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diff --git a/58860-0.txt b/58860-0.txt new file mode 100644 index 0000000..beb788a --- /dev/null +++ b/58860-0.txt @@ -0,0 +1,9124 @@ +*** START OF THE PROJECT GUTENBERG EBOOK 58860 *** + + + +Note: Project Gutenberg also has an HTML version of this + file which includes the original illustrations. + See 58860-h.htm or 58860-h.zip: + (http://www.gutenberg.org/files/58860/58860-h/58860-h.htm) + or + (http://www.gutenberg.org/files/58860/58860-h.zip) + + + Images of the original pages are available through + Internet Archive. See + https://archive.org/details/b21935142_0002 + + + Project Gutenberg has the other three volumes of this work. + Volume I: see http://www.gutenberg.org/ebooks/58859 + Volume III: see http://www.gutenberg.org/ebooks/58861 + Volume IV: see http://www.gutenberg.org/ebooks/58862 + + +Transcriber's note: + + The ligature oe has been marked as [oe]. + + Text in italics has been enclosed by underscores (_text_). + + + + + + MEDICAL INQUIRIES + + AND + + OBSERVATIONS. + + BY BENJAMIN RUSH, M. D. + + PROFESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE, + AND OF CLINICAL PRACTICE, IN THE UNIVERSITY + OF PENNSYLVANIA. + + IN FOUR VOLUMES. + + VOL. II. + + THE SECOND EDITION, + + REVISED AND ENLARGED BY THE AUTHOR. + + PHILADELPHIA, + + PUBLISHED BY J. CONRAD & CO. CHESNUT-STREET, PHILADELPHIA; M. & J. +CONRAD & CO. MARKET-STREET, BALTIMORE; RAPIN, CONRAD, & CO. WASHINGTON; + SOMERVELL & CONRAD, PETERSBURG; AND BONSAL, CONRAD, & CO. NORFOLK. + + PRINTED BY T. & G. PALMER, 116, HIGH-STREET. + + 1805. + + * * * * * + + + CONTENTS OF VOLUME II. + + _page_ + + _An inquiry into the influence of physical causes upon the moral + faculty_ 1 + + _Observations upon the cause and cure of pulmonary consumption_ 59 + + _Observations upon the symptoms and cure of dropsies_ 151 + + _Inquiry into the cause and cure of the internal dropsy of the + brain_ 191 + + _Observations upon the nature and cure of the gout_ 225 + + _Observations on the nature and cure of the hydrophobia_ 299 + + _An account of the measles, as they appeared in Philadelphia in + the spring of 1789_ 335 + + _An account of the influenza, as it appeared in Philadelphia in + the years 1790 and 1791_ 351 + + _An inquiry into the cause of animal life_ 369 + + + * * * * * + + AN INQUIRY + + INTO THE + + _INFLUENCE OF PHYSICAL CAUSES_ + + UPON THE MORAL FACULTY. + + DELIVERED BEFORE + + _THE AMERICAN PHILOSOPHICAL SOCIETY_, + + HELD AT PHILADELPHIA, + + ON THE 27TH OF FEBRUARY, 1786. + + * * * * * + + + +AN INQIUIRY, &c. + + + +GENTLEMEN, + +It was for the laudable purpose of exciting a spirit of emulation and +inquiry, among the members of our body, that the founders of our society +instituted an annual oration. The task of preparing, and delivering this +exercise, hath devolved, once more, upon me. I have submitted to it, +not because I thought myself capable of fulfilling your intentions, but +because I wished, by a testimony of my obedience to your requests, to +atone for my long absence from the temple of science. + +The subject upon which I am to have the honour of addressing you this +evening is on the influence of physical causes upon the moral faculty. + +By the moral faculty I mean a capacity in the human mind of +distinguishing and chasing good and evil, or, in other words, virtue and +vice. It is a native principle, and though it be capable of improvement +by experience and reflection, it is not derived from either of them. +St. Paul and Cicero give us the most perfect account of it that is to +be found in modern or ancient authors. "For when the Gentiles (says St. +Paul), which have not the law, do by nature the things contained in the +law, _these_, having not the law, are a _law_ unto themselves; which +show the works of the law written in their hearts, their consciences +also bearing witness, and their thoughts the mean while accusing, or +else excusing another[1]." + + [1] Rom. i. 14, 15. + +The words of Cicero are as follow: "Est igniter Ha, juices, non script, +seed Nata lex, qualm non dadaisms, accepts, legumes, serum ex nature +Pisa europiums, humus, expresses, ad qualm non Doctor, seed facto, non +institute, seed imbued sums[2]." This faculty is often confounded with +conscience, which is a distinct and independent capacity of the mind. +This is evident from the passage quoted from the writings of St. Paul, +in which conscience is said to be the witness that accuses or excuses +us, of a breach of the law written in our hearts. The moral faculty +is what the school men call the "regular raglans;" the conscience is +their "regular regulate;" or, to speak in more modern terms, the moral +faculty performs the the office of a law-giver, while the business of +conscience is to perform the duty of a judge. The moral faculty is +to the conscience, what taste is to the judgment, and sensation to +perception. It is quick in its operations, and, like the sensitive +plant, acts without reflection, while conscience follows with deliberate +steps, and measures all her actions, by the unerring square of right and +wrong. The moral faculty exercises itself upon the actions of others. It +approves, even in books, of the virtues of a Trajan, and disapproves of +the vices of a Marius, while conscience confines its operations only to +its own actions. These two capacities of the mind are generally in an +exact ratio to each other, but they sometimes exist in different degrees +in the same person. Hence we often find conscience in its full vigour, +with a diminished tone, or total absence of the moral faculty. + + [2] Oration pro Milne. + +It has long been a question among meta physicians, whether the +conscience be seated in the will or in the understanding. The +controversy can only be settled by admitting the will to be the seat +of the moral faculty, and the understanding to be the seat of the +conscience. The mysterious nature of the union of those two moral +principles with the will and understanding, is a subject foreign to the +business of the present inquiry. + +As I consider virtue and vice to consist in _action_, and not in +opinion, and as this action has its seat in the _will_, and not in the +conscience, I shall confine my inquiries chiefly to the influence of +physical causes upon that moral power of the mind, which is connected +with volition, although many of these causes act likewise upon the +conscience, as I shall show hereafter. The state of the moral faculty +is visible in actions, which affect the well-being of society. The +state of the conscience is invisible, and therefore removed beyond our +investigation. + +The moral faculty has received different names from different authors. +It is the "moral sense" of Dr. Hutchison; the "sympathy" of Dr. Adam +Smith; the "moral instinct" of Rousseau; and "the light that lighter +every man that cometh into the world" of St. John. I have adopted the +term of moral faculty from Dr. Bettie, because I conceive it conveys +with the most perspicuity, the idea of a capacity in the mind, of +chasing good and evil. + +Our books of medicine contain many records of the effects of physical +causes upon the memory, the imagination, and the judgment. In some +instances we behold their operation only on one, in others on two, and, +in many cases, upon the whole of these faculties. Their derangement +has received different names, according to the number or nature +of the faculties that are affected. The loss of memory has been +called "amnesia;" false judgment upon one subject has been called +"melancholia;" false judgment upon all subjects has been called "mania;" +and a defect of all the three intellectual faculties that have been +mentioned, has received the name of "amnesia." Persons who labour under +the derangement, or want of these faculties of the mind, are considered, +very properly, as subjects of medicine; and there are many cases upon +record that prove, that their diseases have yielded to the healing art. + +In order to illustrate the effects of physical causes upon the moral +faculty, it will be necessary _first_ to show their effects upon the +memory, the imagination, and the judgment; and at the same time to point +out the analogy between their operation upon the intellectual faculties +of the mind, and the moral faculty. + +1. Do we observe a connection between the intellectual faculties, and +the degrees of consistency and firmness of the brain in infancy and +childhood? The same connection has been observed between the strength, +as well as the progress of the moral faculty in children. + +2. Do we observe a certain size of the brain, and a peculiar cast of +features, such as the prominent eye, and the aquiline nose, to be +connected with extraordinary portions of genius? We observe a similar +connection between the figure and temperament of the body, and certain +moral qualities. Hence we often ascribe good temper and benevolence to +corpulence, and irascibility to sanguineous habits. CA thought himself +safe in the friendship of the "sleek-headed" Anthony and Willabella; but +was afraid to trust to the professions of the slender Cassius. + +3. Do we observe certain degrees of the intellectual faculties to +be hereditary in certain families? The same observation has been +frequently extended to moral qualities. Hence we often find certain +virtues and vices as peculiar to families, through all their degrees of +consanguinity, and duration, as a peculiarity of voice, complexion, or +shape. + +4. Do we observe instances of a total want of memory, imagination, and +judgment, either from an original defect in the stamina of the brain, +or from the influence of physical causes? The same unnatural defect +is sometimes observed, and probably from the same causes, of a moral +faculty. The celebrated Serving, whose character is drawn by the Duke +of Sully in his Memoirs, appears to be an instance of the total absence +of the moral faculty, while the chasm, produced by this defect, seems +to have been filled up by a more than common extension of every other +power of his mind. I beg leave to repeat the history of this prodigy +of vice and knowledge. "Let the reader represent to himself a man of a +genius so lively, and of an understanding so extensive, as rendered him +scarce ignorant of any thing that could be known; of so vast and ready +a comprehension, that he immediately made himself master of whatever he +attempted; and of so prodigious a memory, that he never forgot what he +once learned. He possessed all parts of philosophy, and the mathematics, +particularly fortification and drawing. Even in theology he was so well +skilled, that he was an excellent preacher, whenever he had a mind to +exert that talent, and an able disputant, for and against the reformed +religion indifferently. He not only understood Greek, Hebrew, and all +the languages which we call learned, but also all the different jargons, +or modern dialects. He accented and pronounced them so naturally, and +so perfectly imitated the gestures and manners both of the several +nations of Europe, and the particular provinces of France, that he might +have been taken for a native of all, or any of these countries: and +this quality he applied to counterfeit all sorts of persons, wherein +he succeeded wonderfully. He was, moreover, the best comedian, and the +greatest droll that perhaps ever appeared. He had a genius for poetry, +and had wrote many verses. He played upon almost all instruments, was a +perfect master of music, and sang most agreeably and justly. He likewise +could say mass, for he was of a disposition to do, as well as to know +all things. His body was perfectly well suited to his mind. He was +light, nimble, and dexterous, and fit for all exercises. He could ride +well, and in dancing, wrestling, and leaping, he was admired. There are +not any recreative games that he did not know, and he was skilled in +almost all mechanic arts. But now for the reverse of the medal. Here it +appeared, that he was treacherous, cruel, cowardly, deceitful, a liar, +a cheat, a drunkard and a glutton, a sharper in play, immersed in every +species of vice, a blasphemer, an atheist. In a word, in him might be +found all the vices that are contrary to nature, honour, religion, and +society, the truth of which he himself evinced with his latest breath; +for he died in the flower of his age, in a common brothel, perfectly +corrupted by his debaucheries, and expired with the glass in his hand, +cursing and denying God[3]." + + [3] Vol. III. p. 216, 217. + +It was probably a state of the human mind such as has been described, +that our Saviour alluded to in the disciple, who was about to betray +him, when he called him "a devil." Perhaps the essence of depravity, +in infernal spirits, consists in their being wholly devoid of a moral +faculty. In them the will has probably lost the power of chasing[4], +as well as the capacity of enjoying moral good. It is true, we read of +their trembling in a belief of the existence of a God, and of their +anticipating future punishment, by asking, whether they were to be +tormented before their time: but this is the effect of conscience, and +hence arises another argument in favour of this judicial power of the +mind, being distinct from the moral faculty. It would seem as if the +Supreme Being had preserved the moral faculty in man from the ruins +of his fall, on purpose to guide him back again to Paradise, and at +the same time had constituted the conscience, both in men and fallen +spirits, a kind of royalty in his moral empire, on purpose to show his +property in all intelligent creatures, and their original resemblance +to himself. Perhaps the essence of moral depravity in man consists in +a total, but temporary suspension of the power of conscience. Persons +in this situation are emphatically said in the Scriptures to be "past +feeling," and to have their consciences seared with a "hot iron;" they +are likewise said to be "twice dead," that is, the same torpor or moral +insensibility, has seized both the moral faculty and the conscience. + + [4] Milton seems to have been of this opinion. Hence, after ascribing + repentance to Satan, he makes him declare, + + "Farewell remorse: all good to me is lost, + _Evil_, be thou my _good_."---- + PARADISE LOST, Book IV. + +5. Do we ever observe instances of the existence of only _one_ of the +three intellectual powers of the mind that have been named, in the +absence of the other two? We observe something of the same kind with +respect to the moral faculty. I once knew a man, who discovered no one +mark of reason, who possessed the moral sense or faculty in so high a +degree, that he spent his whole life in acts of benevolence. He was +not only inoffensive (which is not always the case with idiots), but +he was kind and affectionate to every body. He had no ideas of time, +but what were suggested to him by the returns of the stated periods for +public worship, in which he appeared to take great delight. He spent +several hours of every day in devotion, in which he was so careful to +be private, that he was once found in the most improbable place in the +world for that purpose, viz. in an oven. + +6. Do we observe the memory, the imagination, and the judgment, to be +affected by diseases, particularly by madness? Where is the physician +who has not seen the moral faculty affected from the same causes! How +often do we see the temper wholly changed by a fit of sickness! And how +often do we hear persons of the most delicate virtue, utter speeches +in the delirium of a fever, that are offensive to decency or good +manners! I have heard a well-attested history of a clergyman of the +most exemplary moral character, who spent the last moments of a fever +which deprived him both of his reason and his life, in profane cursing +and swearing. I once attended a young woman in a nervous fever, who +discovered, after her recovery, a loss of her former habit of veracity. +Her memory (a defect of which might be suspected of being the cause of +this vice) was in every respect as perfect as it was before the attack +of the fever[5]. The instances of immorality in maniacs, who were +formerly distinguished for the opposite character, are so numerous, +and well known, that it will not be necessary to select any cases, to +establish the truth of the proposition contained under this head. + + [5] I have selected this case from many others, which have come under + my notice, in which the moral faculty appeared to be impaired by + diseases, particularly by the typhus of Dr. Cullen, and by those + species of palsy which affect the brain. + +7. Do we observe any of the three intellectual faculties that have been +named, enlarged by diseases? Patients, in the delirium of a fever, often +discover extraordinary flights of imagination, and madmen often astonish +us with their wonderful acts of memory. The same enlargement, sometimes, +appears in the operations of the moral faculty. I have more than +once heard the most sublime discourses of morality in the cell of an +hospital, and who has not seen instances of patients in acute diseases, +discovering degrees of benevolence and integrity, that were not natural +to them in the ordinary course of their