 2. In the long and dangerous fevers of children, it is very common for them to lose all power of speak- 19 146 Commentaries on the ing for many dajs ; but this is no bad sign, and as the fever abates, the voice always returns. Adults, as well as children, are sometimes ren- dered deaf for a time, without any bad conse- quence. Concerning the wry-neck of children, see chap. 91, OM spasms. CHAPTER 38. Febris Intermittens. The fit of an intermittent fever seldom lasts above twenty hours, and not often so long. The shivering, and sense of coldness, with which it begins, will continue from half an hour to two hours; then succeed the heat, and restlessness; and these yield to a sweat, the degrees of which, and duration, are very various, according as they are more or less promoted by lying in bed and drinking warm liquors. The fit will be a quoti- dian, returning every day ; or a tertian, and re- turn every other day ; and if there be the interval of two days between the fits, it is called a quar- tan. Much longer intervals have been known; but these happen so seldom, that they have been distinguished by no name, and are not of any im- portance to deserve our notice. Besides the common appearances of fever, eve- ry fit has been sometimes accompanied with oth- fistory and Cure of IHseases. 147 er complaints ; in some with rheumatic pains ; in several with a light delirium ; in others with an eruption of the skin, or colic, or faintings, with a pain and swelling of the testicles, a languidness, and almost paralytic weakness of the limbs. — These have regularly come and gone with the fe- ver, and with the cure of that have finally disap- peared. It is a question, or rather perhaps it was a question before men knew well how to cure an intermittent, whether they might safely attempt to cure it. For it was supposed to be an effort of the body to relieve itself from some latent seeds of mischief, which would shew themselves if the intermittent were cured. Some respectable names in physic have patronised this opinion, and i began to practice with a persuasion of its truth: but every year's experience weakened my belief of this doctrine, and I have long since, by num- berless proofs, been convinced of the safety of stopping this fever as soon as possible : nor can I doubt of having observed' ill consequences where the fever has been suffered to remain, by delay- ing to use the effectual means of preventing its returns. The Peruvian bark is the well-known specific, with which Providence has blessed us for the cuie of this disorder ; and if the first fit has been marked so clearly, as to leave no doubt of its being a genuine intermittent, this remedy should be immediately given in such a manner, as to j:)ievent, if possible, a second. If six drams of powdered bark can be got down, by taking a dram at a time, bet'ore the hour of its return, the patient will find the fever at least much weakerin 148 Commentaries on the ed, if not entirely removed ; and the same quanti- ty taken four times a day for six days will usual- ly free the patient from all danger of a relapse. But if this medicine be not uncommonly disgust- ful, there may good arise, but there can be no harm, from his taking it twice a day for ten days longer. This way of using the bark 1 think is the most to be depended upon ; but where the bark in substance cannot be taken, or borne, there two ounces of a strong decoction used as often - will generally be successful. The success would be made less uncertain, if there were no objection from the patient's palate, or stomach, to the dis- solving in each dose one scruple or half a dram of the extract. Bark is a difficult medicine to be got down children's throats, especially in such quantities as would cure their agues. One scru- ple of the extract, and as much sugar, first mixed with half a spoonful of water, and then with a spoonful and a half of milk, is a form which wfll disguise its nauseousness sufficiently for many chil- dren to take it Without any unwillingness. But wherever either in them, or in adults, it cannot be taken or borne in any form upon the stomach, they may still have the benefit of it by having three or four ounces of the decoction with one or two drams of the powder injected at least twice a day as a clyster ; and if this should not readily be retained, ten drops of tincture of opium may be added. It has been proposed to cure an intermit- tent by keeping the feet immersed in a strong de- coction of bark : this I have known tried without success. Cases sometimes occur in which the bark, though properly taken, will not hinder the returns of the fever : this is suspected to be ow- I History and Cure of Diseases. 149 ing to a foulness of the stomach, which hinders the bark from making a due impression upon it ; and therefore an emetic is given, and afterwards the bark is repeated as at first. If it still fail, a scruple of camomile flowers, powdered, may be given in the same manner as the bark, and I have known this method more than once succeed : I have also given in some extraordinary cases two scruples of calamus aromaticus, and have found it more efficacious than a variety of other means which had been previously directed. Sometimes it has been of use to take twenty drops of tinc- ture of opium when the fit is coming on. A quartan ague is far more obstinate than a quotidian, or tertian, an,J will for a long time elude the power of the bark given in the usual manner, and all other remedies. I have found se- veral of the inveterate quartans yield to a quarter of an ounce of the bark taken just before the coming on of the fit. From a persuasion that the bark is dangerous, if taken before the fever has perfectly subsided, many begin to take it with very uneasy apprehensions, and sometimes will too long delay taking it, to their great detriment. Now the only harm which I believe would follow from taking the bark even in the middle of the fit, is, that it might occasion a sickness, and might harass the patient by being vomited up, and might set him against it; but in nay judgment it can ne- ver be taken too soon after the fever begins to decline, provided the stomach will bear it. 150 Commentaries on the CHAPTER 39. Fehris Heclica. A HECTIC fever is frequently mentioned in the writings of physicians, and likewise in common conversation ; but the precise meaning of the term hectic has not been well settled, and generally acknowledged ; so that probably, by different au- thors, it is not always used to express the same illness. I understand by it that fever, which pas- ses under the name of the irregular intermittent, or symptomatic, and what usually attends great suppurations ; of which it may not be useless to give a short description, with some mention of the causes by which it is brought on. This fever very much resembles the true inter- mittent, from which it must be carefully distin- guished ; for their nature is totally different, re- quiring a very different treatment, and the two distempers are extremely unlike in the degree of danger with which they are attended. In the intermittent the fits are longer, and the three stages of cold, and heat, and perspiration, are more exactly defined, and in all the fits con- tinue nearly the same length of time ; after which there is a perfect cessation of the fever. But in the clearest remissions of the hectic there is still some quickness of the pulse, so as to beat at least ten strokes more in a minute than it should in a healthy state. The fits also of the hectic vary from one another, seldom continuing to return in I I History and Cure of Diseases. 151 the same manner for more than three times to- gether. The shivering is sometimes succeeded immediately by perspiration, without any inter- vening heat ; sometimes it begins with heat, with- out any preceding cold ; and the patients some- times experience the usual chillness without any following heat or sweat. The fit therefore of the hectic is usually shorter, but not only because the whole three stages are shorter, but because one of them is often wanted, and sometimes even two. The hectic patient is very little, or not at all relieved by the breaking out of the sweat; but is often as restless and uneasy after he begins to perspire, as he was while he shivered, or burned. All the signs of fever are sometimes found the same after the perspiration is over; and during their height the chilh'ness will in some patients re- turn, which is an infallible character of this disor- der. Almost all other fevers begin with a sense of cold ; but in them it is never known to return and to last twenty minutes, or half an hour, while I the fever seems at its height ; which in the hectic will sometimes happen. I N » However, it is not very unusual for the hectic to have two fits, and even three, as exactly resem- bling one another, as those of a genuine intermit- ent ; but afterwards they never fail to become to- tally irregular : so that 1 hardly remember an in- stance in which the returns continued regular for four successive fits. The hectic in some cases come on so seldom, and is so slight, as scarcely to be perceivable for ±5^ Commentaries on the ten or twelve days ; but in other instances, where the primary disorder is very great, the fever will be strongly marked, and will attack the patient several times on the same day, so that the chilli- ness of a new fit will begin as soon as the perspi- ration of the former is ended. Several little threatenings of a cold fit have been known to re- turn within a few hours. In a regular intermittent, the urine during the fever is pale, and thick in the intervals ; but its appearance in the hectic is governed by no rules; so that it will be either clear, or loaded, equally during the fits and in the intervals ; or even mud- dy in the fever, and clear in its absence ; and will now and then, as in common fevers, be pale dur- ing the attack, and muddy afterwards. Beside the usual distress of a fever, the hectic patient is often harassed with pains like those of the rheumatism, which either wander through the whole body, or remain constant and fixed m one part ; and, what is rather strange, often at a great distance from the primary malady, and in appear- ance unconnected with it. These pains have been so great, as to make no small part of the patient's sufferings, and to be not tolerable without the as- sistance of opium. They are chiefly observable, as far as I can judge, in those whose hectic has been occasioned by ulcers in the external parts, as in cancers of the face and breast, and in other places open to the outward air. In some (ew hectic cases it is remarkable that considerable tu- mours will instantly arise upon the limbs, or body, History and Cure of Diseases. 153 lasting only for a few hours, without pain, or hardness, or discolouring of the skin. There have been those who when they thought liiemselves tolerably well have suddenly and ve- hemently been seized with a {eYC\\ not unlike an inilammatory one; and, like that, seeming very soon to bring the hfe into danger. However, af- ter a few days, the distemper has abated, and the patients have had hopes of a speedy recovery : but these hopes have not improved upon them ; for though the first commotions have subsided, and but little fever remain, yet this little, being kept up by some deep and dangerous cause, re- sists all remedies, and gradually undermining the health, ends only in death. But this is one of the rarer forms of this malady ; for in the beginning it most usually dissembles its strength, making its approaches so slowly, that the sufferers feel them- selves indeed not quite well, but yet for some months hardly think themselves in earnest ill ; for they complain only of a slight lassitude, and that their strength and appetite are a little impaired. This state of their health may be judged not veiy alarming; but yet if at the same time the pulse be found half as quick again as it should be, there will be great reason for solicitude about the event. There are not many diseases in which an attention to the pulse affords more instruction than it does in this ; yet even here, whoever re- lies too confidently and entirely upon the state of the pulse, will in some cases find himself misled : for it happens, as well as 1 can guess, to one among twenty hectic patients, that while all the powers of life are daily declining, with every sign 20 154 Conunentaries on the of an incurable mischief, the artery will to the last minute continue to beat as quietly, and as regular- ly, as it ought to do in perfect health. Great suppurations in any part of the body will bring on this fever; and it will particularly attend a schirrous gland, while it is yet very little inflam- ed, and in the very beginning of the inflammation. It increases in proportion as the gland becomes more inflamed, or ulcerous, or more disposed to a gangrene. Glandular diseases are of such a na- ture, that some patients will linger in them, not only for many months, but even for a few years. When a schirrous inflammation is in any exter- nal part, and obvious to the sight, or touch, or when its seat is in the lungs, or in any of the vis- cera, whose functions are well known, and cannot be disordered without shewing manifest signs of the disease, in all such cases we can be at no loss about the cause of the fever. *But if an internal part, the uses of which are not clearly known, happen, by being diseased, to bring on hectic symptoms, there the fever which is only symp- tomatic, may he mistaken for the original and only distemper. Lying-in vs^omen, on account of the mischief arishig from diflicult births, are liable to this fe- ver, and it often proves fatal. The female sex in general, after they have arrived at their fiftieth year, are in some danger of falling into this irregu- lar intermittent : for in that change which their constitution experiences about this time, the glands of the womb, or ovaries, or of the breasts, History and Cure of Diseases, 155 are apt to become schirrous, and as soon as they begin to inflame, the hectic comes on ; and not only these, but all the glandular parts of the ab- domen, seem at this time particularly liable to be diseased, and to bring on this, of which we are speaking, as well all other signs of a ruined con- stitution. The same evils are the portion of hard drinkers, arising from the schirrous state of the liver in particular, and often of the stomach, and other viscera, which are the well-known ef- fects of an intemperate use of wine and spirituous liquors. The slightest wound from a sharp Instrument has been the cause of many distressful symptoms, and such as have even proved fatal. For after such an accident, not only the wounded part has been in pain and has swelled, but other parts of the body, and those at a great distance from the wound, have been affected with pain and swelling, and have shown some tendency to suppuration. These symptoms never fail to be joined by the ir- regularly Intermittent fever, which continues as long as any of them remain. The time of their continuance is uncertain : some have been harass- ed with them for two or three weeks ; and others for as many months ; and, in a few, they have ended only in death. The hectic fever is never less formidable than when it Is occasioned by a well-conditioned sup- puration, in which all the injured parts are resolv- ed Into matter so circumstanced as to be readily discharged from the body. 156 Commentaries on the Inflammations of scirrhous glands in the breasts, or in the interior parts, sometimes yield to reme- dies, or to nature, and together with their cure, the fever, which depended upon them, ceases. But these diseased glands much oftener end in cancers and gangrenes ; and the fever continues as long as any life remains. It cannot be supposed, that a fever arising from so many different causes, and attended with a great variety of symptoms, should always require, or bear to be treated in the same manner. As the hectic is always occasioned by some other disease, whatever most effectually relieves the primary malady must be the best means of re- lieving all its natural attendants. When the fever has been the consequence of some small wound, a mixture of opium and asafoetida will prove an useful remedy. In almost all other cases, the at- tention of the physician must be chiefly, if not wholly employed, in removing the urgent symp- toms. A cooling regimen will temper the heat, when it is excessive ; the bowels must be kept nearer to a lax than a costive state ; sleep, if wanted, must be procured by opium ; profuse sweats may be moderated by a decoction of bark and elixir of vitriol ; beside which, the greatest care must be taken that the air and food, and ex- ercise, may be all such, as will be most conducive to putting the body into the best general health. After doing this, the whole hope must be placed in that power, with which all animals are endow- ed, not only of preserving themselves in health, but likewise of correcting many deviations from History and Cure of Diseases. 157 their natural state. And in some happj constitu- tions this power has been known to exert itself successfulij, in cases that have appeared all but desperate. For some patients have recovered from this fever, after there had appeared very great signs of its arising from some viscus incura- bly diseased, where every assistance from medi- cine had been tried in vain, and where the strength and flesh were so exhausted, as to leave no hopes of any help from nature. In this deplo- rable state, a swelling has been known to arise, which, though not far from the seat of the prima- ry disorder, yet could not be found to have any immediate communication with it. This tumour has at length suppurated, in consequence of which the pulse has grown calmer, some degree of ap- petite has returned, and all appearances of dis- temper have gradually lessened, till the strength and health were perfectly restored. What in some very few instances I had observed nature thus to effect, I have endeavoured to imitate, by applying a blister, or by opening an issue, or se- ton, near the apparent seat of the internal mis- chief; but the success has not answered my ex- pectations. Not many years ago, in some fortunate recove- ries from mortifications, the Peruvian bark had been prescribed, and had the credit of the cure : since which time it has been very generally used by practitioners in all tendencies to gangrenes, and where suppurations had not proceeded in a kindly manner. There is every reason to believe, that it may safely be employed in such cases ; and no other remedy is known, which has any 158 Commentaries on the pretence to rival it for these purposes. Besides, as the hectic fever is so very like an internaittent, even where there was no suspicion of any gan- grene or ulcer, the desires of the sick, or of their H'iends, for trying the bark, have been too impor- tunate to be controlled ; and physicians have sometimes prescribed it from iheir own judgment. But it has greatly disappointed all expectations of benefit to hectic patients ; for it seems to have no efficacy, where there is no ulcer ; and indeed it has so often been useless in mortifications, that there may be some doubt, whether in the prospe- rous cases the cure were not ovving to other cau- ses. But though I dare not be confident that the Peruvian bark has any extraordinary virtues m stopping the progress of mortifications; yet 1 can have no doubt that it may safely be used : for nei- ther in these cases, nor in any other, have I ever had reason to suspect its doing harm, unless it can be said to do so when it occasions a sickness or diarrhoea, where the stomach happens to be weak, or the dose has been too great, or where it has been taken in hard boluses, which were not readily dissolved in the stomach : and I remember to have heard Sir Edward Hulse say the same, who had for above forty years been giving as much of it as any physician in England, and pro- bably much more than any one had given in all the other countries of Europe. Experience every day more and more confirms this testimony in fa- vour'of the bark : and hence it must have happen- ed, that the quantity of it used in England for the last ten years, is ten times greater than it was History and Cure of Diseases. 159 in the same length of time in the beginning of the eighteentJi century. It is evident, therefore, that the more we know of this noble simple, the less reason we find for those suspicions with which it was at first calumniated ; so that it affords some exception to the general rule, u6i virtus^ ibi viriis„ Yet we are told, that many physicians are still afraid of ever giving it in the beginning of an in- termittent ; and some are afraid of ever curing it at all with this remedy. They may perhaps ad- here to the doctrine (which I believe is founded in errour,) that an intermittent is an effort of na- ture, by which the constitution frees itself from many hurtful humours, and from the rudiments of many impending diseases ; and consequently where these friendly exertions are checked, those dange- rous maladies will fall upon the internal parts, terminating in fatal dropsies. I suspect these groundless fears have had their origin from those fevers, which were falsely judged to be intermit- tent, when in reality they were hectic ; and that the obstructions in the abdominal viscera weie not owing to the bark, but were the original cause of the illness. In all chronical disorders which yield to no other remedies, it is usual for the sick to be urg- ed by their own hopes, and by the advice of their friends, to make trial of the Bath waters. Now the inconveniences of travelling and of missing the comforts of their own houses, must occasion some additional sufferings to the sick ; and lor these the hectic patients can have no just hopes of having any amends made them by going to Bath : on the contrary, those waters would not; 160 Commentaries on the fall, by heightening the fever, to aggravate all their complaints, and to hasten their death. CHAPTER 40. Fistula Ani, Fistula ani, sclrrhi, and ulcers of the rectum, are often attended with griping pains, tenesmus, a want and difficulty of making water, a difficulty of retaining the stools, mucous and bloody stools, the stools always loose, or not round but flatted, shiverlngs, a swelling, and sometimes a gangrene of the testicles, flying pains, and sometimes very acute and fixed ones in a distant part of the limbs. The ulcers which are formed in the rectum near the sphincter ani are often neglected, upon a supposition that they are only piles ; though the pain of the previous inflammation be far greater, and much more Increased by coughing and sneez- ing. Even after the suppuration has been made, and the ulcer Is broken, the discharge from it. If not great, will still be undistinguished from the piles ; for a moisture has for a considerable time continued to ooze out from them, where experi- enced surgeons upon examination have not been able to find any ulcer. However, where the pain is excessive, or there is any purulent discharge, the opinion of a surgeon is indispensably neces- sary ; for, if there be an Inflammation or ulcer, the whole care of it belongs to him, and the sooner he is employed, the better it will be for the pa- tient. A timely use of the proper means may History and Cure of Diseases. 161 hinder the forming of deep sinuses, which cannot perhaps ever be brought to a heahng condition, or not without a much more painful operation than the cure would at first have cost. Fistulous sores of the rectum will remain un- healed, and keep discharging like a fontanel for a long time : one has done so for more than thirty j^ears. In some constitutions a previous unhealth- mess may make a deposit upon the intestine ; in others perhaps a neglected ulcer, arising from slight, and merely local causes, may in time taint the whole body. Whether then we consider the fistula as the cause, or as the effect, it is certain that a bad state of health is often joined with a fistula ani, and the mischief, after the cure of the ulcer, has many times fallen upon other parts, and particularly the lungs, and has brought on asth- mas, spittings of blood, and consumptions. For this reason it is a common, and appears to be a reasonable practice, to make an artificial discharge by an issue, as soon as the wound is healed, in order to drain oif any of those diseased humours, which at first occasioned the mischief, or were afterwards occasioned by it ; and to recommend such a regimen as a consumption requires. CHAPTER 41. Fluor Alhus, The fluor albus is a weakness which has been known to incommode females in everv year of 21 16S Commentaries on the their lives, from the first to extreme old age ; but it is very rarely observed in children, and most usually is first heard of about the time of puberty. This discharge, though generally white, as the name imports, and thin, yet has sometimes had almost a jelly-like consistence, and not unfre- quently a tinge of yellow : in a few women it has been greenish, with an offensive smell. The sharpness of the humour frets the parts, if not duly washed, so as to occasion heat, itching, or soreness, and the urine of course will occasion a little smarting. It is evident from this account, that great attention is necessary to distinguish this disorder from a Venereal infection, wherever there is a possibility of its having been commu- nicated. When a woman has lived entirely free from the fluor albus, or has had it only in a slight degree, and all at once, upon cohabiting with a man finds a great pain in making water, and the discharge suddenly appear, or greatly increased, with a deep yellow or greenish hue, there will be strong reason to suspect an infection. It unluckily happens, that a woman soon after marriage is par- ticularly subject to this disorder, especially if she be of a weakly make, which has often created great uneasiness, and many disagreeable suspi- cions : in these circumstances much caution is ne- cessary in passing judgment upon the nature of the discharge. If the colour of it remain white, or at the deepest is only of a faint yellow, and the smarting of the urine little or none, there will be no reason to believe it more than a simple weak- ness, even though the person should never have experienced any thing of it before. V History and Cure of Diseases. 163 The most common cause of this malady is fre- quent miscarriages, or lyings-in. It has made its first appearance, or been increased, in ma- ny women during a state of pregnancy ; yet I have met with one, who thought herself freer from it at that time. This flux has in many instances returned every month instead of the menstrual one; or has continued without ceasing during an obstruction of the menses, and is not unusual in elderly women just after their final disappearance. A too profuse menstrual evacuation, and this, will often harass the same subject, both of them being perhaps owing to too great weakness. Too vio- lent exercise, the lifting or carrying of too great weights, intemperate venery, great disturbances of mind, and a weakly or strumous habit of body, have been no uncommon causes. Whatever may have been its origin, the patient is sure to find it accompanied with a great pain of the loins, and this is not the least part of their sufferings. Such a constant drain must probably in some measure lower the health and strength, but it is not easy to point out any other ill consequences. We meet with many women who have had it for a great part of their lives, and have not been hindered by it from bearing healthy children. Where a weakness of the whole habit, or a par- tial one of the glands which supply this humour, are judged to be the only causes, the remedies must be calculated to make the whole body more robust, or to strengthen the parts concerned. A powder made of olibanum and Seville orange peel, each ten grains, with five grains of oak bark, taken twice a day, and washed down with an in- 164 Commentaries on the fusion of Peruvian bark, has had a good efifect ; and so has a decoction of oak bark, in the pro- portion of one ounce to a quart of water, injected into the vagina night and morning. These to- gether with cold bathing have proved the most powerful helps. But this disorder, though not dangerous, is often very obstinate from the length of time it has lasted, or from some constitutional weakness ; and will only admit of being checked, and lessened, but never will be entirely cured. Besides, in strumous habits it is not merely a weakness, but a drain by which part of the nox- ious humours is carried off: this creates an addi- tional difficulty of curing it, and an impropriety of attempting it merely by strengthening reme- dies. Where such have been used in these cases, and have either stopped or considerably lessened the discharge, the patients have presently com- plained of pains of the stomach, and have found a general illness, by which they were far more hurt than by the former flux. To such patients injections must not be prescribed ; instead of which, together with internal strengthening medi- cines, they should twice a week take some gentle purging waters, or some of the neutral salts dis- solved either in water, or in an infusion of Peru- vian bark. Bristol water has the reputation of being useful in this complaint, which 1 have no reason to think it deserves. I have known cases in which saccharum Saturni had been used with- out eflecting a cure ; but if it had been ever so successful, the consequences of taking such a dan- gerous substance would have been far more pre- judicial than the distemper. History and Cure of Diseases. 165 Excruciating pains of the womb and hips and thighs, which belong to an ulcer or cancer of the womb, together with the sanious and bloody ap- pearance of the gleet, will generally be sufficient to distinguish it from the fluor albus. CHAPTER 42. Gonorrhoea Miiis. A GLEET in men resembles the fluor albus both in its nature and cur;p ; so that very little needs here be added to what has been already said un- der the last article. Such a weakness is iar less common in men, tharr in women ; being hardly ever known in them, without being owing to Ve- nereal diseases. However, I have been a witness to two or three cases, in which a blow had brought on a copious discoloured flux, exactly re- sembling that from a Venereal infection, except that it went off spontaneously in a few days. Injections into the urethra should be used spa- ringly, if at all, if I am not mistaken in supposing that the free use of them has been the cause of many strictures, as they are called, of the ure- thra, attended with an extreme difficulty and ex- cessive pain in making water, which too often prove an incurable torment, and end in a fatal suppression of urine, or a mortification. An ab- stinence from the causes which brought on the gleet, seldom fails to cure it, or to reduce it so far as never to do any material injury to the health. 166 Commentaries on the Yet many timid minds suffer more from their ap- prehensions of the consequences of this complaint than of any other ; and interested people have en- deavoured to aggravate those fears, in order to make an advantage of them by the sale of their silly books and insignificant medicines. CHAPTER 43. Graviditas. Most of the complaints- incident to breeding women are to be cured only by their delivery. Women readily conceive a little before the time of the menstrual flux. Do they more readily at that time, than at any other? A healthy woman in the fifth month of preg- nancy began to perceive a moisture oozing from the nipples, which continued till two days before her delivery: the breasts were then quite dry for six days, but on the fourth day after the delivery they were filled with milk. I have been told by two married men, that their wives were free from all Venereal appetite ; yet they both of them had been pregnant, and had borne several children. Pregnancy is very commonly accompanied with sickness and with the heartburn : where these two complaints have been excessive, after a va- riety of means had been used in vain, the sickness History and Cure of Diseases, 167 has been cured by rubbing in the anodyne balsam upon the region of the stomach, and the heartburn by repeated doses of eh'xir of vitriol. A woman not suspecting her condition, went on bathing frequently for the first months of her be- ing with child, and drinking the sea water so as to be purged two or three times every day ; and this was the only time she ever escaped a sick- ness, which she had suffered in an uncommon de- gree with all her other children. The juice of oranges and lemons, and plenty of fruit, have also proved remedies for the same sickness. A violent uterine discharge of blood has con- tinued for six weeks about the sixth month, with- out occasioning a miscarriage. I knew one, who never ceased to have regular returns of the men- strua during four pregnancies, quite to the time of her delivery. Consumptive women readily conceive, and dur- ing their pregnancy the progress of the consump- tion seems to be suspended ; but as soon as they are delivered, it begins to attack them with re- doubled strength ; the usual symptoms come on, or increase with great rapidity, and they very soon sink under their distemper. A difficulty, or total suppression of urine, is sometimes occasioned by the weight of the womb pressing upon the urethra, which can only be re- lieved by the catheter. After a suppression for three days, upon introducing a catheter, five pints of water came away Large blisters applied to 168 Commentaries oti the some pregnant woman, who were peculiarly lia^ ble to the strangury, have occasioned it in so vio- lent a degree, as to endanger a miscarriage. CHAPTER 44. Hanwrrhoides, « The veins towards the extremity of the rectum are hable to be surcharged with blood, in conse- quence of which they sometimes burst, and bleed without any pain, like the veins in the inside of the nostrils ; at other times they swell without bursting, to a considerable size both within and without, and are in great pain even after they have begun to bleed. This discharge of blood is commonly reputed to be wholesome, and the checking of it by forcible means, it is supposed, will occasion head-achs, giddiness, pains of the stomach, and even lay the foundation of a broken state of health, some great mischief being deposit- ed upon the vitals by that blood, which should have found an outlet through the haemorrhoidal vessels.' Now, we know very well, that in a per- fectly healthy state there is no want of this eva- cuation, and wherever it happens, it may perhaps more justly be called a symptom, than a remedy of any disease. In many people the veins of the rectum bleed from as trivial causes as those of the nostrils, and there is no harm in neglecting such an haemorr- hage. There are several diseases of the abdo- b^ History and Cure of Diseases. 169 IBninal viscera, which put some obstruction to the IlKfree pagsage of the blood through them, and this If may probably occasion a breach in the lowest part : so we find that in affections of the liver, haemorrhoidal bleedings are very common, and possibly may give some little relief at the time, but are not likely to contribute at all to the cure. Bowel disorders too often prove fatal ; and if the bleeding of the piles should have been checked by any applications, the mischief may falsely be attributed to the want of that evacuation. I have heard a (ew persons say, that a head-ach, an asthma, a giddiness, a redness of the face, and a pain of the stomach, had been prevented, or re- moved, by bleeding piles. There is some diffi- culty in determining whether they were mistaken, which might easily happen ; but certainly the be- ■knefits of the piles are by no means so frequent, H^nd so evident, as to make any one either wish F* for them, or be pleased with having them. There is however no very great use in deciding the ques- tion of the wholesomeness of the piles, the bleed- ing being seldom so excessive as to threaten eith- er present danger, or future mischief. Yet in rare cases I have known so great a flow of blood from them every day for a month together, that it unquestionably weakened the patient. But even in this state of the piles, it is hardly ever found necessary to go beyond the use of half a pint of the decoction of the bark taken at three or four times every day, which perhaps acts less as a styptic, than by obviating the ill effects of such profuse bleedings. 22 170 Commentaries on the The piles spare neither sex ; they have begun as early as at the age of five years ; but they very seldom molest children, and ma^ rather be consi- dered as the disorder of adults. Women during the state of pregnancy, and just after the menses have finally left them, are peculiarly subject to the piles : at all other times they are less troubled with them than men. The piles are habitual in many constitutions, and have continued through life with no great in- terruption. Both costiveness, and purging will irritate them. They will not only bleed at every stool, but a serous moisture will constantly ooze out spontaneously without any ulcer. The blood does not appear intimately mixed with the excre- ment, but lying upon it. The pain is greatly in- creased by going to stool, and will last for some hours after. A heat of urine, a sickness, and pain of the loins, are sometimes, though rarely, com- plained of together with the piles. Aloes is care- iully avoided in this disorder, as a purge which particularly irritates the rectum, and not without some little reason ; but it appears to me, that it has not such an effect so generally, and so strong- ly, as is commonly imagined; and it will there- fore often disappoint those who, having a persua- sion of the salutary nature of the piles, endeavour in some cases to bring them on by giving an aioe- tic purge. In all bsemorrhoidal pains and bleedings, the body should for evident reasons be kept in a state rather inclining to laxity than costiveness ; flow- ers of sulphur in the quantity of ten or fifteen f ^^ History and Cure of Diseases, i7i ains have the reputation not only of effecting this in a gentle and proper manner, but of having some further power of soothing the pain and les- sening the discharge : however, it is so doubtful whether sulphur have in this disorder any other virtue than that of a laxative, that there might perhaps be safely substituted for it a little leni- tive electuary, or a spoonful of castor oil, or half an ounce of tincture of senna mixed with one ounce of oil of sweet almonds, all which 1 have seen used with an equally good effect. The pain is sometimes so excessive as to require immediate relief, and this may be procured by means of a cataplasm of bread and milk with a little oil ; or, in a less troublesome way, by keep- ing the parts anointed with a mixture of a dram of the softened extract of opium and two ounces of any simple ointment. No facts have satisfied roe, whether opium act in this case as a topical anodyne, or in its usual manner of affecting the whole nervous system when applied to any part of the stomach or intestines. The pain, if occa- sioned by immoderate distension of the veins, will be lessened, or cease, upon their being emptied either by the point of a lancet, or the application of leeches. 1 have two or three times been assur- ed by haemorrhoidal patients, that a pint of an in- fusion of box leaves taken night and morning has greatly contributed to their cure ; but I have ne- ver recommended them, because the helps above mentioned appear sufficient, to do every thing that is required, and with as much expedition as th^ nature of the case will admit. « 17S Commentaries on the CHAPTER 45. Hernia. Ruptures require no other remedy, than a proper bandage, or truss. CHAPTER 46. Hydrocephalus, The heads of children sometimes grow enor- mously large, the sutures give way, and the mem- branes of the brain are pushed up with the water within, and make a soft tumour rising above the edges of the sutures. This disorder happens to weakly children, and has been growing upon them above a month. They daily become more and more stupid, with a pulse not above seventy-two. They can hardly be got to take any thing for the last week, even out of a spoon, and seem to have no sense, and hardly utter any sound, and have frequent little convulsions. Upon opening a child who died in this manner, half a pint of water was found in the ventricles. I have no experience of the use of any other means than purging and blistering, and these have not succeeded. The subjects of the hydro- cephalus are chiefly children of both sexes, from the first to the eighth year of their lives. Pains of the head, the hands frequently lifted up to the History and Cure of Diseases. 173 head, sudden exclamations, convulsions, stupidity, deliriousness, a slow pulse, and lastly blindness, usually attend the hydrocephalus, and make it suspected, even without any unnatural enlarge- ment of the head ; but still these are not constant and infallible signs of a dropsy in the head. No unusual quantity of water was found in the head of a child, who died after suffering all these com- plaints. An adult was seized with intolerable pains of the head, sometimes had a voracious ap- petite, and sometimes none, became delirious, con- vulsed, stupid, and died : the ventricles of the brain were found so distended with water, that as soon as a puncture was made the water flew out to a considerable distance. CHAPTER 47. Hydrophobia, I HAVE seen a considerable degree of the hy- drophobia in one whose throat had been much in- flamed, and was suppurated : but I never saw a case, in which it was the consequence of the bite of a mad animal. CHAPTER 48. Hydrops, { Swellings of the ankles or legs towards even- ing, which vanish, or are greatly lessened in the 174 Commentaries on the morning, are very common in women while they are breedin*^, and in hot weather ; and in both men and women, when they are recovering from a long illness, and in old age, and after the gout, or any hurt of the legs. These swellings cease of themselves, or continue without any danger, and therefore require no medicine. But where persons after having laboured for some time un- der complaints of the lungs, or of the bowels, be- gin to find a swelling in the legs, it is a sign of some deep mischief in the breast or abdomen, the swelling will most probably increase to a just dropsy, and the case end fatally. A dropsy is very rarely an original distemper, but is generally a symptom of some other, which is too often incurable ; and hence arises its ex- treme danger. Water has often been found in the thorax ; but there do not appear to me any infallible signs of a hydrops pectoris. The na- ture of this part hinders the swelling from being perceived externally, and the respiration is not oppressed by the water in a manner so different from what it is by other causes of the asthma, as to afford indubitable signs of its presence. A collection of water in the belly shews itself by the swelling, and by the particular feel upon gently pressing the belly with one hand, and hit- ting the distended integuments with the other, by which it may generally be distinguished from pregnancy, or wind, or any enlarged solid viscus or gland ; yet I have known very experienced persons mistaken in some extraordinary cases. The water in the belly, called an ascites, is fr«- History and Cute of Diseases, 17^ quently contained in a cyst formed from a disease ed gland. In women the ovaries very often be- come the seat of the dropsy, which I have known to continue at least ten years with not much more inconvenience than the bulk and weight must ne- cessarily occasion, this part being perhaps less necessary to life than most of the bowels. I judg- ed it to be the seat of the dropsy by its beginning in the region of one of the ovaries. This dropsy, and some others of the abdomen, will not be ac- companied with swelled legs. A very tormenting thirst attends the dropsy most usually, but not universally. In every ascites, where the water is contained in a cyst, or cavity of the abdomen, it is not easy to comprehend how it should ever get into the legs and thighs, after the body had been long in an upright posture ; and perhaps it never does ; the swelling of the legs being occasioned by the great weakness brought on by the distem- per, is more properly of the anasarcous kind, aris- ing from the fluid deposited in the cellular mem- brane, and not derived from the water in the ca- vity of the abdomen. It is found a matter of great difficulty to carry off this stagnating water, either by purging, or by increasing the urinary secretion, and still harder to do it by sweat ; and when this has been done, it is oftener a relief than a cure ; and if no further help can be given by nature, or art, towards re- moving the original distemper, the patient will re- main in as much danger as ever. Great care must be taken in ordering purges for these pa- tients, who are always much weakened by the distemper; and Hot to persist in purging them 176 Commentaries on the longer than their strength will well bear. When they are capable of bearing snch a powerful me- dicine, I choose to begin with one, two, or three grains of elaterium, which may be commodiously taken in one spoonful of brandy, or any strong distilled water. If the first dose evacuate much of the water, without occasioning too great a ruf- fle, and so encourage us to proceed, it may be re- peated twice a week, till the water be all carried off; on the intermediate days some cordial bitter will be the proper medicine. By this method 1 have cured four or five dropsical patients, one of whom continued in tolerable health for fourteen years. Gamboge, in the quantity of half a scru- ple, may be used in the same manner. These rough purges cannot always be borne or continu- ed, and then recourse must be had to the milder, with a view at the same time of increasing the urine. For this purpose the prepared squills may be tried, from one to as many grains as the stomach can bear; and, if they be given mixed with the grateful aromatic powders, or essential oils, a large quantity may be given without occa- sioning sickness. Such a medicine may be di- rected every night, and one dram of diuretic salt in an ounce of tincture of senna every morning or half an ounce of Rochelle salt or soluble tartar, all these neutral salts being, as far as I can judge; from my experience, equally diuretic. The weakness of the patient, or his disposition to purging, may be such, as to allow no room for cathartics, and to admit only of help from diure- tics. Many medicines have been delivered down from former physicians as possessed of this virtue ; History and Cure of Diseases, 177 but it must be owned, that their effects are too uncertain, and often so slight, that whoever rehes much upon them, will in most cases be disappoint- ed. One scruple of the active balsams has been given as a diuretic morning and night, and so has the same quantity of salt of tartar dissolved in water or in wine, which is a neater way of em- ploying it, than to give infusions of the ashes of burnt vegetables, all the activity of which may reasonably be supposed to reside, not in the insi- pid earth, but in their alkaline salt, with which they abound, mixed, in the ashes of some plants, with a portion of neutral salts. A dram of spiri- tus nitri dulcis, or twenty drops of tincture of can- tharides, have been used three times a day with the same view ; or a spoonful of the expressed juice of artichoke leaves mixed with two or three spoonfuls of Rhenish wine. When these, and many others which are reput- ed to belong to the same class, have been tried, as it too frequently happens, in vain, attempts have been made to draw out the water by scari- fying the legs, or by applying blisters to them, (little blisters will often arise of themselves, with- out any application, upon dropsical legs,) from all which a very considerable discharge is usually procured ; but I have never seen them cure the distemper, though in some instances they have for a small time checked its progress. Both these methods are subject to the inconvenience of making bad sores, notwithstanding the legs are fomented two or three times a day, which also very much promotes the discharge. It is often necessary to let out the water of the ascites by 23 178 Commentaries on the tapping; the belly being sometimes so violently distended, that the patient seems in danger of bursting, and can hardly breathe. This opera- tion seems to carry off the whole distemper of the dropsy : but there have been very few instances within my experience, where the water has not gathered again, or even where the patient has not died, though the dropsy never returned ; the reason of which is, what was before mentioned, that the dropsy is a symptom only of another dis- temper, and that most usually a fatal one. In some very rare cases the original bowel dis- ease takes a favourable turn, and the patient re- covers into tolerable health. Among the uncom- mon occurrences in a dropsy, 1 have known the tumour subside and vanish in a few hours, by a spontaneous flux of urine in an amazing quantity ; the water by some unknown power of an animal body, having been absorbed from its cyst, and de- posited upon the kidneys. An event of this sort, and wholly the work of nature, may have given an undeserved reputation to some reputed diure- tics, which had been so lucky as to have it hap- pen during their use. I have attended a few patients, who from their own judgment and choice have entirely abstained from all liquids ; which they have been able to do for a much longer time than I could have easi- ly believed (at least for forty days, and some have forborne all liquids, as I have heard, for six months,) but not with any success, which might encourage others to imitate them. The rubbing of the belly with olive or castor oil night and I History and Cure of Diseases. i7% morning, has been tried with as little success by many, because one or two recovered who had done tliis. Twice 1 have observed a dropsy spon- taneously disappear. In one case the patient grew apoplectic; and in the other became deHri- ous, and died. A man had an ascites, which by a spontaneous and sudden discharge of urine, in a very extraor- dinary quantity, totally disappeared ; but his legs continued to swell for some time, and kept him in tear of a return of his distemper. In this state he was seized with an apoplectic fit, from which he soon recovered. From this time he was troubled with giddiness, and slight threatenings of some apo- plectic mischief; but for many months had no swelling of his legs, nor any signs of a relapse in- to the dropsy. There is one species of dropsy, called anasar- ca, which often appears without being complicat- ed with any other disease ; and this is frequently cured, and the patient left in good health. Though this be for the most part void of danger, yet it it not easily removed ; and will for a long time, not only for four or five months, but even for as man)' years, resist all remedies. Some apparently heal- thy young persons have had an anasarca ; and I have several times seen it in breeding women oth- erwise healthy, and upon their miscarrying it has disappeared. It has been acccompanied in s.ome with an extraordinary flow of tears.