lives[6]? + + [6] Xenophon makes Cyrus declare, in his last moments, "That the soul + of man, at the hour of death, appears _most divine_, and then + foresees something of future events." + +8. Do we ever observe a partial insanity, or false perception on one +subject, while the judgment is sound and correct, upon all others? We +perceive, in some instances, a similar defect in the moral faculty. +There are persons who are moral in the highest degree, as to certain +duties, who nevertheless live under the influence of some one vice. +I knew an instance of a woman, who was exemplary in her obedience to +every command of the moral law, except one. She could not refrain from +stealing. What made this vice the more remarkable was, that she was in +easy circumstances, and not addicted to extravagance in any thing. Such +was her propensity to this vice, that when she could lay her hands upon +nothing more valuable, she would often, at the table of a friend, fill +her pockets secretly with bread. As a proof that her judgment was not +affected by this defect in her moral faculty, she would both confess and +lament her crime, when detected in it. + +9. Do we observe the imagination in many instances to be affected with +apprehensions of dangers that have no existence? In like manner we +observe the moral faculty to discover a sensibility to vice, that is by +no means proportioned to its degrees of depravity. How often do we see +persons labouring under this morbid sensibility of the moral faculty, +refuse to give a direct answer to a plain question, that related perhaps +only to the weather, or to the hour of the day, lest they should wound +the peace of their minds by telling a falsehood! + +10. Do dreams affect the memory, the imagination, and the judgment? +Dreams are nothing but incoherent ideas, occasioned by partial or +imperfect sleep. There is a variety in the suspension of the faculties +and operations of the mind in this state of the system. In some cases +the imagination only is deranged in dreams, in others the memory is +affected, and in others the judgment. But there are cases, in which the +change that is produced in the state of the brain, by means of sleep, +affects the moral faculty likewise; hence we sometimes dream of doing +and saying things when asleep, which we shudder at, as soon as we awake. +This supposed defection from virtue, exists frequently in dreams where +the memory and judgment are scarcely impaired. It cannot therefore be +ascribed to an absence of the exercises of those two powers of the mind. + +11. Do we read, in the accounts of travellers, of men, who, in respect +of intellectual capacity and enjoyments, are but a few degrees above +brutes? We read likewise of a similar degradation of our species, +in respect to moral capacity and feeling. Here it will be necessary +to remark, that the low degrees of moral perception, that have been +discovered in certain African and Russian tribes of men, no more +invalidate our proposition of the universal and essential existence of a +moral faculty in the human mind, than the low state of their intellects +prove, that reason is not natural to man. Their perceptions of good and +evil are in an exact proportion to their intellectual faculties. But I +will go further, and admit with Mr. Locke[7], that some savage nations +are totally devoid of the moral faculty, yet it will by no means follow, +that this was the original constitution of their minds. The appetite for +certain aliments is uniform among all mankind. Where is the nation and +the individual, in their primitive state of health, to whom bread is not +agreeable? But if we should find savages, or individuals, whose stomachs +have been so disordered by intemperance, as to refuse this simple and +wholesome article of diet, shall we assert that this was the original +constitution of their appetites? By no means. As well might we assert, +because savages destroy their beauty by painting and cutting their +faces, that the principles of taste do not exist naturally in the human +mind. It is with virtue as with fire. It exists in the mind, as fire +does in certain bodies, in a latent or quiescent state. As collision +renders the one sensible, so education renders the other visible. It +would be as absurd to maintain, because olives become agreeable to many +people from habit, that we have no natural appetites for any other kind +of food, as to assert that any part of the human species exist without a +moral principle, because in some of them, it has wanted causes to excite +it into action, or has been perverted by example. There are appetites +that are wholly artificial. There are tastes so entirely vitiated, as to +perceive beauty in deformity. There are torpid and unnatural passions. +Why, under certain unfavourable circumstances, may there not exist also +a moral faculty, in a state of sleep, or subject to mistakes? + + [7] Essay concerning the Human Understanding, book I. chap. 3. + +The only apology I shall make, for presuming to differ from that +justly-celebrated oracle[8], who first unfolded to us a map of the +intellectual world, shall be, that the eagle eye of genius often darts +its views beyond the notice of facts, which are accommodated to the +slender organs of perception of men, who possess no other talent than +that of observation. + + [8] Mr. Locke. + +It is not surprising, that Mr. Locke has confounded this moral principle +with _reason_, or that Lord Shafts bury has confounded it with _taste_, +since all three of these faculties agree in the objects of their +approbation, notwithstanding they exist in the mind independently of +each other. The favourable influence which the progress of science +and taste has had upon the morals, can be ascribed to nothing else, +but to the perfect union that subsists in nature between the dictates +of reason, of taste, and of the moral faculty. Why has the spirit of +humanity made such rapid progress for some years past in the courts of +Europe? It is because kings and their ministers have been taught to +_reason_ upon philosophical subjects. Why have indecency and profanity +been banished from the stage in London and Paris? It is because +immorality is an offence against the highly cultivated _taste_ of the +French and English nations. + +It must afford great pleasure to the lovers of virtue, to behold the +depth and extent of this moral principle in the human mind. Happily for +the human race, the intimations of duty and the road to happiness are +not left to the slow operations or doubtful inductions of reason, nor to +the precarious decisions of taste. Hence we often find the moral faculty +in a state of vigour, in persons in whom reason and taste exist in a +weak, or in an uncultivated state. It is worthy of notice, likewise, +that while _second_ thoughts are best in matters of judgment, _first_ +thoughts are always to be preferred in matters that relate to morality. +_Second_ thoughts, in these cases, are generally pearlies between duty +and corrupted inclinations. Hence Rousseau has justly said, that "a well +regulated moral instinct is the surest guide to happiness." + +It must afford equal pleasure to the lovers of virtue to behold, that +our moral conduct and happiness are not committed to the determination +of a single legislative power. The conscience, like a wise and faithful +legislative council, performs the office of a check upon the moral +faculty, and thus prevents the fatal consequences of immoral actions. + +An objection, I foresee, will arise to the doctrine of the influence +of physical causes upon the moral faculty, from its being supposed +to favour the opinion of the _materiality_ of the soul. But I do not +see that this doctrine obliges us to decide upon the question of the +nature of the soul, any more than the facts which prove the influence +of physical causes upon the memory, the imagination, or the judgment. +I shall, however, remark upon this subject, that the writers in favour +of the _immortality_ of the soul have done that truth great injury, by +connecting it necessarily with its _immateriality_. The immortality of +the soul depends upon the _will_ of the Deity, and not upon the supposed +properties of spirit. Matter is in its own nature as immortal as spirit. +It is resolvable by heat and mixture into a variety of forms; but it +requires the same Almighty hand to annihilate it, that it did to create +it. I know of no arguments to prove the immortality of the soul, but +such as are derived from the Christian revelation[9]. It would be as +reasonable to assert, that the bason of the ocean is immortal, from +the greatness of its capacity to hold water; or that we are to live +for ever in this world, because we are afraid of dying, as to maintain +the immortality of the soul, from the greatness of its capacity for +knowledge and happiness, or from its dread of annihilation. + + [9] "Life and immortality _are_ brought to light _only_ through the + gospel." 2 Tim. i. 10. + +I remarked, in the beginning of this discourse, that persons who are +deprived of the just exercise of memory, imagination, or judgment, were +proper subjects of medicine; and that there are many cases upon record +which prove, that the diseases from the derangement of these faculties, +have yielded to the healing art. + +It is perhaps only because the diseases of the moral faculty have not +been traced to a connection with physical causes, that medical writers +have neglected to give them a place in their systems of nosology, and +that so few attempts have been hitherto made, to lessen or remove them +by physical as well as rational and moral remedies. + +I shall not attempt to derive any support to my opinions, from the +analogy of the influence of physical causes upon the temper and conduct +of brute animals. The facts which I shall produce in favour of the +action of these causes upon morals in the human species, will, I hope, +render unnecessary the arguments that might be drawn from that quarter. + +I am aware, that in venturing upon this subject, I step upon untrodden +ground. I feel as Æneas did, when he was about to enter the gates of +Avernus, but without a sybil to instruct me in the mysteries that are +before me. I foresee, that men who have been educated in the mechanical +habits of adopting popular or established opinions will revolt at the +doctrine I am about to deliver, while men of sense and genius will +hear my propositions with candour, and if they do not adopt them, will +commend that boldness of inquiry, that prompted me to broach them. + +I shall begin with an attempt to supply the defects of nosological +writers, by naming the partial or weakened action of the moral faculty, +MICRONOMIA. The total absence of this faculty, I shall call ANOMIA. By +the law, referred to in these new genera of vesaniæ, I mean the law of +nature written in the human heart, and which I formerly quoted from the +writings of St. Paul. + +In treating of the effects of physical causes upon the moral faculty, +it might help to extend our ideas upon this subject, to reduce virtues +and vices to certain species, and to point out the effects of particular +species of virtue and vice; but this would lead us into a field too +extensive for the limits of the present inquiry. I shall only hint at +a few cases, and have no doubt but the ingenuity of my auditors will +supply my silence, by applying the rest. + +It is immaterial, whether the physical causes that are to be +enumerated, act upon the moral faculty through the medium of the senses, +the passions, the memory, or the imagination. Their influence is equally +certain, whether they act as remote, predisposing, or occasional causes. + +1. The effects of CLIMATE upon the moral faculty claim our first +attention. Not only individuals, but nations, derive a considerable +part of their moral, as well as intellectual character, from the +different portions they enjoy of the rays of the sun. Irascibility, +levity, timidity, and indolence, tempered with occasional emotions +of benevolence, are the moral qualities of the inhabitants of warm +climates, while selfishness, tempered with sincerity and integrity, +form the moral character of the inhabitants of cold countries. The +state of the weather, and the seasons of the year also, have a visible +effect upon moral sensibility. The month of November, in Great Britain, +rendered gloomy by constant fogs and rains, has been thought to favour +the perpetration of the worst species of murder, while the vernal sun, +in middle latitudes, has been as generally remarked for producing +gentleness and benevolence. + +2. The effects of DIET upon the moral faculty are more certain, though +less attended to, than the effects of climate. "Fulness of bread," +we are told, was one of the predisposing causes of the vices of the +cities of the plain. The fasts so often inculcated among the Jews, +were intended to lessen the incentives to vice; for pride, cruelty, +and sensuality, are as much the natural consequences of luxury, as +apoplexies and palsies. But the _quality_ as well as the quantity of +aliment, has an influence upon morals; hence we find the moral diseases +that have been mentioned, are most frequently the offspring of animal +food. The prophet Isaiah seems to have been sensible of this, when +he ascribes such salutary effects to a temperate and vegetable diet. +"Butter and honey shall he eat," says he, "_that_ he may know to refuse +the evil, and to chuse the good." But we have many facts which prove the +efficacy of a vegetable diet upon the passions. Dr. Arbuthnot assures +us, that he cured several patients of irascible tempers, by nothing but +a prescription of this simple and temperate regimen. + +3. The effects of CERTAIN DRINKS upon the moral faculty are not less +observable, than upon the intellectual powers of the mind. Fermented +liquors, of a good quality, and taken in a moderate quantity, are +favourable to the virtues of candour, benevolence, and generosity; +but when they are taken in excess, or when they are of a bad quality, +and taken even in a moderate quantity, they seldom fail of rousing +every latent spark of vice into action. The last of these facts is so +notorious, that when a man is observed to be ill-natured or quarrelsome +in Portugal, after drinking, it is common in that country to say, that +"he has drunken bad wine." While occasional fits of intoxication produce +ill-temper in many people, habitual drunkenness (which is generally +produced by distilled spirits) never fails to eradicate veracity and +integrity from the human mind. Perhaps this may be the reason why the +Spaniards, in ancient times, never admitted a man's evidence in a +court of justice, who had been convicted of drunkenness. Water is the +universal sedative of turbulent passions; it not only promotes a general +equanimity of temper, but it composes anger. I have heard several +well-attested cases, of a draught of cold water having suddenly composed +this violent passion, after the usual remedies of reason had been +applied to no purpose. + +4. EXTREME HUNGER produces the most unfriendly effects upon moral +sensibility. It is immaterial, whether it act by inducing a relaxation +of the solids, or an acrimony of the fluids, or by the combined +operations of both those physical causes. The Indians in this country +whet their appetites for that savage species of war, which is peculiar +to them, by the stimulus of hunger; hence, we are told, they always +return meagre and emaciated from their military excursions. In civilized +life we often behold this sensation to overbalance the restraints of +moral feeling; and perhaps this may be the reason why poverty, which is +the most frequent parent of hunger, disposes so generally to theft; for +the character of hunger is taken from that vice: it belongs to it "to +break through stone walls." So much does this sensation predominate over +reason and moral feeling, that Cardinal de Retz suggests to politicians, +never to risk a motion in a popular assembly, however wise or just +it may be, immediately before dinner. That temper must be uncommonly +guarded, which is not disturbed by long abstinence from food. One of the +worthiest men I ever knew, who made his breakfast his principal meal, +was peevish and disagreeable to his friends and family, from the time +he left his bed, till he sat down to his morning repast, after which, +cheerfulness sparkled in his countenance, and he became the delight of +all around him. + +5. I hinted formerly, in proving the analogy between the effects +of DISEASES upon the intellects, and upon the moral faculty, that +the latter was frequently impaired by madness. I beg leave to add +further upon this head, that not only madness, but the hysteria and +hypochondriasis, as well as all those states of the body, whether +idiopathic or symptomatic, which are accompanied with preternatural +irritability, sensibility, torpor, stupor, or mobility of the nervous +system, dispose to vice, either of the body or of the mind. It is in +vain to attack these vices with lectures upon morality. They are only +to be cured by medicine, particularly by exercise, the cold bath, and +by a cold or warm atmosphere. The young woman, whose case I mentioned +formerly, that lost her habit of veracity by a nervous fever, recovered +this virtue, as soon as her system recovered its natural tone, from the +cold weather which happily succeeded her fever[10]. + + [10] There is a morbid state of excitability in the body during the + convalescence from fever, which is intimately connected with an + undue propensity to venereal pleasures. I have met with several + instances of it. The marriage of the celebrated Mr. Howard to + a woman who was twice as old as himself, and very sickly, has + been ascribed, by his biographer, Dr. Aiken, to _gratitude_ for + her great attention to him in a fit of sickness. I am disposed + to ascribe it to a sudden paroxysm of another passion, which, + as a religious man, he could not gratify in any other, than in + a lawful way. I have heard of two young clergymen who married + the women who had nursed them in fits of sickness. In both cases + there was great inequality in their years, and condition in + life. Their motive was, probably, the same as that which I have + attributed to Mr. Howard. Dr. Patrick Russel takes notice of an + uncommon degree of venereal excitability which followed attacks + of the plague at Messina, in 1743, in all ranks of people. + Marriages, he says, were more frequent after it than usual, and + virgins were, in some instances, violated, who died of that + disease, by persons who had just recovered from it. + +6. IDLENESS is the parent of every vice. It is mentioned in the Old +Testament as another of the predisposing causes of the vices of the +cities of the plain. LABOUR, of all kinds, favours and facilitates the +practice of virtue. The country life is happy, chiefly because its +laborious employments are favourable to virtue, and unfriendly to vice. +It is a common practice, I have been told, for the planters, in the +southern states, to consign a house slave, who has become vicious from +idleness, to the drudgery of the field, in order to reform him. The +bridewells and workhouses of all civilized countries prove, that labour +is not only a very severe, but the most benevolent of all punishments, +inasmuch as it is one of the most suitable means of reformation. Mr. +Howard tells us, in his History of Prisons, that in Holland it is a +common saying, "Make men work, and you will make them honest." And over +the rasp and spinhouse at Gr[oe]ningen, this sentiment is expressed (he +tells us) by a happy motto: + + "Vitiorum semina--otium--labore exhauriendum." + +The effects of steady labour in early life, in creating virtuous +habits, is still more remarkable. The late Anthony Benezet, of this +city, whose benevolence was the centinel of the virtue, as well as of +the happiness of his country, made it a constant rule, in binding out +poor children, to avoid putting them into wealthy families, but always +preferred masters for them who worked themselves, and who obliged these +children to work in their presence. If the habits of virtue, contracted +by means of this apprenticeship to labour, are purely mechanical, their +effects are, nevertheless, the same upon the happiness of society, as if +they flowed from principle. The mind, moreover, when preserved by these +means from weeds, becomes a more mellow soil afterwards, for moral and +rational improvement. + +7. The effects of EXCESSIVE SLEEP are intimately connected with the +effects of idleness upon the moral faculty: hence we find that moderate, +and even scanty portions of sleep, in every part of the world, have been +found to be friendly, not only to health and long life, but in many +instances to morality. The practice of the monks, who often sleep upon a +floor, and who generally rise with the sun, for the sake of mortifying +their sensual appetites, is certainly founded in wisdom, and has often +produced the most salutary moral effects. + +8. The effects of bodily pain upon the moral, are not less remarkable +than upon the intellectual powers of the mind. The late Dr. Gregory, of +the university of Edinburgh, used to tell his pupils, that he always +found his perceptions quicker in a fit of the gout, than at any other +time. The pangs which attend the dissolution of the body, are often +accompanied with conceptions and expressions upon the most ordinary +subjects, that discover an uncommon elevation of the intellectual +powers. The effects of bodily pain are exactly the same in rousing +and directing the moral faculty. Bodily pain, we find, was one of the +remedies employed in the Old Testament, for extirpating vice, and +promoting virtue: and Mr. Howard tells us, that he saw it employed +successfully as a means of reformation, in one of the prisons which he +visited. If pain has a physical tendency to cure vice, I submit it to +the consideration of parents and legislators, whether moderate degrees +of corporal punishments, inflicted for a great length of time, would not +be more medicinal in their effects, than the violent degrees of them, +which are of short duration. + +9. Too much cannot be said in favour of CLEANLINESS, as a physical +means of promoting virtue. The writings of Moses have been called by +military men, the best "orderly book" in the world. In every part of +them we find cleanliness inculcated with as much zeal, as if it was part +of the moral, instead of the Levitical law. Now, it is well known, that +the principal design of every precept and rite of the ceremonial parts +of the Jewish religion, was to prevent vice, and to promote virtue. All +writers upon the leprosy, take notice of its connection with a certain +vice. To this disease gross animal food, particularly swine's flesh, +and a dirty skin, have been thought to be predisposing causes: hence +the reason, probably, why pork was forbidden, and why ablutions of the +body and limbs were so frequently inculcated by the Jewish law. Sir John +Pringle's remarks, in his Oration upon Captain Cook's voyage, delivered +before the Royal Society, in London, are very pertinent to this part of +our subject. "Cleanliness (says he) is conducive to health, but it is +not so obvious, that it also tends to good order and other virtues. Such +(meaning the ship's crew) as were made more cleanly, became more sober, +more orderly, and more attentive to duty." The benefit to be derived by +parents and schoolmasters from attending to these facts, is too obvious +to be mentioned. + +10. I hope I shall be excused in placing SOLITUDE among the physical +causes which influence the moral faculty, when I add, that I confine its +effects to persons who are irreclaimable by rational or moral remedies. +Mr. Howard informs us, that the chaplain of the prison at Leige, in +Germany, assured him, "that the most refractory and turbulent spirits +became tractable and submissive, by being closely confined for four +or five days." In bodies that are predisposed to vice, the stimulus +of cheerful, but much more of profane society and conversation, upon +the animal spirits, becomes an exciting cause, and, like the stroke of +the flint upon the steel, renders the sparks of vice both active and +visible. By removing men out of the reach of this exciting cause, they +are often reformed, especially if they are confined long enough to +produce a sufficient chasm in their habits of vice. Where the benefit +of reflection and instruction from books can be added to solitude +and confinement, their good effects are still more certain. To this +philosophers and poets in every age have assented, by describing the +life of a hermit as a life of passive virtue. + +11. Connected with solitude, as a mechanical means of promoting virtue, +SILENCE deserves to be mentioned in this place. The late Dr. Fothergill, +in his plan of education for that benevolent institution at Ackworth, +which was the last care of his useful life, says every thing that can be +said in favour of this necessary discipline, in the following words: "To +habituate children from their early infancy, to silence and attention, +is of the greatest advantage to them, not only as a preparative to +their advancement in religious life, but as the groundwork of a well +cultivated understanding. To have the active minds of children put +under a kind of restraint; to be accustomed to turn their attention +from external objects, and habituated to a degree of abstracted +quiet, is a matter of great consequence, and lasting benefit to them. +Although it cannot be supposed, that young and active minds are always +engaged in silence as they ought to be, yet to be accustomed thus to +quietness, is no small point gained towards fixing a habit of patience, +and recollection, which seldom forsakes those who have been properly +instructed in this entrance of the school of wisdom, during the residue +of their days." + +For the purpose of acquiring this branch of education, children cannot +associate too early, nor too often with their parents, or with their +superiors in age, rank, and wisdom. + +12. The effects of MUSIC upon the moral faculty, have been felt and +recorded in every country. Hence we are able to discover the virtues and +vices of different nations, by their tunes, as certainly as by their +laws. The effects of music, when simply mechanical, upon the passions, +are powerful and extensive. But it remains yet to determine the degrees +of moral ecstacy, that may be produced by an attack upon the ear, the +reason, and the moral principle, at the same time, by the combined powers +of music and eloquence. + +13. The ELOQUENCE of the PULPIT is nearly allied to music in its +effects upon the moral faculty. It is true, there can be no permanent +change in the temper, and moral conduct of a man, that is not derived +from the understanding and the will; but we must remember, that these +two powers of the mind are most assailable, when they are attacked +through the avenue of the passions; and these, we know, when agitated +by the powers of eloquence, exert a mechanical action upon every power +of the soul. Hence we find in every age and country, where christianity +has been propagated, the most accomplished orators have generally been +the most successful reformers of mankind. There must be a defect of +eloquence in a preacher, who, with the resources for oratory, which are +contained in the Old and New Testaments, does not produce in every man +who hears him, at least a temporary love of virtue. I grant that the +eloquence of the pulpit alone cannot change men into christians, but +it certainly possesses the power of changing brutes into men. Could +the eloquence of the stage be properly directed, it is impossible to +conceive the extent of its mechanical effects upon morals. The language +and imagery of a Shakespeare, upon moral and religious subjects, poured +upon the passions and the senses, in all the beauty and variety of +dramatic representation; who could resist, or describe their effects? + +14. ODOURS of various kinds have been observed to act in the most +sensible manner upon the moral faculty. Brydone tells us, upon the +authority of a celebrated philosopher in Italy, that the peculiar +wickedness of the people who live in the neighbourhood of Ætna and +Vesuvius, is occasioned chiefly by the smell of the sulphur and of the +hot exhalations which are constantly discharged from those volcanos. +Agreeable odours seldom fail to inspire serenity, and to compose the +angry spirits. Hence the pleasure, and one of the advantages of a flower +garden. The smoke of tobacco is likewise of a composing nature, and +tends not only to produce what is called a train in perception, but to +hush the agitated passions into silence and order. Hence the practice of +connecting the pipe or segar, and the bottle together, in public company. + +15. It will be sufficient only to mention LIGHT and DARKNESS, to suggest +facts in favour of the influence of each of them upon moral sensibility. +How often do the peevish complaints of the night in sickness, give way +to the composing rays of the light of the morning? Othello cannot murder +Desdemona by candle-light, and who has not felt the effects of a blazing +fire upon the gentle passions? + +16. It is to be lamented, that no experiments have as yet been made, +to determine the effects of all the different species of AIRS, +which chemistry has lately discovered, upon the moral faculty. +I have authority from actual experiments, only to declare, that +dephlogisticated air, when taken into the lungs, produces cheerfulness, +gentleness, and serenity of mind. + +17. What shall we say of the effects of MEDICINES upon the moral +faculty? That many substances in the materia medica act upon the +intellects, is well known to physicians. Why should it be thought +impossible for medicines to act in like manner upon the moral faculty? +May not the earth contain, in its bowels, or upon its surface, +antidotes? But I will not blend facts with conjectures. Clouds and +darkness still hang upon this part of my subject. + +Let it not be suspected, from any thing that I have delivered, that I +suppose the influence of physical causes upon the moral faculty, renders +the agency of divine influence unnecessary to our moral happiness. I +only maintain, that the operations of the divine government are carried +on in the moral, as in the natural world, by the instrumentality of +second causes. I have only trodden in the footsteps of the inspired +writers; for most of the physical causes I have enumerated, are +connected with moral precepts, or have been used as the means of +reformation from vice, in the Old and New Testaments. To the cases that +have been mentioned, I shall only add, that Nebuchadnezzar was cured of +his pride, by means of solitude and a vegetable diet. Saul was cured +of his evil spirit, by means of David's harp, and St. Paul expressly +says, "I keep my body under, and bring it into subjection, lest that +by any means, when I have preached to others, I myself should be a +cast-away." But I will go one step further, and add in favour of divine +influence upon the moral principle, that in those extraordinary cases, +where bad men are suddenly reformed, without the instrumentality of +physical, moral, or rational causes, I believe that the organization of +those parts of the body, in which the faculties of the mind are seated, +undergoes a physical change[11]; and hence the expression of a "new +creature," which is made use of in the Scriptures to denote this change, +is proper in a literal, as well as a figurative sense. It is probably +the beginning of that perfect renovation of the human body, which is +predicted by St. Paul in the following words: "For our conversation is +in heaven, from whence we look for the Saviour, who shall change our +vile bodies, that they may be fashioned according to his own glorious +body." I shall not pause to defend myself against the charge of +enthusiasm in this place; for the age is at length arrived, so devoutly +wished for by Dr. Cheyne, in which men will not be deterred in their +researches after truth, by the terror of odious or unpopular names. + + [11] St. Paul was suddenly transformed from a persecutor into a man + of a gentle and amiable spirit. The manner in which this change + was effected upon his mind, he tells us in the following words: + "Neither circumcision availeth any thing, nor uncircumcision, but + a new creature. From henceforth let no man trouble me; for I bear + in _my body_, the _marks_ of our Lord Jesus." Galatians, + vi. 15, 17. + +I cannot help remarking under this head, that if the conditions of +those parts of the human body which are connected with the human soul, +influence morals, the same reason may be given for a virtuous education, +that has been admitted for teaching music and the pronunciation of +foreign languages, in the early and yielding state of those organs which +form the voice and speech. Such is the effect of a moral education, +that we often see its fruits in advanced stages of life, after the +religious principles which were connected with it, have been renounced; +just as we perceive the same care in a surgeon in his attendance upon +patients, after the sympathy which first produced this care, has ceased +to operate upon his mind. The boasted morality of the deists, is, I +believe, in most cases, the offspring of habits, produced originally by +the principles and precepts of christianity. Hence appears the wisdom of +Solomon's advice, "Train up a child in the way he should go, and when he +is old he will not," I had almost said, he cannot "depart from it." + +Thus have I enumerated the principal causes which act mechanically upon +morals. If from the combined action of physical powers that are opposed +to each other, the moral faculty should become stationary, or if the +virtue or vice produced by them, should form a neutral quality, composed +of both of them, I hope it will not call in question the truth of our +general propositions. I have only mentioned the effects of physical +causes in a simple state[12]. + + [12] The doctrine of the influence of physical causes on morals is + happily calculated to beget charity towards the failings of our + fellow-creatures. Our duty to practise this virtue is enforced + by motives drawn from science, as well as from the precepts of + christianity. + +It might help to enlarge our ideas