- I have known it in all ages ; but women are more subject to it than men. Gentle purges, with cordial bit- ters on the intermediate days, are the proper re 180 Commentaries on the medies. The scarifjing of the legs has eflTected a cure ; and so has an opiate given at night, per- haps by the sweat which it occasioned. CHAPTER 49. Hypochondriacus et Hystericus Affedus. Few persons, if any, have been blessed with such a constant cheerfulness, as not to have some- times felt a languor and dispiritedness, without any manifest cause, which has cast a cloud over all their pursuits, and has afforded only gloomy prospects, wherever they turned their thoughts. This state I call the hypochondriac affection in men, and the hysteric in women. While this is in a slight degree, and of short continuance, it passes off unobserved by others, and is not much regarded by the sufferer ; but when the returns of it are frequent, and strong, and of long conti- nuance, it appears to be a misery much harder to be borne than most other human evils, and makes every blessing tasteless and unenjoyable. It is a sort of waking dream, which, though a person be otherwise in sound health, makes him {ee\ symp- toms of every disease ; and, though innocent, yet fills his mind with the blackest horrours of guilt. Our great ignorance of the connexion and sym- pathies of body and mind, and also of the animal powers, which are exerted in a manner not to be explained by the common laws of inanimate mat- ter, makes a great difficulty in the history of all History and Cure of Diseases. 181 distempers, and particularly of this. For hypo- chondriac and hysteric complaints seem to belong wholly to these unknown parts of the human com- position ; the body itself, as tar as our senses are able to discern, seeming to have all its integrity and perfection in those who have long and great- ly suffered by these disorders. But there is hard- ly any part of the body which does not some- times appear to be deeply injured by tlie influence of great dejection of spirits ; and none more con- stantly than the stomach and bowels, which hard- ly ever escape unharassed with pains, an uneasy sense of fullness and weight, indigestions, acidi- ties, heartburn, sickness, and wind in such an ex- traordinary degree, as to threaten a choking, and to affect the head with vertigo and confusion : the appetite however remains good, and is sometimes voracious. The urine is most commonly pale, and in great abundance, but not universally. No distemper of the heart occasions greater palpita- tions, than extreme lowness of spirits, in those where the heart is free from all distempers. Though the lungs be sound, yet the respiration will be performed with all the tightness and op- pression of the breast attending on an asthma. A sense of fullness in the throat, and of suffoca- tion, is excited with as little material cause, as far as the senses can judge. Tears flow from the eyes without grief; the nose and ears are filled with ideal odours and sounds : and a mist will seem to obscure the sight. A giddiness, confu- sion, stupidity, inattention, forgetfulness and irre- solution, all show that the animal functions are no longer under proper command, and that the mind is controlled by some foreign power. The com- 18^ Commentaries on the forts of sleep are in a great measure denied to these patients ; for thej have but httle, and in it they are harassed with terrifying dreams. Rest- lessness, wandering pains, sudden flushings, cold sweats, a constant terrour, tremours, catchings, numbnesses, contribute to their misery ; which sometimes so overpowers them, that they either sink under it in a fainting {lU or it is with great efforts and struggling that they can keep from it.* All these symptoms are common to hypochon- driac men and hysteric women; but some of them are less, and some more violent in females, and there are others which seem peculiar to them. They are seldom so low-spirited ^s the men, but are more apt to have their faculties and passions benumbed, being turned almost into statues, unaf- fected by occasions of joy or grief. They are far more subject to faintings, and to those univer- sal convulsions, which are called hysteric fits, from which the other sex seems to be saved by their superiour strength. These fits will be brought on by the slightest afTection of the senses or fancy, * How great a confusion of the senses this disorder is capable of producing, will appear by the following history. A gentlemen about thirty years of age, without any obvious cause, fell into a great dejection of spirits, which lasted some time. At length, by some perversion of the mind, he seized a razor, and amputated bis penis and scrotum. After the wound was healed, he said of him- self, it appeared very strange to him that he should have courage to perform such a deed, since he was always at other times of so timid a disposition, that he had great dread even of being bled with a lancet, and could not suffer such a trifling wound without much agitation. Yet he was free f^om all fear when he attempted this hazardous amputation ; which he moreover told me was done without his being sensible of the least pain. A similar case is re- lated in a book entitled Medical Communications, vol. ii. p. 54. r ^B History and Cure of Diseases, 183 ^B beginning with some uneasiness of the stomach or bowels. They will last lor half an hour, or less, and return frequently every clay or even continue for a whole day ; in the mean while it is singular, (hat though the hysteric persons be incapable of speaking, and seem senseless, yet they often hear and understand every thing that their attendants say. After coming a little to themselves, or even without falling into a fit, they will sometimes have a slight delirium upon them, which lasts for seve- ral hours. Women differ likewise from hypo- chondriac men in being much more apt to cry, and to fall into convulsive laughter, or to lose their voice, or utter violent shrieks, and in having hic- cups, yawnings, stretchings and other tendencies to convulsions. The hysteric globe in the throat is scarcely ever heard of among men, but is one of the most familiar symptoms with hysteric women. Man has iraraemorially been said to consist of S(yft«, *v>j»j, Nflw$, the body, the animal faculties, and the mind. In hysteric women the operations of the animal powers seem to be most disturbed and perverted ; but in men the mind is the most affect- ed ; involuntary exclamations, faintings and con- vulsions of all sorts,* being most common in wo- men ; and silent despair in men. Hence, perhaps, suicide is more common with men, than among women. Some speculative persons, seeing such evident marks of a design in the author of mankind, that human happiness in every state should be nearly the same, have considered low-spiritedness as the means by which the happiness of the rich and idle 184 Commentaries on the is reduced to a level with that of the indigent and laborious part of the species. But it is bj no means true, that the poor and industrious are by the lowness of their station sheltered from the ty- ranny of this malady. Some derive it from their parents ; and the seeds of it, brought with them into the world, are sure to make their appearance at the proper time, let the condition of the person be what it may. A dejection of spirits will rob the poor husbandman of the ease and comfort which he should feel when the labour of the day is ended. Neither strength of constitution, nor temperance, nor business, nor the gout, afford a certain security. However, idleness will not only foster a disposition to a languor of spirits, but will unquestionably create it; and so will the other extreme, of an oppression from too much business. An intemperate use of women, and wine, will like- wise be its mother and nurse, as well as too great abstinence in eating. Repeated fevers, excessive purgings, terror, and immoderate grief, are no uncommon causes of its appearance in those who before were strangers to it. Hypochondriac complaints resemble the gout, and madness, and consumptions, in their not ap- pearing before the age of puberty ; from which, to the age of sixty, there is no tiaie at which this malady has not made its first visit. There are very few examples of low-spirited persons who find themselves worse at night than in a morning; the generality of them, like most of those who are afflicted with any of the complaints styled ner- vous, are hurt by their sleep, little as it is ; and the longer they happen to sleep, the worse they History and Cure of Diseases, 185 are ; they awake out of it in confusion, and do not come immediatelj to themselves; and when they do, they can think only of melancholy subjects, and feel the worst horrors of their disorder. This state continues till dinner, with very little abate- ment: after dinner they feel themselves a little revived ; and at night the tide of their spirits re- turns ; which being desirous to enjoy, and dread- ing their certa?h ebb when they lie down, they go late and with reluctance to bed. Three persons employed in examining and smelling tea, have suspected that it occasioned tremours and other hypochondriac ills. The seasons of the year have not appeared to have any constant influence in relieving or exas- perating a disposition to melancholy. Though extreme dejection of spirits seems so nearly relat- ed to epilepsies, madness, and palsies, yet it is not common to see it end in any of these disor- ders. It is the condition of this malady to make the patient hopeless of a cure : but neither reason nor experience justifies his despair. For every part of the body, as far as our senses can judge, is whole and uninjured by his sufferings, great as they are ; and the mind and animal powers are indeed oppressed, and cannot exert themselves, but their abilities are all entire. Hypochondriac and hy- steric persons will look well, and grow fat with their complaints, and have now and then respites from them, in which they have all the sensations of most perfect health. It is well known, that 24 186 Commentaries on the some extraordinary works of genius have been the offspring of the intervals of melancholy. This malady will sometimes cease spontaneously ; and 1 have known it leave a person, without any re- turns, for near twenty years. Now, what more encouraging circumstances can there be in an ill- ness, than to know that the life is in no danger from it, that it is not incurable, and that, when it is removed, the patient will becodle as perfectly well as if he had never experienced it ? In the cure of all chronical distempers, it is a matter of great importance to put the general health, by a proper regimen, into the best state possible; by which the self-correcting principle of an animal body will be enabled to exert itself with the greatest vigour; and this, in some dis- eases, is the whole of what can be done. This therefore must be carefully attended to in a lan- guid state of spirits, by avoiding all the general causes of ill health, together with all the particu- lar ones before mentioned, which may be conjec- tured to have brought on, or to have aggravated this malady. Evacuations are very ill borne in this disorder; but as it is usually accompanied with costiveness, we need not scruple to give occasionally three or four grains of Rufus's pill, or a small portion of any other gentle aperient so as just to procure one motion every day ; for this will mitigate, or prevent many of the bowel complaints. A gentle emetic may also be sometimes wanted, when the stomach is uncommonly loaded and sick. All fur- ther evacuations, and particularly bleeding, scarce- History and Cure of Diseases. 187 ly ever fail to heighten every syraptom. It is -so little in the power of any medicines to give the gout, and it is so uncertain whether the gout would take away the hypochondriac complaints, (for in some persons I have known it constantly bring them on,) that I think it nugatory to attempt a cure by giving any medicines which are suppos- ed to create or to excite a fit. Bath waters, ac- cording to my experience, are at least useless, un- less in some extraordinary disorders of the sto- mach ; and the going thither, or a sea voyage, or foreign countries, can only be advisable when they will remove the patient from a scene of grief, or cares, or too much business. Sea-bathing, and chalybeate waters, may be serviceable upon the same account; and may besides, in some cases, improve the general health. The gum-resins, and wild valerian root, and steel, have the credit of possessing a specific virtue in all maladies at- tributed to the nerves : my experience of them will not add much to their reputation. The nerves of the stomach and bowels have so great a dominion and control over the whole nervous system, and these parts are so generally disorder- ed in hypochondriac and hysteric patients, that, in my judgment, the best medicines will be such as correct their acidities, and are known by expe- rience to be efficacious in recovering them to their proper strength and functions. This pur- pose is best brought about by the aromatic and bitter medicines, with which a small proportion of aperients may be joined when they are wanted. These may be given in pills, in drops, in tinctures, or infusions ; and by this variety of forms, and by the small compass in which they may lie, they 188 Commentaries on the may easily be continued, as long as may be neces- sary, without becoming nauseous. Many in a lowness of spirits are not indisposed to raise them by wine and spirituous liquors ; and they are encouraged and pressed to do it by their well-meaning but ill-judging friends. No words can be too strong to paint the danger of such a practice in its proper colours. The momentary relief is much too dearly bought by the far greater languor which succeeds ; and the necessity of in- creasing the quantity of these liquors in order to obtain the same effect, irrecoverably ruins the health, and in the most miserable manner. If the anxiety of dejection becomes intolerable, and must have some present relief, it is better to seek it in opium than in wine. A few drops of the tincture of opium, with or without the tincture of ,asafoe- tida, or antimonial wine, would be a much safer cordial for the drooping spirits than spirituous li- quors ; and might be increased without equal dan- ger of hurting the health, and without bringing on the same difficulty of ever leaving it off again. My experience has often taught me, how safely and consistently with business, a course of taking opium may be continued for a considerable part of a man's life ; and how practicable it is to be weaned from the habit of it : while every body's experience must have shown them the danger of persisting in a course of drinking immoderately, and the almost impossibility of ever reclaiming a sot. 1 would by no means be understood, by any thing which I have said, to represent the suffer- History and Cure of Diseases. 189 ings of hypochondriac and hysteric patients as imaginary ; for I doubt not tneir arising from as real a cause as any other distemper. However, their force will be very different, according to the patient's choosing to indulge and give way to them, or to struggle against and resist them, which is much more in his power than he is aware of, or can easily be brought to believe : and it is surely a cause worthy of any one's utmost endea- vours and exertions. For his striving to shake off this distemper is not contending about a frivo- lous concern, but whether he shall be happy or miserable ; since it is of the essence of this mala- dy to view every thing in the worst light ; and hu- man happiness, in many instances, depends not so much upon a man's situation and circumstances, as upon the point of view in which he contem- plates them. CHAPTER 50. Icterus, aliique Hepatis Affectus, The obstruction of the gall-ducts from gall- stones is the most common, but the least dange- rous, of all liver complaints ; for it admits more relief from art, and is often surmounted by the unassisted efforts of nature. The bile,^rom causes not hitherto clearly un- derstood, frequently thickens into grumous lumps, which gradually harden into an almost stony substance. It seems probable that these gall- 190 Commentaries on the stones, as they are usually called, are generally formed in the gall-bladder. This, I think, or the ductus choledochus communis, is the place in which they are most frequently found, and often, when the liver is so perfectly sound as probably to have had no share in producing them. At least, it must be owned that the gall-stones ac- quire their chief bulk in the gall-bladder, though it should be judged that the nucleus comes hither from the liver. The contents of the gall-bladder are naturally poured through the ductus cysticus and choledo- chus communis into the duodenum. Together with the bilis cystica the gall-stones readily pass, if they are very small ; and if they are large, they sometimes lie quiet in the gall-bladder, without being at all perceived, and sometimes make fre- quent efforts to get into and pass the gall-ducts ; in the beginning of which, or in any part of them, if they happen to be stopped, they of course ob- struct all, or most of the gall, that should flow in- to the intestines, which therelore is forced back into the liver, and thence into the blood, tinging the serum, and consequently the skin and eyes, of a yellow hue, and deepening the natural colour of the urine, so as to make it of a very dark yel- low, or brown.* . The usual symptoms of the gall-ducts thus ob- structed are, loss of appetite, sickness, vomiting, * The urine of one person in a jaundice, after standing a few hours, changed from a deep yellow to a green colour. The same change may be observed in yellow bile a little while after it hjis been vomited. miory and Cure of Diseases. languor, inactivity, sleeplessness, and if the ob- struction be continued for a few dajs, a very great wasting of the flesh. These complaints are remarkable in the obstructed gall-ducts, but they belong to njany other diseases. The most distin- guishing signs of this malady are, a yellowness of the eyes, skin, and urine, and a want of this colour in the stools. Nor is this disorder much less cer- tainly denoted in some patients, before the yel- lowness appears, by an exquisite pain about the pit of the stomach, the pulse being at the same time as slow as a natural one : and by an atten- tion to these two circumstances, it is not difiicult to foretell the outward yellowness, in many cases, some days before it appears. The slowness of the pulse will almost always distinguish this pain from one which belongs to an inflammation of the bowels ; and wherever, together with this pain, the artery beats in the usual manner, the physi- cian will have the great satisfaction of being able to assure the patient, that his pains can be reliev- ed, and that they are not of a dangerous nature. But this pain, which sometimes is hardly sup- portable In the jaundice by persons of the great- est patience and courage, rises in others only to a slight uneasiness about the region of the liver, or is not felt at all. This perhaps may be owing to the difl'erent parts of the gall-ducts In which tl>e stone happens to lodge. There is great reason to believe that the liver itself has little or no sense of feeling ; and it is probable that not more belongs to the gall-ducts. But every day's expe- rience acquaints us how exquisitely this sense be- longs to the intestines. It may therefore be, that 19S Commentaries on the little or no pain is felt while the stone is forcing its way through the gall-ducts, till it come to the end ; but in stretching that part which is inserted into the duodenum, the intestine is, by a large or angular stone, distended or irritated, to a degree which may account for all the torture that ever attends the jaundice. This pain seldom lasts, without intermission, above two or three days ; but I remember its continuing in one person near a month, without any intervals of ease, except what were procured by opium. Wherever this pain is felt at all, it not only comes before the yel- lowness, but is sometimes more, sometimes less, sometimes entirely disappears, and then rages afresh, throughout the whole fit of the jaundice. There sometimes appears reason to suspect a stone in the ducts of the liver, from the presence of all the other symptoms, though there be no yellowness in the eyes or skin ; which suspicion has been verified by the voiding of a gall-stone, with the relief of all these symptoms ; or after fre- quent returns of them without any discolouring of the eyes and skin, by having one of these fits end at last in a jaundice. Whether it be, that in these cases the stone is of such a form as not per- fectly to fill up the aperture, or that the violent efiforts of vomiting, without dislodging the stone, force some bile between it and the sides of the duct. And as a gall-stone may sometimes be suspect- ed without any marks of it in the eyes or skin, so this yellowness is said to be found without any gall-stone or prseternatural consistence of the bile. History and Cure of Diseases, 193 [t has been supposed that an infraction of the luodenum may be great enough to hinder the ef- lux of the bile : but this may be questioned, if we reflect that the duodenum has seldom any solid jontents in it, and that if it should be so plugged ip by them, or compressed by the distension of the other intestines, as to hinder the passing of the bile, it would for the same reason be incapa-' ble of admitting any thing into it from the sto- lach ; which is a supposition hardly countenanc- id by experience. Sydenham mentions the jaundice as no uncom- Qon symptom in hysteric cases, where there is no lisorder of the gall or gall-ducts. No reasona- ile deference to this accurate observer can make iny one much doubt of his having been mistaken, because nothing like this has occurred to very many other practitioners, as they have assured me, though hysteric complaints be so very fre- quent : and it requires but a very moderate un- derstanding to see, after it has been pointed out, what could not have been discovered bui by one of superiour sagacity. A perfect jaundice is said by physicians of un- questionable authority to be an attendant upon some fevers, and particularly upon the yellow fe- ver of the West Indies. It is also said to be pro- duced by the bite of a viper. And in these cases it is judged to be owing to a convulsive stricture of the duodenum. Of all which I am no judge, as i have never seen these disorders. There is in many exhausted and cachectic persons a skin almost of the colour of a lemon, in which the bile 194 Commentaries on the is not concerned ; but then they have not yellow eyes, and dark urine, and ash-coloured stools, which I have never yet happened to see, without the strongest reason to suspect the gall-ducts ob- structed by bilious concretions, or scirrhi. It has long been a prevailing opinion, that eve- ry object appears yellow to the eyes of a person in the jaundice : " Lurida prseterea fiunt, quaecunque tuentur Arquati :" is the assertion of Lucretius;* and the same has been allowed by some physicians. Now, though the tunica conjunctiva be tinged with this ail, yet, as the milk in the breast preserves its whiteness, it is not probable that the much finer humours of the eye, through which the light is transmitted to the optic nerve, should ever be infected ; nor if they could, would it thence follow, that all ob- jects would appear yellow : accordingly all the jaundiced patients, whom I ever asked, have una- nimously denied the truth of this pretended fact ; excepting two women, whose testimony was very suspicious. The duration of the jaundice is extremely va- rious, and uncertain. In some patients it will dis- appear in two or three days ; in others I have seen it continue near a twelvemonth, before the gall- stone could pass into the intestine, or fall back into the gall-bladder : nor will this long obstruc- * Lib. iv. ver. 333- History and Cure of Diseases. 195 tion of the natural course of the bile have any lasting ill effects, or hinder the patient from being soon reinstated in perfect health, after the remo- val of the obstruction. I have known the jaun- dice return frequently for more than twenty years in some persons, who have had good health in the intervals of the fits. There is no limit to the possible size of gall-stones, except the capacity of the gall-bladder; and they are found of all intermediate magnitudes between this and the minutest dust. When the gall-stone becomes too large to enter the duct, it is probable that its lying in the cystis may be attended with some, though I know not what, inconveni?.nce ; but it is often, we are sure, a very slight one ; fql* many have been opened after their death, in whom a very large stone, or many small^ones have been found without their ever having had in their life- time any complaint, which could certainly be im- puted to this cause. • I attended a woman, who for five years labour- ed under all the usual symptoms of the jaundice in the highest degree. In the sixth jear she void- ed a gall-stone like a small olive in shape and size; after which she enjoyed good health for many years without any return of jaundice, or the ap- pearance of a disorder which could be imputed to her once having had it. The passing of such large stones shews what great efforts nature is capable of making towards freeing itself from such an incumbrance. The natural size of the gall- duct hardly exceeds that of a goose-quill ; and a force may be exerted which will distend this nar- J 96 Commentaries on the row passage so as to let a stone pass, the smallest circumference of which equals two inches : I speak only of what I myself have seen : others give us accounts of the passing of much larger. In the gall-duct of one woman, whom I had attended, there was found after death a gall-stone as big as a small hen's egg. I have had an opportunity of examining the gall-ducts of some, whom I had frequently seen in fits of the jaundice ; and I found them much dis- tended beyond their natural diameter throughout their whole length, but very unequally. The same appearances are very common in the urelers of those, who have had many stones pass from the kidneys to the bladder. The liver of these persons, though they bad for many years suffered frequent fits of the jaundice, was perfectly sound. It is frequently recommended to the attendants upon icteric patients to examine their stools, in order to find the gall-stones, and there can be no reason to hinder them from doing it; but the oth» er signs of this disorder are so certain, that the finding of a gall-stone will add very little to the evidence for the nature of the disorder, and will be of no use to the cure. For whether a gall- stone be found or not, the method of cure must be continued as long as the symptoms remain, by which alone the physician must be directed. Let there be ever so many gall-stones found, if the patient be not relieved, it must be supposed that more remain ; and consequently the same medi- cines must be continued : and, on the other hand, though there be none found, if all the complaints History and Cure of Diseases. 197 cease, the probability is that the stone is fallen back into the c} stis, and therefore little or no- thing more is to be done. Some gall-stones, which I have weighed, have been heavier than water, and others have been to water as nine to ten. They melted also by heat, and were inflammable. 1 have examined only a few in this manner ; and possibly there may be a great difference between these and others, in the texture and materials of which they are compos- ed : most of what I have seen were of a dark brown colour, but some have been almost white externally, though brown within. A very troublesome itching, but without any eruption, is often observed in the jaundice : this is supposed to be owing to the irritation of the skm from the acrimony of the bile mixed with the blood : but it is not easy to say, why this, or any other cause, should make this complaint so ex- ceedingly distressful to some, whilst it is not at all felt by others. In a simple jaundice, without any apparent dis- order of the liver, or other viscera, a hiccup will now and then join itself to the other symptoms, but without denoting any present or future mis- chief. It might naturally be expected, that the want of irritation from the bile should make icteric persons costive ; but in fact they are often dispos- ed to have a purging. Certainly neither of these states is peculiar to their distemper; and the spon- 198 Commentaries on the taneous diarrhoea, or the readiness with which a costiveness is removed, may help to distinguish it from the ileus. In other disorders of the bowels, it is a very alarming symptom, to have the patient subject to fits of shivering : but very strong ones now and then happen in the jaundice, and last an hour, and return every day for two or three times, without being followed by any other complaint. It is dif- ficult to guess satisfactorily at the cause of this: but whatever it be, I have suspected that this symptom happens at the time of the stone's pass- ing into the intestines. However, neither suppu- ration, nor gangrene, nor any other mischief, needs be apprehended from this shivering. It is not constant in this malady, but it is far from being uncommon, to have all solid food taste bitter ; and sometimes, though more rarely, the same is true of liquids. I knew one, to whom all liquids, and solids, tasted bitter, except oysters. The milk of icteric women, who suckle chil- dren, is not tainted with the bile, either in its co- lour or taste. I remember to have seen a wo- man, v?jho with a very deep jaundice had been for six weekr, suckling a child, who sucked with ea- gerness, and was healthy -and robust. One man assured me his tears were tinged in a jaundice. Infants, and children of all ages, are subject to the jaundice ; but they have it in a slight manner, and soon recover from it ; and it does not, as far as I have observed, do them any hurt. Men and History and Cure of Diseases. 199 women seem equally liable to this malady : m a continued succession of a hundred {jatients, I counted fifty-two males, and forty-eight females. They who have once had this distemper, are very liable to returns of it ; not only because oth- er gall-stones are likely to be generated by the same causes which formed the first, but likewise because a fit of the jaundice is frequently termi- nated, not by the passing of the stone into the duodenum, but by its falling back into the cystis ; at its passing out of which it occasions a fresh fit; and many may be thus caused by the same stone. A jaundice, caused merely by an obstruction of the gall-ducts by a stone, is usually void of all danger ; so that many people are not hindered by it from doing all the common business of life, where no great exertion of strength is required. Very different is the danger in diseases, which properly belong to the liver itself. This viscus seems in some instances to have been seized with a sudden and violent inflammation, joined with a fever, and with signs of immediate danger; which are neither followed by a speedy death, or by a lingering one, after an unkindly suppuration, which, though more slowly, yet is scarce less cer- tainly fatal. Such an inflammation perhaps more usually begins in some of the parts to which the liver is contiguous, and is communicated to it from them. But what I have conjectured to be this distemper of the liver, has rarely occurred to me, in comparison of that which begins here, as in other glandular parts, with a small scirrhus. 200 Commentaries on the which gradually spreads itself over its whole sub- stance, and, I imagine, just in the same manner as it happens in the breasts of wonjen. These scirrhi by fits inflame, whence a fever is raised, and the health in many respects much dis- composed. This fever retreats on the abatement of the inflammation, and the patient is encouraged to hope for a recovery ; but his hopes are usually vain ; the intervals between these inflammations becoming shorter, the appetite, flesh, and strength decreasing with a little cough and hiccup, which sometimes without, and often with a dropsy, bring on death ; towards which the progress in different patients is so unequal, as either to take up several years, or to be finished in a few months. The liver having but a very dull, if any, sense of feeling, if the inflammation be confined to the interior parts, it will hardly be attended with any pain; which, as I suspect, is never perceived, but when an ulcer, or inflammation of the surface of the hver, catches the diaphragm, intestines, or parietes of the abdomen. In this state of the liver the patients choose to lie on their right side. A pain of the right shoulder is common in liver cases ; but on what circumstances it depends, no observations have yet ascertained to me ; nor whether it belono-s to a mere obstruction of the gall-ducts, or only to scirrhous inflammations of this part ; which last I rather suspect. History and Cure of Diseases. aoi In the advanced state of these scirrhi, the blood will gush out in great quantities from the nose, the gums, the stomach, the navel, and with the stools ; which is probably to be attributed to the obstruction which it meets with in the scirrhous liver. The worst of these cases, of which I have satis- fied myself by seeing the bodies opened, will sometimes, throughout their whole course, shew no signs of a jaundice ; that is, though the com- plexion may be of a leaden colour, yet the skin and eyes and urine will be free from the jaundice- tincture, and the stools will not be ash-coloured. The reason of which may be this ; that the diseas- ed parts of the liver are so situated, as not to in- tercept the course of the bile in its passage from the sounder parts to the duct. An indurated liver is often very evidently dis- tinguishable by applying the hand to the region of it : and this affords another certain sign of its diseased state. These are the only peculiar signs, that this viscus is the seat of any malady ; for the quick pulse, hiccup, sickness, and averse- ness from food, equally belong to the distemper of the liver, and of many other viscera. I doubt indeed whether it be of any great moment to be able to decide with preciseness, whether the ail be here, or in the pancreas, or spleen : for I know of no remedy peculiarly or specifically appropri- ated to this state of the liver ; and there is not much more to be done in it, than what the com- mon cure of the hectic fever requires, whether the fever arise from this, or from any other cause. 26 S0» Commentaries on the It is probable, if a small part only of the liver be scirrhous, that it maj, by a cool regimen, and by assisting the general health, be kept for many years from spreading. Where frequent inflammations, with a conside- rable degree of fever, cannot be prevented, there the flesh and strength more rapidly decrease ; and if the inflammation be great enough to occa- sion a suppuration, the only chance of a recovery is from the breaking of the abscess in such a man- ner, as that the matter may be carried off by the hepatic duct, or when the inflammation of the li- ver has made it adhere to the parietes of the ab- domen, in which a tumour forms, and is opened, or burst, externally. I have known one or two recover in such circumstances, but more who have sunk. In some, a great abscess of the liver has appeared to have made its way preternaturally into the stomach, or bowels ; and immediately, upon the bursting of it into these parts, the pa- tients void, by vomiting and purging, a most of- fensive matter, filling a whole house with its noi- some smell, and die in a few hours. A woman fifty years of age was for ten days severely afflicted with pain of the stomach, hic- cup, purging, and faintings, and with difficulty struggled through it. A month after there arose a swelling near the navel, which was opened, and discharged a great quantity of yellow fluid for the space of four years; at length the pain increased, together with sickness, and shivering, and after a few days there was discharged a gall-stone three History and Cure of Diseases. SO 3 inches long and as much in circumference, weigh- ing 245 grains. During the two following weeks a thin liquor was poured out in great abundance: soon after the sore healed up, and the woman re- covered. It is evident the gall-bladc(er must in this case have inflamed and suppurated. A sudden inflammation of the parts contiguous to the liver, by which it would soon be aflected, or possibly of the liver itself, may be occasioned by any of the causes to which pleurisies and simi- lar disorders are owing. The more chronical diseases of the liver, which begin with small scir- rhi, arise sometimes from the same ill habit of bo- dy which occasions scirrhi in other glandular parts, or from a blow ; but the most common cause is an intemperate use of spirituous liquors, which specifically hurt the liver, far more than they do the stomach, to which they are immedi- ately applied, or than they do any other of the bowels. Men are more commonly affected with scir- rhous livers than women, because they are more given to intemperate drinking, which is the prin- cipal cause of this disorder. Bath waters are in no cases more useful, than in remedying many of the injuries done to the constitution by drunkenness : but where the liver is become scirrhous, and a hectic fever shews these scirrhi to be in an inflamed state, there the Bath waters will aggravate all the symptoms, and contribute no otherwise to end the disease than by hastening the patient's death. 304 Commentaries on the In the cure of those whose gall-ducts are ob- structed bj biliary concretions, the first thing to be attended to, is the pain ; which is often so ex- cessive, that nothing else ought to be attempted, before this is relieved. Bleeding is here of no use, and should therefore be forborne as a need- less waste of strength. This pain can only be assuaged by giving and repeating opium, or its preparations, as often as the continuance of the pain requires them. And because this pain is very apt to return, the patient should always be advised to keep by him, as long as the distemper lasts, pills of pure opium, each weighing one grain, or what is equivalent to them, that no time may be lost in quieting a sensation which it is so difficult to endure. One of these pills may be ta- ken as soon as the pain comes on ; and it may be repeated once or twice in the space of two hours, if the pain requires it. 1 have found it both safe and necessary to give much more. Vomiting is commonly the next symptom which demands the physician's assistance. This seems to be an effort of nature to dislodge the stones ; but it may be a question, whether it be such an effort as ought to be encouraged, or checked ; for though on the one hand this violent concussion may force the stone back into the cystis, or for- ward into the duodenum, and so effect either a temporary relief or a perfect cure, yet it may be feared, if the stone be so fixed in the duct, as not to be easily moved, that the action of vomiting will lacerate the membraneous duct, and be the cause of future mischief, as well as of present pain. Now, whether this fear be just, or ground- History and Cure of Diseases, 205 less, can only be determined by experience ; and by what I have observed of icteric cases, it has appeared to me, that a vomit excited, while the pain was intense, has rather quieted than aggra- vated it, and has never brought it on. But if we be secure of its doing no harm, there is so good a chance of its being beneficial, that, whether the patient have a vomiting or not, it is a judicious practice to order an emetic, either at first, or as soon as the intenseness of the pain has been alle- viated, and occasionally to repeat it. To excite a vomiting in this malady is much moie easy than to stop it ; and therefore it is always proper, and sometimes necessary, to order an opiate to be ta- ken after a moderate number of strains have been procured, or if the sickness continue longer than usual. Similar good effects may with reason be expect- ed from purging medicines, by their increasing the natural motion of the intestines, and soliciting a greater flow of bile, as well as of all the other humours which are poured into them. Mercurial purges have been preferred by some practition- ers : but there appears nothing in the known pow- ers of mercury peculiarly useful in dislodging a biliary concretion ; and the preference should be given to those purges which act with the most ease, and may be continued with the greatest safety. Such are the sea-water, the water of ma- ny purging springs, as also many of the neutral salts, dissolved either in water, or, if it can be borne, in a weak infusion of some bitter vegeta- ble substance. These, as we know by abundant experience, may be taken for several months, ei- S06 Comtnentaries on the ther every day, or every other day, without ing the appetite, or exhausting the strengtli or spirits. But in some cases there may be reason for using other purgatives ; and I have known a few grains of rhubarb, or one or two drams of tincture of senna, or of rhubarb, taken with ad- vantage in a small draught of some moderately bitter infusion. The jaundice of infants and young children soon yields to a few purging me- dicines. If it happen that the jaundice is of itself attend- ed with a purging, there may be nothing further necessary, than by gentle means to prevent its being excessive, and at the same time to strength- en the stomach by proper bitters. The itching is many times so extremely trou- blesome, as to, require opium; without the help of vi'hich it would be impossible to procure any ease or sleep. Beside these medicines, which have appeared to me the most beneficial of any which I have seen used, there is a class of bodies which have been trusted to, from a belief that they have a power of dissolving gall-stones. Of this kind are the alkaline salts, lime-water, soap-leys, and va- rious soaps : all which I have tried by steeping gall-stones in soap-leys, and lime-water, and in the solutions of soap, and of the salts ; and it is no wonder, that the others did nothing towards dissolving the stones, when the most powerful of them all, the strongest soap-leys, could only fetch out a slight green tincture from a gall-stone, but History and Cure of Diseases, S07 neither seemed to lessen its bulk, nor to alter its shape, in several months ; and there is very little likelihood of their being able to do more in the body than out of it. Gall-stones were likewise infused in every one of the acid spirits, without being dissolved in any. But if we had ever such powerful solvents of gall-stones, it might be doubted whether they could do any service in the obstructions which these occasion ; for whilst they remain in the ducts, or cyst, the solvents cannot reach them ; and when they are come out into the intestines, they want no medicines, but will of course be voided by stool. It would be very desirable to find out a reme- dy, which would medicate the bile, so as to make it unapt to coagulate, or enable it to resolve the concretions already formed ; and such there may be found hereafter; but though this has been pre- tended of several, I have no reason to think it true of any ; and as we do not yet know any which may be safely taken, which can dissolve gall-stones, it is not likely that we know any thing which will make the bile dissolve them. I attended a person, who for a stone in the bladder of urine had been in a course of swallow- ing an ounce of soap every day for seven years. His distemper and advanced age having made him retire from all the business of life, and he being naturally constant in what he undertook, I ima- fine there could be very few days, and 1 do not now that there were any, on which this medi- SOS Commentaries on the cine was omitted. His body was opened after his death, and, notwithstanding such an extraor- dinary quantity of soap had been taken, a great number of stones were found in the gall-bladder, which shewed no sign of having been acted upon by any solvent. The only use of soap and alkaline salts in a jaundice, as far as we can reason upon their probable virtues, is, to make amends for the defi- ciency of the bile, which they resemble, in digest- ing the food, and cleansing the bowels. But too much stress must not be laid upon this reasoning; for I have known large quantities of an acid, such as lemon-juice, taken by some icteric patients, with so much apparent benefit, as to have gained the credit of the cure. A very judicious physician assured me, that he had seen extremly good effects in an inveterate jaundice from a scruple of volatile alkaline salt given three or four times a day; and he seemed to be convinced, that, besides the virtues just men- tioned, it had some peculiar or specific ones in the cure of this disease. Specifics for it are to be met with in great abundance among medical writers, many of which manifestly owe their reputation to inconclusive reasoning, or to fanciful criteria of the virtues of medicines ; others are unsupported by well-attest- ed experience ; and I have no reason, from what I have observed, to think the testimonies in favour of any of them deserve to be examined, or men- tioned. History and Cure of Diseases, S09 The waters of Bath have some credit of being serviceable in a jaundice. But it must be observ- ed, that icteric patients generally recover where- ever they are, and it may be doubted v^^hether they recover the sooner for the use of these wa- ters. However, there can be no medical reason for dissuading any one, in a simple jaundice, from going to Bath ; because the waters are perfectly safe, and the proper medicines may be taken there, as well as any where else; while the va- cancy from care in such public places, together with the change of air, and water, and objects, may be of some use to the general health, and thereby facilitate the cure of this, as they often p do of many other chronical disorders. Before I conclude, it may be of some use to observe, that biliary concretions are probably one jause, amidst various others, of that commonest if all complaints, an uneasiness, or pain, as it is called, of the stomach. This I have been induc- ed to believe, from finding that in many persons a pain of the stomach, which had frequently afflicted them for months, or years, has at last been joined by a jaundice. When therefore a pain of this kind frequently returns, without any other mani- fest cause, especially if there be at the same time a sensation of fulness, a thickening of the bile may generally be suspected ; and gentle vomits, and a course of purging waters, or any other mild purgatives, will prove the most effectual cure. 27 ^10 Commentaries on the CHAPTER />]. Ileus, The ileus, or inflammation of the bowels, has for its subject cliiefly adults, and especially those who have ruptures, or who perhaps from some less apparent, but equally unnatural situation or conformation of the bowels, have often been af- flicted with colicky pains. Yet childhood is not exempt froin this very dangerous disorder: some have died of it in their sixth or seventh year with all the usual symptoms; and it is not unlikely, that this may make one of the many bowel disor- ders which are so fatal to children for the first three or four years of their lives. It begins with a pain usually referred to the sto- mach or the bowels : this sometimes comes on suddenly, and with violence ; or from small be- ginnings gradually increases ; and in rare cases has even seemed to abate for a few days, and then has returned never to yield again to any reme- dies. The navel has been complained of, and so has the back, as the chief seat of the pain, even in those who have had inguinal ruptures ; which have undoubtedly been often the original cause, but, as I suspect, not always the seat of the in- flammation ; and in some cases the colic may have nothing to do with a hernia, which the patient chances to have, but is wholly owing to some of those causes, which produce it in persons who never were ruptured. Eructation of wind, which usually accompanies this illness, and likewise the History and Cure of Diseases, 211 action of coughing, aggravate the pain to a degree hardlj tolerable. It has happened in one or two instances, that the ileus has from the very beginning occasioned restlessness and uneasiness rather than pain, even in those, after whose death a portion of the intes- tine has been found sphacelated. The pain in those who recover, is changed into soreness, with a manifest relief of all the other symptoms ; and into restlessness in those who die, all the other symptoms at the same time becoming worse. The duration of the pain, before it makes a fa- vourable, or fatal change, is very various, accord- ingly perhaps as there may be a small portion of one, or a large part of several of the intestines in- flamed ; and according to the greater or less influ- ence of those causes which retard or hasten the progress of inflammations towards a cure, or a gangrene : so that the distemper has destroyed the patient on all days from the second to the fourteenth. It is obvious, that a violent injury by a blow, or fall, or by some corrosive poison, may excite such an inflammation of the bowels, as will be fatal on the first day, or in a few hours. The state of the pulse is of great importance in ascertaining the nature of those symptoms, which the colic has in common with icteric and spasmodic complaints, where the vomiting and pains are sometimes as great, but without any danger; for in the ileus it almost always has a fe- verish quickness, but in the others it beats in the natural maruier : and yet for some cause, about which lean form no conjecture, it happens, though sue Commentaries on the very rarely, in this and in other inflammatory and malignant cases, as has been elsewhere mentioned, that the pulse continues in a natural state, giving not the least notice of danger, or of approaching death. I have observed this thrice in the ileus. A hiccup, and an unquenchable thirst, often come on early in the distemper, and tease the pa- tient through its whole course. There is such a disposition in the stomach to reject every thing, that it is often difficult, even in the beginning of this malady to contrive any food or medicine which can be kept. Afterwards, be- sides what has been taken down, there is vomited up a brownish liquor, of which I have heard many patients and their nurses say, that it affected their senses like excrement ; and therefore I suppose it to be so, though it never struck me as having a stercoreous smell. The old medical writers like- wise call it liquid excrement. This has made its a|)pearance on the first or second day, but has not usually been observed sooner than the third or fourth ; it has been delayed till the eighth. Above two quarts have been vomited up daily for six or seven xlays, during which the patient hardly took any thing. It is probably supplied in the same manner as the evacuations in a violent diarrhoea. From this symptom it has been concluded, that, at least in some cases, the ileus arises not from a stoppage or stricture in any part of the bowels, but from their irj verted motion ; which opinion is confirmed by what I have heard the patients and their attendant sassert, that clysters had been vom- ited up ; which has happened even where the mis- History and Cure of Diseases. SI 3 chief has arisen from an inguinal rupture, in which it has been supposed that the intestine was stran- gled in the ring so that nothing could pass. In the instant of dying, an inundation of this liquid has suddenly burst forth upwards and downwards. This sort of vomiting, together with a great infla- tion and tension of the belly, are symptoms of the utmost danger ; yet some are said to have recov- ered after these appearances ; but instances of this are, I beheve, extremely rare. When the pain goes off wifliout the patient's being relieved in other respects, a restlessness and anxiety either come on, or are increased to a most distressing degree. Notwithstanding the inquie- tude, and want of sleep, and the great violence which must be done to the powers of life by (his very formidable disease, yet it hardly ever hap- pens that the patient is delirious. The peculiar and distinguishing symptom, which characterises the Inflammatory colic in the very beginning, is a costiveness ; which it is always extremely difficult, and too often impossible to conquer. As soon as a discharge downwards can be procured in a copious manner, the patient per- ceives a quick abatement of all his misery, and it soon restored to health. But it is not from one or two small evacuations, that we can entertain much hope of the distemper's beginning to give way. This has happened on the first or second day from the excrement which was lodged in or near the rectum, far below the seat of j the mis- chief. And later in the distemper, a very small portion of that liquid matter, with which the bow- 5314 Commentaries on the els are deluged, has seemed to have been forced downwards, while the disease was every hour growing worse. Such inefficacious evacuations have been observed more than once or twice in the course of this illness, without saving the pa- tient's life : and two or three of them have come away not many hours before a coldness of the ex- tremities came on, and was soon followed by death. Upon dissection, there have beeh found in some bodies, strictures, subsisting after death so strongly, that when the gut was cut in two, the cavity seemed entirely obliterated. In others there have been various portions of the intestines discoloured and sphacelated, but without any stricture or obstruction throughout their whole length. In an inguinal rupture, the intestine sur- rounded by the ring, was so far from being strangled, that two fingers could pass between them ; and the gut in that part had been less in- flamed than w^hat had fallen into the scrotum, which was black and mortified. Death perhaps might have made some alteration in these appear- ances. A person has died with all the usual symptoms of the ileus, where the only part affect- ed was half the circumference of the outward membrane of the colon, which for the length of five inches was black. A very small portion of the gut, and empty of all contents, so that it was imperceptible externally, had fallen into the groin, and was mortified, in one, who died on the four- teenth day of the disease. This account of the ileus shows that all heating things must be avoided, which have been too of- History and Cure of Diseases. S15 ten given ; and that its cure must depend upon the success of those means which abate inflamma- tions, and procure stools. The first of these pur- poses is best answered by bleeding, as often as it is judged that the symptoms require, and the strength of the patient will bear. Warm bathing will greatly assist the good effects of the bleed- ing, and cannot be repeated too often : it very rarely fails of giving a temporary relief, by pro- curing a perfect respite from the pains, as long as the patient continues in the bath. Fomentations, and bladders half full of warm water applied to the belly, are weaker remedies of the same kind with the bath. The application of a blister to the same part has been attended with apparent benefit, and acts perhaps both by moderating the inflammation, as when put upon the side in pleu- risies, and also by correcting those spasms which obstruct, or invert, the natural motion of the in- testines. All these helps are greatly serviceable in dis- posing the bowels to yield to the power of cathar- tic medicines ; by the failure or success of which the life or death of the patient must at last be de- termined. It is a misfortune that the taste of purging drugs is generally disagreeable and nau- seous ; especially as a loathing of every thing, and a Vomiting, are symptoms which distress these patients in the very beginning. Hence arises a very great difficulty of contriving any purgative, which can be taken and kept. However, they who can swallow pills, have very readily taken five grains of cathartic extract made into a pill, and repealed it every half hour until it had the S16 Commentaries on the proper effect. One or two spoonfuls of a strong solution of cathartic salt in weak broth, or in pep- permint water, has often been retained, when no- thing else would stay upon the stomach. The infusion of senna, given in the same manner, has sometimes been borne ; and so has even the cas- tor oil. In a very {ew instances I have known this oil rubbed for a considerable time over the belly, where the patient has thought that this mode of using it contributed not a little to the bringing on a proper and plentiful evacuation, and sometimes with great pain and griping. Ca- lomel, and other mercurial preparations, have been judged to quicken the virtue ol purgative medicines, and to render their operation far more certain. This power of meri ury has not been sa- tisfactorily confirmed to me by experience ; per- haps because I have not used it often enough, or not in cases which admitted any relief Clysters seem to do very little good, except those prepar- ed from tobacco ; the smoke of which is commo- diously thrown up this way by such an instrument, as is now commonly used by gardeners to fumi- gate trees in order to (tee them from insects.