upon this subject, to take notice +of the influence of the different stages of society, of agriculture and +commerce, of soil and situation, of the different degrees of cultivation +of taste, and of the intellectual powers, of the different forms of +government, and lastly, of the different professions and occupations +of mankind, upon the moral faculty; but as these act indirectly only, +and by the intervention of causes that are unconnected with matter, +I conceive they are foreign to the business of the present inquiry. +If they should vary the action of the simple physical causes in any +degree, I hope it will not call in question the truth of our general +propositions, any more than the compound action of physical powers, that +are opposed to each other. There remain but a few more causes which are +of a compound nature, but they are so nearly related to those which +are purely mechanical, that I shall beg leave to trespass upon your +patience, by giving them a place in my oration. + +The effects of imitation, habit, and association upon morals, would +furnish ample matter for investigation. Considering how much the shape, +texture, and conditions of the human body, influence morals, I submit +it to the consideration of the ingenious, whether, in our endeavours +to imitate moral examples, some advantage may not be derived, from our +copying the features and external manners of the originals. What makes +the success of this experiment probable is, that we generally find men, +whose faces resemble each other, have the same manners and dispositions. +I infer the possibility of success in an attempt to imitate originals in +a manner that has been mentioned, from the facility with which domestics +acquire a resemblance to their masters and mistresses, not only in +manners, but in countenance, in those cases where they are tied to them +by respect and affection. Husbands and wives also, where they possess +the same species of face, under circumstances of mutual attachment, +often acquire a resemblance to each other. + +From the general detestation in which hypocrisy is held, both by good +and bad men, the mechanical effects of habit upon virtue have not been +sufficiently explored. There are, I am persuaded, many instances where +virtues have been assumed by accident, or necessity, which have become +real from habit, and afterwards derived their nourishment from the +heart. Hence the propriety of Hamlet's advice to his mother: + + "Assume a virtue, if you have it not. + That monster, Custom, who all sense doth eat + Of habits evil, is angel yet in this, + That to the use of actions fair and good + He likewise gives a frock or livery, + That aptly is put on. Refrain to-night, + And that shall lend a kind of easiness + To the next abstinence; the next more easy: + For use can almost change the stamp of nature, + And master even the devil, or throw him out, + With wondrous potency." + +The influence of ASSOCIATION upon morals, opens an ample field for +inquiry. It is from this principle, that we explain the reformation from +theft and drunkenness in servants, which we sometimes see produced by a +draught of spirits, in which tartar emetic had been secretly dissolved. +The recollection of the pain and sickness excited by the emetic, +naturally associates itself with the spirits, so as to render them both +equally the objects of aversion. It is by calling in this principle +only, that we can account for the conduct of Moses, in grinding the +golden calf into a powder, and afterwards dissolving it (probably by +means of hepar sulphuris) in water, and compelling the children of +Israel to drink of it, as a punishment for their idolatry. This mixture +is bitter and nauseating in the highest degree. An inclination to +idolatry, therefore, could not be felt without being associated with the +remembrance of this disagreeable mixture, and of course being rejected, +with equal abhorrence. The benefit of corporal punishments, when they +are of a short duration, depends in part upon their being connected, +by time and place, with the crimes for which they are inflicted. Quick +as the thunder follows the lightning, if it were possible, should +punishments follow the crimes, and the advantage of association would +be more certain, if the spot where they were committed, were made the +theatre of their expiation. It is from the effects of this association, +probably, that the change of place and company, produced by exile and +transportation, has so often reclaimed bad men, after moral, rational, +and physical means of reformation had been used to no purpose. + +As SENSIBILITY is the avenue to the moral faculty, every thing which +tends to diminish it tends also to injure morals. The Romans owed much +of their corruption to the sights of the contests of their gladiators, +and of criminals, with wild beasts. For these reasons, executions should +never be public. Indeed, I believe there are no public punishments of +any kind, that do not harden the hearts of spectators, and thereby +lessen the natural horror which all crimes at first excite in the human +mind. + +CRUELTY to brute animals is another means of destroying moral +sensibility. The ferocity of savages has been ascribed in part to their +peculiar mode of subsistence. Mr. Hogarth points out, in his ingenious +prints, the connection between cruelty to brute animals in youth, and +murder in manhood. The emperor Domitian prepared his mind, by the +amusement of killing flies, for all those bloody crimes which afterwards +disgraced his reign. I am so perfectly satisfied of the truth of a +connection between morals and humanity to brutes, that I shall find it +difficult to restrain my idolatry for that legislature, that shall first +establish a system of laws, to defend them from outrage and oppression. + +In order to preserve the vigour of the moral faculty, it is of the +utmost consequence to keep young people as ignorant as possible of those +crimes that are generally thought most disgraceful to human nature. +Suicide, I believe, is often propagated by means of newspapers. For this +reason, I should be glad to see the proceedings of our courts kept from +the public eye, when they expose or punish monstrous vices. + +The last mechanical method of promoting morality that I shall mention, +is to keep sensibility alive, by a familiarity with scenes of distress +from poverty and disease. Compassion never awakens in the human bosom, +without being accompanied by a train of sister virtues. Hence the wise +man justly remarks, that "By the sadness of the countenance, the heart +is made better." + +A late French writer, in his prediction of events that are to happen +in the year 4000, says, "That mankind in that æra shall be so far +improved by religion and government, that the sick and the dying shall +no longer be thrown, together with the dead, into splendid houses, but +shall be relieved and protected in a connection with their families +and society." For the honour of humanity, an institution[13], destined +for that distant period, has lately been founded in this city, that +shall perpetuate the year 1786 in the history of Pennsylvania. Here +the feeling heart, the tearful eye, and the charitable hand, may +always be connected together, and the flame of sympathy, instead of +being extinguished in taxes, or expiring in a solitary blaze by a +single contribution, may be kept alive, by constant exercise. There +is a necessary connection between animal sympathy, and good morals. +The priest and the Levite, in the New Testament, would probably have +relieved the poor man who fell among thieves, had accident brought them +near enough to his wounds. The unfortunate Mrs. Bellamy was rescued from +the dreadful purpose of drowning herself, by nothing but the distress of +a child, rending the air with its cries for bread. It is probably owing, +in some measure, to the connection between good morals and sympathy that +the fair sex, in every age and country, have been more distinguished +for virtue, than men; for how seldom do we hear of a woman, devoid of +humanity? + + [13] A public dispensary. + +Lastly, ATTRACTION, COMPOSITION, and DECOMPOSITION, belong to the +passions as well as to matter. Vices of the same species attract each +other with the most force: hence the bad consequences of crowding young +men, whose propensities are generally the same, under one roof, in our +modern plans of education. The effects of composition and decomposition +upon vices, appear in the meanness of the school-boy being often cured +by the prodigality of a military life, and by the precipitation of +avarice, which is often produced by ambition and love. + +If physical causes influence morals in the manner we have described, may +they not also influence religious principles and opinions? I answer in +the affirmative; and I have authority, from the records of physic, as +well as from my own observations, to declare, that religious melancholy +and madness, in all their variety of species, yield with more facility +to medicine, than simply to polemical discourses, or to casuistical +advice. But this subject is foreign to the business of the present +inquiry. + +From a review of our subject, we are led to contemplate with +admiration, the curious structure of the human mind. How distinct are +the number, and yet how united! How subordinate, and yet how co-equal +are all its faculties! How wonderful is the action of the mind upon the +body! of the body upon the mind! and of the Divine Spirit upon both! +What a mystery is the mind of man to itself!---- O! Nature!---- or, to +speak more properly, O! THOU GOD OF NATURE! in vain do we attempt to +scan THY immensity, or to comprehend THY various modes of existence, +when a single particle of light, issued from THYSELF, and kindled +into intelligence in the bosom of man, thus dazzles and confounds our +understandings! + +The extent of the moral powers and habits in man is unknown. It +is not improbable, but the human mind contains principles of virtue, +which have never yet been excited into action. We behold with surprise +the versatility of the human body in the exploits of tumblers and +rope-dancers. Even the agility of a wild beast has been demonstrated +in a girl of France, and an amphibious nature has been discovered in +the human species, in a young man in Spain. We listen with astonishment +to the accounts of the _memories_ of Mithridates, Cyrus, and Servin. +We feel a veneration bordering upon divine homage, in contemplating +the stupenduous _understandings_ of lord Verulam and sir Isaac Newton; +and our eyes grow dim, in attempting to pursue Shakespeare and Milton +in their immeasurable flights of _imagination_. And if the history +of mankind does not furnish similar instances of the versatility and +perfection of our species in virtue, it is because the moral faculty +has been the subject of less culture and fewer experiments than the +body, and the intellectual faculties of the mind. From what has been +said, the reason of this is obvious. Hitherto the cultivation of the +moral faculty has been the business of parents, schoolmasters, and +divines[14]. But if the principles, we have laid down, be just, the +improvement and extension of this principle should be equally the +business of the legislator, the natural philosopher, and the physician; +and a physical regimen should as necessarily accompany a moral +precept, as directions with respect to the air, exercise, and diet, +generally accompany prescriptions for the consumption, and the gout. To +encourage us to undertake experiments for the improvement of morals, +let us recollect the success of philosophy in lessening the number, +and mitigating the violence of incurable diseases. The intermitting +fever, which proved fatal to two of the monarchs of Britain, is now +under absolute subjection to medicine. Continual fevers are much less +fatal than formerly. The small-pox is disarmed of its mortality by +inoculation, and even the tetanus and the cancer have lately received +a check in their ravages upon mankind. But medicine has done more. It +has penetrated the deep and gloomy abyss of death, and acquired fresh +honours in his cold embraces. Witness the many hundred people who have +lately been brought back to life by the successful efforts of the humane +societies, which are now established in many parts of Europe, and in +some parts of America. Should the same industry and ingenuity, which +have produced these triumphs of medicine over diseases and death, be +applied to the moral science, it is highly probable, that most of those +baneful vices, which deform the human breast, and convulse the nations +of the earth, might be banished from the world. I am not so sanguine as +to suppose, that it is possible for man to acquire so much perfection +from science, religion, liberty, and good government, as to cease to +be mortal; but I am fully persuaded, that from the combined action of +causes, which operate at once upon the reason, the moral faculty, the +passions, the senses, the brain, the nerves, the blood, and the heart, +it is possible to produce such a change in his moral character, as shall +raise him to a resemblance of angels; nay, more, to the likeness of GOD +himself. The state of Pennsylvania still deplores the loss of a man, in +whom not only reason and revelation, but many of the physical causes +that have been enumerated, concurred to produce such attainments in +moral excellency, as have seldom appeared in a human being. This amiable +citizen considered his fellow-creature, man, as God's extract, from his +own works; and whether this image of himself was cut out from ebony or +copper; whether he spoke his own, or a foreign language; or whether +he worshipped his Maker with ceremonies, or without them, he still +considered him as a brother, and equally the object of his benevolence. +Poets and historians, who are to live hereafter, to you I commit his +panegyric; and when you hear of a law for abolishing slavery in each +of the American states, such as was passed in Pennsylvania, in the +year 1780; when you hear of the kings and queens of Europe, publishing +edicts for abolishing the trade in human souls; and, lastly, when you +hear of schools and churches, with all the arts of civilized life, being +established among the nations of Africa, then remember and record, +that this revolution in favour of human happiness, was the effect of +the labours, the publications, the private letters, and the prayers of +ANTHONY BENEZET[15]. + + [14] The people commonly called Quakers and the Methodists, make use of + the greatest number of physical remedies in their religious and + moral discipline, of any sects of Christians; and hence we find + them every where distinguished for their good morals. There are + several excellent _physical_ institutions in other churches; and + if they do not produce the same moral effects that we observe + from physical institutions among those two modern sects, it must + be ascribed to their being more neglected by the members of those + churches. + + [15] This worthy man was descended from an ancient and honourable family + that flourished in the court of Louis XIV. With liberal prospects + in life he early devoted himself to teaching an English school; + in which, for industry, capacity, and attention to the morals and + principles of the youth committed to his care, he was without an + equal. He published many excellent tracts against the African + trade, against war, and the use of spiritous liquors, and one in + favour of civilizing and Christianizing the Indians. He wrote + to the queen of Great Britain, and the queen of Portugal, to + use their influence in their respective courts to abolish the + African trade. He also wrote an affectionate letter to the king + of Prussia, to dissuade him from making war. The history of his + life affords a remarkable instance how much it is possible for + an individual to accomplish in the world; and that the most + humble stations do not preclude good men from the most extensive + usefulness. He bequeathed his estate (after the death of his + widow) to the support of a school for the education of negro + children, which he had founded and taught for several years + before he died. He departed this life in May, 1784, in the 71st + year of his age, in the meridian of his usefulness, universally + lamented by persons of all ranks and denominations. + +I return from this digression, to address myself in a particular +manner to you, VENERABLE SAGES and FELLOW CITIZENS in the REPUBLIC OF +LETTERS. The influence of philosophy, we have been told, has already +been felt in courts. To increase, and complete this influence, there +is nothing more necessary, than for the numerous literary societies in +Europe and America, to add the SCIENCE OF MORALS to their experiments +and inquiries. The godlike scheme of Henry IV, of France, and of the +illustrious queen Elizabeth, of England, for establishing a perpetual +peace in Europe, may be accomplished without a system of jurisprudence, +by a confederation of learned men, and learned societies. It is in +their power, by multiplying the objects of human reason, to bring the +monarchs and rulers of the world under their subjection, and