* (t is not unlike the wooden one described in Heis- ter's Surgery ; but it should be made of brass, and, instead of a pipe at the top, to which in Heis- ter's the mouth is to be applied, there should be a conical brass tube, the top of which should be so small as to enter an inch at least into any com- mon chamber bellows. This is much more com- modious than when the tube is made to screw on * Among the remedies for the ileus, Hippocrates mentions inflate ing the intestines : $yo-*v ^et^MuriMv mtvah km een preferred to an equal weight of water, or ►roth, as being less likely to be vomited up, ei- \er by lying in so small a compass, or by some )ecific anti-emetic virtue of the quicksilver. But the few instances, in which 1 have known it iven, it has by no means succeeded ; and it does lot seem likely that it ever should : for the ob- struction may be in an ascending part of the in- 28 k S18 Commentaries on the testine : and thouj^h this weight could be applied in the most advantageous manner, yet the force which constringes the intestines, or inverts their motion, is in all probability far superiour to the power of gravity alone in any quantity of liquid, or solid, that could be taken down. Against the use of opium in this malady it has been urged, that narcotics deaden the irritability of the bowels, and defeat the operation of cathar- tics, on the effect of which the cure of the patient depends. In favour of opiates it may be consider- ed, that they check the vomiting, and enable the stomach to retain such a quantity of purging drugs, as may far overbalance the binding quality of the anodyne. Besides, it is well known that opium has a sovereign virtue of controlling spasms, and all irrregular convulsive motions of muscular fibres. Lastly, the want of sleep, with which these patients are worn down, and the in- cessant restlessness with which they are fatigued, call aloud for the assistance of this medicine. Upon this view of the reasons on both sides, the probability of advantage from anodynes has deter- mined me to recommend them, and experience has strongly confirmed this judgment. Under the protection of an opiate, I have successfully given more, and stronger purges, than would have stay- ed without its help ; the patient's strength has been kept up by some refreshing sleeps ; and even in hopeless cases, in which the dying person is harassed by unspeakable inquietude, he may be hilled into some composure, and without dying at all sooner, may be enabled to die more easily. Lord Veruiam blames physicians for not making ^B the euthanasia a part of their studies : and surely though the recovery of the patient be the grand aim of their profession, yet where that cannot be obtained, they should try to disarm death of some of its terrours, and if they cannot make him quit his prey, and the hfe must be Jost, they may still prevail to have it taken away in the most merciful manner. .# Where the inflammatory colic is joined with a rupture, it is right to reduce the rupture, if it can be easily done ; but it is doubtful whether much pains should be taken about it, for it is unceKain that the rupture is the seat, or the cause of the in- flammation. An ileus is often seen without a rupture ; and a rupture without an ileus ; and con- sequently the symptoms may go off, though the rupture continue ; just as, without this, they often come on : and the symptoms have continued, and ended in death, notwithstanding the reduction of the rupture. Be the case as it will, all violent means to reduce the hernia will be more likely to aggravate than to relieve the disease. We know that a hernia does not necessarily hinder the operation of purges ; and if their effect be but copious, the patient may be secure of his reco- very. The operation of dilating the ring with a knife, and by that means freeing the gut from the stric- ture by which it is supposed to be strangled, is, as far as I have observed, very rarely, if ever, ad- visable, as well upon other accounts, as for all the reasons which have been just mentioned. No one, who has ever seen it performed, can help :?30 Commentaries on the having a dread of directing such a hazardous ope- ration too soon, or such a painful one too late : and we are, I think, greatly at a loss for any rules of judging in what case, and at what precise time of the ilhiess, this operation may be successful, and nothing else. CHAPTER 52. Inflaiio et Ructus. Flatulence is not an original distemper, but attends upon most disorders of the stomach and bowels. It is very commonly one of the numerous evils belonging to hysteric and hypochondriac pa- tients ; and is sometimes the forerunner of an epi- leptic fit. Great complaints of wlndiness are in different persons accompanied with indigestion, sickness, vomiting, some difficulty in swallowing, excessive uneasiness, almost to choking and con- vulsions, languors, a sense of fainting, a loss of voice, giddiness, and palpitations of the heart. This complaint is commonly rendered worse, but not always, by costiveness ; and though some- times it be relieved^ yet it is oftener increased af- ter eating. Bath is no certain cure for flatulence; nor indeed can it be expected, that the same means should always remove a disorder, whi( h is a symptom of various diseases. If the original disease be known, the remedies must be applied there; but if flatulence be the only complaint, the best medicine will be some warm and gentle ape- History and Cure of Biseases. S8i rient. Tlie following has been signally useful, taken every night in powder, or in pills : lialf a scruple of powder of chaaiomile flowers, three grains of long pepper, and one of aloes. Fits of eructation hrive returned every day both periodically and at uncertain hours. They have been joined with giddiness, heartburn, and hiccup, and have risen almost to a degree of convulsions. Wine and sweet things have proved hurtful. Acids have been beneficial. Vomits and purges have been useless. CHAPTER 63. Insania. Great anxiety of mind, whatever may have been its origin, is a principal cause of insanity, that is, a disordered understanding, with a quiet pulse and without any acute illness. It has been the consequence of some diseases, particularly of worms, and epileptic fits, and of many affections of the head, as dropsies of the ventricles of the brain, and scirrhous tumours, and also of blows. Sleeplessness, and disagreeable sensations of the bowels sometimes also rising up to the head, of- ten precede perhaps rather than cause lunacy. Women seem much more liable to this misfortune than men, and particularly at the time of their ly- ing in. • It is one of those distempers, which hardly ever appear before the age of puberty. I have never SSS Commentaries on the seen it earlier than in the sixteenth jear. An he- reditary cause of madness has lain dormant even till old age, and has made its first appearance af- ter sixty. It is an inveterate opinion, which my experience has uniformly contradicted, that madness is influ- enced by the moon. The gout is supposed to absorb other distem- pers, and to turn them so perfectly into its own nature, that no traces shall appear of any other malady beside the gout. I will not Jiinswer for the truth of this observation ; but I make no doubt of my having observed some power of this kind in madness ; upon the access of which I remarked an extraordinary and immediate recovery of strength and health in one, who was languishing with ex- treme weakness consequent upon a fever. In an- other, who had every sign of a pulmonary con- sumption advancing fast to its last stage, madness came on, and presently made a cure of the con- sumption, pf which 1 almost despaired by any other means. Great violence is probably done to the brain, when a man is deprived of reason, the principal characteristic of his nature : but the parts of the brain subservient to animal life, seem so distinct from those which are essential to the exercise of reason, that insanity has in many instances been no hindrance to the enjoyment of good health in all other respects even to extreme old age. Those who have been cured of lunacy, are very apt to have relapses ; and some divide their whole History and Cure of Diseases. 2S3 lives between madness and reason. Such as ne- ver return to the use of their senses, are alter- latelj under the dominion of spirits either too Irooping, or too elevated ; in each of which states it is nol uncommon to have them pass several months together : they appear most reasonable in the melancholy ^t An old madness in some be- comes stupidity, and idiotcy. Mad persons seem to have a very imperfect manner of measuring time. Some, upon my asking them, have told me that they believed they had passed two months in a state of confinement, in which they had in reali- ty been above twenty years. In the beginning of madness, which the patients are too apt to increase by drinking strong liquors to excess, and by many unnecessary hurries into which they put themselves, quiet and confinement (not under the care of their own servants, but ra- ther of strangers, of whom they may stand in some awe) will often restore them to their senses "without the help of medicines. But where they are at all disposed to be costive, or have heated themselves by their imprudent manner of living, they have been greatly assisted in their recovery by the use of some purging physic. Opium has also been sometimes useful in composing their minds by procuring them sleep. Beside these, and what may be further necessary to put their general health in good order, and to keep it so, I have observed nothing which has been of any ser- vice in removing this great affliction. SS4 Commentaries on the CHAPTER 54. Intcstinorum Dolores. Pains of the bowels arise from a great variety of causes which we know, and probably from se- veral others which we do not suspect, and care must be taken to refer them, as far as we are able, to their true origin ; for according to this, very different treatments may be required. Diseases of the ovaries, womb, bladder, kid- neys, spleen, pancreas, liver, and omentum, are often confounded under the general name of pains in the bowels. A stone in tne gall-bladder I have great reason to believe is a much more common cause of such complaints than has been generally supposed ; for many of them, after returning fre- quently for above twenty years, have shewn their true nature at last by being joined with signs of the jaundice. Scirrhous tumours and ulcers in every part of the abdomen, worms, especially in children, and ruptures in adults, the colica Picto- num, ileus, and strictures in various parts of the intestines, with other mal-conformations, must be kept in mind, as the possible maladies of these patients. The affections of the womb, or of any parts belonging to it, may be probably conjectur- ed from the fixed seat of the pain, and from its relation to the menstrual discharge, to child-bear- ing, or miscarriages. Those of the kidneys and bladder will shew themselves not only by their situation, but also by the preternatural appearan- ces of the urine, or by the frequency and pain of Bistory and Cure of Diseases. §26 making water : and a further sign of the affections of the womb, kidneys, or bladder, is afforded by the small concern which they have with the stools* The ileus or inflammation of the intestines, is too acute, and too strongly marked, to be easily mista- ken. Ruptures cannot but be found out, unless the patient use art to conceal them. Where worms do not shew themselves in the stools, a disposition to them may still be discovered by the state of the [faeces, which requires the same treatment. The colica Pictonum, if the person be not known to have been hurt by lead, is many times not clearly ascertained, until the limbs begin to be paralytic. Ulcers and scirrhous glands in the intestines will greatly derange their functions, and the discharge from the ulcers may appear in the stools ; and ei- ither here, or in any other of the abdominal visce- [ra, they are almost always accompanied with loss [of appetite, of flesh, and of strength, with a quick pulse, and swelled legs. But if we were ever so sure of the presence of these sores, and tumours, or of adhesions, and strictures of the intestines, or .other mal-conformations, they would only direct us to do nothing further, than mitigating the ur- gent symptoms. Beside all these, and the periodical pains before mentioned, the stomach and intestines are liable to uneasiness and pain, arising from a constitution- al weakness and languidness in performing their functions of digestion, assimilation, and expulsion ; or from an accidental one owing to the improper quantity, or quality of the food, to the injudicious healing of cutaneous ails, or to disorders of the head, or limbs, which by some hitherto undisco- 29 226 Commentaries on the vered power are transferable, as experience teach- es us, into the bowels, and from them back again to their former seat. Such a faihng of the natu- ral vigour of these parts will be productive of sickness, vomiting, diarrhoea, tenesmus, flatulence, a sense of fullness, a tension of the bellj, borbo- rygmi, pains like the cramp, a difficulty in making water, and such a strong acid, as will almost ex- coriate the parts through which it passes in going upwards or downwards. A sudd.en attack of pains in the bowels should in no case be treated, as it too commonly is, with spirituous liquors : when they proceed from the improper quantity, or quality of food, or fruit, a vomit, or a purge, according to what nature points out, should be immediately taken ; after either of these has had its proper effect, if the pains or purging require it, they may be checked with an opiate : the consequent weakness of the bowels may sometimes require bitters and aromatics to be taken morning and evening for a few days. Gouty pains suddenly transferred to the bowels are best relieved by such a warm opiate as the confectio opiata, the dose and repetition of which can only be deterniined by the exigency of the case. The less dangerous and less acute uneasi- ness, consequent upon healing old sores, and upon repelling slight pains of the limbs or cutaneous ails, will be sufficiently provided for by a course of aromatics and bitters, taking care at the same time that the body be not costive, which is a cau- tion necessary in every disorder of the bowels. A constitutional weakness will often be strength- ened, and a return of the attendant pains prevent- History and Cure of JDiseases. 227 by drinking Bath water, and by the use of a lannel waistcoat over the shirt ; for cold is detri- lental. Such patients may take with great ad- vantage a bitter and aromatic powder once or twice a day for many months, to each of which »owders, if the persons are teazed with purging, lay be added two or three drops of tincture of ipiura ; but if they are hurt by the other extreme, they may take three or four grains of rhubarb every day mixed with one of the powders, or ten grains twice a week. In shghter cases, an acci- dental increase of pain, if it be not considerable enough for the use of opium, may be relieved by a few spoonfuls of simple peppermint-water, or by applying warm cloths, or a bladder of warm wa- ter to the abdomen. The affections of the sto- mach are so much of the same nature with those of the intestines, and often so undistinguishable from them, that most of what is said under each of these articles is equally applicable to both of them. CHAPTER 55. Ischuria. A DIFFICULTY of making water seems born with some persons, who have been troubled with it from their childhood without any ground to sus- pect either a venereal, or a calculous cause. The weight of the pregnant uterus has often obstructed the passage of the urine, for which a SS8 Commenturies on the change of posture will sometimes be a remedy, and some women are so distressed with it, that while they are in the last months they can never part with any water without the help of the ca- theter. A similar effect may arise from the stone in the bladder. Venereal disorders will disease the urethra ; and sometimes, as I suspect, this mischief has been done by the injections, which have been used for their cure : these may be re- lieved, but I have seldom known them to be cur- ed, by a long continued use of a bougie. 1 have been witness to a fatal suppression of urine from this cause. A woman, after a difficult labour, had a reten- tion of urine for nearly three days : the catheter was then introduced, and brought off above five pints of urine. In a young woman, the taking of an emetic was three times followed by a suppression of urine, All these obstructions of the urinary passages happen without any fault in the kidneys ; but the most dangerous ischuria is that, in which the kid- neys secrete no urine from the blood. Ir^ one pa- tient, stones in the kidneys were probabi} the cause of an incurable retention of tiie urine; but I have had no reason to think this of any other, whom I have attended ; and it is not like}) to hap- pen often, that the kidneys should be destroyed by calculous matter, and both of them be made wholly useless, or that both the ureters should happen to be plugged up at the same time, so as History and Cure of Diseases. 229 to let no water pass. Whatevep probability there may be, that the bladder is empty, and that the disease is in the kidneys, it will still be advisable in every suppression to make the matter certain by the introduction of a catheter. Extreme restlessness, and sometimes a lethar- gic stupor, accompanies an ischuria, together with vomiting, hiccup, fever, and pains in the loins. One of these patients complained of a strangury ; but I have not remarked that others have shewn any desire of making water. One man also com- plained of an urinous taste in his mouth, in whom I had reason to suspect, that urine was secreted in the kidneys, but could not pass off. A total suppression has lasted seven days, and yet the patient has recovered. It has been fatal so early as on the fourth day. But in general those patients, who could not be cured, have sunk under their malady on the sixth or seventh day. A draft with spirit of turpentine from ten drops to thirty has been given every five hours ; a clys- ter with half an ounce of spirit of turpentine has been injected twice a day ; half a grain of cantharides has been taken every four hours; and clysters have been employed with half an ounce of diuretic salt ; and warm bathing as often, and as long as the patients could bear it; and with all these the disteuiper has ended happily. But on the other hand all these remedies have in some case been tried without success. 330 Commentaries on the CHAPTER 56. Lingum et Oris Dolor, Cancers of the tongue and mouth begin with a small hard lump, and sometimes with a little sore ; both of which are attended with pricking pains, and they spread in the same manner with cancerous sores in other parts. This is so great ah evil, that the slightest suspicion of it occasions very great uneasiness. It may prevent some groundless alarms to be assured, that I have known a burning pain of the mouth and tongue continue in several persons for many months with- out any ill consequences. A bitter, acid, putrid, and brassy taste, which infects every thing put into the mouth, are usually the effects of disorder- ed stomachs, or of taking mercurial medicines. A man, who had not taken mercury, found every thing which he put into his mouth infected with a brassy taste to such a degree of nauseousness, that he lost his appetite, and in two months his flesh and strength were greatly wasted : he took test. ostr. 3ss. rad. gent. gr. iv. hier. pier. gr. ss. morning and evening, and soon began to recover his true taste and appetite. CHAPTER 57. Lipothymia, or Fainting. A FAINTING fit is a momentary cessation of life, and is an attendant upon worms in children, and History and Cure of Diseases. 331 upon those who are paralytic ; a slight epileptic fit appears in this form ; and it is a common be- ginning of a fit of the hooping-cough in adults ; it is a symptom familiar to hypochondriac and hy- steric persons, and to breeding women, and fevers sometimes begin with it. In general it is more common in women, than in men. It will seize some persons without any warning, and in others it gives notice of its approach by pain, or a palpitation, or a sense of fulness in the stomach, rising up thence to the head, by a mist, and flashes of light, spasms, and pains of the bow- els, giddiness, cold sweats, tremblings, and great quantities of wind breaking up from the stomach. The posture of kneeling, or standing, too long continued, especially with the back to a large fire, and after exercise, the sight, or smell of disagree- able objects, will make many persons swoon, who are otherwise in good health ; and the same will happen to some without any apparent cause. When a person is apt to faint upon waking in a morning, there is some suspicion of its being a slight degree of an epilepsy. One fit immediately succeeds another in some persons for six or seven times. Some recover out of a swoon with vomiting, or purging, or with great eructations, and complain of giddiness, oth- ers feel themselves perfectly well upon the return of their senses. All kind of evacuations have been found hurt- ful to those who are subject to fainting. Where 2S2 Commentaries on the this disorder is habitual, and not complicated with any other, I have remarked cold bathing to be beneJScial ; but if it be a symptom of another dis- temper, it will cease of course when that is cured by its proper remedies. It seldom happens that the swooning fit continues so long as to require much help to recover a person to life. Volatile salts applied to the nose are generally sufficient. Bleeding is utterly improper. Rubbing the body with hot cloths, also clysters, might be employed, if the fit were to continue any time, and all the other means, which are found expedient in reco- vering drowned persons. CHAPTER 58. Lumborum Dolor. The loins are the seat of various pains derived from many different causes, such as the gout, rheu- matism, a sudden cramp of the muscles lasting two or three days, and making all motion intole- rable, gleets, fluor albus, stones and ulcers of the kidneys, ulcers of the womb, pregnancy, and the approach of an abortion. I saw one person, who had complained of a pain in this part for fifty years, but this was only slight, as may readily be imagined. However I attended another, in whom a pain of the loins had been violent above seven years, and motion increased it to such a degree, that during all this time the patient was incapable at best of bearing a carriage, except for a very short time, and frequently could not be moved History and Cure of Diseases. S33 from one chamber to another without great diffi- culty ; and jet there was no external appearance of harm, nor any such derangement of the animal functions, as to point out the cause ; neither was the nature of the complaint to be ascertained from the effect of any medicines, which were tried for its relief. This woman at last recovered. The remedies for this pain must be the same, which are proper for the distemper of which it is a symptom ; or such as have been mentioned in chapter 29. under the article of pain in general. CHAPTER 59. Lumbrici, Beside the round worms, the ascarides,* and the two kinds of flat worms, there are probably many other small animals taken in with our food, capable of living, and breeding in the human in- testines. The symptoms, which have been found joined with worms, and which, upon their being brought away, have ceased, are pains in the head, giddi- ness, sleepiness, restless sleep, and waking out of it in a fright and with outcries ; convulsions, fever- ishness, thirst, paleness, a bad taste in the mouth, offensive breath, cough, shortness of breath, itch- ing of the nose, pains of the stomach, sickness, loss of appetite, voraciousness, wasting of the * Concerning the Ascarides, see chapter 10. 30 234 Commentaries on the flesh, tenusmus, itching of the fundament towards night, and lastly skins and slime in the stools. The tape, or flat worms, are the most injurious to health : the round worms and ascarides would sometimes hardly be suspected, if they were not discovered by the itching of the fundament, or did not appear among the faeces. I have seen a tape worm of the length of four ells, which came away at once. Separate joints of it are often voided alive. The round worms will come up alive into the mouth, and I have known them live two or three days after they were come out. In two in- stances, which have occurred to me, there was ground to suspect that the jointed tape worm had occasioned epileptic fits, madness, and idiotcy. We have the misfortune to have innumerable remedies for the worms ; this being pretty gene- rally a sure sign, that we have not one, upon which we can with certainty depend. Spirit of turpentine, oil, infusions of tobacco, and mercu- rials, which are such deadly poisons to many small animals, out of the body, have been thrown up in clysters without destroying the ascarides ; they, and probably the other worms, being so defended by the mucus, in which they lie, that they are se- cure from the action of any noxious powders, or liquors. Until therefore the reputation of a spe- cific for worms be better established in some of the many medicines which lay claim to it, nothing better can be done, than giving purging medicines of any kind which are best borne, and can be re- peated without creating too great a degree of loathing. Bitters either joined with these, or in History and Cure of Diseases, S35 the intermediate times, may be useful, not that I have any reason to beheve them hurtful to worms, but because they will help to restore the disor- dered stomach and bowels to their natural strength. A pint of water with as much common salt as could be dissolved in it, has more than once been of singular use in expelling worms from the intestines.* CHAPTER 60. Lymphatica Glandules, Blistering plasters are apt to make the neigh- bouring lymphatic glands swell, but this swell- ing has generally soon disappeared. After a bhs- ter the whole arm of one person continued to be swelled for a long time ; probably from some ob- struction of the lymphatic vessels. A blister ap- plied to the head has in several persons so ob- structed the course of the lymph, that the whole forehead has been enormously swelled for a day or two. This swelling has gradually descended to the cheeks, and chin, and neck, and then dis- appeared. In an old woman, who seemed otherwise heal- thy, and in particular had no disease of the breast, the lymphatic glands under the arms began to swell, and be obstructed, in consequence of which the whole arm and hand swelled to an enormous size without pitting, and after a little while she * See Med. Trans, vol. i. p. 54. SS6 Commentaries on the died. Likewise in a young roan the face, and head, and breast were greatlj swollen without pitting, the veins of the breast were varicous; he had pains in his jaws, was sleepless, short breath- ed, could hardly bear to lie down, and after a few months died. CHAPTER 61. Mammce. It has been known that milk has continued to fill one or both the breasts of a woman for tour months, for five, for six, for seven, and even for twelve months after she had weaned her child. In a nurse, who was seized with the small-pox, the milk went away just at the height of the dis- temper, and returned copiously as soon as that was over. A woman in her fortieth year began to feel her breasts swell: they were soon after filled with milk, which ran out for three months: as soon as this stopped, she became pregnant : she had no child before for six years. It often happens to lying-in women, and it may happen to any other, that the breast inflames, and comes to suppuration: the adipose membrane seems to be the seat of this inflammation, the glandular part being very little concerned in it; and it is of no more consequence in this part, than such a sore would be in any other part of the body. History and Cure of Diseases. S37 A swelling of the breasts with little or no pain, except a sense of tension, attends pregnancy, and sometimes the regular menstrual discharge, as well as its obstructions, and various other irre- gularities. The breasts of women are subject also to pain, either with or without a sweliing, which often lasts for a long tfbie, and yet is of as little consequence as their swelling, while they continue free from any hard lump. A slight blow on one of the breasts has occasioned a pain, which lasted at least ten years without the appearance of its ever coming to any further mischief. In a great variety of instances, pain has come on with- out any external cause, and has lasted in some above twelve years, and then has gone off spon- taneously : great care should be taken, that this paiti be not increased by the pressure and tight- ness of the stays : a gentle opening medicine may now and then be advisable in such a case. It sel- dom happens that pain does not occasion a gene- ral fulness of the breast, but if there be no hard- ness, which denotes a beginning scirrhus, the swelling and pain have often been considerable without any mischief ensuing. A serous or bloody oozing from the nipple, has been the forerunner of a cancer; and it has like- wise often appeared, and the nipple has been tor many years drawn in, without making any further progress to that dreadful evil. A scirrhus, or hard lump, though ever so small, formed in the breast, may justly cause some apprehension of ill consequences ; for I have never known a cancer come without being preceded by this : neverthe- less I have in many instances remarked that this 238 Commentaries on the has been formed without being followed by a cancer ; especially if there have been no previous pain, swelling or discharge from the nipple. For a lump has frequently been felt by accident in the breast, and might perhaps have been there a con- siderable time before it was discovered, the breast being in every oth^V respect in its natural state. While a small scirrhus in the breast continues quiet, it is best to forbear all external applica- tions, and additional coverings to keep the breast warmer than usual ; nor can 1 recommend any internal medicines ; an exact diet seems to answer all reasonable purposes. Nature will sometimes disperse a scirrhous gland in the breast, as 1 have several times observed, and particularly in one woman, where the tumour seemed to tend to so much malignity, that it was thought advisable to cut it out : some accidental circumstances delayed the operation for some time ; and in the mean- while the swelling of the breast became less, and softer, and continued to do so till it totally vanish- ed. These however must be acknowledged to be rare cases ; but it is by no means unusual for a scirrhous swelling of the breasts neither to grow, nor to be painful for many years, especial- ly if it were formed, as happens in a few women, before the age of thirty. The most usual, and the most dangerous time for the coming of a tu- mour in the breast, is near, or after, the fortieth year of life ; yet in a woman of seventy it has oc- casioned neither pain, nor inconvenience for seven years, and seemed to have no connexion at last with the distemper of which she died. I have noted one man, in whose breast a scirrhous lump had arisen exactly the same with what is so com- History and Cure of Diseases. 239 mon in the other sex. In another the breast be- came cancerous, and was successfully cut off. As soon as a hard tumour in this part begins to be uneasy, and to spread with pricking pains, (in which state it has continued for several years be- fore it has broken) many, both external and inter- nal medicines have been recommended to check its progress, and to disperse it. I have not seen much reason to confide in any of the means, which are supposed to have the virtue of resolving such a tumour, after having first soothed it to a state of indolence ; though in two or three instances as I have neted, the extract of hemlock has had the reputation, and perhaps justly, of effecting this. But then it has undeniably failed in so many oth- ers, that it is in my judgment not worth any bo- dy's while to waste, in making a trial of it, any of that time, which is so precious after the tumour has once begun to make advances towards ulcera- tion. The insignificant pain of cutting it out, while it is small, and the prospect of its healing readily on account of the smallness of the wound, and of the health not being yet much hurt, should determine every one to the operation at this time. If the breast be curable, this, I am persuaded, will be the best cure ; and supposing that the mischief is not local, but that the whole body is infected either with an hereditary, or an acquired cancerous taint, I am not aware that the distem- per would either more certainly, more rapidly, or more painfully put an end to life, for having made this most promising effort to elude its power. If the want of resolution in the patient to have the scirrhus taken out, or the delay occasioned S40 Commentaries on the by the trial of various specifics, which had pro- mised much, and performed nothing, have suffer- ed the hardness gradually to occupy the whole breast, and to ulcerate, with a great increase of pain in the part, and flying pains over the whole body, and hectic fever, and loss of appetite, of flesh, and of strength, (at which state it may ar- rive in a few years, or in a few months) what is then to be done ? Now even in this state, if the schirri have not spread too far under the arm-pit to be all cut out, the time of the operation is in- deed almost over, but not entirely ; for in these almost hopeless circumstances I have known it performed with success. It can be no wonder, "when done so late, that the operation often fails, and that the wound should either never heal, or that fresh schirri should arise after it has been healed ; still, there will be some advantages in giv- ing a little respite to the patient, and her atten- dants, from the offensiveness of a foul ulcer, by removing at once the putrid mass. Where the cancer is spread deeply. under the arm, and the whole ami is swelled from the ob- struction of the lymphatic glands, with loss of ap- petite, and strength, and shortness of breath, and every sign of inevitable death, all which then re- mains to be done, is to keep the ulcer with proper dressings, (by washing it with water impregnated with fixed air, or by the application of a carrot poultice, in which this air abounds) as clean, and as quiet, as may be ; and to sooth the pains, and procure rest with as much opium as is necessary for these purposes. The degree of pain attend- ing a cancer is extremely various ; in some it ap- History and Cure of Diseases. S4ji pears to be great, and in others but slight and in- considerable. CHAPTER 62. Menstrua, The regular and natural state of the menstrual flux in women is well known to be intimately connected with their health. They seldom suf- ■fer much from any distemper without experienc- ing some deviations in this particular from the or- derly course of nature ; and the irregularities of this evacuation, if they continue long, except in pregnancy, will most commonly have bad effects upon the general health ; but these irregularities are perhaps oftcner a sign, than the cause of oth- er distempers. The proper ticfte of the first appearance of the ■menstrua, is from the age of twelve years to iif- *teen. Some shew of them has been known in girls of eight or nine years, and even of five years ; but 1 never knew an instance of their con- tinuing to return regularly, when they began sooner than the tenth year of life. These very early appearances have not been attended with any ill consequences, and required only a little rest and patience. When the catamenia begin first to flow at the proper time, it happens to many young women, that for the first year or two they will not go op .31 )34S Commentaries on the to observe their exact periods, without either ex- ceeding, or falling short of the just quantity : in this case, and likewise where thej delay to come on for one or two years beyond the usual time, it is better not to be too hasty in prescribing medi- cines ; for as the strength of the body increases, nature will most usually set all such little anoma- lies to right, where there is no other distemper, and in the meantime the constitution will suffer no harm. The case is very different after women are come to their full growth, and strength ; for eve- ry function of life will suffer, and often in a vio- lent manner, from great disorders of this evacua- tion ; yet nature has allowed some latitude, so that no inconvenience will arise from the catame- nia coming a week sooner or later, staying a day less or more : all which we hnd by experience to be very consistent with good health. There are constitutions, in which not only mis- carriages, difficult births, and frequent lyings-in : but even terrour, uneasiness of mind, and mode- rate exercise, occasion such a loss of uterine blood, as hatli brought on great pains in the head, back, and bowels, and a dangerous weakness. Some- times without any apparent cause the menses have exceeded the healthy limits, by returning too often, or by continuing to flow too long, or in too great abundance. These haemorrhages have been so lasting as to have continued for many months together; or so profuse, as by their abun- dance to have threatened immediate death. But these cases, where pregnancy was not concerned, History and Cure of Diseases, S43 have been usually more alarming than dangerous ; for among the many instances of excessive flood - ings which I have known, I have remarked only two, who, without being pregnant, have bled till they were exhausted, and died. The menstrual discharge gradually" lessens be- tween the fortieth and fiftieth year ; and some- times misses for two or three periods, and after giving warning in this manner for a year or two, it then totally ceases. This seems to be the most natural way of its going off. But it very com- monly happens, that at this time the uterine flux, instead of lessening, returns more frequently, and with more violence ; so that, except in cases of pregnancy, the greatest uterine ha3morrhages have been observed at the time when nature is about ceasing to supply them any longer. Young unmarried women sometimes have their monthly evacuation too often, and in too great quantity, but they are more subject to having it flow too sparingly, or to its not observing the re- gular periods, or to its being totally obstructed. The obstruction of the catamenia has been im- puted by the persons themselves to wetting their feet at the time of this flux, to lerrour, and to fre- quent venaesections. The injury done by diflicult births more frequently occasions floodings, but has sometimes been followed by obstructions, es- pecially if the milk continued to come into the breasts, which it has been known to do for seve- ral months after the child had been weaned, or though it had never sucked. Somtt distemper of S44 Commentaries on the the parts concerned, or a mal-conformation pro- bably occasions irregularities or obstructions in some, especially in those, for such there are, who never experienced this eracuation. But perhaps obstructions are most frequently owing to other antecedent disorders of the health, which by weakening the powers of life, and hindering the due nourishment of the body, reduces it to such an exhausted state, as to afford no supply for this evacuation. If a woman ever so regular in this particular happen to have a long fever, the men- strual discharge is almost always obstructed. So likewise consumptive women in the last stage of their distemper, cease to have their courses re- turn, merely from their weak and exhausted con- dition. The effects which I have noted of suppressed menstruation, where it was not wholly dependent upon other disorders, are a weight and pain of the head, giddiness, a pale, and often bloated ap- pearance of the face, flatulence, sickness, loss of appetite, indigestion, pains and a sense of fulness in the stomacn and bowels, a swelling of the bel- ly, which may be mistaken for pregnancy, pains of the breast, sides, back, and knees, swelling of the legs, loss of flesh, sleepiness, flushings, lassi- tude, fainting, melancholy, and the whole train of hysteric symptoms. The fluor albus has been a substitute for the menses, returning regularly for several months. The catamenia nave in more uncommon cases been represented by a periodical bleeding of the nose, or by a vomiting of blood. Barrenness is an usual attendant upon any consi- derable deficiency of the menses ,* yet I have History and Cure of Diseases, S4^ Known a wotnan have children, who was not above twice in the year in the way in which she. should have been every month. The menstrua are often regular both as to time and quantity, but attended always with so much pain about the womb, as to occasion greater pre- sent misery, than any other irregularity, though with less hurtful consequences. This pain is most usually felt on the first day, and sometimes only for the first six hours, and is then so violent, as to make the persons keep their beds. In two or three instances I have known it not come on till the second day. A strangury has begun to be troublesome only on the last day. Pains of the head, limbs, back, and stomach, and particu- larly of the breasts, which are usually fuller at this time, together with sickness, and tenesmus, with all kind of hysteric evils, harass some wo'- men during the whole time of their menstruation. The catamenia in the ordinary course of nature cease between the fortieth and fiftieth year. A very few have lost them before the fortieth (and one even before the thirtieth year of life) and yet enjoyed a good state of health afterwards, and have lived long. I have remarked some, who have continued to have them till they were sixty years old. They have become irregular in their time, and quantity, not only a few months, which is their common method, but even for a few years, before they have entirely disappeared ; and after ceasing three or four years have been known to return. The animal powers, while the menses are preparing to cease, seem to be greatly op- ;S46 Commentaries on the pressed, and less able to keep any constitutional disorder under, or to exert themselves in shak- ing oflf any ^accidental illnesses, which therefore at this time are unusually troublesome, and less disposed to yield to their proper remedies ; so that any lurking gout, or madness, or cutaneous diseases, have often taken the advantage of this weak state of the health, and have established a lasting tyranny. It is probable that the menstrua leave most wo- men in a kindly manner, without exciting, or creat- ing any disorders, which require the assistance of medicine. But some, upon the occasion of this great change in the animal economy, experience a variety of disorders. The most common is that of excessive- floodings, attended sometimes with faintings, and convulsions, which though hardly ever immediately fatal, yet are always very alarm- ing, and have been succeeded by dropsical swell- ings of the legs, of the abdomen, and of the whole body, and by a broken state of health, from which some are with great difficulty, and others never recovered. In the intervals of these discharges, the fluor albus often conspires to drain away the strength. Sleepiness, numbnesses, and palsies have followed, and probably have been occasion- ed by these weakening complaints. Cramps, and wandering pains, have been the next most gene- ral attendants upon this revolution in the health of women ; which may perhaps be the effect of a great loss of blood, where the catamenia have gone off in this manner ; for I have observed the same after other imoioderate bleedings. Giddi- ness, and shortness of breath, belong also to this History and Cure of Diseases, 347 train of evils : but no part seems to suffer more than the stomach and bowels, which are apt to be afflicted at the time of this change with pains, sickness, loss of appetite, heartburn, flatulence, an uneasy sense of fullness, the tenesmus, and piles. Every hysteric symptom has joined itself with these disorders. The legs at this time of life are more peculiarly liable to inflammations, and obstinate ulcers. It is less to be wondered at that some constitutions sink under the greatness, or multiplicity of such evils, than that others, after struggling three or four years under several of the worst of them, have happily been restored, and their health perfectly established. Perhaps when the menstrua are fully over, after escaping, or surmounting these difiiculties, the health of a female becomes firmer than ever, and she bids more fairly for long life, than a man of the same age. After the menses have disappeared at the natu- ral time, and have seemed for many years to be totally gone, they have in some women returned beyond all expectation. This has happened at the sixtieth, at the seventieth, and even at the eightieth year of life ; and consequently after they had ceased for twenty or thirty years. In some of these they have observed their ordinary pe- riods, as they had done in the earlier part of life ; but these unseasonable discharges have oftener been irregular in their returns, too abundant in quantity, or joined with the fluor albus. The ca- tamenia have in this manner returned and conti- nued for seven years from no apparent cause, and without any evident injury to the health. This 348 Commentaries on the effect however most usually proceeds from some unnatural state of the womb ; and if these dis- charges be accompanied with great pains about the OS pubis, the hips, and the loins ; and if in their intervals an offensive discoloured liquor drain away, they may justly be charged to an ulcer of the womb, which usually becomes cancerous, and incurable. A profuse uterine haemorrhage may be occa- sioned by something in the womo, which must be brought away before the bleeding can be restrain- ed. In other cases the patient should be kept quiet and cool ; the body must be rather inclining to purging than costiveness ; and liquors should be frequently sipped acidulated with lemon-juice, or acicl of vitriol. A dram or two of syrup of poppies will often be of great use in soothing a restlessness or anxious state of mind, which m- crease the malady. A very able and experienced physician* has proposed to me in consultation, the giving of one scruple of flowers of sulphur morning and night to such patients, where he judged it to be as useful, as in an immoderate flow of the piles. The Peruvian bark is seldom omitted among the remedies prescribed in this case ; and other styptic substances, as alum, galls, and oakbark, are often joined with it, as well as given without it. If I were satisfied that experi- ence of the good effects of such medicines had es- tablished their reputation, no reasoning, however specious, would make me hesitate to confide in them ; but if they be used because of the sense of * Sir Edward Wiliuot. History and Cure of Diseases. 249 astringencj which they impart to the tongue, it may be questioned whether this quahty can afford us a reasonable expectation of their stopping the bleeding, in a part which they cannot reach till after they have been diluted by a great quantity of various liquids : and what degree of effectual stypticity can they then be supposed to possess, when they are not readily able to restrain the bleeding of a small wound made by a leech, though the powder of these substances be imme- diately applied to the orifice ? I am cautious of opening a vein, for reasons given in the second vo- lume of the Medical Transactions, Query the fourth.* One scruple of alum has been given every day with safety : but I remember to have seen one woman near fifty years old in a bad state of health, whose belly and pudenda were swelled in a remarkable manner, so as almost to close up the vagina, all which was attributed (perhaps without reason) to checking an uterine haemor- rhage by taking daily ten grains of alum. Four grains of saccharum Saturni stopped a pjofuse bleeding, as I was informed, in four hours ; but the violent and lasting colic which I saw occasion- ed by this preparation of lead, ought to make every one dread its use. Thirty drops of tinctura Saturnina had been taken every day by a woman for a like purpose, whom I afterwards saw la- bouring under a similar, though less violent, dis- order of the bowels. Steel waters have in seve- ral instances increased the haemorrhage. • Camo- mile jflowers have done the same : and so likewise * See Appendix. 32 2d0 Commentaries on the has \y'incr down ; contrarily to what 1 should have supposed. The opposite disorder to flooding, namely, where the catamenia are too sparing, or totally obstructed, may be occasioned, as was before ob- served, by a variety of other complaints, the re- medies of which will be the hkeliest means of rec- tifying all the ailments dependent upon them. But where there appears no ill health, except what is the effect, rather than the cause of the partial or total obstruction, there stimulating, bit- ter, aloetic, and chalybeate medicines are what physicians from general experience seem to have rested in ; various forms of which are to be found in all pharmacopoeias. The black hellebore root claims some specific virtue as an emmenagogue, of which in my practice I have never met with any decisive proof. Camomile flowers undoubt- edly possess it with relation to particular women; for 1 have known more than one, in whom they constantly brought on some degree of an uterine haemorrhage, at whatever time of the month they ^vere taken. Warm bathing, putting the feet in warm water, and sitting over its vapour for half an hour every day, have been used successfully. Electrifying, when employed for other purposes, has frequently bi ought on the menses before their time. But there are too many cases in which all these means have been found ineffectual. The pains, which several women experience during some part of the menstrual flux, are safely mitigated with opium ; and such persons should always have in readiness half a grain or a grain History and Cure of Diseases. S5 i of opium, to be taken as soon as the pain comes on, and to be repeated once or twice if the pain require, at the distance of half an hour. This has been very frequently given without checking, or in any manner deranging this evacuation. To those, whose stomach will not bear opium, it has been given as safely in a clyster. The tincture of opium has not appeared to be without some ef- fect, when only rubbed in by a warm hand over the abdomen. Warm bathing, sitting over the steam of warm water a few mornings before the expected return of the catamenia, Bath waters, both externally and internally, have all been em- ployed against this complaint, and with advan- tage. At the time of life, when it is according to the course of nature that the menstrual flux should en- tirely cease, if it go off gradually and without any troublesome symptoms, which it most frequently does, no medicines will be wanted, nature herself being fully sufficient to bring about this revolution without any tumult or commotion. However, some attention may bo useful in keeping the body from any tendency to costiveness, by taking occa- sionally a little lenitive electuary, or some purg- ing water. If the menses leave a woman very abruptly, and either from this cause, or from any other, there should come on at this time vertigos, sleepiness, numbnesses, or pains of the head, with a sense of fulness, the taking away of six ounces of blood by cupping once a month, as long as these complaints remained, has been experienced with success. Whatever other disorders may chance to shew themselves, they must be treated 35S Commentaries on the with their usual remedies. In constitutions, which have been subject to cutaneous diseases, or which may be judged to be in danger from palsies, or some hereditary cancerous taint, an issue may be advisable ; which in other cases, as far as I have observed, may very safely be omitted. A return of the menstrual flux to old women, after having left them for some years, may either be excessive, or it may be a symptom of an ulcer- ed, or cancerous womb ; and then the proper re- medies for these ails must be employed : but if it continued to make its visits in a regular manner, as it has happened to some women, and the health appear in no respect to suffer, such persons will stand in need of no assistance from physicians. CHAPTER 63. MorbillL I PURPOSE first to give a history of the measles in a single patient, who had a regular and mid- dhng sort, and in whom, on account of the fair- ness of the skin, it was easy to observe with pre- ciseness the appearance and disappearance of the eruption : after which I will relate the varieties, which I have noted in a considerable number of other patients. On the first day The symptoms were very slight shiverings, a fai- lure of appetite, some degree of sickness, a quick- History and Cure of Diseases, 258 iiess of pulse, a drj cough, no sneezing, no tears, nor redness of the eye-lids, a very little thirst, and pains in the limbs. 2d. The night was quiet without any great complaint, the appetite still fails, and the cough and pulse are as before. 3d. This day all is much the same as yester- day. 4th. A faint eruption is to be seen by attentive looking upon the face : red spots are much more visible about the throat. The fever, restlessness, and want of appetite, are increased. The cough is rather less. The eyes are less impatient of light. There is no vomiting. The face burns, and is unusually flushed. 5th. Faintly red spots are sprinkled over the chin, and (at a greater distance from one anoth- er) over the rest of the face. The spots are of an irregular figure, and are much redder about the throat and breast. The fever and cough re- main. There is yet no appearance of the erup- tion on the hands and arms. 6th. The spots of the face rise a little above the skin, so as to afford a perceivable roughness to the touch, and are visibly formed of many mi- nute heads much less than a millet seed. On this day the eruption begins to appear on the arms. The fever, and restlessness, and impatience, are considerably increased. The cough is very trou- blesome, but without any difficulty of breathing. S54j Commentaries on the The eyes are weak, the eye-lids are swelled. There is a total loathing of all food. Towards evening the symptoms grow worse, and with some oppression of the breath. The spots in the face are of a lively red. Yesterday the menses came on before their regular time, and lasted only twenty-four hours. 7th. Bleeding yesterday gave some relief. The night was a little quieter ; but the fever and anxie- ty ar.e very little abated. The eruption in the face is paler. The skin begins to itch in a trou- blesome manner. 8th. The symptoms are much abated, and the appetite begins to return. The eruption is more faint. The languor and fever are now and then much complained of. 9th. The night was tolerably quiet, and the pa- tient is now a little revived; but still there are in- tervals of fever, and uneasiness, and lowness, which are much relieved by a repetition of bleed- ing. 10th. The night was very good. The erup- tion has totally disappeared, and hardly any fever remains. 11th. Some cough still remains. 12th. The sleep and appetite are returned, but the cough still remains ; and so it continued to do for three or four days more : bleeding much weak- History and Cure of Diseases, 255 ened it, and in a few days more it went entirely away. I shall now proceed to relate some diversities in the symptoms, which have attended the several stages of the measles, collected from a considera- ble number of patients. Some have had weak and watery eyes one or two days before the eruption, and sometimes the same sharp humour has irritated the nostrils, and occasioned sneezing. The cough most usually has come on two or three days before the erup- tion; but it has been known to precede the mea- sles seven or eight days, and it generally did so in the year 1753, when they were remarkably epidemical. Pains of the throat and head and back, have not been unusual in this preparatory stage. One person in particular had a most ex- cruciating pain in the back, which continued a day or two after the eruption. Sickness and vo- miting as well as want of appetite, have come on at the beginning, and lasted till the middle, or de- cline of the distemper. Some have been so for- tunate as to have the measles appear after suffer- ing so very little from (e\er or any of the prepa- ratory symptoms, that they could hardly say they had been ill. The longer the preparatory symp- toms continued, and the worse they were, so much the less mild has the distemper proved. The first day of the eruption. In one or two patients I have seen the eruption appear upon the arms on the first day, a few 256 Commentaries on the hours after its having been observed on the face and neck. But it so seldom happens that the arms and hands shew any mark of the distemper before the second day of its being visible on the face, that possibly in those instances the eruption on the face might have been earlier than it was taken notice of. In one patient no cough nor sneezing v^^as complained of till the day of the eruption. The appearance of this distemper does not at all mitigate the symptoms, as it does in the small pox. One patient was seized with a spit- ting on this day, which continued to teaze him for forty-eight hours, without suffering him to rest at all by day, or to sleep by night ; the cough in the mean time almost ceased, and all the other symp- toms were as mild, as in a favourable sort of the measles. 2d. I have scarcely ever observed the eruption on the hands and arms fail of being perceived in the course of this day; and where it has been supposed to have been deferred a day longer, it is most probable that there was an errour in dat- ing the beginning of the eruption. Once or twice the distemper has been observed never to have reached the arms, which throughout the whole of it shewed none of the usual spots. On this day the measles appear in full vigour upon the face, but without any rehef of the symptoms, which are often rather aggravated, and a diar- rhoea has been joined to them, but without any danger. The nose has bled about this time, and the eye-lids have been so swelled, that for twen- ty-four hours they could not be opened. Uistory and Cure of Diseases. 257 3cl. Now the eruption usually appears very lively on the other parts, but is a little deadened upon the face ; yet in several the marks on the face have been at this time of as bright a red as ever. In others I have observed them to disap- pear entirely on this day, and all the other symp- toms likewise to retreat. However, the cough and fever most commonly continue the same ; some patients have thought them a little better, others a little worse. Where the eyes have been very watery, and the eye-lids red, they have still remained so to this time ; and 1 have noted a very troublesome and constant sneezing, which first came on upon this day. A child ^ye years old became comatose the third day of the eruption, and died the next. 4tb. The spots in most patients become of a much paler colour in the face, and begin to grow fainter in the breast and arms of some; in others the arms are of as high a colour as ever : yet in more persons than one I have observed no dimi- nution of the colour even in the face on this day. Those, who have shewn the least remains of the eruption at this time (and some have shewn hard- ly atiy) have appeared the best ; and in those, where it was still in undiminished vigour, the couirh and fever have been the worst. The coucrh in several is very sensibly abated on this day; others find both cough and fever as bad as ever. The eyes seldom continue to water any longer, except where they have been so hurt by this ill- ness, as to continue weak for a long time after. The sneezinjr has lasted till this time : but this las very rarely happened. The face now begins 33 S58 Commentaries on the to be branny and itch, which itching is propagat- ed over the whole body, so as to be the chief, or only complaint. The catamenia have appeared on this day before their regular time. 5th. The marks are very pale both in the face and arms, though perceivable in some ; in others they are quite gone, the appetite returns, and the patients seem well. Those patients have been the worst, in whom most of the eruption ^vas still remaining. The cough in some is much better, in others it is quite gone ; but several are teazed with it a long time after the distemper is ended. The menses have made their appearance on this day, out of their regular course. 6th. The vestiges of the eruption have been still visible on the arms, and even in the faces of a few patients, with a considerable degree of cough, sneezing, hoarseness, and fever ; and I have once or twice seen soij)e marks of the mea- sles so late as on the tenth daj of the eruption; but on the sixth day most patients are tolerably well recovered, except in those unfortunate cases, in which the fever, instead of abating, begins at this time to increase, and continues to do so, until it have destroyed the patient. In others, who escape this immediate danger, the lungs are some- times so injured by this distemper, that a lasting cough succeeds ; and sometimes a pulmonary con- sumption. Weak eyes, inflamed eye-lids, glandu- lar tumours, and many other scrofulous appear- ances have followed the measles ; whether they were formed by them, or, the seeds being before in the constitution, were only excited by this dig- History and Cure of Diseases. S59 temper; or possibly the appearance of scrofulous symptoms was wholly owing to other causes, and would have come on at this time though there had been no measles. Bleeding may be used at any time of the mea- sles, and is always beneficial where the symptoms are very distressing, particularly if there is an oppression of the breath, to which every stage of this distemper is liable. Bleeding, together with such medicines as the occasional symptoms would require in any other fever, is the whole of the me- dical care requisite in the measles. The flowing of the menses ought to be no objection to the opening a vein, if the cough and shortness of breath make it otherwise advisable. I never saw any bad consequences from bleeding a woman in these circumstances ; but the greatest danger might attend the omitting to do it in a violent cough, or oppression of the breath. The measles are far less dangerous to pregnant women, than the small pox. I have attended se- veral, who were greatly harassed by the violence of all the usual symptoms in this illness, but I ne- ver knew it make one woman miscarry, or be in more danger on account of the pregnancy. Is not this distemper worse in proportion to the quantity of eruption, as in the small pox ? The preparatory symptoms of the measles have appeared thirteen days after the infection had probably been received. In two others there was the greatest reason to judge, that they began to N a60 Commentaries on tht come on fourteen days after the time of infection. In four others the infection seemed not to have lain dormant above ten dajs. An infant sucked a nurse till the measles ap- peared upon her, and then was taken away, and escaped catching the distemper : is it therefore, like the small pox, not infectious in its first stage ? or did the incapacity of this child's receiving the measles at that time arise from some other cause ? CHAPTER 64. Narium Hcemorrhagia, A SPONTANEOUS bleeding of the nose more par- ticularly belongs either to children, or to such as have past the meridian of life. In children it sel- dom comes to any excess ; but in adults will con- tinue so long, or with such violence, that many pounds of blood will be lost, or the person faint away. Weakly children seem more subject to it, than the strong ; and among adults, beside its being an usual attendant upon the diseases of the liver in hard-drinkers, it often accompanies the gout, head- ach, giddiness, numbnesses, a broken state of the health, and threatenings of a palsy or apoplexy. In a few extraordinary cases I have known it come on a little before the catamenia, and conti- nue till after they were over : in some females it History and Cure of Biseases. S6l has seemed to supply the place of the menstrual discharge ; on the other hand, that discharge has proved, as long as it continued, an eifectual stop to a bleeding of the nose, in some, who were ne- ver free from it for so many days together at any other time. The loss of blood by the nostrils is perhaps a symptom of some internal morbid cause, rather than a remedy ; for it has not appeared to me to be of any certain use in those distempers with which it is joined, and therefore it is not a desira- ble evacuation. But, on the other hand, it is far from being a constant sign of any great mischief either present or impending ; for 1 have known it continue in persons of an advanced age for many years, consistently with very tolerable health. An old head-ach has been judged to be relieved by a bleeding of the nose ; but «this is made doubtful by its having been a companion in other cases of head-achs, and various disorders of the head, without affording them any mitigation. Nothing so effectually stops a profuse bleeding of this part, as a compress put up the nose, when it is possible to apply it to the mouth of the bleed- ing vessel ; but where this cannot be done, I know no other method of cure, than what is mentioned in the Medical Transactions, vol. ii. Query 4.^ In habitual bleedings of the nose, a moderate dose of some purging salt has been given twice or three times a week with success. * See Appendix. 262 Commentaries on the CHAPTER 65. Nausea,^ Pregnancy, the gout, hard drinking, hypochon- driac disorders, giddiness, violent head-achs, a cough, and particularly the hooping-cough, worms, a stone in the kidneys, and irregularities of the menstrua : all these causes, beside blows on the head, and many fevers, and the improper quality or quantity of the food, are apt to disorder the stomach, and to bring on a nauseating and sick- ness ; which is sometimes preceded by a large quantity of water filling the mouth. The morn- ing is the time when this sickness is commonly greatest (the nerves of the stomach, like all the others, seeming to be weakest in the morning ;) it will likewise come on sometimes about three hours after dinner. As this complaint is owing to such a variety of causes, it might easily be expected, as it is found to happen, that the same method of treating it will not always have the same success. An eme- tic, lying down, aromatic and spirituous medicines, a spontaneous or artificial purging, essential oils, and opium applied to the region of the stomach in the form of a plaster, or in the form of a lini- ment rubbed over the abdomen, the juice of le- mons and salt of tartar drunk in the act of effer- vescence, infusions of common mint with or with- out tincture opii, are sometimes, but not always * See chapter 99. de Vomitu. I History and Cure of Biseases. S63 employed with advantage in curing a nauseating fit. Infusions of camomile flowers will often re- lieve, by provoking a vomit, or only by strength- ening the stomach. In cases where it is a symp- tom dependent upon other disorders, its cure can only be effected by curing the principal malady. Bath waters drunk warm at the spring will re- move several of the causes of sickness, and per- form a lasting cure. CHAPTER 66. Oculorum Morbi, A WEAKNESS will sometimcs attend the eyes, and make the wind* the fire, and reading very un- easy to them, though there appear no outward sign of any complaint. A greater degree of weak- ness is accompanied with wateriness, or gummi- ness, where the tears are not supplied faster than they can dry into such a consistence. Strumous inflammations of the eye-lids will long be troublesome without much affecting the eye, or making it impatient of the light or of reading. Where the eye itself is inflamed, all that part which should be white will have its vessels dis- tended, and be red with blood ; it feels as if it were full of dust or sand, and any degree of light is intolerable ; wind, heat, and dust, greatly ag- gravate the inflammation. If the inflammation ex- cite no great pain, while the eyes are kept dark, it has continued for a year, or longer, without 264 Commentaries on the ending in blindness ; though it will often leave films, or specks upon the eje, which hurt the sight if they be upon the cornea, and in any other part are a defornaity. But dimness of sight, and blindness, will sometimes follow long and violent inflammations. I have known the eye frequently inflamed by the irritation of hairs growing in the internal part of the eye-lid and pricking the eye ; the plucking out of these hairs is the certain and only cure. The eyes are subject to excessive and constant pain without any outward appearance of disorder : this has been known to last for several days ; and considerable pain at the bottom of the eye has continued for a year without any ill consequence ; but in general it is a state of the eye much to be dreaded. It has in six-and-thirty hours brought on a dimness of sight, which increased to blind- ness ; and it has by fits been troublesome for six years, and then blindness has come on. In many instances the sight has gradually be- come dim, and at last been totally lost, even with- in the space of a few days, probably from the op- tic nerves becoming paralytic. I have seen this occasioned by a preternatural mass being formed in the brain, which compressed the origin of those nerves. A giddiness has been the forerunner of blindness ; and so have the appearance of an iris round the candles, of flashes of fire, of flies or threads floating in the air, which are black in the day time and of a fiery colour in the dark, of co- lours dancing before the eyes, and of a multipli- cation of the objects : but at other times all these History and Cure of Diseases. 265 confusions of vision have happened, and some of them have continued for ten jears, yet the sight has not afterwards been hurt. A blindness will also come and go, lasting only a few hours, and this for several times, observing no certain periods ; unlike the nyctalopia, which returns every night. The few blindnesses of this sort, which I have known, have ceased at last, and left the eyes in their natural state. A blindness of the right eye has lasted for fourteen days, and then has suddenly passed to the left, where it fixed. A cataract is always preceded by a dimness, or blue cloudiness of objects, as if they were seen through gauze ; it is known by the pupil of the eye, instead of being black, becoming coloured. In affections of the eyes it is common to hear complaints of all objects appearing double ; I re- member one who said they were quadruple. A gutta serena is known by an unusual dilata- tion of the pupil, and by its ceasing to contract or enlarge according to the different degrees of light ; it seems to be a palsy of the optic nerves. It is sometimes confined at first to one eye, but in the course of a few years is often extended to both. It comes with so little pain, and the sight of one eye is so little missed, that I have met with three or four persons, who by accident found out that one of their eyes was dark, of which in all proba- bility they had lost the sight for some months be- 34 so 6 Commentaries on the fore. This will happen both in the gutta serena and cataract. There is a dimness of sight, in which dark spots float before the eyes, or only half, or some part of all objects appear, which continues for twenty or thirty minutes, and then is succeeded by a head- ach lasting for several hours, and joined some- times with sickness. The disagreeableness and pain of these paroxysms are very considerable, biJt as far as I have observed, the danger is no- thing, though I have known some persons subject to them for twenty years. Their returns seem to observe no certain period, nor have 1 even been able to guess at the immediate occasions of bring- ing them on, nor to discover any remedies either for their cure or relief, except that lying down appears to make the fit more tolerable, if not to shorten it. It is less in summer and warm cli- mates, and age seems to lessen or cure it. Eme- tics have done no good ; it has even been suspect- ed that they rather did harm. A violent giddiness has suddenly made a person presbyops, or long-sighted ; and I have known two persons, who after having been unable to read without the help of convex glasses for several years, found their sight come of itself to its natu- ral state, so that they had no further occasion for spectacles. A giddiness has instantly brought on squinting, and made all objects appear double for twenty days, at the end of which the squinting and doubleness of objects ceased. The same thing happened to another every morning just after waking, and continued for some time. History and Cure of Diseases. 267 Many are persuaded that perpetual blisters weaken the sight. To which notion we may be tempted to pay very little regard, when we consi- der, that they are frequently applied with advan- tage in disorders of the eyes ; and further, the lit- tle probability, which appears from all the known effects of cantharides, that they should particular- ly affect this part ; and lastly the great number of persons, who keep a blister for many years, or even a considerable part of their lives, without finding reason for suspecting any such mischief. But, on the other hand, we so often meet with those, who are confident upon repeated trials, that during the application of cantharides their eyes were growing weaker, and that they recovered upon the leaving the blisters off, that we can diffi- culty account for the rise and prevalence of this opinion, without its having some real foundation in nature. Various parts of the eye are liable to ulcers and cancers. Weak and watery eyes may often be assisted by taking twice a week some purging water, and twice every day a wine glass of the decoction or infusion of the bark. For this, and for some pain- ful affections of the eyes, many washes are recom- mended, as white vitriol, flowers of zinc, tutty, saccharum Saturni, spirit of wine, or milk and water. From the use of any of which ingredients I have never observed any such certain benefit, as to make me sure that a wash of pure water would not have been as useful. S68 Commentaries on the Strumous inflammations of the eje-lids, where the eye itself is but little, or not at all affected, do not require bleeding ; but where the eyes themselves are inflamed, nothing can be done without frequently taking away some blood. Of all the ways of doing which, I prefer leeches ap- plied to the temples or behind the ears, and it is sometimes necessary to have recourse to them once or twice a week for several weeks. Cata- plasms of conserve of roses, or of the pulp of boiled apples, or of bread and milk, put between two pieces of very fine lawn, and applied to the eyes at least every night, and if the pain and in- flammation be considerable, both day and night, renewing them once in eight hours, are more ser- viceable than any collyria. The purging waters, and bark, are perhaps the best internal medicines both in this, and in all other painful maladies of the eyes. It is useful always at bed-time to an- oint the margins of the eye-lids with a little lard softened with water, wherever the eye-lids would otherwise be glued together in the morning ; for if this be not prevented, and any force be used to pull them open, it wfll not fail to increase the soreness and pain. Setons, issues, and blisters, will often be necessary to assist in the cure, and to prevent the return of these diseases. In a gutta serna I have known issues, blisters, and all kinds of nervous medicines, strong sneez- ing powders, and a salivation, used without any success. Electrification is said to have been use- ful. A cataract admits no remedy, except that of the depression or extraction of the crystalline lens. History and Cure of Diseases. S69 It is observable that the ancients mixed opium with many of their topical medicines for the eyes; if we reason upon any of its known powers and manners of acting, we should judge that as an acrid it would do no harm, and as a soporific it would do nothing at all in this way of application; and probably should not judge amiss: for not- withstanding the prepossession in its favour from the authority of the ancients, this ingredient in collyria has sunk into disuse ; for which nothing can account, but a conviction of its inefficacy from repeated trials. Yet by some late experiments three drops of tincture of opium, applied every day to the eyes, have been thought useful iq oph- thalmies. Some oculists have succeeded in taken off films from the eyes with a knife, or with acrid applica- tions. But this practice has been condemned by many experienced and judicious surgeons, as too likely to excite an inflammation; from which cause most of these films arise. Of the Nyctalopia, or Night-Blindness, A MAN about thirty years old had in the spring a tertian fever, for which he took too small a quantity of bark, so that the returns of it were weakened without being entirely removed. He therefore went into the cold-bath, and after bath- ing twice he felt no more of his fever. Three days after his last fit, being then on board of a ship in the river, he observed at sun-setting, that all objects began to look blue, which blueness gradually thickened into a cloud ; and not long 270 Commentaries on the after he became so blind, as hardly to perceive the light of a candle. The next morning about sunrising his sight was restored as perfectly as ever. When the next night came on, he lost his sight again in the same manner; and this continu- ed for twelve days and nights. He then came ashore, where the disorder of his eyes gradually abated, and in three days was entirely gone. A month after, he went on board of another ship, and after three days stay in it, the night-blindness returned as before, and lasted all the time of his remaining in the ship, which was nine nights. He then left the ship ; and his blindness did not return while he was upon land. Some little time afterwards, he went into another ship, in which he continued ten days, during which time, the blindness returned only two nights, and never af- terwards. In the August following, he (Complained of loss of appetite, weakness, shortness of breath, and a cough: he fell away very fast, had frequent shi- verings, pains in his loins, dysury, and vomitings ; all which complaints increased upon him till the middle of November, when he died. He had formerly been employed in lead-works, and had twice lost the use of his hands, as is usu- al among the workers in this metal. History and Cure of diseases. »7i CHAPTER er. Osana, or a Suppuration of the Antrum HighmorL A^ oozing of matter from the cavity called an- trum Highmorianum has continued for many months. The frequent injection of a liquor to cleanse it, was the only help which it seemed to admit. An infusion of camomile flowers is a very proper injection for this purpose. CHAPTER 68. Palpitatio Cordis, Children sometimes bring with them into the world a preternatural palpitation of the heart, to- gether with a mal-conformation of the breast, or other signs of great unhealthiness ; and it is found, at all times of life, either following or joined with the asthma, hypochondriac and hysteric com- plaints, the gout, cutaneous diseases, too much care and business, flatulence, giddiness, faintings, lan- guor, an urgent and troublesome micturition, and that general failure of the powers of life which is known by the name of a broken constitution. It has been attended with a perceptible noise, and rarely fails to make the pulse very irregular both in time and strength. The resemblance which this disorder bears to those complaints that are called nervous, and S7S Commentaries on the which are exasperated by bleeding, allows us very little hopes of relief from the use of this evacua- tion ; yet in one or two cases I have known it tri- ed without any manifest hurt, and, as the patient supposed, with some benefit. Lying down also has in one person not increased, but rather eased the palpitation. In every other case, which I have observed, the bed has constantly aggravated this uneasy sensation, which has usually been worst of all just upon waking out of the first sleep. A full stomach is not easily borne by these pa- tients. If we consider the rapid and irresistible pro- gress of this complaint from bad to worse in some, and the very little disordering of the health which it occasions, together with the length of time which it continues in others, and the long truces, during which it is wholly suspended; and lastly, that it will be excited in the healthiest persons by a mere thought of the mind, we must necessarily conclude that it is owing to a variety of causes widely differing from one another in point of dan- ger. Where it is curable, and requires a remedy, it must be found among the medicines which are proper in nervous maladies : but a palpitation of the heart in many instances arises from causes too fatal to admit, or too frivolous to stand in need of any cure. History and Cure of Diseases, S73 CHAPTER 69. Paralysis et Apoplexia, Palsies and apoplexies are only different de- grees of the same distemper. All sudden deaths are put down to the account ofapoplexies; though some of them be unquestionably owing to ruptures of great blood vessels, to suffocations from inun- dations of phlegm, or from the breaking of absces- ses in the lungs, and other causes of immediate death, very different from those by which genu- ine apoplexies are produced. A sudden, or ra- pid weakness in some of the muscles of voluntary motion, constitutes a palsy, and in this manner it aiost usually begins ; and a total loss of motion in every part of the body except the heart and or- gans of respiration, together with insensibility, is called an apoplexy ; the cause of which istsome- times strong enough to put a stop; to the mption even of the heart and lungs, and to occasion in- stant death. The power of moving in every part of the body by means of ihe muscles which obey the will, or by means of others the actions of which are invol- untary ; the various perceptions by the live ex- ternal senses ; and lastly, those mental powers named memory, imagination, attention, and judg- ment, together with the passions of the mind ; all these seem to be exercised by the ministry of the nerves : and are impaired, disturbed, or destroyed, in proportion to any injury done to the brain, the spinal marrow,, and nerves, not onlv bv their pe- 35 ^74 Commentaries on the ciiliar diseases, of which we know little, but b) contusions, wounds, ulcers, and distortions, and hj many poisons of the intoxicating kind. The loss of the power of moving is the obvious and strik- ing character of this disease, and what is chiefly meant by the name of a palsy ; and it sometimes happens that one or more limbs may become pa- ralytic, with little or no perceivable defect in the office of those nerves on which the senses and operations of the mind depend. It is perhaps more rare, but by no means unknown, that from a paralytic shock one or more of the external sen- ses have lost the exquisiteness of their perception, or the mind has become inattentive, forgetful, and stupid, with very little diminution of muscular strength : but it is most commonly found, that the bodily strength, and senses, and mind, all suffer from a considerable stroke of a palsy. Certain degrees of a paralytic debility of the senses and intellects, have had particular names assigned them, as carUS, coma, lethargy. The reasoning faculty has in a palsy become dull and wild to such a degree as to amount to melancholy, idiot- cy, and madness. Likewise madness and palsy have returned alternately. An epilepsy in some instances partakes so much of the palsy or apo- plexy, that it is hard to determine which symp- toms are most predominant, and to which of these diseases the fit most properly belongs. The same is sometimes observable in the disease called St. Vitus's dance. Paralytic complaints chiefly attack those who are past the meridian of life, and are either sink- ing into the infirmities of age, or are broken with I History and Cure of Diseases. S75 them and other disorders. But the middle ages are not secure, especially where persons are born of paralytic parents, or have impaired their health by fatigue, or intemperance. Children of all ages from infancy to puberty have sometimes lost the use of their limbs without any other manifest disposition to ill health; but this has happened more frequently to the weakly, and to those whose constitutions had been shattered by convulsive fits, by epilepsies, and St. Vitus's dance. The gout disposes the subjects of it to apoplexies, eith- er by a general debilitating of the powers of life, or by som^ affinity between the causes of the two distempers. There appears some tendency, though a more remote one, in hypochondriac and hysteri- cal ails to be aggravated till the shattered state of the nerves become truly paralytic. Chronical rheumatisms, or imperfect gouts, after hanging on for many months, have deadened and perfectly destroyed all ability to stir the limbs affected ; but this species of palsy has gone no further; so that the senses and faculties of the mind have still con- tinued in their usual vigour. It is observable, that palsies arising from chronical rheumatisms, or im- perfect gouts, affect chiefly the lower limbs ; but those arising from the colica Pictonum more usu- ally affect only the arms and hands. So many women otherwise healthy have been struck with a loss of their limbs, and an imperfection of utte- ranee, and sometimes with fatal apoplexies, in the pregnant, and puerperal state, that I can have no doubt of their being liable to these mischiefs in consequence of these peculiar situations. One palsy, which had this origin, hardly went off in two years ; but from other palsies of the samcj 276 Commentaries on the kind most women have entirely recovered, and in no long time, and without any relapse. The child of a mother, who during her breeding became pa- ralytic, was born in perfect health. Many palsies of a small part, or of one half of the body, have begun with an apoplexy, or a sud- den and total abolition of the strength and senses, which has continued from less than a minute to many hours ; and the patients have been so far from having any previous notice, that for a few hours, or a few days before the fit, they have found themselves uncommonly well and cheerful. But more palsies have advanced gradually, with- out the patient's falhng down in a motionless and senseless state : and the approach of some has not hindered the person from remaining in the full possession of his understanding. A faltering and inarticulation of the voice, drowsiness, forgetful- ness, a slight delirium, a dimness of sight, or ob- jects appearing double, trembling, a numbness gradually propagated to the head, a frequent yawning, weakness, distortion of the mouth, a pal- pitation, a disposition to faint ; some, or most of these, have preceded a palsy for a few minutes, or for some hours, or even for a few days; and a weakness of a limb, or of one side, has been ma- ny months, or a few years, gradually increasing to a perfect loss of one side, or a hemiplegia. I have known a sleepiness and duplicity of objects with violent pains and tightness of the head for two days, then the senses and voice were lost, and on the third the man expired. A numbness of the hand has come on the first day, on the second a faltering of the voice, and a palsy on the third. History and Cure of Diseases, S77 Similar instances are very common. The notices of an approaching fit have come and gone for se- veral hours, as if there were a struggle between the disease and the constitution, before these ihreatenings have either wholly disappeared, or ended in a palsy. Violent pains of the head, or a weight, and tightness, as if it were surrounded with a stiff bandage, giddiness, numbnesses, noi- ses in the ears, and a frequent bleeding of the nose in adults or old persons, may probably pro- ceed from a slight degree of some paralytic cause ; but they have continued for a considerable part of a man's life without being joined by any other mischief, and therefore are by no means reasons for much alarm, though they may justify the use of some precautions. Flashes of fire, or dark spots before the eyes, have preceded some apo- plexies, but have for the most part no relation to them, being merely disorders of the eyes, and not proceeding from any general affection of the nerves. A palsy of the lower limbs has often been preceded by a great pain in the loins. Where the origin of all the nerves is injured, all their functions are consequently affected. In practice there occur instances of all possible va- rieties in paralytic affections of the nerves, from the numbness and weakness of a single joint of one of the fingers, to a total abolition of sense and otion throughout the whole body, or a fatal poplexy ; and there is an infinity of intermediate degrees between these two extremes. The mus- I cles of the lower lip have been paralytic, and no [ other part of the body. It is not very uncommon ^Bto see this happen to the muscles of one or both 278 Comtnentaries on the the eye-lids ; and a still more frequent palsy is that of the organs of speech, taking away all pow- er of speaking articulately, or of speaking at all ; and that also of the muscles of one side of the face, which suffers that corner of the mouth to sink lower than the other, and hinders the meat from being easily moved about in mastication, and sometimes lets the spittle and drink run out of the mouth. In one person a palsy of the right side of the face was attended with an exquisite pain behind the right ear ; and in another a like pain behind the left ear was joined with a palsy of the left side of the face. The paralytic weakness has been confined to the muscles of deglutition, or to those of the tongue. One arm, one leg, a hand, or a single finger, have been the only parts affected. The muscles of the thighs and legs have frequently been the seat of the distemper, having lost all power of contraction, and so have at the same time the sphincters of the bladder and rectum, so that the urine and faeces could not be retained ; in other instances of a palsy of the lower limbs, these excrements have been with dif- ficulty expelled, the muscles serving to their ex- pulsion having been more weakened than the sphincters. Scarcely any species of palsy is more common than the hemiplegia, in which the motion of one side is impaired or lost, from the forehead to the extremity of the foot. The right and left side are equally disposed to be paralytic ; at least it appeared so in a great number of patients, in whom a particular attention was paid to this cir- cumstance. The same paralytic cause seems de- terminable by slight and unimportant accidents to fix upon one side^ rather than another ; for I have Histoi^y and Cure of Diseases. S79 noted eight persons, who had recovered from a hemiplegia, and in a subsequent attack were struck on the opposite side. Though paralytic persons often find the per- ception of the ^ve senses dull and confused, yet 1 attended one, whose sense of smelling, instead of being impaired, became so exquisite, as to fur- nish perpetual occasions of disgust and uneasi- ness, and from some very ridiculous causes. A lethargy in another patient was succeeded by a sleeplessness, and at the same time all the exter- nal senses became more acute : but 1 do not re- member any other instances of a palsy, in which the functions dependant upon the nerves (if at all affected) were not altered for the worse ; except that the appetite has in some cases become more keen. No symptom is more common in this dis- ease, than a numbness, or some degree of a loss of feeling ; aqd yet a total loss of it is extremely rare. Out of the very great number of palsies, which I have seen, there have been only seven in which the sense of feeling was annihilated. In three of these the feeling was totally gone, while some motion remained ; and in another it did not return, though some degree of motion was restor- ed. In a fifth the feeling began to return in half a year. In the two others neither the feeling, nor [motion, were ever, as far as I knew, retrieved.