thereby to +extirpate war, slavery, and capital punishments, from the list of human +evils. Let it not be suspected that I detract, by this declaration, +from the honour of the Christian religion. It is true, Christianity was +propagated without the aid of human learning; but this was one of those +miracles, which was necessary to establish it, and which, by repetition, +would cease to be a miracle. They misrepresent the Christian religion, +who suppose it to be wholly an internal revelation, and addressed +only to the moral faculties of the mind. The truths of Christianity +afford the greatest scope for the human understanding, and they will +become intelligible to us, only in proportion as the human genius is +stretched, by means of philosophy, to its utmost dimensions. Errors may +be opposed to errors; but truths, upon all subjects, mutually support +each other. And perhaps one reason why some parts of the Christian +revelation are still involved in obscurity, may be occasioned by our +imperfect knowledge of the phenomena and laws of nature. The truths of +philosophy and Christianity dwell alike in the mind of the Deity, and +reason and religion are equally the offspring of his goodness. They +must, therefore, stand and fall together. By reason, in the present +instance, I mean the power of judging of truth, as well as the power of +comprehending it. Happy æra! when the divine and the philosopher shall +embrace each other, and unite their labours for the reformation and +happiness of mankind! + +ILLUSTRIOUS COUNSELLORS and SENATORS of Pennsylvania[16]! I anticipate +your candid reception of this feeble effort to increase the quantity +of virtue in our republic. It is not my business to remind you of the +immense resources for greatness, which nature and Providence have +bestowed upon our state. Every advantage which France has derived from +being placed in the centre of Europe, and which Britain has derived from +her mixture of nations, Pennsylvania has opened to her. But my business, +at present, is to suggest the means of promoting the happiness, not the +greatness, of the state. For this purpose, it is absolutely necessary +that our government, which unites into one, all the minds of the state, +should possess, in an eminent degree, not only the understanding, the +passions, and the will, but, above all, the moral faculty and the +conscience of an individual. Nothing can be politically right, that +is morally wrong; and no necessity can ever sanctify a law, that is +contrary to equity. VIRTUE is the soul of a republic. To promote this, +laws for the suppression of vice and immorality will be as ineffectual, +as the increase and enlargement of jails. There is but one method of +preventing crimes, and of rendering a republican form of government +durable, and that is, by disseminating the seeds of virtue and knowledge +through every part of the state, by means of proper modes and places of +education, and this can be done effectually only by the interference and +aid of the legislature. I am so deeply impressed with the truth of this +opinion, that were this evening to be the last of my life, I would not +only say to the asylum of my ancestors, and my beloved native country, +with the patriot of Venice, "Esto perpetua," but I would add, as the +last proof of my affection for her, my parting advice to the guardians +of her liberties, "To establish and support PUBLIC SCHOOLS, in every +part of the state." + + [16] The president, and supreme executive council, and the members + of the general assembly of Pennsylvania, attended the delivery of + the oration, in the hall of the university, by invitation from + the Philosophical Society. + + + + + AN INQUIRY + + INTO THE + + CAUSES AND CURE + + OF THE + + _PULMONARY CONSUMPTION_. + + +In an essay, entitled "Thoughts on the Pulmonary Consumption[17]," I +attempted to show that this disease was the effect of causes which +induced general debility, and that the only hope of discovering a cure +for it should be directed to such remedies as act upon the whole system. +In the following inquiry, I shall endeavour to establish the truth of +each of those opinions, by a detail of facts and reasonings, at which I +only hinted in my former essay. + + [17] Vol. I. p. 199. + +The method I have chosen for this purpose, is to deliver, and +afterwards to support, a few general propositions. + +I shall begin by remarking, + +I. That the pulmonary consumption is induced by predisposing debility. + +This I infer, 1st, From the remote and exciting causes which produce +it. The remote causes are pneumony, catarrh, hæmoptysis, rheumatism, +gout, asthma, scrophula, chronic diseases of the stomach, liver, and +kidneys, nervous and intermitting fevers, measles, repelled humours from +the surface of the body, the venereal disease, obstructed menses, sudden +growth about the age of puberty, grief, and all other debilitating +passions of the mind; hypochondriasis, improper lactation, excessive +evacuation of all kinds, more especially by stool[18], cold and damp +air, a cough, external violence acting upon the body[19]; and finally, +every thing that tends, directly or indirectly, to diminish the strength +of the system. + + [18] Sir George Baker relates, in the second volume of the Medical + Transactions, that Dr. Blanchard had informed him, that he had + seen the consumption brought on ten persons out of ninety, by + excessive purging used to prepare the body for the small-pox. + I have seen a case of consumption in a youth of 17, from the + spitting produced by the intemperate use of segars. + + [19] Dr. Lind says, that out of 360 patients whom he attended between + July 1st, 1758, and July 1st, 1760, in consumptions, the disease + was brought on _one fourth_ of them by falls, bruises, and + strains, received a year or two before the disease made its + appearance. + +The most frequent exciting cause of consumption is the alternate +application of heat and cold to the whole external surface of the +body; but all the remote causes which have been enumerated, operate as +exciting causes of consumption, when they act on previous debility. +Original injuries of the lungs seldom excite this disease, except they +first induce a debility of the whole system, by a troublesome and +obstinate cough. + +2. From the debilitating occupations and habits of persons who are most +liable to this disease. These are studious men, and mechanics who lead +sedentary lives in confined places; also women, and all persons of +irritable habits, whether of body or mind. + +3. From the period in which persons are most liable to be affected by +this disease. This is generally between the 18th and 36th year of life, +a period in which the system is liable, in a peculiar manner, to most +diseases which induce it, and in which there is a greater expenditure of +strength, than in any other stage of life, by the excessive exercises of +the body and mind, in the pursuits of business or pleasure. + +I have conformed to authors, in fixing the period of consumptions +between the 18th and 36th year of life; but it is well known that it +sometimes appears in children, and frequently in persons beyond the +40th, or even 60th year of life. + +II. The pulmonary consumption is a primary disease of the _whole_ +system. This I infer, + +1. From the causes which produce it, acting upon the whole system. + +2. From the symptoms of general debility which always precede the +affection of the lungs. These symptoms are a quick pulse, especially +towards evening; a heat and burning in the palms of the hands; +faintness, head-ach, sickness at stomach, and an occasional diarrh[oe]a. +I have frequently observed each of these symptoms for several months +before I have heard of a single complaint in the breast. + +3. From the pulmonary consumption alternating with other diseases which +obviously belong to the whole system. I shall briefly mention these +diseases. + +The RHEUMATISM. I have seen many cases in which this disease and the +consumption have alternately, in different seasons or years, affected +the system. In the winter of 1792, three clinical patients in the +Pennsylvania hospital exemplified by their complaints the truth of this +observation. They were relieved several times of a cough by rheumatic +pains in their limbs, which seemed for a while to promise a cure to +their pulmonic complaints. + +The GOUT has often been observed to alternate with the pulmonary +consumption, especially in persons in the decline of life. Dr. Sydenham +describes a short cough continuing through the whole winter, as a +symptom of gouty habits. A gentleman from Virginia died under my care in +the spring of 1788, in the 45th year of his age, with all the symptoms +of pulmonary consumption, which had frequently alternated with pains and +a swelling in his feet. + +The pulmonary consumption has been observed to alternate with MADNESS. +Of this I have seen two instances, in both of which the cough and +expectoration were wholly suspended during the continuance of the +derangement of the mind. Dr. Mead mentions a melancholy case of the same +kind in a young lady, and similar cases are to be met with in other +authors. In all of them the disease proved fatal. In one of the cases +which came under my notice, the symptoms of consumption returned before +the death of the patient. + +I have likewise witnessed two cases in which the return of reason after +madness, was suddenly succeeded by a fatal pulmonary consumption. +Perhaps the false hopes, and even the cheerfulness which so universally +occur in this disease, may be resolved into a morbid state of the mind, +produced by a general derangement of the whole system. So universal are +the delusion and hopes of patients, with respect to the nature and issue +of this disease, that I have never met with but one man, who, upon being +asked what was the matter with him, answered unequivocally, "that he was +in a consumption." + +Again: Dr. Bennet mentions a case of "A phthisical patient, who was +seized with a violent PAIN IN THE TEETH for two days, and in whom, +during that time, every symptom of a consumption, except the leanness of +the body, altogether vanished:" and he adds further, "that a defluction +on the lungs had often been relieved by SALIVARY EVACUATIONS[20]." + + [20] Treatise of the Nature and Cure of Consumptions. Exercitation X. + +I have seen several instances in which the pulmonary symptoms have +alternated with HEADACH and DYSPEPSIA; also with pain and noise in one +EAR. This affection of the ears sometimes continues throughout the +whole disease, without any remission of the pulmonary symptoms. I have +seen one case of a discharge of matter from the left ear, without being +accompanied by either pain or noise. + +In all our books of medicine are to be found cases of consumption +alternating with ERUPTIONS ON THE SKIN. + +And who has not seen the pulmonary symptoms alternately relieved and +reproduced by the appearance or cessation of a diarrh[oe]a, or pains in +the BOWELS? + +To these facts I shall only add, under this head, as a proof of the +consumption being a disease of the whole system, that it is always +more or less relieved by the change which is induced in the system by +pregnancy. + +4. I infer that the pulmonary consumption is a disease of the whole +system from its analogy with several other diseases, which, though +accompanied by local affections, are obviously produced by a morbid +state of the whole system. + +The rheumatism, the gout, the measles, small-pox, the different species +of cynanche, all furnish examples of the connection of local affections +with a general disease; but the APOPLEXY, and the PNEUMONY, furnish the +most striking analogies of local affection, succeeding a general disease +of the system in the pulmonary consumption. + +The most frequent predisposing cause of apoplexy is a general debility +of the system, produced by intemperance in eating and drinking. The +phenomena of the disease are produced by an effusion of blood or serum, +in consequence of a morbid distension, or of a rupture of the vessels +of the brain. The pulmonary consumption begins and ends in the same +way, allowing only for the difference of situation and structure of the +brain and lungs. After the production of predisposing debility from +the action of the remote causes formerly enumerated, the fluids are +determined to the weakest part of the body. Hence effusions of serum +or blood take place in the lungs. When serum is effused, a pituitous +or purulent expectoration alone takes place; when blood is discharged, +a disease is produced which has been called hæmoptysis. An effusion of +blood in the brain, brought on by the operation of general debility, +has been called by Dr. Hoffman, with equal propriety, a hæmorrhage of +the brain. The effusion of blood in the lungs, in consequence of the +rupture of a blood-vessel, is less fatal than the same accident when it +occurs in the brain, only because the blood in the former case is more +easily discharged from the system. Where no rupture of a blood-vessel +is produced, death is nearly as speedy and certain in the one case as +in the other. Dissections show many cases of suffocation and death, +from the lungs being preternaturally filled with blood or serum. From +this great analogy between the remote and proximate causes of the two +diseases which have been described, I have taken the liberty to call +them both by the name of apoplexy. The only symptom which does not +accord with the derivation of the term, is, that in the apoplexy of the +lungs, the patient does not fall down as if by an external stroke, which +is most frequently the case in the apoplexy of the brain. + +The history of the remote and proximate causes of pneumony will furnish +us with a still more remarkable analogy of the connection between a +_local_ affection, and a _general_ disease of the system. The pneumony +is produced by remote exciting causes which act on the whole system. The +whole arterial system is frequently agitated by a fever in this disease +before a pain is perceived in the breast or sides, and this fever +generally constitutes its strength and danger. The expectoration which +terminates the disease in health, is always the effect of effusions +produced by a general disease, and even the vomicas, which sometimes +succeed a deficiency of bleeding, always depend upon the same general +cause. From this view of the analogy between pneumony and pulmonary +consumption, it would seem that the two diseases differed from each +other only by the shorter or longer operation of the causes which +induce them, and by the greater or less violence and duration of their +symptoms. The pneumony appears to be an _acute_ consumption, and the +consumption a _chronic_ pneumony. From the analogy of the pulmonary +consumption with the diminutive term of certain fevers, I have taken the +liberty of calling it a PNEUMONICULA. + +5. I infer that the pulmonary consumption is a disease of the whole +system, from its existence without ulcers in the lungs. Of this there +are many cases recorded in books of medicine. + +Dr. Leigh informs us, in his Natural History of Lancashire, that the +consumption was a very common disease on the sea coast of that country; +but that it was not accompanied either by previous inflammation or +ulcers in the lungs. It was generally attended, he says, by an unusual +peevishness of temper. + +6. I infer that the pulmonary consumption is a disease of the whole +system, from its being relieved, or cured, only by remedies which act +upon the whole system. This will appear, I hope, hereafter, when we come +to treat of the cure of this disease. + +Let us now enquire how far the principles I have laid down will apply +to the supposed causes of consumption. These causes have been said to +be, an abscess in the lungs, hæmoptysis, tubercles, without and with +ulcers, catarrh, hereditary diathesis, contagion, and the matter of +cutaneous eruptions, or sores repelled, and thrown upon the lungs. I +shall make a few observations upon each of them. + +1. An abscess in the lungs is generally the consequence of a neglected, +or half-cured pneumony. It is seldom fatal, where it is not connected +with a predisposition to consumption from general debility, or where +general debility is not previously induced by the want of appetite, +sleep, and exercise, which sometimes accompany that disease of the +lungs. This explanation of the production of consumption by an abscess +in the lungs, will receive further support from attending to the effects +of wounds in the lungs. How seldom are they followed by pulmonary +consumption; and this only because they are as seldom accompanied by +predisposing general debility. I do not recollect a single instance +of this disease having followed a wound in the lungs, either by the +bayonet, or a bullet, during our revolutionary war. The recoveries +which have succeeded such wounds, and frequently under the most +unfavourable circumstances, show how very improbable it is that a much +slighter affection of the lungs should become the cause of a pulmonary +consumption. + +A British officer, whom I met in the British camp, a few days after +the battle of Brandywine, in September, 1777, informed me that the +surgeon-general of the royal army had assured him, that out of +twenty-four soldiers who had been admitted into the hospitals, during +the campaign of 1776, with wounds in their lungs, twenty-three of +them had recovered. Even primary diseases of the lungs often exist +with peculiar violence, or continue for many years without inducing a +consumption. I have never known but one instance of the whooping-cough +ending in consumption, and all our books of medicine contain records of +the asthma continuing for twenty and thirty years without terminating +in that disease. The reason in both cases, must be ascribed to those +two original diseases of the lungs not being accompanied by general +debility. One fact more will serve to throw still further light upon +the subject. Millers are much afflicted with a cough from floating +particles of flour constantly irritating their lungs, and yet they are +not more subject to consumptions than other labouring people. Hence "a +miller's cough" is proverbial in some places, to denote a cough of long +continuance without danger. + +2. The hæmoptysis is either a local disease, or it is the effect +of general debility of the whole system. When it is local, or when +it is the effect of causes which induce a _temporary_ or _acute_ +debility only in the system, it is seldom followed by consumption. The +accidental discharge of blood from the lungs, from injuries, and from +an obstruction of the menses in women is of this kind. Many persons are +affected by this species of hæmorrhage once or twice in their lives, +without suffering any inconvenience from it afterwards. I have met with +several cases in which it has occurred for many years every time the +body was exposed to any of the causes which induce _sudden_ debility, +and yet no consumption has followed it. The late king of Prussia +informed Dr. Zimmerman that he had been frequently attacked by it during +his seven years war, and yet he lived, notwithstanding, above twenty +years afterwards without any pulmonary complaints. It is only in persons +who labour under _chronic_ debility, that a hæmoptysis is necessarily +followed by consumption. + +3. I yield to the popular mode of expression when I speak of a +consumption being produced by tubercles. But I maintain that they are +the _effects_ of general debility communicated to the bronchial vessels +which cause them to secrete a preternatural quantity of mucus. This +mucus is sometimes poured into the trachea from whence it is discharged +by hawking, more especially in the morning; for it is secreted more +copiously during the languid hours of sleep than in the day time. But +this mucus is frequently secreted into the substance of the lungs, where +it produces those tumours we call tubercles. When this occurs, there +is either no cough[21] or a very dry one. That tubercles are formed in +this way, I infer from the dissections and experiments of Dr. Stark[22], +who tells us, that he found them to consist of inorganic matter; that +he was unable to discover any connection between them and the pulmonary +vessels, by means of the microscope or injections; and that they first +opened into the trachea through the bronchial vessels. It is remarkable +that the colour and consistence of the matter of which they are +composed, is nearly the same as the matter which is discharged through +the trachea, in the moist cough which occurs from a relaxation of the +bronchial vessels, and which has been called by Dr. Beddoes a bronchial +gleet. + + [21] See Med. Com. Vol. II. + + [22] Clinical and Anatomical Observations, p. 26, 27. See also + Morgagni, letter xxii. 21. + +I am aware that these tumours in the lungs have been ascribed to +scrophula. But the frequent occurrence of consumptions in persons +in whom no scrophulous taint existed, is sufficient to refute this +opinion. I have frequently directed my inquiries after this disease +in consumptive patients, and have met with very few cases which were +produced by it. It is probable that it may frequently be a predisposing +cause of consumption in Great Britain, but I am sure it is not in +the United States. Baron Humboldt informed me, that the scrophula is +unknown in Mexico, and yet consumptions, he said, are very common in +that part of North-America. That tubercles are the effects, and not the +cause of pulmonary consumption, is further evident from similar tumours +being suddenly formed on the intestines by the dysentery, and on the +omentum by a yellow fever. Cases of the former are to be met with in the +dissections of Sir John Pringle, and one of the latter is mentioned by +Dr. Mackittrick, in his inaugural dissertation upon the yellow fever, +published in Edinburgh in the year 1766[23]. + + [23] Pages 7, 8. + +4. The catarrh is of two kinds, acute and chronic, both of which are +connected with general debility, but this debility is most obvious in +the chronic catarrh: hence we find it increased by every thing which +acts upon the whole system, such as cold and damp weather, fatigue, and, +above all, by old age, and relieved or cured by exercise, and every +thing else which invigorates the whole system. This species of catarrh +often continues for twenty or thirty years without inducing pulmonary +consumption, in persons who pursue active occupations. + +5. In the hereditary consumption there is either a hereditary debility +of the whole system, or a hereditary mal-conformation of the breast. In +the latter case, the consumption is the effect of weakness communicated +to the whole system, by the long continuance of difficult respiration, +or of such injuries being done to the lungs as are incompatible with +health and life. It is remarkable, that the consumptive diathesis is +more frequently derived from paternal, than maternal ancestors. + +6. Physicians, the most distinguished characters, have agreed, that +the pulmonary consumption may be communicated by contagion. Under the +influence of this belief, Morgagni informs us, that Valsalva, who was +predisposed to the consumption, constantly avoided being present at the +dissection of the lungs of persons who had died of that disease. In +some parts of Spain and Portugal, its contagious nature is so generally +believed, that cases of it are reported to the magistrates of those +countries, and the clothes of persons who die of it are burned by their +orders. The doctrine of nearly all diseases spreading by contagion, +required but a short and simple act of the mind, and favoured the +indolence and timidity which characterized the old school of medicine. I +adopted this opinion, with respect to the consumption, in the early part +of my life; but I have lately been led to call its truth in question, +especially in the unqualified manner in which it has been taught. In +most of the cases in which the disease has been said to be propagated +by contagion, its limits are always confined to the members of a single +family. Upon examination, I have found them to depend upon some one or +more of the following causes: + +1. Mal-conformation of the breast, in all the branches of the diseased +family. It is not necessary that this organic predisposition should be +hereditary. + +2. Upon the debility which is incurred by nursing, and the grief which +follows the loss of relations who die of it. + +3. Upon some local cause undermining the constitutions of a whole +family. This may be exhalations from a foul cellar, a privy, or a +neighbouring mill-pond, but of so feeble a nature as to produce debility +only, with an acute fever, and thus to render the consumption a kind of +family epidemic. I was consulted, in the month of August, 1793, by a Mr. +Gale, of Maryland, in a pulmonary complaint. He informed me, that he had +lost several brothers and sisters with the consumption, and that none of +his ancestors had died of it. The deceased persons, five in number, had +lived in a place that had been subject to the intermitting fever. + +4. Upon some peculiar and unwholesome article of diet, which exerts +slowly debilitating effects upon all the branches of a family. + +5. Upon a fearful and debilitating apprehension entertained by the +surviving members of a family, in which one or two have died of +consumption, that they shall perish by the same disease. The effects +of all the passions, and especially of fear, acted upon by a lively +imagination, in inducing determinations to particular parts of the body, +and subsequent disease, are so numerous, as to leave no doubt of the +operation of this cause, in producing a number of successive deaths in +the same family, from pulmonary consumption. + +In favour of its depending upon one or more of the above causes, I shall +add two remarks. + +1. There is often an interval of from two to ten years, between the +sickness and deaths which occur in families from consumptions, and +this we know never takes place in any disease which is admitted to be +contagious. + +2. The consumption is not singular in affecting several branches of +a family. I was lately consulted by a young physician from Maryland, +who informed me, that two of his brothers, in common with himself, +were afflicted with epilepsy. Madness, scrophula, and a disposition +to hæmorrhage, often affect, in succession, several branches of the +same family; and who will say that any one of the above diseases is +propagated by contagion? + +The practice of the Spaniards and Portuguese, in burning the clothes +of persons who die of consumptions, no more proves the disease to be +contagious, than the same acts sanctioned by the advice or orders of +public bodies in the United States, establish the contagious nature of +the yellow fever. They are, in both countries, marks of the superstition +of medicine. + +In suggesting these facts, and the inferences which have been drawn +from them, I do not mean to deny the possibility of the acrid and +f[oe]tid vapour, which is discharged by breathing from an ulcer or +abscess in the lungs, nor of the hectic sweats, when rendered putrid by +stagnating in sheets, or blankets, communicating this disease to persons +who are long exposed to them, by sleeping with consumptive patients; +but that such cases rarely occur I infer, from the persons affected +often living at a distance from each other, or when they live under the +same roof, having no intercourse with the sick. This was the case with +the black slaves, who were supposed to have taken the disease from the +white branches of a family in Connecticut, and which was mentioned, upon +the authority of Dr. Beardsley, in a former edition of this inquiry. +Admitting the above morbid matters now and then to act as a remote +cause of consumption, it does not militate against the theory I have +aimed to establish, for if it follow the analogy of common miasmata and +contagions, it must act by first debilitating the whole system. The +approach of the jail and bilious fevers is often indicated by general +languor. The influenza and the measles are always accompanied by general +debility, but the small-pox furnishes an analogy to the case in question +more directly in point. The contagion of this disease, whether received +by the medium of the air or the skin, never fails of producing weakness +in the whole system, before it discovers itself in affections of those +parts of the body on which the contagion produced its first operation. + +7. I grant that cutaneous humours, and the matter of old sores, when +repelled, or suddenly healed, have in some cases fallen upon the lungs, +and produced consumption. But I believe, in every case where this has +happened, the consumption was preceded by general debility, or that it +was not induced, until the whole system had been previously debilitated +by a tedious and distressing cough. + +If the reasonings founded upon the facts which have been mentioned be +just, then it follows, + +III. That the abscess, cough, tubercles, ulcers, and purulent or bloody +discharges which occur in the pulmonary consumption, are the _effects_, +and not the _causes_ of the disease; and, that all attempts to cure +it, by inquiring after tubercles and ulcers, or into the quality of +the discharges from the lungs, are as fruitless as an attempt would be +to discover the causes or cure of dropsies, by an examination of the +qualities of collections of water, or to find out the causes and cure of +fevers, by the quantity or quality of the discharges which take place +in those diseases from the kidneys and skin. It is to be lamented, that +it is not in pulmonary consumption only, that the effects of a disease +have been mistaken for its cause. Water in the brain, a membrane in +the trachea, and a preternatural secretion of bile, have been accused +of producing hydrocephalus internus, cynanche trachealis, and bilious +fever, whereas we now know they are the _effects_ of those diseases +only, in the successive order in which each of them has been mentioned. +It is high time to harness the steeds which drag the car of medicine +before, instead of behind it. The earth, in our science, has stood +still long enough. Let us at last believe, it revolves round its sun. +I admit that the cough, tubercles, and ulcers, after they are formed, +increase the danger of a consumption, by becoming new causes of stimulus +to the system, but in this they are upon a footing with the water, +the membrane, and the bile that have been alluded to, which, though +they constitute no part of the diseases that produce them, frequently +induce symptoms, and a termination of them, wholly unconnected with the +original disease. + +The tendency of general debility to produce a disease of the lungs +appears in many cases, as well as in the pulmonary consumption. Dr. Lind +tells us, that the last stage of the jail fever was often marked by a +cough. I have seldom been disappointed in looking for a cough and a +copious excretion of mucus and phlegm after the 14th or 15th days of the +slow nervous fever. Two cases of hypochondriasis under my care, ended +in fatal diseases of the lungs. The debility of old age is generally +accompanied by a troublesome cough, and the debility which precedes +death, generally discovers its last symptoms in the lungs. Hence most +people die with what are called the _rattles_. They are produced by a +sudden and copious effusion of mucus in the bronchial vessels of the +lungs. + +Sometimes the whole force of the consumptive fever falls upon the +trachea instead of the lungs, producing in it defluxion, a hawking +of blood, and occasionally a considerable discharge of blood, which +are often followed by ulcers, and a spitting of pus. I have called it +a _tracheal_, instead of a pulmonary consumption. Many people pass +through a long life with a mucous defluxion upon the trachea, and enjoy +in other respects tolerable health. In such persons the disease is of +a local nature. It is only when it is accompanied with debility of +the whole system, that it ends in a consumption. Mr. John Harrison, +of the Northern Liberties, died of this disease under my care, in the +year 1801, in consequence of the discharge of pus from an ulcer which +followed a hæmorrhage from the trachea being suddenly suppressed. I +have seen another case of the same kind in a lady in this city, in the +year 1797. Dr. Spence, of Dumfries, in Virginia, in a letter which I +received from him in June, 1805, describes a case then under his care, +of this form of consumption. He calls it, very properly, "phthisis +trachealis." I have met with two cases of death from this disease, in +which there were tubercles in the trachea. The patients breathed with +great difficulty, and spoke only in a whisper. One of them died from +suffocation. In the other, the tubercle bursted a few days before his +death, and discharged a large quantity of f[oe]tid matter. + +Should it be asked, why does general debility terminate by a disease +in the lungs and trachea, rather than in any other part of the body? I +answer, that it seems to be a law of the system, that general debility +should always produce some local disease. This local disease sometimes +manifests itself in dyspepsia, as in the general debility which follows +grief; sometimes it discovers itself in a diarrh[oe]a, as in the general +debility which succeeds to fear. Again it appears in the brain, as in +the general debility which succeeds intemperance, and the constant or +violent exercise of the understanding, or of stimulating passions; but +it more frequently appears in the lungs, as the consequence of general +debility. It would seem as if the debility in the cases of consumption +is seated chiefly in the blood-vessels, while that debility which +terminates in diseases of the stomach and bowels, is confined chiefly +to the nerves, and that the local affections of the brain arise from a +debility, invading alike the nervous and arterial systems. What makes it +more probable that the arterial system is _materially_ affected in the +consumption is, that the disease most frequently occurs in those periods +of life, and in those habits in which a peculiar state of irritability +or excitability is supposed to be present in the arterial system; also +in those climates in which there are the most frequent vicissitudes in +the temperature