* Of all the powers of the mind, the memory, and [the government of the passions, appear to be the * RamazziDi mentions a case of palsy in wblcti one leg had lost all power of motion, but preserved its sense of feeling ; and the other leg was deprived of its feeling, but retained its motion. D* Morb. Artif. p. 286. E. S80 Commentaries on the most weakened' in palsies, though it may be doubted whether they be more affected than the imagination or judgment. There are perpetual occasions for shewing the loss of memory, and that childish impotence of mind, which suffers a man to fall into tears, or to be transported with joy and anger for frivolous causes ; but the exer- cise of the imagination and judgment are more seldom called for, and therefore their usual pow- ers will not be so readily missed. The faculties of the mind are enfeebled in all possible degrees, as- well as those of the body. When a person therefore has been struck on the left side, and has at the same time lost his voice, there is no certainty of his being able to signify his feelings, or his wants, by writing. They, who have been put upon this, have sometimes been able to do it, though in a confused manner ; and the same per- son on different days would either write intelligi- bly, or make only an illegible scrawl. The shock upon the understanding has been such, that it was not possible to make the patients mark upon a slate yes or wo, or point to them when written, so as to make a right answer to any question. The inability to speak is owing sometimes not to the paralytic state of the organs of speech only, but to the utter loss of the knowledge of language, and letters ; which some have quickly regained and others have recovered by slow degrees, get- ting the use of the smaller words first, and being frequently unable to find the word they want, and using another for it of a quite different meaning, as if it were a language which they had once known, but by long disuse had almost forgotten. After an apoplectic state for several days (owing History and Cure of Diseases, S81 to a blow upon the head) one person was forced to take some pains in order to learn again to write, having lost the ideas of all the letters ex- cept the initials of his two names. A palsied arm has been accompanied in many persons with an excessive pain about the shoul- der, so that they could hardly be persuaded that there was no fracture nor dislocation. Costive- ness is an attendant upon this distemper, where the stools do not come away involuntarily; but it is usually accompanied with an uncommon flow of urine. A paralytic affection of one side has appeared, upon opening the head, to have been occasioned in some by a hurt, or some preterna- tural state of the brain on the same side, and on the opposite side in others. The general rule in a hemiplegia is, that if the patient recover, the motion of the leg begins first to be gained, and afterwards that of the arms ; but to this rule there are many exceptions. In a slight palsy of the tongue, it has felt as if it had been scalded. The apoplectic fit rarely goes off without leaving some part paralytic ; however it is not often that an apoplexy or palsy proves fa- tal in the first attack ; but whoever has suffered from either of them, the same person is more live- ly to be affected again ; and the more frequently the fits have returned, the sooner and more cer- tainly is a fresh attack to be expected. Yet it has happened, that persons have been restored from a strong attack of a hemiplegia, and have had no relapse h\ fourteen, eighteen, or twenty years. It must be owned indeed that such cases 36 S8S Commentaries on the are rare, and that a violent degree of palsy, how well soever it may seem to have been cured, sel- dom fails to be repeated within the space of a few years, and it has frequently returned in a few months. It is not uncommon to recover from a palsy of a small part, as of one side of the face, without any ill effects upon the health ; and, though it happen in youth, without experiencing an) return to extreme old age." After the first considerable shock there are often repetitions of smaller fits, "which, by coming in the night, or during a nap, are not observed, but may be conjectured by se- veral circumstances, and particularly by all the effects of former attacks becoming much worse either suddenly, or in a few hours. There is particular danger of these repetitions for several days after a great fit, till the constitution have a little recovered from the violence which it has suffered ; and if the patient escape these, yet af- ter a strong: fit the functions ascribed to the nerves are every day more and more enfeebled, though without any fresh acce&s of the distemper. The general health does not always suffer in propor- tion to the apparent violence of the attack. Some slight fits have been succeeded by a great and ir- • remediable feebleness both of body and mind. After all fits, there is too apt to be left some de- gree of head-ach, giddiness, inattention, forgetful- ness, sleepiness, slight delirium, inarticulation of the voice, hiccup, tremblings, weakness, cramps, and involuntary or causeless laughing and crying. Among the many ill consequences of apoplexies I have seen one good one, and that was in an epi- I History and Cure of Diseases. ^83 leptic person, who never had any return of the epilepsy after an apoplectic fit. But at other times it has happened, that an epilepsy first came on after a stroke of a hemiplegia; and the same has been followed in a child by St. Vitus's dance. A long unsteadiness and trembling of the right hand entirely ceased, and the person, who had been a remarkable penman, was able to write again as finely as ever, upon being attacked with a palsy of the left side. I know no certain rule of judging how long a person may be struggling with an apoplexy or palsy, before he sinks under them, or begins to recover. A perfect apoplectic fit, in which no signs of life remain beside the motion of the heart and lungs, is seldom seen unless for a few hours before death. A less complete apoplexy, but yet without any sense, or voice, or power of swallow- ing nourishment, has continued for ten days be- fore it proved fatal. A hemiplegia has been fol- lowed by death in a few months, in a few days, or in a few hours, and most commonly by an apo- plectic fit supervening. But where a person has either been struck at first only with a hemiplegia, or has recovered into this state from an apoplexy, there most usually, instead of growing worse, the patient has been found to recover from some of the symptoms, and sometimes, though very rare- ly, from all of them. The signs of a beginning recovery have sometimes been perceivable in a few minutes, and sometimes have been delayed for several days, or even for some months, and the symptoms have been gradually retreating for several years. A man of eighty has recovered in S84 Commentaries on the two months. The use of the legs even in an old man has been regained after nine months, so that he was able to walk. In one heraiplegiac the motion of the parts began to return so late as the end of the second year. Two paralytic parox- ysms in an old asthmatic man left no trai es be- hind them, and he continued well for more than ten years. Many who have been almost in a senseless state wnth a hemiplegia, have been per- petually at work with their sound arm in shoving the bed-clothes from their breasts. If the hemi- plegiacs are desired to try if they can move the affected arm, they all of them presently take hold of it and move it about with the other hand. The most melancholy scene of this distemper is, when it has kept weakening all the powers of the body and mind by very slow degrees, and letting loose the passions almost to madness, so that a man survives himself for several years, and is at last reduced to a most miserable state (if he knew his own misery,) in which he is unable to stand, to talk, to feed himself, or to retain his urine or stools, and yet lives on in this helpless condition for many months. Those who are near their end in an apoplexy, very remarkably puff out both their cheeks in every expiration. It is probable that far the greater part of pa- ralytic and apoplectic patients would recover some degree of life and strength by the unassist- ed efforts of nature Hence arises a difficulty of ascertaining the real efficacy of any means which may have been used, unless often repeated trials should be found to have an uniform effect. — Whenever any one falls down in an apoplectic fit, I History and Cure of Diseases. S85 or is suddenly struck with a palsy, it is necessary in the first place to loosen whatever bandage may be about the neck; for upon the access of these distempers I have known it instantly sw^ell to such a size, that the person without this relief would be in danger of being strangled. Bleeding is one of the first means usually em- ployed for the recovery of an apoplectic person ; and if he be in the vigor of his age, or very ple- thoric, and accustomed to living in a full manner, it seems a very fit remedy, and likely to be high- ly beneficial. But an indiscriminate use of large and repeated bleedings in all apoplexies and pal- sies can hardly fail of being often attended with mischief, since the young and vigorous are not the most frequent victims of these maladies, but rather sickly children, and the old, the infirm, and exhausted, in whom the vis vitCE wants to be ex- cited, rather than lowered, and where bleeding will damp every effort of nature, and irrecovera- bly extinguish the small remains of life, as it is found to do in drowned persons. The practice of taking away blood must be founded either in experience, or theory; and if 1 were to judge from the cases, which have occurred to me, I should say that the occasions, where it could be supposed to do good, have been extremely few, and that large bleedings have several times ap- peared to me to be prejudicial. Theory may teach, but will find some difficulty in proving, that apoplexies must arise from a com- pression of the brain, owing either to a distension of the blood-vessels, or to extravasated blood 286 Commentaries on the from their rupture, and that the energies of the nerves can be deadened by no other cause beside fulness. The usual subjects of palsies, as before mentioned, do not favour this hypothesis ; and the operation of several poisons in disturbing or annihilating the nervous functions can hardly be accounted for by such a theory : as little can it be reconciled with the gradual manner in which most palsies, and many apoplexies, are found to advance, and with the strong disposition to re- lapses in those who have been emaciated and bro- ken by many former fits. Some palsies must be owing to other causes besides fulness; and what- ever these causes be, they may be the only ones of most palsies. A rupture of some blood-ves- sels in the brain may be the origin of some apo- plexies, but probably of few; because these can hardly escape being instantly fatal ; and we know that there is a far greater proportion which do not end in present death. Some practical authors tell us they have been glad of finding a fever in a paralytic ; or desirous of exciting one. This but ill accords with the evacuating, and cooling regi- men. But I must own that I have no faith at all in this doctrine ; for, according to all my experi- ence, the more fever there is, the worse it always fares with the patient, in every external and in- ternal ail ; and the more natural the pulse is, the more hopes there will be of a prosperous event. I have known the gout seize persons ill of pa- ralytic complaints, without at all fulfilling the ex- pectations of the patients and their friends by giv- ing them the least relief; but this cannot appear strange to any one, who considers that the gout 1 b History and Cure of Diseases. S87 appears from experience to be rather a cause than the remedy of apoplectic diseases. No circum- stances have encouraged me to hope for benefit from giving any other emetic than a little carduus tea, in order to make the person vomit more easi- ly, and empty the stomach more effectually, where it was pointed out by the sickness and retching of the paralytic patient. A purge, if it can be given, or a sharp clyster, which may both unload and stimulate the bowels, is alw^ays useful; but violent purging has appeared to do harm, rath- er than good. Blisters should be applied as soon as possible to the head, between the shoulders, and to the paralytic limbs. The medicines proper to be given, when the patient is sufficiently recovered to be able to swal- low, are such as have the general property of strengthening and invigorating; which purpose is well answered by one drop of oil of cloves mixed with a little sugar, and then added to an ounce and a half of an infusion of Peruvian bark and bit- ters, which may be given every four hours. Musk, wild valerian root, and camphor, are also recommended as specifically friendly to the nerves, and possessed of virtues, which revive their lan- guid motions, and sooth their irregular ones. The root of valerian has often been given with- out much apparent effect ; but yet I have met with some, whom it threw into such agitations and hur- ries of spirits, as plainly shewed that it is by no means powerless. Most cats are fond of gnawing it, and seem to be almost intoxicated by it into out- rageous playfulness; and the nerves of cats afford a very tender test of the powers which any sub- »88 Commentaries on the stances possess of affecting the nerves. The pois* oned darts of the Indians, tobacco, opium, brandj, and all the inebriating nervous poisons, are far more sensiblj felt by this animal than by any other, that I know, of an equal size. When the patient is judged to be pretty well out of the reach of present danger, he must in the next place be assisted in freeing himself from the several disagreeable reliques of the former attack, and in preventing a return. For these purposes a journey to Bath is generally proposed : about which physicians seem to be divided in their opinions; some thinking, that the drinking and bath- ing at Bath help to recover paralytics, while others are persuaded that they are the ready means of turning a palsy into an apoplexy. If I were to judge from my own experience, I should say that the Bath waters do neither good nor harm to these patients; some of whom gradually recover while they stay at Bath ; and others suffer a fresh attack and die there; just as they would in any other place. I therefore cannot advise Bath ; but if it be desired by the invalids themselves, or any of their friends, there is no reason to hinder their going thither. There is not much more to be said in favour of the cold bath. Out of a great number of persons, whom I have known to use sea-bathing for several successive seasons, and long courses of cold bathing in weakness and gid- diness; left by palsies, some have thought them prejusliciai, and more have thought them useful: but from all their accounts 1 have concluded, that cold bathing is innocent, or in a small degree be- neficial. So that the chief reason against advis- History and Cure of Diseases, 289 ing, or allowing it, is, that paralytics are liable to relapses oT their disorder, let them do what they will ; and if any fresh access, or aggravation of their symptoms should happen at the time of us- ing the cold bath, or soon after, it would of course be charged, though very unjustly, to the bathing. Sleep is the great restorative after labour, and indispensably necessary to life ; yet it unquestion- ably disposes the body to be invaded by all those diseases which are peculiarly attributed to the in- firm or disordered state of the nerves, and among them to apoplexies and palsies, many of which first appear, or are much aggravated during sleep. In all these maladies therefore it behoves those who wish to be restored from what they still suf- fer, and to prevent any further mischief, to be cautious of indulging themselves in sleep, and to be contented with as moderate a portion of it, as is found consistent with their general health. An issue should be made in the neck, as soon as the blisters are all healed, and should be kept open during life. The symptom of giddiness is moderated in those who can bear this small loss of blood, by taking giway six ounces by cupping glasses, more than by any other means : this has been well borne by those who could not bear the loss of blood from a vein by a lancet. I have known it experienced in several, and particularly in a woman of sixty-eight, who had such bad fits of it, as made her several times fall, and frequent- ly threatened an apoplexy. She began the cup- ping at that time of life, and used it constantly every six weeks until she died, which happened 37 290 Commentaries on the at the age of eighty-five. She was in no danger of ever forgetting it ; for she felt the most evident marks of wanting this relief, whenever she de- ferred it beyond the usual period. During all this time the giddiness was inconsiderable, and came but seldom. She was struck at last with a palsy, which had probably been kept off for ma- ny years by this practice of cupping. When I knew no more of physic than what I had learned from books, I was very apprehensive, as I was taught to be, and by plausible reasoning, that opium was hurtful in palsies and apoplexies ; for it is supposed to have the effect of deadening the powers of the nerves, and therefore must be improper where we want to enliven them. This hypothesis, however specious, wants the attesta- tion of experience. I have met with some, who, while they were recovering from a palsy, used opium plentifully, and afterwards never passed a night without taking twenty or thirty drops of tinctura opii for many years : which practice did not hinder them from being very well, and was supposed to assist in making them so. In conse- quence of these examples, 1 have frequently given it in paralytic cases where the restlessness seem- ed to require it, and with as much advantage as in any otner distempers.* The good success of electricity in paralytic ma- ladies has not yet been sufficiently ascertained ; but it evidently has some influence over the nerves. * M. Chapelain, medecin de Montpellier, avoit gu^ri un bomme eo apoplexie par un grain de laudanum.— ^cad. Roi/. des ScienA 1703, Hist. p. 57. History and Cure of Diseases, S91 An intermittent fever has more than once, during the fit, been attended with paralytic symptoms ; but these have all yielded, together with the fe- ver, to the Peruvian bark. A Case of Catalepsy, 26th June 1764, in St. Thomas's hospital, I saw a woman six-and-thirty years of age motionless with a fit of the catalepsy. Her pulse was quite natural ; her breathing easy. Her eyes were fix- ed, as by attentive contemplation, not like those of a person who is either dying, or sick, or under any pain or uneasiness. Her limbs all retained the situation in which they were placed by the bystanders, however inconvenient. I extended her arm, and saw it remain stretched out for twenty minutes ; and I was told it continued soon a former trial above an hour, which scarcely any body in health could support. 1 heard even that it would remain extended with a weight of seven pounds in the hand. If the patient was placed upright, she continued upright, and was not very easily thrown down. While she was sitting down, both the legs were extended, and raised from the ground ; and they remained in that un- easy posture, as if they had been made of clay, or of wax. Her mouth was closed, and 1 was una- "ble by any means to open it. The eye-lids wert^ constantly open ; or if forcibly closed, they open- ed again as soon as the force was removed. She winked, but in a very slight manner, upon moving the finger quick towards the eye ; at other times the eye-lids did not move. At the approach of e* S9S Commentaries on the candle the pupil contracted. If the nostrils were compressed, after a little effort, and apparent struggle, the lips opened for the purpose of breathing. I heard that she had been in this state some months. The fits returned morning and evening almost every day, and continued sometimes an hour, at other times three hours. The nurse reported that one fit had lasted twelve hours. She used to be suddenly seized, without any previous notice. CHAPTER ro. Pectoris Dolor. Beside the asthma, hysteric oppressions, the acute darting pains in pleurisies, and the chroni- cal ones in consumptions, the breast is often the seat of pains, which are distressing, sometimes even from their vehemence, oftener from their duration, as they have continued to teaze the pa- tient for six, for eight, for nine, and for fourieen years. There have been several examples of their returning periodically every night, or alter- nately with a head-ach. They have been called fouty, and rheumatic, and spasmodic. Tiiere as appeared no reason to judge that they pro- ceed from any cause of much importance to health (being attended with no fever,) or that they lead to any dangerous consequences ; and if the pjalient were not uneasy with what he feels, he needs ne- ver to be so on account of any thing which he has tp fear. History and Cure of Diseases. S93 If these pains should return at night, and dis- turb the sleep, small doses of opium have been found serviceable, and may be used alone, or joined with an opening medicine, with a prepara- tion of antimony, or with the fetid gums. Exter- nally, a small perpetual blister applied to the breast has been succeessful, and so has an issue made in the thigh. A large cumin plaster has been worn over the seat of the pain with advan- tage. The volatile, or saponaceous liniment, may be rubbed in over the part aflfected. Bath- ing in the sea, or in any cold water, may be used at the same time. But there is a disorder of the breast marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it, and not extremely rare, which deserves to be mentioned more at length. The seat of it, and sense of strangling, and anxiety with which it is attended, may make it not improperly be called angina pec- toris. They who are afflicted with it, are seized while they are walking, (more especially if it be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or to continue ; but the moment they stand still, all this uneasiness vanishes. In all other respects, the patients are, at the beginning of this disorder, perfectly well, and in particular have no shortness of breath, from which it is totally different. The pain is sometimes si- 294 ComnientaHes on the tuated in the upper part, sometimes in the mid- dle, sometimes at the bottom of the os sterni, and often more inclined to the left than to the right side. It likewise very frequently extends from the breast to the middle of the left arm. The pulse is, at least sometimes, not disturbed by this pain, as I have had opportunities of observing by feeling the pulse during the paroxysm. Males are most liable to this disease, especially such as have past their fiftieth year. After it has continued a year or more, it will not cease so instantaneously upon standing still ; and it will come on not only when the persons are walking, but when they are lying down, especial- ly if they lie on the left side, and oblige them to rise up out of their beds. In some inveterate cases it has been brought on by the motion of a horse or a carriage, and even by swallowing, coughing, going to stool, or speaking, or any dis- turbance of mind. Such is the most usual appearance of this dis- ease ; but some varieties may be met with. Some have been seized while they were standing still, or sitting, also upon first waking out of sleep : and the pain sometimes reaches to the right arm, as well as to the left, and even down to the hands, but this is uncommon : in a very few instances the arm has at the same time been numbed and swell- ed. In one or two persons the pain has lasted some hours, or even days ; but this has happened when the complaint has been of long standing, and thoroughly rooted in the constitution : once Histoid and Cure of Diseases, S95 only the very first attack continued the whole night. I have seen nearly a hundred people under.this disorder, of which number there have been three women, and one boy twelve years old. All the rest were men near, or past the fiftieth year of their age. Persons who have persevered in walking till the pain has returned fi^ur or five times, have then sometimes vomited. A man in the sixtieth year of his life began to fee!, while he was walkmg, an uneasy sensation in his left arm. He qever perceived it while he was travelling in a carriage. After it had conti- nued ten years, it would come upon him two or three times a week at night, while he was in bed, and then he was obliged to sit up for an hour or two before it would abate so much as to suffer him to lie down. In all other respects he was very healthy, and had always been a remarkably strong man. The breast was never affected. This disorder, its seat excepted, perfectly resem- bled the angina pectoris, gradually increasing in the same manner, and being both excited and re- lieved by all the same causes. He died suddenly without a groan at the age of seventy-five. The termination of the angina pectoris is re- markable. For if no accident intervene, but the disease go on to its height, the patients all sud~ denly fall down, and perish almost immediately. Of which indeed their frequent faintnesses, and 296 (Commentaries on the sensations as if all the powers of life were failing, afford no obsure intimation. The angina pectoris, as far as 1 have been able to investigate, belongs to the class of spasmodic, not of inflammatory complaints. For, In the 1st place^ the access and the recess of the fit is sudden. 2dly, There are long intervals of perfect health. 3dly, Wine, and spirituous liquors, and opium, afford considerable relief. 4thlj, It is increased by disturbance of the mind. 5thly, It continues many years without any other injury to the health. 6thly, In the beginning it is not brought on by riding on horseback, or in a carriage, as is usual in diseases arising from scirrhus, or inflammation. 7thly, During the fit the pulse is not quicken- ed. Lastly, Its attacks are often after the first sleep, which is a circumstance common to many spasmodic disorders. Yet it is not to be denied that I have met with one or two patients, who have told me they now and then spit up matter and blood, and that it History and Cure of Diseases. 297 seemed to them to come from the seat of the dis- ease. In another, who fell down dead without any notice, there immediately arose such an offen- sive smell, as made all who were present judged that some foul abscess had just then broken. On opening the body of one, who died sudden- ly of this disease, a very skilful anatomist could discover no fault in the heart, in the valves, in the arteries, or neighbouring veins, excepting some small rudiments of ossification in the aorta. The brain was likewise every where sound. In this person, as it has happened to others who have di- ed by the same disease, the blood continued fluid two or three days after death, not dividing itself into crassamentum and serum, but thick, like cream. Hence when a vein has been opened a little before death, or perhaps soon after, the blood has continued to ooze out as long as the body remained unburied. With respect to the treatment of this complaint, I have little or nothint; to advance : nor indeed is it to be expected we should have made much pro- gress in the cure of a disease, which has hitherto hardly had a place or a name in medical books.* * Cceliiis Aurelianus, as far as I know, is the only ancient writer who has noticed this complaint, and he but slightly : " Erasistra- " tus moraorat paralyseos genus, et paradoxon appellat, quo ambu- *' lantes repente sistuntur, ut ambuiare non possint, et turn rursum '' ainbulare sinuntur." Chron. lib. ii. c. 1. — 31 Saussnre in his Voyage dans leu Alyes says, that at the height of 13 or 1400 toises above the sea, a peculiar tiredness often comes upon those who are ascending such high hills, so that it is impossible to proceed four steps further ; and if it were attempted, such strong universal pal- pitations would come on, as could not fail to end in swooning. I pon resting three minutes, even without sitting down, this tired- 38 ^98 Commentaries on the Quiet, and warmth, and spirituous liquors, help to restore patients who are nearly exhausted, and to dispel the effects of a fit when it does not soon go off. Opium taken at bed-time will prevent the attacks at night. I knew one who set him- self a task of sawing wood for half an hour every day, and was nearly cured. In one also the dis- order ceased of itself Bleeding, vomiting, and purging, appear to me to be improper. CHAPTER n. Pedicularis Morbus. 1762. Aug. 23. I was this day informed by Sir Edward Wilmot, that he had seen a man who was afflicted with the morbus pedicularis. Small tumours were dispersed over the skin, in which there was a very perceptible motion, and a vio- lent itching. Upon being opened with a needle they were found to contain insects in every re- spect resembling common lice, excepting that they were whiter. Sir Edward Wilmot ordered a wash, consisting of four ounces of spirits of wine, four ounces of rectified oil of turpentine, and six drams of camphor. The day following he told me all the insects had been killed on be- ing touched with this liquor, and that all the itch- ing had immediately ceased. ness passes, and the power of going on is perfectly restored. Tlir clinabing of steep hills, which are not so high above the sea, does not occasion this pecuUar fatigue. Vol. i. p. 482. History and Cure of Biseases. S99 CHAPTER 72. Phthisis Pulmonum, A CONSUMPTION appears by the London bills of mortality to be in that city the most destructive of all maladies to adults ; one in four of those that grow up to manhood being reported to be carried off by this distemper. But all these must not be charged to the account of a pulmonary consumption ; because whoever decline and waste away by any obscure, unnamed distemper, are all charged to this article, though the lungs be not at all diseased. The phthisis pulmonum usually begins with a dry cough, so slight and inconsiderable, that little or no notice is taken of it, till its continuance, and gradual increase, begin to make it regarded. Such a cough has lasted for a few years without bringing on other complaints. It has sometimes wholly ceased, and after a truce of a very uncer- tain length it has returned, and after frequent re- coveries and relapses, the patient begins at last to find an accession of other symptoms, which in bad cases will very soon follow the appearance of the first cough. These are shortness of breath, hoarseness, loss of appetite, wasting of the flesh and strength, pains in the breast, profuse sweats during sleep, spitting of blood and matter, shiver- ings succeeded by hot fits, with flushings of the face, and burning of the hands and feet, and a pulse constantly above ninety, a swelling of the legs, and an obstruction of the menstrua in wo- 300 Commentaries on the men; a very small stone has sometimes been coughed up, and in the last stages of this illness a diarrhoea helps to waste the little remainder of flesh and strength. A spitting of blood has sometimes been the first symptom ; but while it is found alone, it is but a slender proof of an imminent consumption, even when the blood certainly flows from the lungs ; and many have been unnecessarily alarmed by the appearance of what came only from their nos- trils, gums, or throat.* But this, when united with other symptoms, is of great importance in determining the true seat ot the distemper. The spitting of matter would at least be as certain a proof, if we had any infallible signs by which to distinguish the matter of an ulcer from the mere exudation of an inflamed membrane ; but all the criteria mentioned in books are insufficient for this purpose ; and I have known some attentive and very experienced physicians mistaken in their judgment upon this point. All the other symp- toms of a pulmonary consumption, except bloody and purulent spitting, I have observed in one, whose mesenteric glands after death were found to be scirrhous, but whose lungs were sound. However, this happens so very seldom, that very little doubt is to be made of the diseased state of the lungs, where all the other symptoms concur, though these two should be wanting. A shortness of breath, and a quick pulse, are the two most dangerous signs in a suspected * See chapter 84, on spitting of blood. History and Cure of Diseases. 301 phthisis. I have known a person die of a con- sumption, whose lungs upon dissection were found in a nfjost diseased state, and yet during the wljole illness there was no spitting of blood, no pain of the breast, nor any difficulty in lying upon either side. A consumption is a distemper of that kind, which is most certainly derived from the parents, and yet rarely makes its appearance before pu- berty ; between which and the age of thirty is the time of the greatest danger. Some have been at- tacked at forty, and have died after struggling with it four or five years. Others have been af- flicted with a cough every winter for twenty years, or more, who so late in life as at the age of fifty have had all the other phthisical symptoms come on very hastily, and have died truly con- sumptive. The more common event of such a long cough has been to degenerate in the decline of life into an asthma. Some violent causes, such as the measles, hooping-cough, or peripneumony, may make the latent seeds of a pulmonary con- sumption begin to appear, or may form this dis- temper, even in childhood, or decrepit age, of which there have been too many examples. ■ The persons most subject to a pulmonary phthisis are those who are born of consumptive parents, and those in whom, during their infancy, or childhood, the mesenteric glands, or the lym- phatic glands of the neck and jaw were swelled, and scirrhous, and especially if they have suppu- rated. We are too little acquainted with the ani- mal economy to account lor this disposition of 302 Commentaries on the these glands to swell in the earliest part of life, and that of those in the lungs to be affected in youth and manhood ; while it is more usually af- ter the meridian of life, that the glands in the breast of women and in the womb begin to be dis- eased, and likewise the prostate gland in men, and those of the stomach, intestines, and other ab- dominal viscera in both sexes. In women of con- sumptive habits the state of pregnancy seems to hasten the appearance of the cough, and of all the other symptoms : the distemper makes a rapid progress at this time, and yet the patients often hold out beyond expectation till they are brought to bed, and not long after. The state of the pulse is of great importance in acquainting us with the degree of danger in a cough, which, on account of its duration, and of the bad symptoms with which it is accompanied, begins to be of a suspicious nature. A young man of eighteen, together with a cough, had a spitting of blood, a shortness of breath, vomiting, pains in the side, night sweats, and was much wasted for two years ; but with these complaints his pulse was hardly quit;ker than it should be, and in three years he had perfectly recovered his health. Nor is this the only instance of the kjr.d, of which I have been a witness. I impute the cure not to any medicine, but rather to the patient's constitution, which was neither scrofu- lous, nor derived from consumptive parents ; and therefore the hurt done to his lungs bj a violent cold, which he had catched, might be considered in the same light with a wound made in the lungs of a healthy man ; which, though it be attended History and Cure of Diseases. 308 with many consumptive symptoms, yet we know by experience may be healed, and the health re- stored. Something of the same kind is observa- ble in peripneumonies, from which after great in- flammation, and cough, and spitting of blood, ma- ny have perfectly recovered. In England we have very little apprehension of the contagious nature of consumptions ; of which in other countries they are fully persuaded. I have not seen proof enough to say that the breath of a consumptive person is infectious; and yet I have seen too much appearance of it, to be sure that it is not; for I have observed several die of consumptions, in whom infection seemed to be the most probable origin of their illness, from their having been the constant companions, or bed-fellows, of consumptive persons. Our great experience of this distemper has hith- erto availed but little in enabling us to find out an effectual remedy. The cure o( a disease inhe- rited from parents, or owing to such a vitiated habit of body, as that, which is called scrofulous, has proved at least as difficult as it might have been expected, and physicians have hardly ad- vanced farther towards it, than by being able to mitigate some of the symptoms. Asses milk puts some check upon the tendency to emaciate. The dilute acid of vitriol in a decoction of bark is a very effectual remedy of the night sweats, and, as far as 1 have seen, is perfectly safe in all stages of this malady. A shortness of breath is no reason against using either this medicine, or an opiate at bed-time, which is the most certain soother of the 304 Commentaries on the cough, and saves the patient from being harassed with a restless night after a wearisome day. Where the pain of the side is violent, it will re- quire, and is generally relieved by taking away four or five ounces of blood. If this pain be ra- ther lingering and teazing, than violent, a small blister applied to the part rarely fails of making a cure. A diarrhoea has seldom resisted three or four drops of tinctura opii taken after every stool. No medicines need be directed for the hoarseness, swelling of the legs, or obstruction of the men- strua, which necessarily belong to the disease of the lungs and windpipe, and to the weak, exhaust- ed state of the patient, and are no otherwise to be cured, than by curing the principal distemper. The fever and the signs of inflammation may rise so high, as to justify the losing a little blood ; but frequent bleedings, though small, have appeared to injure the patient, by conspiring with the dis- temper to rob him of his flesh and strength. Dissections of those who have died of pulmona- ry consumptions, have acquainted me, that their lungs are full of little glandular swellings, many of which are in a state of suppuration. They ap- pear to be of the same nature as the strumous swellings in the neck, but must always be more dangeroub, because the texture of the lungs dis- poses them to spread, and because the office of the lungs is necessary to life, so that they cannot be greatly injured without the worst effects upon the health. Many medicines have been delivered down from former physicians, as remedies in strumous dis- History and Cure of Diseases. 305 eases; the efficacy of all which have upon trial appeared so dubious, that I cannot from experi- ence recommend any of them as hkely to correct the strumous habit, or to disperse the glandular swelhngs of the lungs which have not yet suppu- rated, or to heal those which are already ulcered, or to prevent any more from becoming scirrhous. In this case therefore, as in all others where the proper remedies have not yet been discovered, the patient must be contented with instructions, which may enable him to avoid what has been found to aggravate the distemper, and by a pro- per regimen to put the general health into the best possible state ; that the natural powers im- planted in the body of readjusting any disordered part, may be able to exert themselves with the greatest vigor: nor needs the patient to despair of success from this care and attention. The breasts of women seem to be as full of glands, and of as lax a texture as the lungs; yet 1 have sometimes seen scirrhous knots in them of a very alarming appearance, which have dispersed, or become indolent, so that a final stop was put to any further mischief, merely by a proper diet and the strength of their constitution. That something of this kind may happen in re- gard to the lungs is probable ; for some, who in their youth have had symptoms of a consumption in great number, and in no inconsiderable degree, have recovered and reached old age without any relapse. This was the case with that very inge- nious and learned physician Sir Edward Wilnjot, who, as he told me, when he was a youth, was so far gone in a consumption, that the celebrated Dr. 39 306 Commentaries on the Radcliffe, whom he consulted, gave his friends no hope of his recovery : yet he Hved to be above ninety years old. A youth of sixteen, after hav- ing the usual signs of a phthisis for many months, and being apparently in the last stage of it, vi^as almost suffocated by bringing up at once a great quantity of matter, and, after a few days, the bag, in which it had probably been contained. He soon recovered his flesh and strength, became a strong man, and lived to old age, with a family of robust children and grandchildren ; yet he was remarkably subject to a cough upon every slight cold, and had returns of spitting of blood several times every year. It is common to have very bad consumptive symptoms abate, and keep quiet for a whole sum- mer, or for a few years, and then after some se- vere weather, or intemperance, or catching cold, to return, and end fatally. Now, whatever has checked the distemper for a year or two, might possibly have kept it under till old age. Agreea- bly to this supposition, I have known an heredi- tary consumption at the age of twenty-nine cured after removal into a warm climate, without any relapse for twenty years ; and 1 know not that it ever returned. An ample provision has been kindly made, sometimes by duplicates, of several parts of the body which are indispensably useful to life, that in case one of them, or some part should fail, there may still be enough remaining to answer their purpose in a tolerable manner. The lungs afford an example of this ; for in bo- dies, which have been opened, one lobe has some- times been almost annihilated, and so much of the History and Cure of Diseases. 307 other destroyed, as to make it probable, that not only life, but even tolerable health might be car- ried on after the strumous swellings had made great ravages in the lungs, if we had but the means of stopping the mischief here, and of effec- tually hindering it from going any further. This is confirmed by what is seen in pocky consump- tions, from which, by means of the specific anti- dote, many have been restored to health after great injury done to the lungs. Hereafter we hope there may be found out as certain a remedy for the strumous virus. In the mean time the consumptive patient does not want encourage- ment to persevere steadily in a strict regimen, and a solicitous shunning of whatever may weaken the natural strength, or aggravate the distemper. Cold weather, and bleak winds, will occasion coughs in the soundest lungs, and cannot be too carefully avoided, where they are morbidly ten- der. Warm covering, as a flannel waistcoat, will have its use ; but where a removal to a warm cli- mate is not impracticable, this will prove the most successful means. An island without any very high hills in it, and at a sufficient distance from the snowy mountains of the continent, and where the heat is from sixty to ninety degrees, is the most favourable situation ; for it enjoys an equal temperature, secure from bleak winds. In the three or four summer months, the air of England is as mild as the tenderest lungs need breathe, and there can be no use in leaving this country from May until October ; but for his abode during the other months, the consumptive patient should remove to such a situation as has been mentioned. 308 Commentaries on the The exercise which he can take with the most pleasure, and with the least fatigue, will be the most desirable, In his diet he must abstain from all wine and spirituous liquors, and either wholly, or as much as he well can, from meat. There are some, who are very averse from vegetables and all faiina- ceous food, and to such a moderate indulgence of their taste must be allowed, lest a total abstinence should weaken the patients more than the distem- per : the cravings of the appetite, though not en- tirely to be gratified, yet are not in any illness to be wholly disregarded. The water which is used should be the purest that can be had, such as springs out of the Malvern hills, or distilled wa- ter. Those waters which are loaded with lime- stone and mineral acids, will be extremely perni- cious. I have great reason to believe, that such impure waters have a strong tendency to obstruct the lymphatic glands, and make them become scirrhous and ulcered, even in adults, who have no hereditary strumous taint ; and I think I have evidently seen such dispersed by the use of purer waters. Sailing, so as to be out at sea for some months, has been tried by some for whom I have been con- sulted, and they have thought it useful. How- ever, it has failed in others ; and I can go no fur- ther in its commendation, than to say, that con- sumptive patients have borne it well, even those whose principal symptom was a spitting of a great quantity of blood ; which complaint has not been in the least aggravated by a voyage of six weeks, Hi^ory and Cure of Diseases. 309 notwithstanding the sea-sickness was so great, as to make the patient vomit excessively during the whole time. A disagreeable tickhng in the throat, causing a constant provocation to cough, is sometimes so importunate as to force the patient to have re- course to various means of procuring some present relief: a few raisins will sometimes answer this purpose ; for which innumerable other sweet and soft things have been employed, as a little liquo- rice-root tea, rob of elder, currant jellv, jelly of , 1*1 .7 w J J ^ qumce-seeds sweetened with some syrup, a mix- ture of oil, honey, and lemon-juice, to which, or similar compositions, it is sometimes requisite to add a small portion of syrup of white poppies. A lump of sugar moistened with a few drops of tinc- tura opii camphorata has been very serviceable. Of all which it must be remembered, that they can only afford a little temporary ease, that they do not contribute in the least to the cure of the distemper, that they pall the appetite, and there- fore should be used very sparingly. CHAPTER 73. Pidonum Colica. There appear two species of this disorder, one of which may be called the acute, and the other the chronical. In the former, the pain of the sto- mach and bowels comes on suddenly, and is ex- cessively great, joined with an obstinate costive- 310 Commentaries on the ness, and sometimes with a stupor and loss of un- derstanding, and ends in a palsj of the hands, if not in death. The chronical begins with dull pains of the bowels, not always accompanied with costiveness, which sometimes increase so as to be very tormenting, sometimes are inconsiderable, or cease ; they continue in this way for half a year, for two, for three, for five, or for ten years, before the hands become paralytic : at which time in both these colics there rises in several, but not in all, a swelling on the back of one or of both hands, about the beginning of the metacarpal bone of the middle finger, of the size of a small nut, with- out pain or change of colour. After the more violent colicky pains have ceased, and the palsy has come on, a dull pain of the stomach has re- mained, accompanied with flying pains all over the body, with very little appetite, if not with sickness and vomiting. The patients have conti- nued gradually to lose their flesh (particularly in the ball of their thumb) and their strength, and not long before death have grown delirious and blind. The legs have been paralytic for a night, and I have remarked some, but not many cases, in which they too as well as the hands have been afiected with a lasting palsy. Anxiety, restlessness, and want of sleep, harass these patients almost as much as the pain ; they are perpetually turning themselves in bed, and when they are able to keep out of it, they are walking to and fro all day. Muscular pains all over the body, (more particularly of the scapulae) extreme languor, hiccups, want of appetite, vomit- ing and a drawing in of the navel, are not unusual History and Cure of Diseases. 311 attendants upon a fit. A quiet sort of delirious talkativeness, without any fever, will continue in some for a little while after the fit has ceased. In a chronical Saturnine colic the fits have kept re- turning every two or three months for several years, lasting from one week to a month or lon- ger. In time, as the distemper becomes stron- ger, and the body weaker, the fits return more frequently ; and even in the intervals the patients are far from being perfectly well. The pulse is less quickened in the fit, than might be expected from such exquisite anguish. When the difficulty of procuring stools is conquered, the patient finds some relief from them, and often not much. A person has been apparently dying in a fit of this colic, and in two days has been well enough to go abroad. Some of these patients have expired suddenly; and such an event may probably have been owing to the peculiar mischief which the nerves suffer from the poison of lead. Upon opening the abdomen of one, who died of this colic, nothing preternatural could be disco- vered. All the solutions and calxes of lead will certain- ly occasion this disease. The acute colic perhaps arises from a large quantity of this poison taken in a short time ; and the chronical from very small quantities persisted in for a long time. Experi- ence had taught mankind these singular eflects of lead near two thousand years ago ; and it has not yet been clearly and satisfactorily discovered that they have ever been produced by any other cau- ses, though some have been suspected. It is re- 3 IS Commentaries on the markable, that the chronical Saturnine colic has often attacked only one person in a large family, all of which, as far as could be learned, lived in the same manner. But this must not be urged as an argument, that it could not be produced by lead ; because it would prove equally against any other external cause. The very small quantity of this poisonous metal, which is sufficient to pro- duce the peculiar symptoms, makes it extremely difficult to trace its passage into the stomach. Three grains of sugar of lead, taken every day for four days, brought on colic, costiveness, inquie- tude, and loss of appetite. Thirty drops of the Saturnine tincture taken every day for a month created a colica Pictonum, which was long trou- blesome, though cured at last. It is hard to esti- mate the precise quantify of lead in these thirty drops, but I judge it can hardly exceed a grain. In the tinning of copper vessels much lead has ge- nerally been mixed with the tin, and if one of the family were to use a greater quantity of what had been boiled in such vessels, especially if he were fond of acid sauces prepared in them, this would affi^rd the ready means of accounting for that per- son's being singled out as the only suffl[3rer. Dri- ed acid fruits, or their jellies or rob, or pickles made in tinned or glazed vessels, or vinegar if it were kept any time in such, might easily be made the vehicles by which the lead was conveyed into the stomach ; and the liking which some have for these, and the indifference, or aversion of others, may account for the unequal portions of lead, which may fall to the share of different persons in the same family. This poison might also lurk in some of the liquors used in the same house, and History and Cure of Diseases. 