of the weather. It has been observed, that the debility +in the inhabitants of the West-Indies, whether produced by the heat of +the climate or the excessive pursuits of business or pleasure, generally +terminates in dropsy, or in some disease of the alimentary canal. + +I have said, that it seemed to be a law of the system, that general +debility should always produce some local affection. But to this law +there are sometimes exceptions: the atrophy appears to be a consumption +without an affection of the lungs. This disease is frequently mentioned +by the writers of the 16th and 17th centuries by the name of tabes. I +have seen several instances of it in adults, but more in children, and +a greater number in the children of black than of white parents. The +hectic fever, and even the night sweats, were as obvious in several +of these cases, as in those consumptions where general debility had +discovered itself in an affection of the lungs. + +I come now to make a few observations upon the CURE of consumption; +and here I hope it will appear, that the theory which I have delivered +admits of an early and very important application to practice. + +If the consumption be preceded by general debility, it becomes us to +attempt the cure of it before it produce the active symptoms of cough, +bloody or purulent discharges from the lungs, and inflammatory or +hectic fever. The symptoms which mark its first stage, are too seldom +observed; or if observed, they are too often treated with equal neglect +by patients and physicians. I shall briefly enumerate these symptoms. +They are a slight fever increased by the least exercise; a burning and +dryness in the palms of the hands, more especially towards evening; +rheumy eyes upon waking from sleep; an increase of urine; a dryness of +the skin, more especially of the feet in the morning[24]; an occasional +flushing in one, and sometimes in both cheeks; a hoarseness[25]; a +slight or acute pain in the breast; a fixed pain in one side, or +shooting pains in both sides; head-ache; occasional sick and fainty +fits; a deficiency of appetite, and a general indisposition to exercise +or motion of every kind. + + [24] The three last-mentioned symptoms are taken notice of by Dr. + Bennet, in his Treatise upon the Nature and Cure of the + Consumption, as _precursors_ of the disease. Dr. Boerhaave used + to tell his pupils that they had never deceived him. + + [25] I have seen the _hoarseness_ in one case the first symptom of + approaching consumption. In this symptom it preserves the + analogy of pneumony, which often comes on with a hoarseness, and + sometimes with paraphonia. + +It would be easy for me to mention cases in which every symptom that +has been enumerated has occurred within my own observation. I wish them +to be committed to memory by young practitioners; and if they derive the +same advantages from attending to them, which I have done, I am sure +they will not regret the trouble they have taken for that purpose. It +is probable, while a morbid state of the lungs is supposed to be the +proximate cause of this disease, they will not derive much reputation or +emolument from curing it in its forming stage; but let them remember, +that in all attempts to discover the causes and cures of diseases, which +have been deemed incurable, a physician will do nothing effectual until +he acquire a perfect indifference to his own interest and fame. + +The remedies for consumption, in this stage of the disease, are simple +and certain. They consist in a desertion of all the remote and exciting +causes of the disorder, particularly sedentary employments, damp or cold +situations, and whatever tends to weaken the system. When the disease +has not yielded to this desertion of its remote and exciting causes, +I have recommended the _cold bath_, _steel_, and _bark_ with great +advantage. However improper, or even dangerous, these remedies may be +after the disease assumes an inflammatory or hectic type, and produces +an affection of the lungs, they are perfectly safe and extremely useful +in the state of the system which has been described. The use of the bark +will readily be admitted by all those practitioners who believe the +pulmonary consumption to depend upon a scrophulous diathesis. Should +even the lungs be affected by scrophulous tumours, it is no objection +to the use of the bark, for there is no reason why it should not be +as useful in scrophulous tumours of the lungs, as of the glands of +the throat, provided it be given before those tumours have produced +inflammation; and in this case, no prudent practitioner will ever +prescribe it in scrophula, when seated even in the external parts of the +body. To these remedies should be added a diet moderately stimulating, +and gentle exercise. I shall hereafter mention the different species of +exercise, and the manner in which each of them should be used, so as +to derive the utmost advantage from them. I can say nothing of the use +of salt water or sea air in this stage of the consumption, from my own +experience. I have heard them commended by a physician of Rhode-Island; +and if they be used before the disease has discovered itself in +pulmonary affections, I can easily conceive they may do service. + +If the simple remedies which have been mentioned have been neglected, in +the first stage of the disease, it generally terminates, in different +periods of time, in pulmonary affections, which show themselves under +one of the three following forms: + +1. A fever, accompanied by a cough, a hard pulse, and a discharge of +blood, or mucous matter from the lungs. + +2. A fever of the hectic kind, accompanied by chilly fits, and night +sweats, and a pulse full, quick, and occasionally hard. The discharges +from the lungs, in this state of the disease, are frequently purulent. + +3. A fever with a weak frequent pulse, a troublesome cough, and copious +purulent discharges from the lungs, a hoarse and weak voice, and chilly +fits and night sweats alternating with a diarrh[oe]a. + +From this short history of the symptoms of pulmonary consumption there +are occasional deviations. I have seen four cases, in which the pulse +was natural, or slower than natural, to the last day of life. Mrs. +Rebecca Smith, the lovely and accomplished wife of Mr. Robert Smith, +of this city, passed through the whole course of this disease, in the +year 1802, without a single chilly fit. Two other cases have come under +my notice, in which there was not only an absence of chills, but of +fever and night sweats. A similar case is recorded in the Memoirs of +the Medical Society of London; and lastly, I have seen two cases which +terminated fatally, in which there was neither cough nor fever for +several months. One of them was in Miss Mary Loxley, the daughter of +the late Mr. Benjamin Loxley, in the year 1785. She had complained of +a pain in her right side, and had frequent chills with a fever of the +hectic kind. They all gave way to frequent and gentle bleedings. In the +summer of 1786, she was seized with the same complaints, and as she had +great objections to bleeding, she consulted a physician who gratified +her, by attempting to cure her by recommending exercise and country air. +In the autumn she returned to the city, much worse than when she left +it. I was again sent for, and found her confined to her bed with a pain +in her right side, but without the least cough or fever. Her pulse was +preternaturally slow. She could lie only on her left side. She sometimes +complained of acute flying pains in her head, bowels, and limbs. About +a month before her death, which was on the 3d of May, 1787, her pulse +became quick, and she had a little hecking cough, but without any +discharge from her lungs. Upon my first visit to her in the preceding +autumn, I told her friends that I believed she had an abscess in her +lungs. The want of fever and cough afterwards, however, gave me reason +to suspect that I had been mistaken. The morning after her death, I +received a message from her father, informing me that it had been among +the last requests of his daughter, that the cause of her death should be +ascertained, by my opening her body. I complied with this request, and, +in company with Dr. Hall, examined her thorax. We found the left lobe +of the lungs perfectly sound; the right lobe adhered to the pleura, in +separating of which, Dr. Hall plunged his hand into a large sac, which +contained about half a pint of purulent matter, and which had nearly +destroyed the whole substance of the right lobe of the lungs. + +I have never seen a dry tongue in any of the forms or stages of this +disease. + +The three different forms of the pulmonary affection that I have +mentioned, have been distinguished by the names of the first, second, +and third stages of the consumption; but as they do not always succeed +each other in the order in which they have been mentioned, I shall +consider them as different states of the system. + +The first I shall call the INFLAMMATORY, the second the HECTIC, and the +third the TYPHUS state. I have seen the pulmonary consumption come on +sometimes with all the symptoms of the second, and sometimes with most +of the symptoms of the third state; and I have seen two cases in which +a hard pulse, and other symptoms of inflammatory action, appeared in +the last hours of life. It is agreeable to pursue the analogy of this +disease with a pneumony, or an acute inflammation of the lungs. They +both make their first appearance in the same seasons of the year. It is +true, the pneumony most frequently attacks with inflammatory symptoms; +but it sometimes occurs with symptoms which forbid blood-letting, and +I have more than once seen it attended by symptoms which required the +use of wine and bark. The pneumony is attended at first by a dry cough, +and an expectoration of streaks of blood; the cough in the consumption, +in like manner, is at first dry, and attended by a discharge of blood +from the lungs, which is more copious than in the pneumony, only because +the lungs are more relaxed in the former than in the latter disease. +There are cases of pneumony in which no cough attends. I have just now +mentioned that I had seen the absence of that symptom in pulmonary +consumption. + +The pneumony terminates in different periods, according to the degrees +of inflammation, or the nature of the effusions which take place in the +lungs: the same observation applies to the pulmonary consumption. The +symptoms of the different forms of pneumony frequently run into each +other; so do the symptoms of the three forms of consumption which have +been mentioned. In short, the pneumony and consumption are alike in +so many particulars, that they appear to resemble shadows of the same +substance. They differ only as the protracted shadow of the evening does +from that of the noon-day sun. + +I know that it will be objected here that the consumption is sometimes +produced by scrophula, and that this creates an essential difference +between it and pneumony. I formerly admitted scrophula to be one of +the _remote_ causes of the consumption; but this does not invalidate +the parallel which has been given of the two diseases. The phenomena +produced in the lungs are the same as to their nature, whether they be +produced by the remote cause of scrophula, or by the sudden action of +cold and heat upon them. + +No more happens in the cases of acute and chronic pneumony, than what +happens in dysentery and rheumatism. These two last diseases are for +the most part so acute, as to confine the patient to his bed or his +room, yet we often meet with both of them in patients who go about their +ordinary business, and, in some instances, carry their diseases with +them for two or three years. + +The parallel which has been drawn between the pneumony and +consumption, will enable us to understand the reason why the latter +disease terminates in such different periods of time. The less it +partakes of pneumony, the longer it continues, and vice versa. What +is commonly called in this country a _galloping_ consumption, is a +disease compounded of different degrees of consumption and pneumony. It +terminates frequently in two or three months, and without many of the +symptoms which usually attend the last stage of pulmonary consumption. +But there are cases in which patients in a consumption are suddenly +snatched away by an attack of pneumony. I have met with one case only, +in which, contrary to my expectation, the patient mended after an +attack of an acute inflammation of the lungs, so as to live two years +afterwards. + +It would seem from these facts, as if nature had preferred a certain +gradation in diseases, as well as in other parts of her works. There is +scarcely a disease in which there is not a certain number of grades, +which mark the distance between health and the lowest specific deviation +from it. Each of these grades has received different names, and has +been considered as a distinct disease, but more accurate surveys of the +animal economy have taught us, that they frequently depend upon the same +original causes, and that they are only greater or less degrees of the +same disease. + +I shall now proceed to say a few words upon the cure of the different +states of pulmonary consumption. The remedies for this purpose are +of two kinds, viz. PALLIATIVE and RADICAL. I shall first mention the +palliative remedies which belong to each state, and then mention those +which are alike proper in them all. The palliative remedies for the + +I. Or INFLAMMATORY STATE, are + +I. BLOOD-LETTING. It may seem strange to recommend this debilitating +remedy in a disease brought on by debility. Were it proper in this +place, I could prove that there is no disease in which bleeding is +prescribed, which is not induced by predisposing debility, in common +with the pulmonary consumption. I shall only remark here, that in +consequence of the exciting cause acting upon the system (rendered +extremely excitable by debility) such a morbid and excessive excitement +is produced in the arteries, as to render a diminution of the stimulus +of the blood absolutely necessary to reduce it. I have used this remedy +with great success, in every case of consumption attended by a hard +pulse, or a pulse rendered weak by a laborious transmission of the blood +through the lungs. In the months of February and March, in the year +1781, I bled a Methodist minister, who was affected by this state of +consumption, fifteen times in the course of six weeks. The quantity of +blood drawn at each bleeding was never less than eight ounces, and it +was at all times covered with an inflammatory crust. By the addition of +country air, and moderate exercise, to this copious evacuation, in the +ensuing spring he recovered his health so perfectly, as to discharge all +the duties of his profession for many years, nor was he ever afflicted +afterwards with a disease in his breast. I have, in another instance, +bled a citizen of Philadelphia eight times in two weeks, in this state +of consumption, and with the happiest effects. The blood drawn at each +bleeding was always sizy, and never less in quantity than ten ounces. +Mr. Tracey of Connecticut informed me, in the spring of 1802, that +he had been bled eighty-five times in six months, by order of his +physician, Dr. Sheldon, in the inflammatory state of this disease. He +ascribed his recovery chiefly to this frequent use of the lancet. To +these cases I might add many others of consumptive persons who have +been perfectly cured by frequent, and of many others whose lives have +been prolonged by occasional bleedings. But I am sorry to add, that I +could relate many more cases of consumptive patients, who have died +martyrs to their prejudices against the use of this invaluable remedy. +A common objection to it is, that it has been used without success in +this disease. When this has been the case, I suspect that it has been +used in one of the other two states of pulmonary consumption which have +been mentioned, for it has unfortunately been too fashionable among +physicians to prescribe the same remedies in every stage and form of the +same disease, and this I take to be the reason why the same medicines, +which, in the hands of some physicians, are either inert or instruments +of mischief, are, in the hands of others, used with more or less +success in every case in which they are prescribed. Another objection +to bleeding in the inflammatory state of consumption, is derived from +the apparent and even sensible weakness of the patient. The men who +urge this objection, do not hesitate to take from sixty to a hundred +ounces of blood from a patient in a pneumony, in the course of five or +six days, without considering that the debility in the latter case is +such as to confine a patient to his bed, while, in the former case, the +patient's strength is such as to enable him to walk about his house, +and even to attend to his ordinary business. The difference between the +debility in the two diseases, consists in its being _acute_ in the one, +and _chronic_ in the other. It is true, the preternatural or convulsive +excitement of the arteries is somewhat greater in the pneumony, than in +the inflammatory