313 not in others ; and besides, like all other nervous poisons, may have stronger effects upon peculiar constitutions. Three or four persons, who drank only white Lisbon wine from half a pint to a pint daily, have complained of this colic, and a conse- quent palsy, of which I suspected the wine was the cause ; and the good effects in one of them upon leaving it off confirmed my suspicion. The acute species of this distemper has never occurred to me, unless among plumbers, or paint- ers, or those who had been exposed to the fumes of melted lead, the dust of old lead, or its calxes. The unknown manner in which the lead is in- troduced into the stomach in the chronical colic makes probably the great, and often unconquera- ble difficulty of curing it. For if, from not being aware how they take this poison, they continue to take it on, no remedies can be of any avail ; and accordingly most of these cases have proved incurable. Many children probably die of this distemper, (though confounded with their other bowel complaints) which they contract by having play-things painted with white or red lead, and by putting them, as they are apt to do, into their mouths. The painters of these play-things are liable to this illness ; and I have had them under cure for it. The first attack even of the acute species of this colic has not always ended in a palsy ; and by quit- ting the employment which occasioned it, the cure of a very bad tit has not been succeeded by a re- lapse. Some active purge to procure a passage, 40 314< Commentaries on the and opium, if it be necessary, to allay the pain, and soothe the convulsions of the bowels, or a warm balh, and sometimes a blister to the belly, have proved the most successful remedies in a violent fit of the colica Pictonum. Aromatic and bitter infusions seem to be pointed out after the fit is over, as the properest means to recover the stomach and intestines from all the ill effects of the Saturnine poison, and to prevent or to cure the paralytic weakness, which so generally succeeds to repeated fits. Bath water, from its friendly effects upon debilitated stomachs, promises to be useful in this disease ; and though some have found no benefit, yet others have been much re- stored at Bath, and perhaps the sooner for having used those waters both inwardly and outwardly. There is a further use in a Bath journey to those who are afflicted with the chronical colic ; for by changing their manner of life, and their liquors, and cuhnary vessels, they may hope to cut off the communication which the lead had found to their stomachs, and against which, by being unknown, they were at a loss how to guard themselves at their own homes. CHAPTER 74. Pituita. An inundation of phlegm, almost to a degree of choking, especially in a morning, is to many a very afflicting complaint, and is chiefly heard of among those whose strength has begun to decline, History and Cure of Diseases. 315 either by the approach of age, or by the shock of some distemper. This phlegm has been much lessened by a vo- mit, to the great relief of the patient ; afterwards, to keep it under, it has been found advisable to take every day half a scruple of columbo root with one grain of long pepper, in powder or in pills ; to which may be occasionally added a grain of aloes, if there be any tendency to costiveness, which would much aggravate this complaint. CHAPTER 75, Prostaice Scirrhus. A SCIRRHUS of the prostate gland has been ob- served only in adults, and chiefly those who were in the decline of life. The symptoms are, some degree of tenesmus, a pain in expelling hard faeces, and a frequent irritation to make water, which comes away with pain, stretching sometimes to the extremity of the urethra, and passing up to the kidney. In the advanced state of this mala- dy, a bloody mucus follows the urine, and the tes- ticles swell. The ulcer has sometimes penetrat- ed into the rectum, and wind has passed through the ulcer into the urethra, and come out with the urine. There is a great resemblance between these symptoms and those of a stone in the bladder; and the two distempers are not always readily ■ t 1 ^316 Commentaries on the distinguishable. The two principal criteria are, that in a diseased prostate the pain precedes, and in the stone it follows the making of water ; then, riding in a carriage, or on horseback, which so much increases the bloody water and anguish of a calculous patient, is borne in a scirrhus of the prostate, even in its ulcered state, without any ag- gravation of the pain, or any more copious dis- charge of bloody mucus. Wherever this disorder is suspected, the assistance of a surgeon should be desired, who by an examination will seldom fail to discover the swelling, if it be considerable ; but in the early state of this disorder I have known surgeons, after they have Examined, differ in their opinions about the state of this gland.* A scirrhous prostate hardly admits of a cure. Mercurials have appeared to do mischief. A de- coction of the Peruvian bark, with as much extract or powder of hemlock as can be borne without giddiness, is at least safe. An opiate civster made of five or six ounces of water either warm or cold, and from thirty to a hundred or more drops of tinctura opii, cannot be enough com- mended for the important services which is capa- ble of doing these patients. One of them taken constantly at bed-time will always insure a tolera- ble night ; and it may be repeated in the day, whenever the pain is excessive, with a certain ef- fect of procuring ease. Beside these, I know no other useful instructions, which these patients can have from a physician ; for their own prudence will teach them, that regular hours, temperance, * Sfie above, chapter 16, on the stone. History and Cure of Diseases. 317 and a strict abstinence from •all heating food and liquors, must be rigorously observed. CHAPTER re. Pruritus Cutis. The scrotum of men, and the pudenda of wo- men, are subject to be afflicted in a very torment- ing manner with itching, which has continued for many years. In women this complaint is often joined with the fluor albus, and may be partly owing to the irritation of this acrimonious humour drying- upon their skin for want of being duly washed off. There is besides, an universal itching of the skin, without any eruption, or jaundice, familiar to very old men, and to those whose health is much broken with gout or palsy, harassing them both day and night, and hardly suffering them to get any sleep. Elderly men often experience likewise a slighter itching about the scapulae. Warm bathing has been tried with very little success. A wash of spirit of wine has allayed the itching for an hour. An infusion of white hel- lebore root, as directed under cutis vitia, has in some cases made an effectual cure. A very bene- ficial lotion has also been [)repared from a solu- tion of alum, from sea- water, tar-water, and a de- coction of staves-acre. In some constitutions it 318 Commentaries on the has been judged useful to open an issue in the thigh. 1 know no use of any internal medicines. CHAPTER 77, Puerperium, Beside great marks of weakness, and of a shat- tered constitution, left by difficult labours and pu- erperal fevers ; and beside some diseases, as men- tioned under their proper heads ; a thick miliary eruption has covered every part of the skin in a lying-in woman, without any one bad symptom, and has lasted three days. Was this entirely ow- ing to keeping her too hot ? It has also been ob- served, that sometimes a little before, or a few days after the end of the first month, one of the thighs has begun to be painful, not without fever, and has swelled to an enormous size, with great hardness, and inability to extend the leg. This swelling has continued near a month, before the thigh has been reduced to its natural size, and be- fore the use of it has been fully restored. The paralytic, and maniacal complaints, to which the puerperal state is subject, have been sooner, and more perfectly cured, than when they have been brought on by any other causes. The puerperal fever must be treated like other similar fevers. Bleeding is proper in the beginning. History and Cure of Diseases. 319 CHAPTER rs. Purpurem Macula, Some children, without any alteration of their health at the time, or before, or after, have had purple spots come out all over them, exactly the same as are seen in purple fevers. In some pla- ces they were no broader than a millet-seed, in others they were as broad as the palm of the hand. In a few days they disappeared without the help of any medicines. It was remarkable, that in one of these, the slightest pressure was sufficient to extravasate the blood, and make the part appear as it usually does from a bruise. A boy four years old, for several days had swell- ings rise on his knees, legs, thighs, buttocks, or scrotum. The part affected was not discoloured, and when at rest, was easy, but could not be moved without some degree of pain. Together with these swellings there appeared red spots, sometimes round, sometimes angular, a quarter or half an inch broad, which on the second day be- came purple, and afterwards yellow, just as it happens from a bruise. The child continued per- fectly well in all other respects. These swelhngs ceased to appear in about ten days ; but the red spots continued coming out a few days longer. Another boy five years old, was seized with pains and swellings in various parts, and the penis in particular was so distended, though not disco- loured, that he could hardly make water. He 3S0 Commentaries on the had sometimes pains in his belly, with vomiting, and at thai time some streaks of blood were per- ceived in his stools, and the urine was tinged with blood. When the pain attacked his leg, he was unable to walk ; and presently the skin of his leg was all over full of bloody points. After a truce of three or four days the swellings returned, and the bloody dots, as before. These dots became paler on the second day, and almost vanished on the third. The child struggled with this uncom- mon disorder for a considerable time, before he was entirely freed from it. The first of these boys immediately grew bet- ter after being gently purged : the other took a decoction of the bark for several days without any manifest good effect. CHAPTER 79. Hheumatisfnus. The rheumatism is a common name for many aches and pains, which have yet got no peculiar appellation, though owing to very different cau- ses. It is besides often hard to be distinguished from some, which have a certain name and class assigned them : it being in many instances doubt- ful, whether the pains be gouty, or venereal, or strumous, and tending to an ulcer of the part af- fected. There are two different appearances of the rheumatism, one of which may be called the acute, and the other the chronical. Uistovy and Cure of Diseases. 32 i The acute species is attended with great rest- lessness, and intolerable pain upon moving the affected joint, which hkewise swells and acquires a faint blush of redness. The degree of fever, as far as is denoted by the quickness of the pulse, less injures the faculties both of body and mind, in the rheumatism, than in any other distemper ; for what might be considerable enough to make others delirious, will scarcely make these patients lose their appetites, or shew much sign of distress, or of sinking under their illness. The pains and swellings, contrary to what happens in the gout, have in the first fit seized successively many dif- ferent parts, seldom remaining long in any, and have continued in this manner sometimes for more than two months. These patients are subject to excessive sweats without any relief. Many of them have their pains greatly increased by the warmth of a bed : but this is not constant; for some, especially in the chronical species, are easier in bed. The rheumatism has in more than one or two patients returned once or twice a year for several years, and upon account of this circumstance it is a borderer upon the gout, and many would doubt to which of the two distempers it properly be- longed ; for though one, who has had a fit of a rheumatism, may have a second or third, yet it has seldom been found to be regularly periodical in its returns ; oftener indeed it has never return- ed at all. The rheumatism is undoubtedly near- ly allied to the gout; and fits of it have been more common in children born of gouty parents; as if it were a prelude to what they were afterwards 41 R... 3^S Commentaries on the to suffer. The chronical species equally partakes of the palsy; for there is always a trembling, weakness, and numbness left for some time in the limb affected, and in the chronical sort the use has at last in many been wholly taken away. A rheumatic pain in the shoulder of a woman gradu- ally weakened the arm, till it became almost pa- ralytic and useless : in six or seven months the motion of the arm began to return, and after the use of Buxton water, was perfectly restored. Strumous constitutions likewise have appeared particularly liable to pains, and swellings, either rheumatic, or by every mark exactly resembling them. Such have either forerun, or accompanied strumous ulcers, and collections of matter ; and strumous opthalmies have more than once been changed into rheumatic pains of the limbs. A pain with a swelling fixed in a single part, as the knee, or wrist, without cv^r removmg to any other, is hardly to be called rheumatic, and is more likely to be a cramp, or strain, or strumous, that is, to have a tendency to an ulcer from some in- ternal cause. ' An exception however must be made in regard to the sciatica, which is of the rheumatic kind, though it be fixed in the same part : as for the lumbago, it seems to be rather a cramp, or strain. The chronical differs from the acute rheuma- tism in being joined with little or no fever, in hav- ing a duller pain, and commonly no redness, but the swellings are more permanent, and the dis- ease of much longer duration ; for if the acute species have continued some months, the other has continued for many years. It oftener hap- J I History and Cure of Diseases, 3SB pens that the fits return, at no certain intervals, till they have brought on a deplorable weakness, or entirely destroyed the health. Both kinds of the rheumatism attack indiscriminately males and females, rich and poor. The rheumatism has appeared so early as in a child only four years old, and 1 have seen several afflicted with it at the age of nine years : in v^hich it differs from the gout, which J never have ob- served before the years of puberty. Many of the worst rheumatisms have never of- fered to go beyond the external muscles and joints ; yet 1 have seen some, in whom the rheu- matism has spontaneously passed these bounds, and attacked the stomach, or head. As in a great number of rheumatisms this has happened so seldom, it may be, that those disorders, in which the stomach and head have been affected, were more truly gouty, or strumous, or belonged to the chronical rather than acute rheumatism. An immoderate vomiting, and restlessness, and entire loathing of every thing, which ended in death, oc- curred in the case of one man, whose complaints in many respects partook more of the nature of rheumatism, than of gout. The rheumatism is not more like the gout in its appearance, than in the little progress which has hitherto been made in settling the proper me- thod of cure ; which perhaps is partly owing to the different disorders, which have been called by this name. In the acute sort, bleeding has been much trusted to, which is so much dreaded in that 3S4 Commentaries on the very similar distemper the gout : and it seems to be plainly pointed out in young persons of vigor- ous health, who have contracted this illness by the common causes of inflammatory distempers, such as being exposed to cold air when they were heated with labour. But as much as I have been able to observe, the benefit of large and repeated bleedings is in most cases far from being clear and unquestionable. One of the worst rheuma- tisms, which I remember, immediately succeeded a most profuse bleeding of the nose, which con- tinued so long, as almost to exhaust the patient, and to bring his life into imminent danger. Some- thing like this has happened in a second instance. Among the common people, tradition has pre- served the use of the linum catharticum, and other very strong purges ; but these have not been attended with such good effects, as to establish their general usage. Sweating is another evacua- tion, which has been employed both in the acute and chronical rheumatism, and sometimes, as it has seemed, with advantage ; but it is notorious, that these patients are of themselves subject to excessive sweats without any mitigation of the distemper. I have remarked some instances, in which warm bathing seemed prejudicial, but not one, in which it did any good in either species of this distemper. Cold bathing has often been use- less, but at least as often serviceable. A blister has relieved the more fixed pains of the chronical rheumatism ; and the volatile and saponaceous li- niments have been rubbed in upon the parts af- fected, and perhaps with benefit. The motion of a carriage has been so far from increasing these History and Cure of I)i8ease,%. S25 pains, even when they have been very bad, that 8ome patients have been easier when traveUing, than when sitting still in their chairs. Preparations of quicksilver huve been frequent- ly given with purging medicines, and sometimes with an opiate ; but there will be cause of hesitat- ing about making use of mercurial preparations, since they have indubitably in many cases con- stantly brought on fits of the rheumatism : and never could be used, though several times trie.d, without having this effect. The rheumatism has m some persons been the sure attendant upon a venereal disorder, probably in consequence of the mercury which had been used for its cure. The Peruvian bark, gum guiacum, the Portland powder, preparations of antimony, a mixture of ni- tre and volatile salt, the powder or infusion of bogbean and other bitters, are supposed to pos- sess some specific virtue in the cure of this mala- dy ; but all these must be looked upon as being in a state of probation only, not as being yet estab- lished in the class of efficacious remedies. Opi- um, notwithstanding Sydenham's objections, has at least proved a safe and effectual remedy for the purpose of mitigating the pains, and of procur- ing easy nights of sleep ; and has not only palliat- ed the symptoms, but has been judged to contri- bute to the cure of the rheumatism, more by its calming, than by its sudorific power : nor do I know that it is more efl[icacious, when administer- ed in Dover's powder, or mixed with antimony, than when given alone. 3g6 Commentanes on the Pains of the hips are well known to arise some- times from a morbid state of the joint, of a very different nature from the rheumatism."^ CHAPTER 80. ■^ Semen Virile, Intemperance in venereal pleasures is punished with various symptoms of weakness, generally causing a greater languor of mind, than of body, proceeding from the reflection upon that miscon- duct, which has done this injury to the health. In these cases the semen will come away too promptly both iri sleep, and in the day-time, and sometimes without the person's having any sense of it. Cold bathing has been useful in such com- plaints ; but living in a more cautious manner, and abstaining from all the practices, which occa- sioned them, is the most effectual remedy, and what I believe will seldom fail. I have in two persons known the semen of a chocolate colour, probably owing to the breaqh of some small blood vessel. This discolouring has continued for some time, but without any bad consequences. See above, chapter 21, History and Cure of Diseases. S27 CHAPTER 8L Singultus, A HICCUP is the companion both of chronicat and acute distempers. It has been the forerun- ner of epilepsies, and has attended palsies, and seldom fails to be one of the symptoms of diseas- ed livers, and sometimes will belong to simple ob- structions of the gall-ducts. Various other dis- eases of the stomach and bowels, have this for one of the symptoms ; whether they arise from ruptures, scirrhi, and ulcers, or from mischief done by the violent operation of drastic antimoni- al, or corrosive mercurial medicines. All these have been the causes of hiccups, which have last- ed for months, and for years ; some almost con- stant, and others with intervals of various lenghts. One or two patients have been harassed with them for several months without any other sign of ill health. A hiccup is a symptom of a dangerous nature in acute distempers : it has begun on the first day of a fever, and lasted for the whole seven days, that the patient lived, without yielding to any of the known helps. In other less violent, though at last mortal, fevers it has admitted of no relief for twenty days. The cure of it must either de- pend on the cure of the primary distemper ; or it must be treated with antispasmodics, such as mo- derate doses of opium, or a spoonful of the musk julep frequently administered. 3S8 Comnientaries on the ' CHAPTER 82. Sitis. An unquenchable thirst, and, what is often joined with it, a dropsy, or diabetes, are not so much distempers themselves, as attendants upon great disorders of the abdominal bowels ; which most commonly admit of no relief, but end in deaths However, the primary malady, though fatal at last, will in some cases be two or three years undermining the health, before the patient sinks under it ; during all which time he is harass- ed with this most distressing ail, which is usually accompanied with a feverishness, and loss of ap- petite, and strength, shortness of breath, and oth- er signs of a ruined constitution. Formidable as this symptom is, yet it has not always been fatal ; the original distemper in a few instances having admitted, and happily met with a cure. The thirst has been increased by indulg- ing the desire of drinking ; and has been relieved by the use of a little nitre. But unless the prin- cipal disease can be put into a successful method of cure, it is plain, that this among other symp- toms dependent upon it, though it may be check- ed, yet is not likely to he entirely subdued. History and Cure of Biseases. B29 CHAPTER 83. Spasmus, Involuntary agitations, and cramps or involun- tary contractions, in those muscles which should obey the will if much increased, are called convul- sions. Every external muscle of the body is lia- ble to spasms, as our senses inform us, and proba- bly all the internal muscles likewise. These pre- ternatural contractions of the muscles have some- times burst a small blood-vessel, and the extrava- sated blood running under the skin has discolour- ed it black and blue, and yellow, as it appears when bruised. Cramps and involuntary agitations are familiar to gouty and hysteric patients, and often forerun and attend palsies, and are the principal symp- toms of epilepsies and St. Vitus's dance. The causes of them are either in the nerves only of the part affected, or in the brain and spinal mar- row. That species of cramp, called chorda penis, is usually occasioned by the acrimony of the vene-, real virus affecting those particular nerves ; but it may be brought on by other similar local mis- chief, for I have twice known it without any vene- real infection. A perpetual agitation of the left leg and arm arose from a purulent mass, into which the right side of the brain was changed, its natural texture being obliterated. Instances of a like nature with these perpetually occur, ^whether the irritation of the part, or the preternatural 42 330 Commentanes on the state of the brain and spinal marrow, be owing to any disease, or to some external violence. On the sixth day after the extirpation of a scirr- hous testicle, the patient began to. complain of a difficulty of swallowing, or rather of a sudden sense of suffocation : and in two days the jaw be- came immoveably locked, and the patient soon died. I observed the same happen in an hysteric woman, without any sore or wound. She died about the tenth day ; opium and warm bathing proving ineffectual. After a dangerous fever the sleep of a man wajs sometimes broken by excessive cramps. Two or three days previous to such a bad night, there us- ed to appear about the middle of the tibia a small soft tumour hardly bigger than a pea ; and by this never-failing sign the approach of the cramp was certainly known. In the fevers of children the face is sometimes drawn to one shoulder. I have often seen this, but never knew it continue long after the fever was cured. This happens both in continual, and in intermittent fevers. A similar circumrotation of the face, sometimes to the right, sometimes to the left shoulder, has continued for a long time in several elderly women who had no other com- plaint ; but in them this involuntary motion has been so little violent, as to be overpowered by a very small force, and therefore has ceased while the head rested upon a pillow. Fevers in the West Indies, as we are told, by some disturbance of the brain, give occasion to History and Cure of Diseases. 381 those very formidable cramps called emprosthoto- nus, and opisthotonus ; somo less derangement has been left by fevers in England, in consequence of which cramps of the legs have returned every night in a most tormenting manner. But the change made in the state ot the nerves by a fever has not always in this respect been for the worse; for the only time that one person was free from spasmodic agitations, was during a fever. Sleep favours the access of cramps, as it does of all other nervous complaints ; and therefore they are chiefly complained of in the night; they attack some just as they are sinking into sleep, and others just as they are waking at the usual time, or forcibly awake them in what vvoiild else have been the middle of their sleep. Acids have sometimes brought them on. Slight cramps are cured by altering the posi- tion of the limb. JEther has been rubbed into the calves of the legs at bed-time with success. Habitual cramps have yielded to five drops of tinctura thebaica mixed with forty drops of tinctu- ra assefoetidae taken every night. A fit of the gout has been judged to suspend the power of cramps ; but I am much more strongly convinced, that the gout is apt to breed and foster them. A course of warm bathing effectually cured an ob- stinate cramp, which had for some months kept the body crooked, and one hand immoveably clenched, so that the nails had grown into the palm, and made sores. The waters of Bath have been useful, as it is probable, more on account of 33S Commentaries on the their warmth, than of any other qualities. The cold bath has been tried without any benefit. CHAPTER 84. Sputa Cruenta, A CONSIDERABLE spitting of blood, proceeding not from the stomach with the action of vomiting, nor trickhng down from the back of the nostrils, but coming from the lungs, is a very just ground of alarm to the patient. This is very seldom seen in children; many having kept free from this, as v^^ell as from the other symptoms of a pulmonary consumption, during their childhood, though they were born of consumptive parents, and died of that disease before they were twenty. This com- laint has made its first appearance at all times of ife from puberty to old age. ph lift The danger belonging to it will be greater in proportion to the greater number and degree of the other consumptive symptoms, with which it is accompanied, and to the tenderness of the age at which it comes on. A spitting of blood seems sometimes to be the whole complaint, so that not even a cough shall be joined with it, but the blood will be brought up with as little effort as the easi- est phlegm : it does indeed most commonly de- note an unsound state of the lungs; but from ma- ny facts it seem reasonable to infer the possibility of a slight haemorrhage from the vessels of the lungs, or trachea, while the lungs are otherwise History and Cure of Diseases.* 838 in a healthy state, and consequently with as little dan^jer, as from the hsemorrhoidal vessels, or those of the nose, especially if it happen at the meridian of life. I have seen a man in good health at seventy, who for fifty years had never been free from spitting of blood above two years together. In others I have known it return every now and then for as long time. In a peripneu- mony a bloody mucus will be brought up as the patient recovers, and no cough, nor sign of any in- jury remain. A peripneumony, in which bloody phlegm had been spit up for two or three days, gradually abated, and the patient seemed to be recovered ; but the cough soon came on again, and in a month's time there was a great wasting of the flesh, and a difficulty of breathing, with many signs of approaching death : after going into the country, and riding, the patient lost his cough and shortness of breathing, and lived healthy for many years. A very considerable wound may be made in the lungs of a healthy man, as I have known, by a bullet, without either death, or a consumption following. The loose texture of the lungs, and their great number of large blood-ves- sels, together with their constant motion, and the impossibility of any topical application, might make one fear that a large haemorrhage from them could never be stopped, and must. prove fa- tal ; yet I have known such a breach entirely cur- ed,* as was probable, from there being no return of spitting blood for near forty years ; and I do * In the second volume of Transactions of a Society for the Ira- proveineut of Medical and Chirurgical Knowledge, is given an ac- count of a dissection, where a wound of the lungs had been pe rfert- ly healed. E. 334 * Commentaries on the not remember, as common as this complaint is, to have seen more than one, who was evidently ex- hausted by large and repeated returns of it, and might truly be said to have bled to death. A man has survived at least for two years the loss of a pint of blood from the lungs every day for a n^onth. Not only the common motion of the lungs is borne without much increasing their hae- morrhage, but a perpetual sickness and vomiting during a voyage of six weeks did not apparently make a spitting of blood more profuse. These facts may afford some hope in accidents of this kind ; which however most frequently end in a quick consumption, or leave a lasting cough, growing worse every winter, and making the breathing more laborious. Among the notes which I have taken of these cases, 1 do not find that I have reason to recommend any new reme- dy, or that I have made any practical remarks upon those which are in common use. The ne- cessity of keeping quiet, and cool, is evident, and therefore of avoiding all strong liquors, high sau- ces, hot rooms, costiveness, loud speaking, and exertions of all kinds. Two or three large spoon- fuls of tincture of roses may be frequently taken with advantage ; and there will sometimes in these cases be occasion for a gentle opiate. If I give so much to the established practice as to al- low of one or two small bleedings, where the spit- ting of blood has not already occasioned too great a loss, I must think a caution necessary against large and repeated bleedings, which would proba- bly conspire with the distemper to exhaust the patient. History and Cure of Diseases, 335 CHAPTER 85. Sleatomata. Two children, the one four, the other eight years old, had tumours all over them, some of the size of sDiall nuts, others as larjoje as nutmegs. I judged them to be of a steatomatous kind. One of these children had a voracious appetite : they were both very weakly, and soon pined away, and died. Softish subcutaneous tumours, between the size of a pea and that of a small nut, without any pain, have been very numerous in the arms only ; and in another they were chiefly seated about the an- cles, elbows, and knees, and were suspected to be venereal. In a third, similar tumours continued six years in the arms, and then spontaneously re- treated. They have lasted so long as ten years. The large steatomatous swellings, or wens, are safely cut out, and they seem to admit no other cure. CHAPTER 86. Stranguria, The strangury, or a frequent and most urgent desire to make water, with excessive pain in the attempt, is sometimes an attendant upon pregnaa- 336 Commentariea on the cj, and usually accompanies diseases of the womb, of the prostate gland, and of the bladder, hard faeces obstructing the rectum, and injuries of the urethra from fresh, or frequent, or ill-cured go- norrhoeas. It has been caused by some sorts of food, and some medicines, as pepper, particularly long pep- per, mustard-seed, horse-radish, and other acrid vegetables, and rough cyder. This pain has come on from taking six drams of diuretic salts, and very certainly follows the use of spirit of tur- pentine, one dram of which is on this account a greater dose than (*an generally be borne. Can- tharides are well known to possess the same power beyond all other substances, even applied externally, as well as when taken into the sto- mach. It is one among the many instances of our imperfect knowledge of the animal economy, that we can by no means understand how the cantha- rides should pass so quietly without hurting the various passages, and some of them of exquisite fineness, through which they are carried to the bladder, and yet irritate this part in that extraor- dinary manner, which is too often experienced from the application of blisters. The difficulty of accounting for this is increased by our finding, that one blister has sometimes occasioned this ir- ritation, though afterwards in the same person, and the same illness, five blisters applied at once have had no such effect : and what is called a per- petual blister, after it has been kept open seven years without doing the least hurt to the bladder, has all at once, without any apparent reason, af- History and Cure of Diseases. 337 fected it so strongly, as to make it impossible to continue the blister any longer. There are persons, who from some unknown peculiarity in their constitution, have such a dis- position to the strangury, that after the applica- tion of a blister this complaint has continued upon them for several months: others, without any of the known causes, have frequently had returns of it throughout their whole lives from their infancy, particularly in every illness, whatever it were, though no blister had been applied. It is a disor- der familiar to elderly persons, both men and wo- men : and it has been suspected, that a tendency to this evil has been created by a gouty habit. No medicines taken into the stomach have ap- peared to do much good in the strangury. Oil, and gum arable, roay perhaps do a little; but I have reason to believe, that camphor, like other substances of the same class, will create a dysury, rather than prove its cure. The uva ursl is at best a doubtful remedy, and yet it is capable of doing something to the parts concerned in secret- ing and containing the urine, for in one patient it was trequently tried, and it always changed the urine to a green colour. Bougies have afforded great ease in difficulties of urine from venereal in- juries of the urethra, but they have seldom effect- ed a complete and lasting cure. Injections of oil into the urethra, sitting over the steam of warm water, warm fomentations of the perinaeum, and about the os pubis, have often procured a truce with these pains; but an opiate clyster made of a quarter of a pint of water, and from twenty to a 43 338 Commentaries on the hundred or more drops of tinctura opii, has most readily cured the strangury arising from a blis- ter, and has been the most certain and expeditious temporary rehef in those cases, which admitted nothing further. CHAPTER 87. Struma. That habit of body is called strumous, or scro- fulous, or the evil, in which the lymphatic glands are swelled with little or no pain. This happens most commonly in the neck, and armpits, more rarely in the groin. Those of the mesentery are found liable to the same disorder, and probably all the other internal lymphatic glands. Together with these appearances, the end of the nose, and both the lips are apt to swell, and the eye-lids are often inflamed, and ulcered. These ails have sometimes followed, or been joined with cuta- neous eruptions, and purulent discharges from the ears. Some constitutions experience frequent re- turns of an inflammation of the tonsils, which lasts a few days, not without fever: in others there is an enlargment of them, which sometimes continues for a long time with considerable uneasiness to the patient, and some difficulty of swallowing. Infants and children are particularly subject to strumous disorders, and more especially the weak- ly with very fair skins. After the age of puberty the tumours of the glands, and the inflammation History and Cure of Diseases. 339 of the eje-lids, usually begin to abate, and In adults often disappear entirely; but in some per- sons, upon their retreat from the outward parts of the body, they seem to fall upon the lungs, whence arise incurable consumptions. But chil- dren are not the only sufferers by this malady; for I have noted eight or ten healthy persons, in whom the lymphatic glands began first to be en- larged after the age of thirty, and the swelling in some of them did not shew itself till near their sixtieth year. The origin of this mischief in these adults was probably to be found in the unwhole- someness of their diet, or situation. The use of a very hard water was suspected to have made one of them scrotulous ; for he began to be so after using it constantly for a few years, and con- tinued so long as he used it, but upon leaving it off, all the scrofulous appearances left him. It is most probably owing to some bad quality of the water, that swellings of the throat are endemial in some parts of England, and notoriously among the inhabitants of the Alps ; though 1 by no means think it owing to the use of snow-water, to which it has been attributed : for I believe, on account of its great purity, this would bo one of the best remedies they could employ.* * The inhabitants of Rheims had been so afflicted with strumous diseases, that they maintained an hospital for the sole purpose of curing such patients. They then made use of no other water than what they had from wells. After a machine was constructed, which brought the water from a neighbouring river, and distributed it into all quarters of the city, it was observed that scrofulous disor- ders became less common ; and in the space of thirty years the number of these patients was reduced to one half of what it had usualy been: it continued to decrease so fast, as to give occasion for thinking, Uiat the greater part of the revenues of the hospital might be applied to other purposes. Soc. RoT/ale de Medecine, vol. ii. Hist. p. 280. 340 Commentaries on the Beside these swelled glands, which make one species of the evil, there is another, which is call- ed the Joint evil, which has begun in the hands, or elbows, or feet, with a small tumour situated so deep, that the bones are often affected. These have continued two or three years, before they have come to ulcers, which have been of such a malignant nature, as at length to make the hands or feet almost useless, or to make the fingers arid toes fall off. Are the diseases of the head of the thigh-bone, and its socket, and also what is called the white swelling of the knee, to be referred to this class ? This seems not unlikely, as they have been found joined in the same person with the usual marks of an inveterate scrofula. Some strumous appearances have shewn them- selves not long after the measles, and small pox^. and this has created a suspicion, that this altera- tion of the health was to be attributed to some re- liques of those diseases : but this has happened too seldom within my observation to give any just grounds for such an opinion, which perhaps has been entertained the more readily, because the patients, or their friends, were unwilling to think the scrofulous complaints hereditary, or constitu- tional. The scrofula, and lues venerea, when they meet, seem greatly to exalt the malignity of each other. The swellings of the lymphatic glands in the neck, and armpits, have continued above twenty years without any other variation, than being a I History and Cure of Diseases. 341 little enlarged upon catching cold ; but this is ex- traordinary, and happens but seldom : they thore usually either lessen by degrees, and vanish in not many months, or in a very few yeai s ; or else in- flame, and suppurate. The larger break into smalldr parts with a slight degree of itching in the skin previously to their going away ; and tlie smaller first grow softer, and so gradually sink down, and are reduced to their natural size ; in- stances of all which are very common. When, mstead of dispersing, these tumours inflame and grow red, they are a long time in coming to a sore, in which state they are slowly dissolved into an imperfect pus, and afterwards heal. These sores have never within my observation shewn a disposition to turn cancerous in children, and only in two or three adults. I never saw any occasion for using poultices, plasters, or warm covering to strumous swellings. They cannot be wanted to mitigate the pain, be- cause it is so inconsiderable ; and if it be meant to disperse them by plasters, it may be doubted whethier any have a power of this kind ; but if the application be intended to make them suppurate, it is doing that, which too much pains can never be taken to prevent ; for they cannot terminate in a worse manner. If this event cannot be hinder- ed, and the glands spontaneously tend to become ulcerous, they should be suffered to break of themselves without the help of a knife or a caus- tic ; and the mildest defensative plaster is all the further care which they require. The scrofulous inflammations of the eye-lids, and eyes, sometimes make bleeding necessary ; and they have been 34S Commentaries on the much more benefited by leeches, than by taking away blood in any other manner : two or three may be put to each temple once or twice a week for a considerable time. Many external applica- tions to the eyes are recommended, all which have been often found of very little service, except soft cataplasms put between two pieces of fine linen, and so applied to the eyes, and touching the edges of the sore eye-lids every night with some softened animal fat, which will hinder their being glued together in the night; for the force used to open them in a morning keeps them constantly raw and sore. Mercurial medicines have been judged to hurt, rather than to help scrofulous patients; and per- haps strumous distempers have been aggravated by the accession of a venereal infection, chiefly on account of the preparations of mercury which these require. Sea-water internally, and exter- nally, extract of hemlock, bark infused in purging water, or taken in substance at night, .while purg- ing waters, or salts, are used in the morning, burnt spunge,'sal sodae, issues, and perpetual blisters, are the principal means which have been recom- mended as alteratives of a strumous habit ; all which, as experience has taught, may be employ- ed with safety ; but the reputation of their effica- cy is far from being fully established. Where the patient has not perseverance enough to conti- nue the use of any of these for a proper length of tiuie, he may do himself some, and I believe con- siderable service, by a temperate course of life, and by drinking no other water than such a pure one as that of Malvern. History and Cm*e of Diseases. 843 CHAPTER 88. Tenesmus, A CONSTANT needing, or wanting to go to stool, though Httle or no faeces could be voided, has been owing to the following causes : hard faeces, which had loaded the rectum, and which could not be expelled without assistance ; a scirrhus of the womb, of the rectum, or of the prostate gland ; a stone in the bladder; a strangury, parti- cularly, one brought on bj cantharides ; and a weakness of the sphincter ani left by an apoplexy, or a difficult labour. It is usually troublesome for a little while after a dysentery ; and has accompa- nied the colica Saturnina, and a prolapsus of the inner coat of the intestine. A tenesmus is usually increased by standing or walking, and relieved by sitting. When it is merely owing to acrimony, an opiate clyster will be the best remedy. In other cases the relief of this uneasy sensation must depend upon the cure of the original disease, of which it is a symptom. I CHAPTFR 89. Testiculus, Besides tumours of the testicles from external, or venereal injuries, they have been found joined with an intermittent fever, coming on and going 344 Commentaries on the off with every fit, and finally ceased upon the cure of the intermittent : this has happened more than once. A common cold has had a sieiilar effect upon several persons. A scirrhous prostate gland has made the testicles swell ; which also is no very uncommon consequence of stones, and other af- fections of the kidneys. Without any manifest cause a swelling has begun in one of the testicles, and after continuing a few months has sponta- neously subsided. A tumour of them has at other times slowly increased for many years, and at last made the whole testicle scirrhous, which has been twenty years before it became cancerous and fa- tal. A fistulous sore has formed in such a testi- cle, and has long harassed the patient. Purges, except very gentle ones, have been at least useless. Poultices are necessary when the pain is considerable. Whether there be pain, or swelling, a bag-truss is of indispensable use to suspend the scrotum. There is no cure for a scir- rhous testicle, but castration ; and this may be safely performed, if the spermatic chord be in to- lerable order ; but where this too is diseased, the case admits of no cure. The hydrocele is incon- venient, but void of danger ; and may be suffici- ently relieved, wit})out pain or hazard, by tap- ping, as often as there is occasion. An operation is sometimes performed in the hydrocele, which makes a lasting cure. History arid Cure of Diseases, 3-15 CHXpTER 90. Torpor, A NUMBNESS, or sense of tingling in a limb, which is commonly called its being asleep, has been experienced in every part of the body, but chiefly in the limbs, and particularly the extremi- ties. It is a half loss of the sense of feeling, and is extremely common, though a total loss of it be so rare even in the most hopeless palsies. A numbness, like a cramp, has been either a slight complaint brought on by an inconvenient posture, or other trivial causes, unattended with any ill consequences, and presently removed ; or else it has arisen from that preternatural state of the nerves, which is inconsistent with tolerable health, or, \i may be, with life, and has been the forerunner of convulsions, palsies, and apoplexies. The old seem most subject to it, and both sexes equally ; in youth, females have oftener been suf- ferers than males. Where a torpid state of any part has not been constant, it has been found to come on chiefly in the night, owing partly to a long continuance of the same posture, and partly to sleep, which favours the access of all disorders in which the. nerves are more immediately con- cerned. Numbnesses are familiar to broken constitutions, and such as have been derived from paralytic pa- rents. They have been the forerunners, the at- tendants, and followers of palsies, and apoplexies. 44 346 Commentaines on the and are commonly joined with other symptoms of these maladies. This very frequently makes one of the numerous complaints, which are heard of among hypochondriac and hysteric patients, and has continued in them and others not onlj for ma- ny months, but often for many years, and then has gone off without having done any mischief to the health. The whole left side has been be- numbed for five-and-twenty years. The true nature and tendency of a numbness '•^roay be best known by its attendant circumstan- ces ; for if it be associated with other paralytic symptoms, and affect a considerable part of the body, especially in persons derived from paralytic parents, no doubt can be made of its betokening mischief, and the proper preventives of palsies should be employed. But if a torpor should af- fect only a small part, as one or two fingers, or toes, and be united with no other symptoms, or only such as are common in hypochondriac disor- ders, the less notice the patient takes of it, the happier he will be. But if there should be rea- sons tor endeavouring to cure this more innocent species of the complaint, blisters, and warm bath- ing, have been found the most serviceable means ; cold bathing, and bleeding, have been found pre- judicial ; the gout has been useless; and as for electricity, its virtues have not yet been sufficient- ly ascertained. ^ History and Cure of Diseases. 34'; CHAPTER 91. Tremor. A TREMBLING of the hands, or a shaking of the head, may be judged to have some alhance with paralytic, and apoplectic maladies ; yet it has been found by experience, that such a tremour has often continued for a great part of a person's hfe, without any appearance of further mischief; and therefore, if it have a tendency to palsies, it is a very remote one, and the inconvenience is far more considerable than the danger. Hypochon- driac persons are troubled with frequent fits of it; hard drinkers have it continually ; and some de- grees of it usually attend old age. This, like other affections of the nerves, is greatest in a morning, and is aggravated by any disturbance of mind. Coffee and tea make the hands of some persons shake ; and yet I have known strong coffee drunk every day for forty years, by one who was remarkable for the steadi- ness of his hands even in extreme old age. There are many others, who know no such ill effect from these liquors ; and indeed, if it were general, few Chinese, and Turks, would escape it ; but their history does not acquaint us, that these people are more subject to tremours, than those of other nations. If any medicines are wanted, they must be such as are found serviceable in paralytic and hypo- chondriac complaints. 348 Commentaries on the CHAPTER 92. Tussis, A COUGH seems to have been sometimes occa- sioned either by an acrimonious, or a too copious defluxion on the trachea, without any material, or permanent injury of the lungs ; or merely by disorders of the stomach and bowels, as hath ap- peared upon dissections, examples of which are often seen in children with worms, and swelled mesenteric glands. In cases where the lungs themselves have been diseased, it is observable that they are sometimes in a disposition to let the mischief spread in a rapid manner all over them, and in a very short time become a fatal consump- tion ; while in other instances the injured part pf the lungs has seemed to remain in the same state for twenty, forty, or even sixty years, with very little inconvenience beside the cough, so that the patient has grown fat with it ; or else the disease of the lungs has spread so slowly, that though the cough has become a little worse every wjnter from youth to old age, yet it has not been till to- wards the end of a long life, that the lungs have become so diseased, as to do their duty with that difficulty, which is called an asthma. Even an ulcer of the lungs, as was adjudged from the blood and purulent liquor spit up, has for a consi- derable time kept itself confined within the same bounds. In a few cases the ulcer has probably been seated in a capsula, which has at last been coughed up with great efforts, and some danger of suffocation ; after which there has been a total i History and Cure of Diseases. 849 cessation of all the complaints, the sore being in all probability entirely healed. In hysteric, and convulsive diseases, arising from som^ disordered state of the whole system of nerves, ^hose serving to respiration have among the rest been disturbed so as to occasion violent roughs, without any more injury to the lungs, than the convulsions of the limbs, or body, occasion in those parts, which they have seized. These coughs, and those aris- ing from defluxions upon the lungs, are attended sometimes with an unusual noise, and are general- ly much stronger, than consumptive coughs are, not only in their beginning, but even in their ad- vanced state. The same is likewise the case with those coughs, which are owing to some hard body fallen into the trachea. I have seen a vib- lent, and almost perpetual cough, arising from a bone fixed in the windpipe, which had lasted some months with an unusual sound, and present- ly ceased upon coughing up the bone. Coughs have molested some persons alternate- ly with opthalmies, the gout, scald head, and other cutaneous disorders. It must be remembered, that in all long coughs there is danger of a con- sumption, and therefore a cool regimen is of indis- pensable use, in order to keep the lungs in that state, which is most likely to hinder the sound parts from being infected by the diseased. There have been too many examples of coughs remain- ing in a tolerable state for twenty years, and which with proper care might have remained so for twenty more, which have by mismanagement, or catching cold, been joined by all the symptoms of a quick consumptiori, soon terminating in death. 350 Commentaries on the Hence arises a difficulty of deciding, whether a cough be a consumptive one : most coughs natu- rally tend to a pulmonary phthisis ; and though the tendenc)^ be sometimes so strong, that there is no hazard of being mistaken in pronouncing the cough consumptive, yet in many instances no physician can prognosticate the event, unless he be able to predict also what the patient's manner of living will be, and whether he will always es- cape violent colds, and peripneumonies. Abstemiousness, change of air, and a judicious use both of bleeding, and of opium, have proved the best means of soothing a troublesome cough, and of hindering it from becoming a dangerous one. I CHAPTER 93. Tussis convulsiva. The hooping-cough is most common among children, and is undoubtedly contagious ; it is a tedious disorder, lasting often for several months ; and though sometimes slight, yet in some children it proves fatal. An inundation of phlegm, or a vomiting, the clearness of the intervals, and the violence of the fits, may generally distinguish it from a common cough in the very beginning ; but afterwards it cannot be mistaken, when the expi- ration in coughing continues so long, that they can hardly recover the power of drawing in their breath, which is done at last with a peculiar History and Cure of Diseases. 351 sound, called hooping ; and this jprincipally cha- racterizes this distemper. A child has had one of these coughs three months before the hooping came on. The violence of the cough sometimes makes the nose bleed, and the face blackish, and has strained the eyes so as to do them a lasting injury. It does not usually attack a person more than once; but to this I have heard some few ex- ceptions among those whom 1 have attended in it, of whom more than one have assured me they had been ill of it before. Old persons are less liable to this malady, but by no means exempt from it : I have seen it in a woman of seventy, and in a man of fourscore. A child has some notice of the approach of a fit, so as to be able to run to his nurse, or mother, be- fore it begins ; but adults are, as it were, over- powered at once upon the access of the fit, so that they fall down instantly, as in an apoplexy, but very soon come to themselves : this is a distin- guishing symptom of the disease in those who are grown up ; and if they have not before been sub- ject to a cough, and have lately been in the way of catching this distemper, the circumstance of their falling down in this manner may take away all doubt about the nature of their illness. Fla- tulence in an extraordinary degree often accom- panies this cough. Experience has instructed us, that a change of air is of singular use in abating the force, and shortening the stay of this distemper. The sto- mach is so much disordered in it by being over- loaded with phlegm and oppressed with wind. 35^ Commentaries an the that it seems very reasonable to relieve and strengthen this part by the help of rhubarb and bitters. The hooping-cough has so much the na- ture of a convulsion, that a prudent use of opium, together with musk, lac ammoniaci, and viaum an- timonii, might probably be beneficial ; but I have not seen such undoubted success from these medi- cines, as to be confident of their virtues. As for the numberless specifics, which are every where to be met with, I have nothing to say in their favour from my own observation. CHAPTER 94. Valetudo conquassata. A DANGEROUS disease, or great decay of the parts necessary to life, occasions what is called a broken state of health ; by which is meant an as- semblage of many- or most of the following com- plaints : A paleness, or sallowness of the counte- nance; a bloated face; thirst; shortness of breath; palpitation of the heart; flatulence; loathing of food ; sickness ; frequent making of water ; incon- tinence of the stools, and of the urine ; swelling of the legs; wandering pains; spasms; wasting of the flesh ; weakness ; lassitude ; itching of the skin ^tremblings ; numbnesses ; feverishness ; lan- guor ; faintings ; sleepiness in the day-time ; want of sleep at night ; forge tfulness. h History and Cure of Diseases. 358 CHAPTER 95- Variolce, The experience which I have had of inocula- tion, does not enable me to add any thing to what has been already estabhshed in relation to its uti- lity, or the management of the inoculated. I am sorry to liave found, that this operation has not always secured the patient from having the small pox afterwards, if the eruption have been imper- fect without maturation. 1 attended one in a very full small pox, which ran through all its stages in the usual manner ; yet this person had been ino- culated ten years before, and on the fifth day af- ter inoculation began to be feverish with a head- ach followed by a slight eruption, which eruption soon went off without coming to suppuration ; the place of inoculation had inflamed, and remained open ten days, leaving a deep scar, which I saw. By some accident, most of the notes are lost, which had been made during my attendance on a great number of patients in the uninoculated small pox ; therefore I shall not attempt to give a full history of this distemper, but confine myself to the relating of such observations as are justifi- ed by the few remaining papers. Many instances have occurred to me, which shew that one who has never had the small pox, may safely associate, and even lie in the same bed with a variolous patient, for the two or three first days of the eruption, without any danger of re- 45 354 Commentaries on the ceiving the infection. One woman continued to suckle her infant for two dajs after the small |;ox had begun to appear upon her ; and the child be- ing then removed escaped the distemper for that time, but was unquestionably capable of being in- fected, because he catched it about a year and half after. Parents have several times judged it proper, when one of their children has fallen ill of the small pox, not to send those away, who had not had this distemper, but to let them all continue together in the same house, and often in the same chamber. About the sixth day alter the distem- per had arrived at its height in the sic k child, the others have for the most part begun to complain ; and therefore it is probable that this is the time, when the distemper begins to be communicable ; the infection lying dormant about the same num- ber of days, that it does in those who have been inoculated. But there are much greater varieties in this way of taking the small pox, than by ino- culation, accordingly as persons go more or less into the way of receiving the breath ol the sick person, or of touching things daubed with the va- riolous matter. Two children were constantly kept in the sick chamber, and yet did not fall ill till a month after; and there are not a few exam- ples of persons, who have seemed to be equally exposed to the infection, and yet have received it at different times. An excruciating pain in the loins has never fail- ^ ed to be succeeded by a bad small pox, and the ; more violent the pain the greater has been the -*■ I History and Cure of Diseases. 355 danf^pp; it is much safer to have it between the shoulders ; but it is safest to have none in any part of the back. Excessive vomiting for the whole time before the eruption is seldom followed bv a mild disease; and if the vomiting be continued after the erup- tion "is completed, the patient's life is in great danger, even though the small pox be not conflu- ent, as I have seen more than once. It is very common to have convulsions precede a mild small pox in children, and the same has been known in some adults with as prosperous an event. The variolous infection does some force to the vessels, which supply the menstrual discharge in women ; and^in the worst sort of small pox this evacuation has come on out of its regular course two days before the small pox has begun to shew itself, and has continued to flow in an excessive manner. It has sometimes appeared before its re- gular time, together with the eruption. But what I have more usually observed, is, that this uterine flux in almost all female patients has begun as soon as the eruption was completed, and it has continued from one day to fixe. This discharge, though sometimes much greater than the natural one, does not seem to check the progress of the small pox, nor to sink the patient's strength, and therefore very little pains need be taken to stop it, even though we had any ready and innocent way of doing it. 856 Commentaries on the That very formidable symptom, bloody urine, has come on about the fifth day from the first sick- ness ; the eruption in the mean time has hardly risen above the skin, chiefly shewing itself in pur- ple spots and blotches, and resembling variolous pimples only in very few places, The stools are likewise bloody; the very tears have been like lotura carnium ; and if a small scratch has any where been made in the skin, the blood has for many hours continued to ooze out, and has hard- ly been stopped. This hopeless state has been terminated by death in three or four da^s after the eruption ; nor have I remarked one exception. But the urine may be discoloured in the small pox, and have a hue as dark as coffee, even where there is no reason to suspect its proceeding from gravel, and yet afford no ground for alarm, if not joined with other bad symptoms. In a middling sort of small pox, the urine became black on the fourth day of the eruption, and continued so for four dayg. In another, the same black urine be- gan on the second day of the sickness, having a sediment like coffee-grounds for two days. Both these patients went on prosperously, without any other bad or unusual syniptom. The pustules have sometimes shewn themselves not very diffe- rent from their general appearance in a middling sort; but the interstices have been filled with small round purple spots, and the distemper has been fatal on the third day of the eruption. It has been remarked above, that the variolous virus has a peculiar etTect in exciting the uterine j8ux, and upon this property of it perha|}s depends its well-known effect upon pregnant women» who History and Cure of Diseases. 357 usually miscarry on the seventh or eight clay fronoi the first eruption, and in a day or two aiter die. The foetus of tliis abortion I have often examined vs^ith great attention. The skin of it has been much discoloured, in some parts of a dirty red, in others blackish, and in a few places of a natural colour; but I could never see any appearance of a variolous eruption. I have known a very few pregnant women, who have gone through this distemper without miscarrying, and have after- wards been brought to bed at the natural time ; but I could never see upon these children any such marks as might be left by a variolous erup- tion ; and 1 am well assured, that such children have afterwards had the smaTI pox. A young girl was opened, who died full of the small pox, and I observed that none of the bowels or inter- nal parts shewed the least marks of their having any variolous pustules : now the foetus in utero seems to be so much in the same state witii the bowels, that if these are never the seat of the pus- tules, it is hardly to be expected that any should be found upon the foetus. A great shortness of breath coming on about the fifth day of the eruption, scarcel} leaves any hopes that the patient will survive the distemper. The difficulty of breathing is sometimes so great, as not to suiter the patient to lie down, or to have breath sufficient for speaking a common sentence. A sudden sinking of the swelling in the face, so that the eyes can be opened ; an abrupt stop- page of the spitting; a frequent wanting to make water, and making very little at a time ; a total 358 Commentanes on the absence of all foetor; and great shiverings ; though thej be very dangerous signs, jet have been seen without proving fatal. Watery bladders, full of a yellow serum, like those raised by blistering pfasters, rise up among the pustules in some kinds of the small pox, and may shew an irregularity and malignity ; but such patients have recovered. In the decline of the distemper, when most of the scabs had fallen off, I have twice seen a few pimples with watery heads, without any redness or inflammation, which afterwards maturated and resembled the true small pox. These pustules were only in the soles of the feet and palms of the hands. In one child the pocks were large, and fewj for four days, and then there was an eruption of very small and numerous pustules, from which the child with difficulty escaped. In another there were a few pocks, and the child notwithstanding was very restless and oppressed; after these were dried, others broke out, and came to maturation ; and even afterwards one or two made their appearance. The child died, though all the pocks, if they had appeared toge- ther, were so few, that I never saw any other per- son die, who had not more. These are the only instances, which have occurred to me something like, what is often talked of, a second crop. It has happened to three variolous patients in the decline of their distemper, when they were thinking of having a little meat allowed, and of taking, as usual, some purging medicine, that they History and Cure of Diseases. 359 have suddenly become gloomy and suspicious, and in forty -eight hours have died raving mad. An excessive spitting, which proves so benefi- cial in the confluent small pox, has in a few per- sons continued for several days after the decline of the distemper, in a degjree equal to a common salivation, and no harm has ensued. The milk of a woman, who suckled a child, be- gan to lessen at the height of the small pox, and soon after went quite away ; but after a few days it returned as plentiful as ever. In all distempers, it is considered as a favoura- ble circumstance, that the person is dee from all other complaints, with a constitution naturally good, and unimpaired : for when there is nothing to divert the powers of life from opposing the pre- sent illness with their whole force, a happy event may reasonably be expected : and yet a complica- tion of the small pox with other formidable mala- dies, has in several instances not exalted its malig- nity, or produced a bad sort, nor disabled the pa- tient from struggling through it in the usual man- ner. Venereal distempers have often been join- ed by a mild small pox ; and in a worse sort they have not at all added to the usual danger or suf- ferings of the patient. Others have catched the small pox, when they wefe dying of scrofulous consumptions ; but have still had all the necessary strength to recover unhurt from the new distem- per, and they have not appeared to die a day the sooner of their old one. 360 Commentanes on the In a large town, at a time when agues were epidemical, it chanced that the small pox was brought in, and many catched it before they were cured of their agues. It was observable, that the ague stopped spontaneously in these patients, as soon as the small pox fever began, and constant- ly returned after the small pox was over and one or two purges had been taken. The two distem- pers seemed to have no other influence over one another. Mankind has hitherto been blessed with speci- fics for very few distempers. The small pox is one among many others, the proper remedy for which, if there be one, is left to be found out by the sagacity, or good fortune, of futui^ physi- cians. Sanguine expectations have been enter- tained of the great service, which the Peruvian bark, and the preparations of antimony, and of merdury, would do in opposing the variolous vi- rus. But such hopes have upon trial all dwin- dled away, and left us just where we were.' The method therefore of treating the small pox will not differ from that which is contairjed in the gene- ral doctrine of the regimen and diet of the sick ; and the troublesome symptoms, which may arise, must be relieved, and the functions of life kept as much as possible in their natural state, by the same means which are used in any other fever. Costiveness in particufer is as hurtful in the vaiio- lous fever, as in any other : which i mention, be- cause the contrary opitnon formerly prevailed, and is hardly yet quite worn out. History and Cure of Diseases. 361 CHAPTER 96. Variola Pusilla, The Chicken Pox. The chicken pox and swine pox differ, I be- lieve, onlj in name : thej occasion so little danger or trouble to the patients, that physicians are sel- dom sent for to them, and have therefore very few opportunities of seeing this distemper. Hence it happens that the name of it is met with in very few books, and hardly any pretend to say a word of its history. But though it be so insignificant an illness, that an acquaintance with it is not of much use for its own sake, yet it is of importance on account of the small pox, with which it may otherwise be confounded, and so deceive the persons, who have had it, into a false security, which may prevent them either from keeping out of the way of the small pox, or from being inoculated. For this reason I have judged it might be useful to contri- bute, what 1 have learned from experience, to- wards its description. These pocks break out in many without any illness or previous sign : in others they are pre- ceded by a little degree of chillness, lassitude, cough, broken sleep, wandering pains, loss of ap- petite, and feverishness for three days. In some patients I have observed them to make their first appearance on the back, but this per- haps is not constant. Most of them are of the 46 ^6^ Commenlaries on the common size of the small pox, but some are less. I never saw them confluent, nor very numerous. The greatest number, which I ever observed, was about twelve in the face, and two hundred over the rest of the body. On the first day of the eruption they are red- dish. On the second day there is at the top of most of them a very small bladder, about the size of a millet-seed. This is sometimes full of a wa- tery and colourless, sometimes of a yellowish li- quor, contained between the cuticle and skin. On the second,, or, at the farthest, on the third day from the beginning of the eruption, as many of these pocks, as are not broken, seem arrived at their full maturity ; and those which are fullest of that yellow liquor, very much resemble what the genuine small pox are on the fifth or sixth day, especially where there happens to be a larger space than ordinary occupied by the extravasated serum. It happens to most of them, either on the first day that this little bladder arises, or on the day after, that its tender cuticle is burst by the accidental rubbing of the clothes, or by the patient's hands to allay the itching which attends this eruption. A thin scab is then formed at the top of the pock, and the swelling of the other part abates, without its ever being turned into pus, as it is in the small pox. Some few escape being burst; and the little drop of liquor contain- ed in the vesicle at the top of them grows yellow and thick, and dries into a scab. On the fifth day of the eruption they are almost all dried and covered with a slitjht crust. The inflammation of these pocks is very small, and the contents of History and Cure of Diseases. 363 them do not seem to be owing to suppuration, as in the small pox, but rather to what is extravasat- ed immediately under the cuticle by the serous vessels of the skin, as in a common blister. No wonder therefore that this liquor appears so soon as on the second day, and that upon the cuticle being broken it is presently succeeded by a slight scab : hence too, as the true skin is so little affect- ed, no mark or scar is likely to be left, unless in one or two pocks, where, either by being acciden- tally much fretted, or by some extraordinary sharpness of the contents, a little ulcer is formed in the skin. The patients scarce suffer any thing throughout the whole progress of this illness, except some languidness of strength and spirits and appetite, all which may probably be owing to the confining of themselves to their chamber. I saw two chil- dren ill of the chicken pox, whose mother chose to be with them, though she had never had this illness. Upon the eigth or ninth day after the pocks were at their height in the children, the mother fell ill of this distemper then beginning to shew itself. In this instance the infection lay in the body much about the same time that it is known to do in the small pox. Remedies are not likely to be much wanted in a disease attended with hardly any inconvenience, and which in so short a time is certainly cured of itself. The principal marks, by which the chicken pox may be distinguished from the small pox, are, b 364 Commentaries on the 1. The appearance on the second or third day from the eruption of that vesicle full of serum up- on the top ot the pock. 2. The crust, which covers the pocks on the fifth day ; at vehich time those of the small pox are not at the height of their suppuration. Foreign medical writers hardly ever mention the name of this distemper; and the writers of our own country scarce mention any thing more of it, than in name. Morton speaks of it as if he supposed it to be a very mild genuine small pox. But these two distempers are surely totally diffe- rent from one another, not only on account of their diflferent appearances above mentioned, but because those, who have had the small pox, are capable of being infected with the chicken pox ; but those, who have once had the chicken pox, are not capable of having it again, though to such, as have never had this distemper, it seems as in- fectious as the small pox. I wetted a thread in the most concocted pus-like liquor of the chicken- pox, which I could find ; and after making a slight mcision, it was confined upon the arm of one who had formerly had it ; the little wound healed up immediately, and shewed no signs of an infection. From the great similitude between the two dis- tempers, it is probable, that, instead of the small pox, some persons have been inoculated from the chicken pox, and that the distemper which has succeeded, has been mistaken for the small pox by hasty and unexperienced observers. There is sometimes seen an eruption, concern- ing which I have been in doubt, whether it be History and Cure of Diseases. 365 one of the many unnoticed cutaneous diseases, or only, as I am rather inclined to beheve, a more mahgnant sort of chicken pox. This disorder is preceded for three or four days by all the symptoms which forerun the chicken pox, but in a much higher degree. On the fourth or fifth day the eruption appears, with very little abatement of the fever ; the pains likewise of the limbs and back still continue, to which are joined pains of the gums. The pocks are redder than the chicken pocks, and spread wider, and hardly rise so high, at least not in proportion to their size. Instead of one little head or vesicle of a serous matter, these have from four to ten or twelve. They go off just like the chicken pox, and are distinguishable from the small pox by the same marks ; besides which the continuance of the pains and fever after the eruption, and the degree of both these, though there be not above twenty pocks, are, as far as I have seen, what never hap- pen in the small pox. Many foreigners seem so little to have attend- ed to the peculiar characteristics of the small pox, particularly the length of time, which it re- quires to its full maturation, that we may the less wonder at the prevailing opinion among them, that the same person is liable to have it several times. Petrus Borellus* records the case of a woman, who had this distemper seven times, and catching it again died of it the eighth time. It would be no extravagant assertion to say, that " Hist, and Ol». Rar. Med. Phys. centnr. iii. o?)s. 10 366 Commentaries on the here in England not above one in ten thousand patients is pretended to have had it twice ; and vs^herever it is pretended, it will always be as likely that the persons about the patient were mistaken, and supposed that to be the small pox, which was an eruption of a different nature, as that there was such an extraordinary exception to what we are sure is so general a law. r CHAPTER 97, Ventriculi MorhL One among the many disorders of the stomach is a disagreeable sense of acidity rising from it, which is accompanied often with pain, or a sort of anxiety worse than pain, sickness and vomit- ing, a sense of weight, voraciousness in some, and loss of appetite in others, flatulence, and disten- sion of the stomach, head-ach, great quantities of phlegm, and a waking out of sleep with some degree of terrour. If we were to reason upon chemical principles, nothing seems more practicable, than to neutral- ize, and subdue an acid, to which we can imme- diately add whatever we think proper ; but the animating principle makes so much difference be- tween a living stooiach and an inanioiate vessel, that this, which appears easy in theory, has been found very difficult in practice ; and persons have been teased with this complaint for twenty years, without being able to find a cure. Lime water, History and Cure of Diseases, 367 magnesia, testaceous powders in the quantity of an ounce every day, and alkaline salts, have in se- rai instances been tried in vain. Milk, vegetables, fish, fat of any kind, a full meal, especially with any exercise soon after it, have generally disagreed with stomachs disposed to acidities, which they have much increased. Acids themselves have not always been hurtful, but have sometimes proved a relief. Emetics and Bath waters have succeeded with some, and failed with others. Large quantities of testa- ceous powders, and rhubarb, have been the most generally useful ; and a costive habit of body has been always prejudicial. After trying a variety of means for many years upon the most uncon- querably acid stomach which I ever knew, the method, in which the patient settled, and which alone was able to keep the complaint in tolera- ble order, was the taking one ounce of testa- ceous powders every morning, and drinking a gallon of warm water, as an emetic, every night; which course, with a little rhubarb occasionally, was pursued for several years. The heartburn is an usual companion of acidi ties in the stomach, differing very little from them, either in its causes, or cure, and has been as ob~ stinate in resisting all sorts of medicines. It has been attended with hiccups, eructations, and an immoderate flow of saliva. During pregnancy it is apt to be uncommonly troublesome, and is often added to the evils of the gout, and some- times to those of the jaundice. A disposition to it seems to be born with some persons, who have 368 Commentaries on the been teased with this uneasy sensation for the greatest part of their Hves. Cutaneous erup- tions, and the heartburn, have alternately harrass- ed some persons. One woman, while she was breeding, could find no relief for a violent heart- burn from any of the usual remedies, and was at last cured by elixir of vitriol. i 2. Ventriculi Dolor. Inflammations, or cancerous scirrhi of the liver, spleen, and pancreas, with all other kinds of pains between the breast and the navel, are usually referred to the stomach ; and beside the disorders, which properly belong to it, and have their ori- fin there, it sympathises with all parts of the ody in many of their ails. The gout, and per- haps the rheumatism, wandering pains, and those that are fixed, all sores and cutaneous diseases, have frequently either deserted their first seats and fallen upon the stomach, or else have drawn it to suffer together with the parts first affected. With regard to giddinesses, and head-achs, though they be sometimes the causes, yet they seem oftener the effects of stomach disorders. The diseases of the womb injure the stomach in a very remarkable manner ; and it rarely escapes without pain, or sickness, whenever any of the various irregularities of the menstrua are com- plained of. It is equallv a sufferer in hysteric and hypochondraic maladies, in all great pertur- bations of mind, and in worms, even those which are generally found only in the great intestines. Where there is no reason to suspect and pro» vide against any of these causes, and where the History and Cure of Diseases. 369 pain does not proceed from any poison, or impro- per food ; if it be very excessive by fits with in- tervals, especially very long ones, of perfect ease and blameless health, there we have the great- est reason to believe it owing to gall-stones. I have noted a very considerable number of per- sons, who for many years (some not less than twenty) had been subject to returns of pains in what is called the pit of the stomach, and at last the appearance of the jaundice clearly pointed out their origin, or the voiding of a gall-stone has entirely removed them. In others, after a fit of the jaundice, the same pain which preceded it, and had given the patients too much reason not to mistake it, has continued to torment them at irregular times, sometimes without a yellowness, and sometimes with, tor at least twelve years. Some have been subject for a great part of their lives to a moderate or dull pain in the side, or about the stomach, which, as I judged from the appearances after death, upon their being open- ed, was most probably owing to some gentler movements of a gall-stone. The great variety of pains attributed to the stomach, and the ditferent causes of those which truly belong to it, will account for the variety of their concomitant symptoms, and the different events of similar treatments. Bath, wine, hot medicines, a full stomach, a ve- getable diet, cathartics, emetics, the state of preg- nancy, a fit of the gout, acids, worm medicines, blisters to the region of the stomach ; all these have in many instances been found to do good, to 47 a70 Commentaries on the do harm, and to do nothing at all. After due at- tention has been used to discover the true nature of the pain, if there be reason to think that its ori- i^in is in the stomach, and that it does not proceed iVom any inflammatory or scirrhous affection, an emetic is generally useful at first, and afterwards the method of cure, which has often succeeded, is either the drinking of Bath water, or a daily use of some of the bitter and aromatic simples, joined with as much rhubarb, or aloes, as may be neces- sary to keep off all tendency to costiveness. A tea-spoonful of some aromatic tincture has like- wise been taken with great advantage in a little water*immediately after dinner. A great variety of such medicines is to beTound in all pharmacopoeias, out of which such may be chosen as will suit most stomachs, and hardly of- fend any palates. They are of frequent and very important use in the practice of physic, not only because the disorders of this part are far more common than those of any other, but because in unknown distempers, or in those where there is no good to be done by evacuations, and for which we have no specifics, we can only aim at putting the general health into the best state possible, the principal means of doing which will be to strengthen the stomach. § 3. Morbi Lienis, A man in his fiftieth year began to lose his flesh .and strength w^ith some degree of fever. He sometimes felt slight shiverings, and sometimes very strong ones, returning irregularly during the History (mil Cure of Diseases, 371 whole illness. His appetite was lost, but lie had no vomiting. The stools were regular till the two last months of his life. The urine was in a natural state. The pulse was very rarely too cjuick. There was no tension of the belly. In the second month of his illness he had an exces- sive pain in his stomach. Pains of the loins, hips, and back, would come on suddenly, without con- tinuing above half an hour. For a few days his right hand was swelled, and in pain ; and for two days the calf of the left leg was too painful to bear bemg touched, but without any heat, redness, or swelling. He complained chiefly of the right side of the belly. During the last two months of his life he was harassed with an unconquerable diarrhoea. This illness proved fatal about the sixth month. A large ulcer was found in one part of the spleen, and the rest of it seemed rotten. An ad- hesion had been formed between the spleen and peritonaeum. No other parts were distempered. A man forty-two years old had complained for several months of loss of appetite, flatulence, white stools, dark coloured urine, frequent bloody stools, tenesmus,, perpetual nausea and attempts to vomit, chiefly in an empty stomach, excessive restlessness, want of sleep, bleedings at the nose, thirst, and light-headedness, though the fever was moderate. At last a sudden vomiting of blood came on ; which returning in five hours, put an end to his life. The spleen was found of an un- common magnitude, but without hardness ; the in- side of it was all dissolved into a bloody sanies. ei7S CommeiUaries on the The glands of the mesentery were full of the same matter. The liver was sound. The por- tion of the stomach nearest to the spleen was in- flamed ; and there were signs of inflammation in many parts of the intestines. A woman was languishing for six months with a failure of appetite, and a swelling of the left side of the belly. There then came on sickness, and pain of the stomach, a total loss of appetite, a diarrhoea with great pain, which could not be stopped, and extreme restlessness, which lasted about six months longer. The spleen weighed fifty-two ounces, but was not ulcered, or scirrhous. The intestines were in a natural state, and there was no water in the abdomen. § 4. Morhi Pancreatis, A woman had long been afflicted with a pain, as she said, of her stomach; which was excessive for the last year of her life. She had no appetite, and what she did get down was vomited up. She could hardly procure any sleep. The pancreas was found scirrhous. Another woman, whose pancreas was scirrhous, had complained for seveh years of a pain in her stomach, and of pains in her bowels, and hips ; a numbness of her thigh and leg with a sense of cold ; loss of appetite, and frequent acid vomit- ings.* * A man, twenty-three years of age, had been afflicted for five months with pains in the bowels, upon the ceasing of which the stomach swelled, and there came on indigestion, a diminution of History and Cure of Diseases. 373 CHAPTER 98. Vertigo. "i?' A VERTIGO, giddiness, or swimming of the head, is a disorder incident to both sexes ; from which young persons, especially females, are not secure, though it be far more frequently found in the old and infirm. From a consideration of the cases, which I have had an opportunity of observing, it seems proba- ble, that many vertigos have arisen from disorders of the stomach, more still from those of the head, but most of all from general weakness. If I were to judge from the ages, the constitutions, the ju- vantia and laedentia, there is a very inconsiderable number of vertiginous complaints, which can be attributed to a fulness of blood, and too high health ; therefore in cases, in which there may be reason to suspect a plethora, we should proceed with caution, and feel out our way by observing how the first moderate evacuants were borne, and be guided accordingly in determining the de- gree of strength, and the number of repetitions, which we may afterwards venture to use. Want of appetite, indigestion, flatulence, pain and weight in the stomach, sickness, vomiting, costiveness, and worms, have been found either to the quantity of urine, and weakness, which gradually increased ; lastly a purging that could not be restrained. In the third month from the swelling of the stomach this man died. The pancreas Tvas found enlarged to an enormous size, ^nd ulcerated. E. 374* Commentaries on the precede, or to be joined with a swioiming of the head. Now, where some of these make either the only, or the principal complaints, next to the giddiness, we may reasonably conclude, that the head is affected only secondarily, and that the ori- ginal seat of the disorder is in the stomach. Tormenting head-achs, a lightness of the head, deafness, a singing in the ears, objects appearing^ double, temporary blindness, mists, black spots, or sparks and flashes of fire before the eyes, bleed- ings at the nose, hypochondriac' and hysteric ma- ladies, epileptic, paralytic, or apoplectic fits, le- thargy, spasms, and convulsions (many of which are often united with vertigos,) are all such mani- fest affections of the head, that where these pre- dominate, the giddiness probably has its origin in the brain. Lastly, a vertigo has been accompanied with languor, tremblings, faintings, and palpitations, and has supervened inveterate gouts, obstinate intermittents, asthmas, and other long disorders, profuse bleedings, and diarrhoeas, and has often made one of the train of evils belonging to a state of health much injured by the obstruction of some customary evacuation, as the menstrua, piles, sores, and cutaneous disorders, or utterly broken by intemperance, diseases, or old age. Nor is it unknown, that a vertigo should be the single com- plaint, the health bemg in all other respects un- impaired. Where there is satisfactory proof that the ver- tigo is dependent upon some other disorder, the Ilistovy and Cure of Diseases, 375 most reasonable manner of endeavouring to cure it will be bj removing the primary complaint. But it must be owned, that it is often difficult, from the strange complication of symptoms, to decide what is the precise nature of the giddiness, or to account for the different events of reme- dies in circumstances apparently the same. By the notes, which I have taken, it appears, that a spontaneous vomiting and diarrhosa have always been beneficial ; that snuff, too much busi- ness and fatigue, a crowd, the first waking in the morning, stooping, standing, walking, turning in bed, and any alteration of posture, not weather, a warm climate, fasting, and evacuations, have generally tended to bring on, or to aggravate a swimming of the head : that cupping, a discharge by the piles, bleeding by leeches, or by the lan- cet, blisters, cutaneous eruptions, emetics, issues, cold bathing, and the gout, have sometimes been judged to relieve a vertigo ; but that many of them have been far oftener useless, especially the gout, and blisters; but bleeding by the lancet, and strong cathartics have appeared to do harm much more frequently than good, and in most in- stances have at best been useless. If Bath wa- ters have been innocent in this malady, they have never given me reason to think them beneficial. Cupping has often failed in relieving a present fit, but it has in several instances been singularly useful in preventing the returns, or in greatly mitigating their violence, by being used every two months, about six ounces of blood being tak- en away each time. 376 Commentaries on the The danger attending a vertigo, and the diffi- culty of relieving it, are to be estimated from its havmg no concomitant ails, or from their kind and number. Where it is accompanied with such as arise from the stomach, and especially if there be but a few of them, it is then more easily remedied, than when it, is joined with affections of the head, the cure of which is tedious and uncertain. How- ever, in hypochondriac and hysteric cases, the dan- fer of a vertigo is not much though, it may not e easily removed. But if the giddiness be only one of the many evils, of which an irreparably broken state of health consists, what hope can there be of a cure ? A vertigo unconnected with any symptoms of other diseases may probably be brought on by causes of too little importance to create any dan- ger, or much disturbance to the general health; for such a vertigo, thoush considerable enoujjh in some young men to endanger their falling, has not hindered their outliving it, and arriving at a healthy old age ; and several have been frequent- ly troubled with it for twenty, or even thirty years, with good health in all other respects. CHAPTER 99. Vomitus,'*' A DISPOSITION to vomiting is very various in different constitutions : some cannot be made to * See cbap. 65, coDcemiDg nauseOt or sUkne&s of the stomach. History and Cure of Diseases. 377 vomit by any means ; others not without extreme difficulty, and. great pain ; while seve^ral are prompted to it upon the shghtest occasions, and it costs them not the least trouble. I have seen one, who performed a sort of rumination : and if the food staid too long in his stomach, before it was returned back for this purpose, it became sour, and made him sick, and was vomited up. Vomiting seems so contrary to nature, that ex- perience alone could satisfy us of the possibility of its being continued, as I have known it two or three times a day ' for many months, or many years, with little or no ill consequences to the health. One woman told me she had for thirty years vomited up all she had taken. In some cases, though all the food seemed to be vomited up, yet the patients have thriven, and grown fat. In pregnancy many women have judged that they brought up more than the whole of what had b^en swallowed, and that for a considerable time, without endangering the life either of the mother, or the child. In hard drinkers, and breeding women, the morning is the most usual time of vomiting; this has likewise happened, though rarely, in some so- ber men ; but in general it is either soon, or a a few hours after eating, that the sickness comcfs on, which ends in throwing up the contents of the stomach. The stomach is secondarily affected by sym- pathizing, in a great many disorders, with other parts of the body : and it has many ails peculiar 4« 378 Commentaries on the to itself, which hinder it from receiving, or re- taining.what has been swallowed : some of these are manifest after death, as scirrhous obstruc- tions of the cardia, or pylorus : there are many others connected with the unknown powers of the stomach, which occasion no alteration of its appearance after death, as far as our senses are able to judge ; there being no more traces of them left, than of a nausea or vomiting excited by sud- den ill news, or the sight or remembrance of dis- gustful objects. I remember one, who for many years had been subject to a vomiting of almost all his food, and often of great quantities of blood, whose stomach after death shewed no signs of any disorder, though it was examined by some very experienced and skilful anatomists. The matter thrown up by vomiting has been sometimes the food unchanged, sometimes a salt or acid liquor, or phlegm, and by great straining a little bile will be pumped into the stomacfi, and thence brought up. A fat, inflammable matter, has often been forced up by mouthfuls not long after eating; and lastly blood, or a liquor deeply tinged with blood, has been vomited frequently, and in great abundance, for several days together, with extreme loss of strength ; or else has re- turned, more like a chronical affection, in a slighter degree, two or three times a year for se- veral years ; and though it have relieved a pain of the stomach, yet even this chronical sort must always be considered as the symptom of a dan- gerous disorder of this part. The apparent quan- tity of blood voided from the stomach upon these occasions is very alarming, and would be much History and Cure of Diseases. 379 more so, if it were not probable that blood itself makes often the least part of the bloody liquor which has been thrown up. Bloody, or black stools, have always accompanied a vomiting of blood. Some have had several returns of vomit- ing blood, and apparently in large quantities, for several years : and in others their first vomit- ing of blood has in two or three days ended in death. I know of no treatment required for this sort of haemorrhage different from what is men- tioned in the Medical Transactions, vol. ii. Query 4. The necessity of keeping the patient quiet, and calm, and cool, appeared very strongly in one case, where the least drop of wine, warming the hands at the fire, putting them into warm water, a warm- ed bed, a blister, a purge, and any ruffle or dis- turbance of mind, were often experienced to re- new the bleeding. For other vomitings I have taken notice that purging, riding, and fat of every kind, have been pre- judicial ; that the spontaneous clearing of the stom- ach has given no relief; that an emetic has some- times failed, or even aggravated the complaint. I was told by one person, that he had the pa- tience to persevere in the use of emetics, till he had taken near forty, without any success. How- ever, an emetic has very generally proved ser- viceable : it seems better calculated to relieve ^ sudden sickness, than to cure an old habitual vo- miting. Bath waters have been remarkably effi- cacious in curing the morning sickness of hard drinkers ; but has failed in many otlier cases of sickness. The anodyne balsam rubbed in upon the stomach, has been very successful ; and so 380 Commentaries on the • likewise has a blister applied to the region of the stomach. Acids have been useful to some of these patients, and Ihe alkaline salts and testa- ceous powders to others. One person was cured by leaving off the use of bread ; and another by drinking water cooled by ice. But it must hap- pen that these and all other means will fail in stop- ping a sickness and vomiting, which arises, as it has often done, from incurable disorders of the sto- mach or neighbouring bowels. CHAPTER 100. Vox. The voice without any pain, or other disorder of the health, has been weakened so as never to rise above a whisper. In a slight degree of this complaint the persons are able to laugh in the usual manner ; but they are sometimes as incapa- ble of laughing, as of speaking, loud. Those, who have once experienced such a failure of voice, have been very subject to relapses. They have lost their voices suddenly without any pre- vious notice, and recovered them as quickly with- out any apparent cause. Nine out of ten of those, whom I have seen in this complaint, have been women, and most of them, but not all, have been young and puny, or hysteric, or old and infirm. An inability to speak beyond a weak whis- per has frequently lasted for many months, History and Cure of Diseases. 381 and in some for several years in the same uniform manner. Others have lost their voices only for the morning, or afternoon, of every day ; or for a certain number of months in every year. Sea bathing, and blisters, have been sup- posed to do some little service. Internal stimu- lants, and evacuants, have hardly been innocent; they have certainly been useless, and so have all other means which I have tried. The sudden weakness of voice, of which I have been speaking, is very different from that hoarse- ness, which belongs to bad cough, asthmas, and catarrhs. CHAPTER 101. Urina,^ An eager desire of making water has been considered under the article of Stranguria, and Prostatas Scirrhus, and Calculus. Beside the causes there mentioned, it has been an attendant upon a scirrhous spleen, and upon hysteric and paralytic maladies, and has been one of the infir- mities of old age, where there has been no other distemper. It has been very troublesome to se- veral in the night, so as greatly to interrupt their rest ; and it has teased others only in the day- time, suffering them to rest quietly in the night. A difficulty of expelling the urine has not only arisen from the causes mentioned under Stran- * See Cakulusy Graviditas, Ischuria^ and Stranguria. ass Commentaries on the guria, and Ischuria, but also from a paralytic ina- bility of the muscles which should expel it. In one man the catheter was necessary for this pur- pose during the space of two years, after which the parts recovered their use, and the inconve- nience ceased. The colour of the urine has been milky in a diseased prostate gland, and in other cases, where it might be owing to some purulent liquor with which it was mixed. A large suppuration of an inflamed. sore throat has been attended with^ a considerable quantity of pus at the bottom of the vessel which held the urine, for three or four days. As soon as the ab- scess broke and discharged itself, this purulent appearance in the urine ceased. This is the only instance that has occurred to me of any thing like a translation of matter from other parts to the kidneys, In some broken constitutions, whenever water was made, there has followed a great languor, or sickness of the stomach. An ulcer of the womb has in several women pierced the rectum and the bladder, so that wind and fseces would come away with their urine. An ulcer, probably of the prostate gland, has had the same effect in men : and one person believed that the breach between the bladder and rectum had been the consequence of efforts occasioned by ex- cessive costiveness. History and Cure of Diseases. 383 A stone in (he bladder, a diseased prostate, the fluor albus, frequent miscarriages, and some rough or pungent h'quors, have occasioned a heat of urine, where there was no reason to suspect a venereal cause. The bladder is naturally defended from the sharpness of the urine by a mucous substance with which it is lined. All irritation, from what- ever cause it may arise, increases this glairy mat- ter, which will adhere to the vessel into which it is made, like starch. It is very different from true pus, which settles at the bottom of the urine like cream ; both these appearances have been found to arise from irritation joined with some inflammation, without any ulcer : there will at the same time be more or less eagerness to make water, and pain in making it, according to the degree and cause of the irritation. A diseased prostate gland, inflammations or ulcers of any of the urinary passages, strictures of the urethra, frequent venereal injuries, and the stone, or gra- vely have been the common sources of these ap- pearances in the urine. If the purulent liquor be considerable in quantity, mixed with streaks of blood, and fetid, while the neck of the blad- der is in a natural state, it may probably be con- jectured that there is an ulcer of the kidney, but of this it is hard to form a certain judg- ment. An incontinence of urine, though void of dan- ger, is yet an extremely inconvenient and distress- ing infirmity. Youth and old age are peculiarly lia- ble to it. In some weakly boys it has continued 384 Commentaines on the from their infancy almost to the age of puberty ; but much longer in girls, and in many more of them, and such who seemed in all other respects healthy. Females in general* are more apt to have their urine pass away ; so that laughing, or coughing, will more frequently force some of it from them, than from men ; and some women, without any ill health, have ali their lives had no power to retain their water. It is therefore a less alarming symptom in dangerous illnesses of wo- men, than of men. Among the morbid causes of incontinence of urine may be reckoned all disor- ders of the urinary passages, the cutting for the stone, or the extraction of it by dilating the ure- thra, difficult labours, a prolapsus vaginae, vene- real injuries, epileptic and paralytic affections, and whatever else can bring on extreme weakness in general, or of the urinary parts in particular. A decoction of the Peruvian bark, and cold bathing, may be of some use in restoring more expeditiously the general strength after any ill- ness, and so far contribute to remedy this infirmi- ty ; a blister may also be applied just above the OS sacrum, in order to stimulate more particularly the parts concerned in retaining the urine. Where these have no effect, either time alone must cure the complaint, or it must be considered as incura- ble ; in which case, for the use of males, a yoke has been contrived, which by means of a screw, compresses the urethra, and hinders the dripping of the water. I have known several try this con- trivance, but they found it so inconvenient, that they soon laid it aside. Some in its room have substituted a bladder, in which the penis was con- History and Cure of Diseases, 385 stantly kept in the day-time : this may be less cuQibersome, but is not so neat as ^a tin vessel^ which others have used for the same purpose. The most effectual way of keeping the bed dry, is to put the' penis and scrotum into a small cham- ber-pot, and to keep them in this situation all night. A little practice has made this method easy to several persons, who have preferred it to all others. Urine made of a deep coffee colour, or mani- festly mixed with a large quantity of blood, has within my experience very rarely been the effect of any thing but a stone in the urinary passages. I therefore suppose a strong probability of this cause, wherever I see this appearance ; and if there be joined with it any of the usual symptoms of the stone, I have no further doubts. A very painful strangury from the internal or external use of can- tharides, has seldom, if ever, gone beyond making a slight redness of the water, with some few streaks of blood in the mucus. A scirrhous prostate gland, when it becomes ulcerated, has occasioned some blood in the urine; but the quantity is very small, and is not increas- ed by riding or walking ; and whenever this is the cause, a surgeon by examining can hardly fail to discover it by the swelling and hardness. Can- cerous sores communicating with any part of the urinary passages, may tinge the urine with blood; but these too may be conjectured from the con- stancy of the pains, from the small quantity of blood, from its not being remarkably increased upon motion, from the fetid mucus, or sanies, which 49 886 Commentaries on the issues from them, as well as from their wanting several peculiar signs of the presence of a stone. A blow upon the loins has appeared to occa- sion bloody urine; and I suppose a blood-vessel maj happen to burst in the kidneys^ or bladder, k , not only from such a violent cause, but from as slight an one as it often does in the nose ; though I do not remember such an instance. But 1 have once or twice known a very profuse bleeding into the urethra from some of the neighbouring ves- sels, without any previous distemper, or extraor- dinary injury of the part : the blood kept constant- ly running out without any elTort to make water, and without its being in the person's power to check it. In one of these cases the bleeding re- turned frequently for two years, during which time the health was gradually impaired, and at the end of the second year the patient died ; the grumes of blood were often voided with difficulty, and occasioned great distress. In the worst kinds of small pox the blood is well known to pour out from the urinary passages, as well as from other parts, in great abundance. Many other causes of bloody urine are to be found in medical writers, which, if they exist, have never occurred in my practice. Quiet, and keep- ing the body cool, and open, are all the means of relief, with which 1 am acquainted. History and Cure of Diseases. 387 CHAPTER 102. ♦ Uterus. A PROLAPSUS of the vagina or womb Is only to be relieved by a pessary : it is apt to be attended with an incontinence of urine. Several women have experienced a sudden and great discharge of water from their wombs ; this has happened to the same woman more than once, and about the time of the menstrua taking their final leave. No ill consequences have followed this appearance, besides weakness. / There has grown out from the womb a fleshy substance like a pear, the body of it being much larger than the stalk. This has extended itself so as to be perceivable in the vagina in straining upon going to stool. The great evil arising irom this, is a constant discharge of blood irom the di- lated parts, which discharge will necessarily con- tinue till the excrescence be removed. An expe- rienced accoucheur assured me that he had taken away near twenty of these by passing a ligature as near as possible to the part adhering to the womb : in a few days after this has been done, the mass falls off, and the remaining stalk putrefies away, requiring nothing but frequent injections of an infusion of camomile flowers. He told nie this operation had been generally successiul, and it has proved so, where i liave known it performed. The furor uterinus docs not always arise fron^ a preternatural state of the womb, but, sometimes^ 388 Commeniaries on the at least, differs not from common madness; the mind no longer under the guidance of reason, is made a prey to such thoughts as work it up to the oestrum venereum, instead of those \V1iich might inflame it with religious zeal, ambition, or a desire of revenge. I have seen it not only in the young and middle-aged, but in a dying old wo- man, who had long been in a broken state of health, from which circumstances, as well as from the decency of her character, it may be judged that all delight in the objects upon w^hich she rav- ed, had been long passed and forgotten. Besides, it happens sometimes to the other sex, that mad- ness lets loose the passion of lust, as well as those of fear, or anger. The womb, as well as the breasts of women, is subject to scirrhous tumours, which slowly turn to incurable ulcers. This happens at the same time of life, with similar disorders of the breasts, that is, generally after the age of forty. The first symptom is often a return of the menstrual discharge after it had long ceased : but this is no certain sign ; for its re-appearance has sometimes proceeded from other causes,* as well as from a scirrhous state of the womb. In some women the first alarm is given by a copious discharge of a te- nacious mucus like jelly, or of a thinner fluid, like the fluor albus : this has continued for one or two years, intermixed now and then with a discharge of blood, before any of the more violent symptoms have come on. These are, pains of the womb, in the groin, in the loins, in one or both of the hips, * See chapter G2. History and Cure of Diseases, 389 and in the thighs ; pains in going to stool, and in making water, with a tenesmus, and a frequent call to make water, a manifest fulness of the ab- domen, and at the same time, a sense of empti- ness, and a hectic fever. The discharge after- wards becomes jellow, green, or black, and fetid; and the pains are so excessive, as hardly to be en- dured without benumbing the sense of them in some degree by large quantities of opium. They are scarcely increased by the motion of a carriage. In a few cases the ulcer of the womb has eaten a passage to the bladder, and to the rectum. All these symptoms do not happen in every case ; but a very few of them are sufficient to shew the na- ture of the disease, even before it has been ascer- tained by a naidwife's examination of the womb. The extract of hemlock washed down with a decoction of the Peruvian bark is at least inno- cent in this disorder; but I have had very little reason to judge this, or any other medicine, to be of much avail in curing, or checking the progress of the cancer. One woman was very remarkably relieved, while she was taking the extract, and at the same time using an injection of the decoction of hemlock ; the pains almost vanished, and the womb remained in such a quiet state for some years, as to give very little interruption to her usual amusements, or manner of living. But in most other cases no good could be done, but by administering in a proper manner some prepara- tion of opium. THE CONCLUSION. It might be expected, that the experience of fifty years spent in the practice of Physic, would have taught me more, than I here appear to have learned, of distempers, and their remedies. I rea- dily confess my knowledge of them to be slight, and imperfect; and that a considerable share of this imperfection is chargeable upon my want of ability to make a better use of the opportunities I have had : but at the same time it must be allow- ed, that some part must be put dov^Tn to the very great difficulty of making improvements in the me- dical art. This is too evident from the slow pro- gress which has been made, though men well qua- lified by their learning, experience, and abilities, have for above two thousand years been commu- nicating to the world all they could add by just reasoning to the facts collected by attentive ob- servation. Whoever applies himself lo the study of nature, must own we are yet greally in the dark in regard even to brute matter, and that we know but little of the properties and powers of the inanimate creation : but we have all this dark- ness to perplex us in studying animated nature, and a great deal more arising from the unknown peculiarities of life ; for to living bodies belong many additional powers, the operations of which can never be accounted for by the laws of lifeless matter. The art of healing therefore has scarce- ly hitherto had any guide but the slow one of ex- THE CONCLUSION. 391 perience,* and has yet made no illustrious advan- ces by the help of reason ; nor will it probably make any, till Providence think fit to bless man- kind by sending into the world some superiour genius capable of contemplating the animated world with the sagacity shewn by Newton in the inanimate, and of discovering that great principle of life, upon which its existence depends, and by which all its functions are governed and directed, ;^§ova, «««, Stobcei Eclog. Phys. lib. i. page 19. CONTAINING 1. A Sketch of a Preface designed for the Medical Transactions, 1767. 2. Observations on the Chronical Rheumatism. 3. On the Pulse. 4. On opening a Vein in Haemorrhages. 1 . A Sketch of a Preface designed for the Me- diced Transactions, 1767. The world has had more than sufficient expe- rience how far either building upon the ancients, or upon reasonings a priori, is likely to improve us in natural knowledge. By laying aside both these methods, and by attentively observing na- ture itself, a greater progress has been made dur- ing the last century, than had been till that time from the days of Aristotle. The manner in which these observations have been communicated to the world, appears to have had no small share in the advantages which have been gained. The several learned societies in Europe, which have joined in forming one com- mon stock of knowledge, have received contribu- tions from many, who would otherwise never have published the remarkable phaenomena which 50 391 APPENDIX. chance had thrown in their way. They have likewise hindered many from overlaying their Ht- tle original knowledge, by compilations from oth- ers, or by crude reasonings of their own, which they might think necessary to furnish out a just volume. Thus they have had the good effects of inviting some to tell all that they knew, and have lessened the temptation which others might have, to say more than they knew. It' is a misfortune to the world, that the several societies of physicians in Europe have not more generally adopted the same plan ; as there can be no question made of its being attended with as much success in their particular study, as it has been in that of every other part of nature. It is high time that this should be done, as physicians have, like other natural philosophers, (uUj run the round of commenting the ancients, and con- triving theories, and teaching systeniatical doc- trines in many a celebrated school ; and just with the same success. The deference, which is sometimes required in physic to the authority of the ancients, would in- cline any one to suspect, that the improvements in the art of healing had not kept pace with those, which have been made in other branches of natu- ral knowledge. Philosophers have long ago thrown off Aristotle's tyranny ; yet some physi- cians still choose to wrangle about the meaning of the ancients, rather than to consult nature her- self. Are they afraid of approaching her imme- diate presence, without making use of the inter- cession of Hippocrates and Galen ? and is that re- APPENDIX. 395 verence to be still paid to her once faithful minis- ters, which is properly due to nature alone ; not- withstanding all that Bacon, and Harvey, and Newton, and our other great reformers, have wit- nessed against this mistaken veneration ? In works of genius the ancients are unquestionably our su- periours, and best patterns; but in that sort of knowledge which depends wholly upon experience, the latest writers must in general be the best. But this disagreeable. and unpopular topic needs be pursued no further; not only because every scholar must be loth to say, or hear, any thing against the ancients ; but because they are in rea- lity very little read and attended to by practition- ers, though the fashion of quoting and recommend- ing them be still prevalent in some modern wri- ters. It has been an old dispute among physicians, whether the empirical, or rational method of cur- ing diseases was to be preferred. If by the em- pirical method be meant that which is founded on facts recorded by others, or observed by ourselves, it must be allowed, that by this means only has the practice of physic been established. Fact, and repeated experiments, have alone informed us that jalap will purge, andipecacuanha vomit, that the poppy occasions sleep, that the bark will cure an ague, and that quicksilver will salivate. If we examine the whole materia medica, and the whole practice of physic, we shall not find one efficacious simple, nor one established method of cure, which were discovered, or ascertained, by any other means. h 396 APPENDIX. Experience may, in politics and morality, be called the teacher of fools ; but in the study of nature, there is no other guide to true knowledge : accordingly the practice of physic has been more improved by the casual experiments of illiterate nations, and the rash ones of vagabond quacks, than by the reasonings of all the once celebrated professors of it, and theoretic teachers in the seve- ral schools of Europe ; very few of whom have furnished us with one new medicine, or have taught us better to use our old ones, or have in any one instance at all improved the art of curing diseases. Hence, though they have been applaud- ed during the lives of their disciples, yet disinte- rested and impartial posterity has suffered each succeeding master of this sort to be gathered to his once equally famous predecessors, and to be, like them, in his turn utterly unread and forgot- ten. It is necessary to be upon our guard even against experience itself, when delivered in a sys- tem ; the very notion of which seems to imply, that the facts and observations are not barel)' re- lated, but are ranged into some method, and form- ed into one body dependent upon what the com- piler takes to be their general cause or nature ; and hence arises the great danger of their being misrepresented, in order to make them fit more exactly the several places which are assigned them. The Jews were commanded to build their altar with stones unhewn and untouched by any tool ; and, in like manner, the best materials of natural knowledge are the plain facts themselves, just as they come from nature ; he who pretends m APPENDIX. 397 to new model and polish them, in order to their being adapted more perfectly to his system, has utterly polluted them, and made them unfit for the altar of truth. Nor let any one apprehend, that physic will be- come too easy a study, by making it thus wholly depend upon experience ; and that, hy losing the fence of learned theories, it will be an easy prey, open to the invasions of every ignorant pretender. For, whatever weight there may be in this objec- tion, it will be found to be greatest against the way of theory and hypothesis ; this being much the cheapest, and most expeditious method of making a physician. A heated imagination will always supply us with knowledge, such as it is, much faster than the ordinary course of nature. The road of experience is tedious, and requires great judgment, as well as patience. The con- trary to this seems, indeed, to be the general per- suasion ; for every one is apt to fancy himself a competent judge of medical experience, and is ready to trust any one else who pretends to it. But, to form a right judgment, a man must be trained to a habit of thinking attentively by a learned education, and should not only be ac- quainted with the nature of the materia medica, but also with the several hypotheses, with the false philosophy, the mistakes in language, and other sources of errour, upon which the supposed virtues of remedies have been, and are still often founded. And after all, it will be found extreme- ly difficult, to determine rightly upon the intricate and contradictory evidence which is frequently brought for the effects of medicines. 398 APPENDIX. The Peruvian bark was known and tried in Eu- rope, at least forty years before its virtues and dose could be properly ascertained. The solvent power of medicines for the stone of the bladder, is what lies much more obvious to the' senses, than the efficacy of most other medicines ; and yet, in the late instance of Mrs. Stephens's remedy, how difficult a thing was it found to determine this, though tried in a variety of cases, which were di- ligently attended by the ablest judges ? No won- der, therefore, that out of the innumerable catho- licons, or universal medicines, with which every nation and age has swarmed for these last thou- sand years, not one has survived ; and out of as great an inundation of speci6cs, or remedies for particular diseases, which have readily found, pa- trons* sufficient to give them a fair trial, the bark and quicksilver are almost the only two, which have stood the test of time and general experi- ence. As therefore the art of healing owes so little to any other teachers, and so much to experience, the College of Physicians in London is desirous of collecting the experience of its members, and their correspondents, in the manner which has answered so well in the Royal Society here, and m many other literary associations abroad, and is therefore ready to receive medical papers in order to communicate such as are approved to the pub- lic. * Coramuni enim fit vitio naturae, ut invisis, latitantibus, (al. in- tentatis) atque incognitis rebus magis confidamus. Caesar de Bell. Civ. lib. ii. c. iv. APPENDIX. 399 For want of such an opportunity of communi- cating their knowledge, it has often happened, that many judicious practitioners have carried the whole experience of forty years, spent in an exten- sive practice, with them to the grave, much of which would, probably, by the means now pro- posed, have been preserved, and might have been as useful to posterity, as it had been to their con- temporaries. Medical papers are, indeed, received into our own Philosophical Transactions, as well as into the journals and memoirs of many other learned societies; but it is apprehended, that if a society of physicians professed to receive such papers, and communicate them to the public, there would be many more communicated, and perhaps, with better choice, and they would more certainly come into the hands of physicians, without being lost in the crowd of other papers. If the present intentions of the College are se- conded, as there is reason to hope they will be, they may excite in every practitioner belonging to it, a more constant attention to all the circum- stances of remarkable and instructive occurren- ces ,- they may strengthen the habit of noting, and of recollecting, and of forming conclusions from what passes before him, and prove the means of preserving some observations, which would otherwise be lost, not only to the public, but to the observer himself. Though the principal view of the College be to perfect the history of diseases, and to ascertain 400 APPENDIX. the effects of medicines, yet any other papers will be received, which in any manner relate to medi- cal subjects. Many, who have communicated their observa- tions to the world, have purposely picked out such as were rare and extraordinary, such as have seldom happened before, and may never happen again. Now, though these may be worth pre- serving, for almost all facts teach something, yet surely the preference ought not to be given to such as these, unless the chief end of our writing be to amuse the reader by gratifying his curiosity. If a man have only leisure to give either his un- usual cases and cures, or such as may frequently occur in every day's practice, it would be more for the reader's use, if not for the writer's credit, to draw up only the latter, and leave, according to the proverb, ®ctv^otT» fAu^oi?, It were also to be wished, that writers would not confine themselves to relate only their suc- cessful practice, but that they would have the cou- rage to tell us the ineffectual and hurtful. It is sometimes almost as useful to know the laedentia (especially if they are likely to throw themselves in our way, if not carefully avoided) as the juvan- tia ; and any physician of great experience might make a very useful paper, by giving an account only of such medicines and methods of cure, which he had found to be useless and inconve- nient. Single cases of the catalepsy, hydrophobia, and other rare distempers, may be worth the relating: APPENDIX. 401 but histories of particular cases, where the distem- per is a common one, and of such effects of medi- cines as occur every day, must be endless, and would rather tire and oppress, than instruct the reader. Whatever important additions, or excep- tions to the common practice, are contained in such cases, would much better be drawn out by the author, who can best do it, and presented by themselves, without giving along with them a tire- some hihtory of common appearances, which e\e- ry one had often seen, and was well acquainted with Ions: before. There may be some, but it is hoped there will not be much occasion for bespeaking the reader's candour, if some papers thus published by the College should appear less deserving of his no- tice. In so small a society, where the members are all personally known to one another, some- thing must be expected to be given to civility ; as an author, who is usually not the best judge of his own works, may now and then have a fond- ness for some paper beyond its merit ; and the College may determine more out of regard to the writer, than to the piece. But this, we trust, will not often happen, nor in any flagrant instan- ces ; and little matters, which may be imputed to this cause, the considerate reader will easily over- look, as without some indulgence of this kind, the design could hardly be carried on, and consequent- ly, the papers of more importance would be lost. 51 102 APPENDIX. 2. Of the Chronical Rheumatism. The disease called the chronical rheumatism, which often passes under the general name of rheumatism, and is sometimes supposed to be the gout, is in reality a very different distemper from the genuine gout, and from the acute rheumatism, and ought to be carefully distinguished from theiil both. It is attended with little or no fever, and most commonly with no very great pain ; and in both these respects it differs from the acute rheuma- tism. The swellings are in most instances, though not in all, very great, but have hardly any red- ness ; they are not particularly apt to begin in the foot, or if they do, they soon leave it, and pass on to other parts of the limbs, several of which, one after another, become the seat of the distemper in the very first fit. The true arthri- tic- pains are different in all these circumstances, if we except the swelling, as well as in their in- tensity. An attention to these particulars will enable us in the very first week of the fit to form a judgment of its nature, and will shew us to which of these three it belongs. Afterwards this will be further evinced by the extreme weakness it occasions in the limbs, and the severe shock which it gives to the constitution and general health, patients being often more disabled by a single attack of the chronical rheumatism, than they are by annual returns of the true gout for many years. APPENDIX. - 403 Arthritic patients seem peculiarly liable to the palsy, and apoplexy, beside having the use of their limbs destroyed in consequence of frequent inflam- mations of the joints, or contractions of the mus- cles : but all this mischief is in these patients the work of a long time, and to many of them it hap- pens either not at all, or but in a slight degree ; while the first fit of the chronical rheumatism, if it be continued, as it often has been, for several months, will do irreparable injury to the limbs, bringing on a state of almost paralytic weakness, and greatly impairing their use during the whole life. A frequent repetition of the disease has in six years totally taken away the use of all the limbs ; and in some very bad cases this has hap- pened even in the first year. Nor is this rheumatism less strongly marked by the continuance of the first fit, from which few are so fortunate as to be released under three or four months ; while the first fit of the true gout, sel- dom lasts twenty days. It is much more apt to return, than the acute species, under which many have laboured once, without ever experiencing it a second time. But though the chronical rheu- matism most usually repeats its visits, yet their intervals are far more unequal, than those of the gout. It may in some cases come on regularly once a year, for a (ew years; but others suffer two or three returns within the same year ; and some patients have been hardly ever free for se- veral years ; while others again have had inter- missions for five, or six, or even for near twenty years. 404 APPENDIX. Cramps are very common in this disorder, as well as in the gout. The swellings, which it occasions, are often re- markably great, and some degree of them will continue for many years, or for the patient's life, particularly in the wrists, and sometimes in the fingers, and ankles. The pains are not subject, like those of the acute sort, to be increased, but are rather relieved by the warmth of a bed. I have observed very few instances where the con- trary to this has happened. The stomach and bowels are much oftener, and more readily affected in this rheumatism, than in the true gout. Pain, nausea, and universal lan- guor, are its ordinary effects in these parts. Up- on the application of a vt^arm plaster, or liniment, to the affected limb, the distemper has presently been thrown upon the bowels ; and in some in- stances, pains have seized the limbs and stomach alternately. Sometimes the anguish of the abdo- minal viscera, and the weakness of the extren)i- ties, make tliis disease bear no little resemblance to the colic of Poitou ; and they both bring on a rapid decline of the general health. The distemper of which I am speaking, seems confined to no sex, and hardly to any age. The rich and the poor are equally liable to it. It has happened to me to see rather more women than men afflicted with it. In some it has begun at the age of twelve years; in others not till they were past sixty. Is it not in some degree hereditary ? APPENDIX. 405 The chronical rheumatism for a- few days ap- pears to be a milder distemper than either the acute sort, or the goqt : but in its consequences, that is, in the great weakness, or total loss of power it produces in the limbs, and in the mis- chief done to the general state of the body, it is much more formidable than either of them ; and being so very different in its symptoms, as well as in the event, it would be useful if it were distin- guished by a peculiar name, which might prevent its being confounded with other disorders, by be- ing called a spurious and wandering gout, or a chronical rheumatism. The waters of Bath and Buxton, preparations of antimony and of quicksilver, seabathmg, cold and warm bathing, blisters, and warm liniments, have in some of these patients been thought ser- viceable; but all these, together with bleeding, purging, sweating, and electrification, have been of no use to others ; some have even thought them hurtful. A course of mercurial medicines has with great reason been suspected of bringing on something like this distemper in many persons ; and it has appeared to do so in the same person five or six times, that is, as often as the mercury was repeated. It is not surprising, if against a disease which has been so imperfectly discriminated, as the chronical rheumatism, no certain method of cure should have been discovered. Wherever that is the case, the physician will fully discharge his duty by attending to the troublesome syi^iptoms, which it is often in his power to relieve, to the 406 APPENDIX. great ease and comfort of the sick, and by assist- ing nature in bringing all the functions of life as near as raay be to their natural state in health. A prudent use of ^pium will be one of the means of obtaining these very desirable ends ; and much good may also be done by supporting the appe- tite and digestion with Peruvian bark, and bitters, and other stomachic medicines ; the class of which appears to have some specific power not only in this distemper, but likewise in the gout. 3. Remarks on the Pulse. Read at the College of Physicians, July 7th, 1768. All, who begin the study of physic, must find in the doctrine of the pulse, as collected from me- dical writers by Bellini and others, a great deal which they do not understand ; and all, 1 imagine, who have advanced a little in the practice of phy- sic, can have very little doubt of its not being un- derstood by the authors themselves. Such mi- nute distinctions of the several pulses, if they do not exist chiefly in the imagination, at least have little place in the knowledge and cure of diseases. Time indeed has so fully set them aside, that most of these names of pulses are now as unheard of in practice, as if they had never been given : and it may be doubted, whether some of those, which are retained, are perfectly understood, or applied by all to the same sensations, and have in every one's mind the same meaning. I have more than once observed old and eminent practi- c APPENDIX. 407 doners make such different judgments of hard, and full, and weak, and small pulses, that I was sure they did not call the same sensations by the same names. It is to be wished, therefore, that physicians in their doctrine of pulses, and descriptions of cases, had attended more to such circumstances of thti ulse, in which they could neither mistake, nor e misunderstood. Fortunately there is one of this sort, which not only on this account, but like- wise for its importance, deserves all our attention. What 1 mean is, the frequency or quickness of the pulse, which, though distinguished by some wri- ters, I shall use as synonymous terms. This is generally the same in all parts of the body, and cannot be affected by the constitutional firmness or flaccidity, smallness or largeness of the artery, or by its lying deeper or more superficially ; and is capable of being numbered, and consequently of being most perfectly described and communi- cated to others. " The degrees of quickness of the pulse belong- ing to the several ages, and distempers, have been taken notice of by few physicians in their writ- ings ; and as many observations are necessary to settle this doctrine, what I have made and am go- ing to relate, may be of use towards confirming, correcting, or enlarging those, which have been made by others. When the number of pulsations is mentioned without any time being specified, a minute is to be understood. The pulse of children under two years old should be felt when they are asleep; for their 408 APPENDIX. pulses are greatly quickened by every new sensa- tion, and the occasions of these are perpetually happening to them while they are awake. The pulse then of a healthy infant asleep on the day of its birth, is between 130 and 140 in one mi- nute ; and the mean rate for the first month is J 20; for during this time, the artery often beats as frequently as it does the first day, and I have never found it beat slower than 108. During the first year the limits may be fixed at 108 and 120. For the second year at 90 and 108. For the third year at 80 and 100. The same will very nearly serve for the fourth, fifth, and sixth years. In the seventh year the pulsations will be some- times so few as 72, though generally more : and, in the twelfth year in healthy children they will often be not more than 70 ; and therefore, except only that they are much more easily quickened by illness, or any other cause, they will differ but little from the healthy pulse of an adult, the range of which is from a little below 60 to a little above 80. It must be remembered, that the pulse be- comes more frequent, by ten or twelve in a mi- nute, after a full meal. If the pulse either of a child, or an adult, be quickened so as to exceed the utmost healthy li- mit by ten in a minute, it is an indication of some little disorder. But a child is so irritable, that during the first year, a very slight fever will make the artery beat 140 times, and it njay beat even 160 without danger; and as there begins to be some difficulty in counting the pulse when the motion is so rapid, the thirst, quickness of breath- ing, averseness from food, and above all, the want APPENDIX. 409 of sleep, enable us, better than the pulse, to judge of the degree of fever in infants. A child of two years may die of an inflammato- ry (ever, though the artery beat only 144 times in a minute ; and I have seen a child of four years recover from a fever, in which it beat 1-^)6 times ; and one of nine, where it beat 152. If the pulse of a child be 15 or 20 below the lovTest limit of the natural standard, and there be at tlie same time, signs of considerable illness, it is a certain indication, that the brain is affected, and conseqjiently such a quiet pulse, instead of giving us hope, should alarm us with the proba- bility of imminent danger. In adults ill of an inflammatory {ever., the dan- ger is generally not very great, where the beats are fewer than 100; 120 shew the beginning of danger ; and they seldom exceed this number un- attended with deliriousness, and where the pa- tient does not die. There are two exceptions to this observation : the first is^ that before some cri- tical swelling or deposit of matter begins to shew itself in fevers, the pulse will be so rapid and in- distinct, as hardly to admit of being counted ; but I have known it certainly not less than 150, and yet the patient has recovered. Acute rheuma- tisms afford a second exception ; in which the ar- tery will often beat above 120 times without any sort of danger; and in both these cases we may remark, that the appetite and senses, and sleep, and strength are put less out of their natural 52 410 APPENDIX. state, than where the hTe of the patient is in immi- nent danger. Though it be difficult to count above 140 strokes in a minute, if they be unequal in time or in strength, jet where they have been very dis- tinct, I have been able to count 180. Asthmatic persons are often seized with an un- commonly bad fit, arising probably from some great inflammation of the lungs; and here, if the pulse exceed 120, they very rarely recover. In an illness where the pulse all at once be- comes quiet from being feverishly quick, while all the other bad signs are aggravated, it is a proof, not of the decrease of the disorder, but of the les- sened ' irritableness of the patient, the disease being translated to the brain ; and a palsy, apo- plexy, or death, is to be apprehended. In low fevers, and in exhausted old men, the pulse will often continue below 100, or even 90, and yet the distemper be attended with want of sleep, deliriou&ness, restlessness, and a parched tongue, and end in death, without any comatous or lethargic appearances. Scirrhous disorders of any of the viscera in an inflamed state, cancers, and gangrenous or other- wise ill-conditioned large ulcers, usually occasion a gradual loss of flesh, a heat, thirst, and a pulse between 90 and 120 for many months. This state of the body is called a hectic fever; and some judgment may be formed of the degree of APPENDIX. 4ii danger by the frequency of the pulse. But a quickened pulse more certainly denotes danger, than a natural one does security, where there are ulcers, or vvheie disorders of the viscera are sus- pected. I have known persons die of cancerous ulcers of the anus, testicles, prostate gland, and of almost all the viscera, without ever shewing any preternatural quickness of the pulse. It is observable in hectic, as w^eli as in rheumatic pa- tients, that they will eat with a tolerable appetite for many months, and bear little journies, with such a quickness of pulse, as in acute fevers would be joined with an averseness from all food, and an inability to keep out of bed. From these remarks it appears, that tiie pulse, though in many cases an useful index of the state of the health, yet is no certain one in ail ; and that, without a due regard to other signs, it may mis- lead us: a good pulse (which 1 have known in comatous fevers) with deliriousness, rapid loss of appetite, and strength, sleeplessness, quickness of breathing, and great thirst, would afford very lit- tle hope ; and a bad one without any of these might be harmless. I remember two young women ill together with others in the same house, of the same infectious fever; the pulse of one of which was never above 84, and the pulse of the other was always ex- tremely quick, and I once counted it, when I thought her d}ing, 180. Both of them recover- ed, and the latter quite beyond my expectation ; for, except in this in^'ance, 1 hardly remember any one recover from such a fever, wliere the pulse 412 APPENDIX. exceeded 120. But the first of these was stupid, insensible of the coming away of her water or stools, and perhaps her brain was affected coma- touslj, which might make her pulse so slow. The pulses of women will sometimes exceed what 1 have mentioned as the highest limit of the healthy standard, and sometimes, though more rarely, those of men ; but the pulses of men afford more exceptions in falling short of the lowest. There are very few healthy men, whose pulses are more than 90; and I knew one, whose chief distemper was the age of fourscore, in whom for the last two years of his life, I only once counted so many as 42 pulsations ; but they were seldom above 30, and sometimes not more than 26 ; and though he seemed heavy and torpid, yet he could go out in a carriage, and walk about his garden, receive company, and eat with a tolerable appe- tite. I saw another, whose pulse, as I was told, was sometimes in the beginning of his illness not above 12 or 16 in a minute ; but in this, and all other in- stances where it is below 40, I suspect that the artery beats oftener than it can be felt ; because such slow pulses are usually unequal in their strength, and some of the beats are so faint as but just to be perceived ; so that others, probably, still fainter, are too weak to make a sensible im- pression on the finger. Some books speak of intermitting pulses as dan- gerous signs, but, 1 think, without reason ; for such trivial causes will occasion them, that they APPENDIX. 413 are not worth^jregarding in any illness, unless joined with otner bad signs of more moment. They are not uncommon in health, and are often perceived by a peculiar fe'el at the heart by the persons themselves every time the pulse inter- mits. A woman above fifty years of age, who died of a cancer of the womb, had from her youth frequently experienced this sort of intermittent pulse ; and that the cause of this intermission might be discovered, she was opened after her death, as she had desired she might be. It was done by a very experienced and able anatomist : but he could discover not the least appearance of any thing preternatural in the pericardium, or heart, or any of the great vessels belonging to it; so that, for aught that appeared to the contrary, she might, notwithstanding this complaint, have died of old age. Many persons will likewise have unequal pulses without any other sign of 111 health. 1 have met with two, who in their best health always had pulses very unequal both in their strength and the spaces between them; upon their growing ill, their pulses constantly became regular; and it was a never-failing sign of their recovery, when their arteries began again to beat in their usual irregular manner. It is often supposed that great pain will quick- en the pulse : 1 am more sure that mere pain will not always do it, than I am that it ever will. The violent pain occasioned by a stone passing from the kidneys to the bladder, is often unattended with any quickness of the pulse ; and the exces- 414 APPENDIX. sive and almost intolerable torture produced by a gall-stone passing through the gall-ducts, has in no instance quickened the pulse beyond its natu- ral pace, as far as I have observed, though it be a disorder which occurs so very frequently : and this natural state of the pulse, joined with the ve- hement pain about the pit of the stomach, affords the most certain diagnostic of this illness. I have seen a man of patience and courage rolling upon the floor and crying out through the violence of this pain, which I was hardly able to lull into a tolerable state with nine grains of opium given within twenty-four hours, to which he had never been accustomed, and yet his pulse was all the time as perfectly quiet and natural, as it could have been in the sweetest sleep of perfect health. 4. On opening a Vein in Hamorrhages, Read at the College of Physicians, December 11, 1771. It has been the practice of physicians to take away blood from the arm, or foot, in order to slop violent haemorrhages from some other parts, which do not admit of a topical application. . If it be intended by this practice to weaken the power of the heart, and to give the lips or ends of the broken blood-vessel a chance of collapsing, or of being plugged up by means of a more languid circulation, would not all this be as likely to hap- pen after the patient had been equally weakened by losing the same quantity of blood from the ori- APPENDIX. 415 ginal rupture ? And in the mean time he might stand a chance of its stopping spontaneously, be- fore he was reduced to that degree of weakness. It seems probable, from all the experience which I Ijave had of such cases, that where the hsemorr- hage proceeds from the breach of some very large vein, or artery, there the opening of a vein will not stop the efflux of blood ; and it will stop without the help of the lancet, when it proceeds from a small one : in the former case, bleeding does no good ; and in the latter, by an unnecessa- ry waste of the patient's strength, it will do harm. But if the opening of a vein be intended to stop an haemorrhage by deprivation or revulsion, may it not be questioned, whether this doctrine be so clearly established, as to remove all fears of hurt- ing a person, who has already lost too much blood, by a practice attended with the certain loss of more ? The best remedies seem to be a cool air ; quiet ; a very sparing mild nourishment, administered in small quantities at a time ; drinks acidulated with any acids ; opiates in small doses (for any strong- perturbation of mind will often occasion a return of the bleeding ;) and lastly, keeping the body moderately open. A very experienced physician told me, that, by the help of gently purging with some of the salts, he had done more good in ex- cessive losses of blood from the nose, than by any other means. I do not lay any great stress upon the use of internal astringent remedies, because it does not appear likely from reasoning that they should do any service ; and I am far from being 416 APPENDIX. , convinced by experience, that they ever do, ex- cept perhaps in haemorrhages of the primae viae. They may sometimes have appeared to be attend- ed with success, because there is but a very small proportion of haemorrhages, not ovi^ing to exter- nal violence, which would prove fatal, though no means were used to stop them ; and hence it has happened, that a great number of other external and internal medicines have been very undeser- vedly advanced to the rank of specifics in this complaint. Saccharum saturni has appeared to me to have the best title to be called an internal specific : and it is very unfortunate, that the use- ful quality of this, and other preparations of lead, should be joined with others of such a dangerous nature ; for I hardly ever saw a case, in which the probable good to be expected from them as styp- tics, would counterbalance the many certain mis- chiefs arising from their internal use. ENGLISH INDEX. A Page. BDOMEN 11 Ague 146 Aneurysm 15 Angina pectoris . . . 292 Ascarides 49 Asthma ...... 50 Bath Water .... 58 Bowels, inflammation of . 210 Bowels, pains of . . . 224 Breast, pains of . . . 336 Breasts 292 Bristol Water .... 64 Broken State of Health . 352 Bronchocele .... 64 Carbuncle 82 Catalepsy 291 Chicken Pox .... 361 Child-bearing . . . . 318 Cold and Catarrh . . . 108 Colic of Poitou ... 309 Consumption .... 299 Cough 348 Diabetes 113 Diarrhoea 116 Diet 1 Dropsy 173 Drunkenness .... 125 Dysentery 123 53 Page. Ears, disorders of . . . 56 Epilepsy 126 Erysipelas, or St. Antho- ny's Fire .... 135 Eyes, disorders of . . . 263 Fainting 230 Fever 141 Fingers, nodes of . . . 119 Fistula 160 Flatulence 220 Fluor Albus 161 Giddiness 373 Gleet . 165 Gout 26 Haemorrhage . . . . 414 Head-ach 74 Head-ach, intermitting . 80 Head, water in . . . . 172 Hectic Fever : ... 150 Hiccup 327 Hip, disease of ... . 86 Hooping Cough . . . 350 Hydrophobia .... 173 Hypochondriacal and Hy- sterical Affections . 180 Jaundice, and Diseases of the Liver .... 189 Itch 90 418 INDEX. Itching of the Skiu . . 317 Legs, diseases of . . . 87 Loins, pain in .... 232 Lymphatic Glands . . 235 Madness 221 Measles 252 Menstrua 241 Method of curing Diseases 4 Miscarriage . • . . . 12 Mouth, disorders of . . 230 Nettie-Rash 137 Nose bleeding .... 260 Numbness 345 Nyctalopia, or Night-blind- ness 269 Pain 120 Pains, wandering . . . 122 Palpitation of the Heart . 271 Palsy and Apoplexy . . 273 Pancreas diseased . . . 372 Pedicularis Morbus . . 299 Phlegm 314 Piles 168 Pregnancy 166 Prostate Gland scirrhous . 315 Pulse .406 Purple Spots .... 318 Rectum 13 Rheumatism .... 320 Rheumatism Chronical . 402 Rupture 172 St» Vitus's Dance , . . 83 Scald Head 103 Scarlet Fever .... 15 Scrofula 338 Semen Virile .... 326 Shingles 101 Sickness of the Stomach . 362 Skin, diseases of . . . 90 Small Pox 353 Sore Throat . , . . . 19 Spasms 329 Spitting of Blood ... 332 Spleen diseased . . . 370 Stomach, pain of . . . 368 Stomach, sourness of . . 366 Stone 65 Strangury 335 Suppression of Urine . . 227 Suppuration of the Jaw . 271 Swallowing Ill Tenesmus 343 Testicles 343 Thirst 328 Thrush 25 Tremor , 347 Voice ....... 380 Vomiting ...... 376 Urine 381 Waking with Fright . . 140 Wens 335 Womb, disorders of . . 387 Worms ...... 233 LOCKKD CASE ^i ■«'"S-,^*f^ 'fe ^...^ -^^>^"'V^ r