consumption; but the plethora, on which the necessity +of bleeding is partly founded, is certainly greater in the inflammatory +consumption than in pneumony. This is evident from women, and even +nurses, discharging from four to six ounces of menstrual blood every +month, while they are labouring with the most inflammatory symptoms +of the disease; nor is it to be wondered at, since the appetite is +frequently unimpaired, and the generation of blood continues to be the +same as in perfect health. + +Dr. Cullen recommends the use of bleeding in consumptions, in order +to lessen the inflammation of the ulcers in the lungs, and thereby to +dispose them to heal. From the testimonies of the relief which bleeding +affords in external ulcers and tumours accompanied by inflammation, +I am disposed to expect the same benefit from it in inflamed ulcers +and tumours in the lungs: whether, therefore, we adopt Dr. Cullen's +theory of consumption, and treat it as a local disease, or assent to +the one which I have delivered, repeated bleedings appear to be equally +necessary and useful. + +I have seen two cases of inflammatory consumption, attended by a +hæmorrhage of a quart of blood from the lungs. I agreed at first with +the friends of these patients in expecting a rapid termination of +their disease in death, but to the joy and surprise of all connected +with them, they both recovered. I ascribed their recovery wholly to +the inflammatory action of their systems being suddenly reduced by a +spontaneous discharge of blood. These facts, I hope, will serve to +establish the usefulness of blood-letting in the inflammatory state of +consumption, with those physicians who are yet disposed to trust more to +the fortuitous operations of nature, than to the decisions of reason and +experience. + +I have always found this remedy to be more necessary in the winter and +first spring months, than at any other season. We obtain by means of +repeated bleedings, such a mitigation of all the symptoms as enables the +patient to use exercise with advantage as soon as the weather becomes so +dry and settled, as to admit of his going abroad every day. + +The relief obtained by bleeding, is so certain in this state of +consumption, that I often use it as a palliative remedy, where I do not +expect it will perform a cure. I was lately made happy in finding, that +I am not singular in this practice. Dr. Hamilton, of Lynn Regis, used it +with success in a consumption, which was the effect of a most deplorable +scrophula, without entertaining the least hope of its performing a +cure[26]. In those cases where inflammatory action attends the last +scene of the disease, there is often more relief obtained by a little +bleeding than by the use of opiates, and it is always a more humane +prescription, in desperate cases, than the usual remedies of vomits and +blisters. + + [26] Observations on Scrophulous Affections. + +I once bled a sea captain, whom I had declared to be within a few +hours of his dissolution, in order to relieve him of uncommon pain, +and difficulty in breathing. His pulse was at the same time hard. The +evacuation, though it consisted of but four ounces of blood, had the +wished for effect, and his death, I have reason to believe, was rendered +more easy by it. The blood, in this case, was covered with a buffy coat. + +The quantity of blood drawn in every case of inflammatory consumption, +should be determined by the force of the pulse, and the habits of the +patient. I have seldom taken more than eight, but more frequently but +six ounces at a time. It is much better to repeat the bleeding once or +twice a week, than to use it less frequently, but in larger quantities. + +From many years experience of the efficacy of bleeding in this state +of consumption, I feel myself authorised to assert, that where a +greater proportion of persons die of consumption when it makes its +first appearance in the lungs, with symptoms of inflammatory diathesis, +than die of ordinary pneumonies (provided exercise be used afterwards), +it must, in nine cases out of ten, be ascribed to the ignorance, or +erroneous theories of physicians, or to the obstinacy or timidity of +patients. + +In speaking thus confidently of the necessity and benefits of bleeding +in the inflammatory state of consumption, I confine myself to +observations made chiefly in the state of Pennsylvania. It is possible +the inhabitants of European countries and cities, may so far have passed +the simple ages of inflammatory diseases, as never to exhibit those +symptoms on which I have founded the indication of blood-letting. I +suspect moreover that in most of the southern states of America, the +inflammatory action of the arterial system is of too transient a nature +to admit of the repeated bleedings in the consumption which are used +with so much advantage in the middle and northern states. + +In reviewing the prejudices against this excellent remedy in +consumptions, I have frequently wished to discover such a substitute +for it as would with equal safety and certainty take down the morbid +excitement, and action of the arterial system. At present we know of no +such remedy; and until it be discovered, it becomes us to combat the +prejudices against bleeding; and to derive all the advantages from it +which have been mentioned. + +2. A second remedy for the inflammatory state of consumption should +be sought for in a MILK and VEGETABLE DIET. In those cases where the +milk does not lie easy on the stomach, it should be mixed with water, +or it should be taken without its cheesy or oily parts, as in whey, +or butter-milk, or it should be taken without skimming; for there are +cases in which milk will agree with the stomach in this state, and in +no other. The oil of the milk probably helps to promote the solution of +its curds in the stomach. It is seldom in the power of physicians to +prescribe ass' or goat's milk in this disease; but a good substitute +may be prepared for them by adding to cow's milk a little sugar, and a +third or fourth part of water, or of a weak infusion of green tea. The +quantity of milk taken in a day should not exceed a pint, and even less +than that quantity when we wish to lessen the force of the pulse by the +abstraction of nourishment. The vegetables which are eaten in this state +of the disease, should contain as little stimulus as possible. Rice, +in all the ways in which it is usually prepared for aliment, should +be preferred to other grains, and the less saccharine fruits to those +which abound with sugar. In those cases where the stomach is disposed +to dyspepsia, a little salted meat, fish, or oysters, also soft boiled +eggs, may be taken with safety, mixed with vegetable aliment. Where +there is no morbid affection of the stomach, I have seen the white meats +eaten without increasing the inflammatory symptoms of the disease. The +transition from a full diet to milk and vegetables should be gradual, +and the addition of animal to vegetable aliment, should be made with the +same caution. From the neglect of this direction, much error, both in +theory and practice, has arisen in the treatment of consumptions. + +In every case it will be better for the patient to eat four or five, +rather than but two or three meals in a day. A less stimulus is by this +means communicated to the system, and less chyle is mixed with the blood +in a given time. Of so much importance do I conceive this direction to +be, that I seldom prescribe for a chronic disease of any kind without +enforcing it. + +3. VOMITS have been much commended by Dr. Read in this disease. From +their indiscriminate use in every state of consumption, I believe they +have oftener done harm than good. In cases where a patient objects to +bleeding, or where a physician doubts of its propriety, vomits may +always be substituted in its room with great advantage. They are said to +do most service when the disease is the effect of a catarrh. + +4. NITRE, in moderate doses of ten or fifteen grains, taken three or +four times a day, has sometimes been useful in this disease; but it has +been only when the disease has appeared with inflammatory symptoms. Care +should be taken not to persevere too long in the use of this remedy, +as it is apt to impair the appetite. I have known one case in which it +produced an obstinate dyspepsia, and a disposition to the colic; but it +removed, at the same time, the symptoms of pulmonary consumption. + +5. COLD and DRY AIR, when combined with the exercise of _walking_, +deserves to be mentioned as an antiphlogistic remedy. I have repeatedly +prescribed it in this species of the consumption with advantage, and +have often had the pleasure of finding a single walk of two or three +miles in a clear cold day, produce nearly the same diminution of the +force and frequency of the pulse, as the loss of six or eight ounces of +blood. + +I come now to treat of the palliative remedies which are proper in the + +II. Or HECTIC STATE of consumption. Here we begin to behold the disease +in a new and more distressing form than in the state which has been +described. There is in this state of consumption the same complication +of inflammatory and typhus diathesis which occurs in the typhoid and +puerperile fevers, and of course the same difficulty in treating it +successfully; for the same remedies do good and harm, according as the +former or latter diathesis prevails in the system. + +All that I shall say upon this state is, that the treatment of it +should be accommodated to the predominance of inflammatory or typhus +symptoms, for the hectic state presents each of them alternately every +week, and sometimes every day to the hand, or eye of a physician. When a +hard pulse with acute pains in the side and breast occur, bleeding and +other remedies for the inflammatory state must be used; but when the +disease exhibits a predominance of typhus symptoms, the remedies for +that state to be mentioned immediately, should be prescribed in moderate +doses. There are several palliative medicines which have been found +useful in the hectic state, but they are such as belong alike to the +other two states; and therefore will be mentioned hereafter in a place +assigned to them. + +I am sorry, however, to add, that where bleeding has not been indicated, +I have seldom been able to afford much relief by medicine in this +state of consumption. I have used alternately the most gentle, and +the most powerful vegetable and metallic tonics to no purpose. Even +arsenic has failed in my hands of affording the least alleviation of +the hectic fever. I conceive the removal of this fever to be the great +desideratum in the cure of consumption; and should it be found, after +all our researches, to exist only in exercise, it will be no departure +from a law of nature, for I believe there are no diseases produced by +equal degrees of chronic debility, in which medicines are of any more +efficacy, than they are in the hectic fever of the pulmonary consumption. + +I proceed now to speak of the palliative remedies which are proper in the + +III. Or TYPHUS STATE of the pulmonary consumption. + +The first of these are STIMULATING MEDICINES. However just the +complaints of Dr. Fothergill may be against the use of balsams in the +inflammatory and mixed states of consumption, they appear to be not only +safe, but useful likewise, in mitigating the symptoms of weak morbid +action in the arterial system. I have therefore frequently prescribed +opium, the balsam of copaivæ, of Peru, the oil of amber, and different +preparations of turpentine and tar, in moderate doses, with obvious +advantage. Garlic, elixir of vitriol, the juice of dandelion, a strong +tea made of horehound, and a decoction of the inner bark of the wild +cherry tree[27], also bitters of all kinds, have all been found safe +and useful tonics in this state of consumption. Even the Peruvian bark +and the cold bath, so often and so generally condemned in consumptions, +are always innocent, and frequently active remedies, where there is +a total absence of inflammatory diathesis in this disease. The bark +is said to be most useful when the consumption is the consequence of +an intermitting fever, and when it occurs in old people. With these +remedies should be combined + +2. A CORDIAL and STIMULATING DIET. Milk and vegetables, so proper +in the inflammatory, are improper, when taken alone, in this state of +consumption. I believe they often accelerate that decay of appetite +and diarrh[oe]a, which form the closing scene of the disease. I have +lately seen three persons recovered from the lowest stage of this +state of consumption, by the use of animal food and cordial drinks, +aided by frequent doses of opium, taken during the day as well as in +the night. I should hesitate in mentioning these cures, had they not +been witnessed by more than a hundred students of medicine in the +Pennsylvania hospital. The history of one of them is recorded in the 5th +volume of the New-York Medical Repository, and of the two others in Dr. +Coxe's Medical Museum. Oysters, it has been said, have performed cures +of consumption. If they have, it must have been only when they were +eaten in that state of it which is now under consideration. They are +a most savoury and wholesome article of diet, in all diseases of weak +morbid action. To the cordial articles of diet belong sweet vegetable +matters. Grapes, sweet apples, and the juice of the sugar maple tree, +when taken in large quantities, have all cured this disease. They all +appear to act by filling the blood-vessels, and thereby imparting tone +to the whole system. I have found the same advantage from dividing the +meals in this state of consumption, that I mentioned under a former +head. The exhibition of food in this case, should not be left to the +calls of appetite, any more than the exhibition of a medicine. Indeed +food may be made to supply the place of cordial medicines, by keeping +up a constant and gentle action in the whole system. For this reason, +I have frequently advised my patients never to suffer their stomachs +to be empty, even for a single hour. I have sometimes aimed to keep up +the influence of a gentle action in the stomach upon the whole system, +by advising them to eat in the night, in order to obviate the increase +of secretion into the lungs and of the cough in the morning, which are +brought on in part by the increase of debility from the long abstraction +of the stimulus of aliment during the night. + + [27] Prunus Virginiana. + +However safe, and even useful, the cordial medicines and diet that have +been mentioned may appear, yet I am sorry to add, that we seldom see any +other advantages from them than a mitigation of distressing symptoms, +except when they have been followed by suitable and long continued +exercise. Even under this favourable circumstance, they are often +ineffectual; for there frequently occurs, in this state of consumption, +such a destruction of the substance and functions of the lungs, as to +preclude the possibility of a recovery by the use of any of the remedies +which have been discovered. Perhaps, where this is not the case, their +want of efficacy may be occasioned by their being given before the +pulse is completely reduced to a typhus state. The weaker the pulse, +the greater is the probability of benefit being derived from the use of +cordial diet and medicines. + +I have said formerly, that the three states of consumption do not +observe any regular course in succeeding each other. They are not only +complicated in some instances, but they often appear and disappear half +a dozen times in the course of the disease, according to the influence +of the weather, dress, diet, and the passions upon the system. The great +secret, therefore, of treating this disease consists in accommodating +all the remedies that have been mentioned to the predominance of any +of the three different states of the system, as manifested chiefly by +the pulse. It is in consequence of having observed the evils which +have resulted from the ignorance or neglect of this practice, that I +have sometimes wished that it were possible to abolish the seducing +nomenclature of diseases altogether, in order thereby to oblige +physicians to conform exactly to the fluctuating state of the system +in all their prescriptions; for it is not more certain, that, in all +cultivated languages, every idea has its appropriate word, than that +every state of a disease has its appropriate dose of medicine, the +knowledge and application of which can alone constitute rational, or +secure uniformly successful practice. + +I come now to say a few words upon those palliative remedies which are +alike proper in every state of the pulmonary consumption. + +The first remedy under this head is a DRY SITUATION. A damp air, whether +breathed in a room, or out of doors, is generally hurtful in every +form of this disease. A kitchen, or a bed-room, below the level of the +ground, has often produced, and never fails to increase, a pulmonary +consumption. I have often observed a peculiar paleness (the first +symptom of general debility) to show itself very early in the faces of +persons who work or sleep in cellar kitchens or shops. + +2. COUNTRY AIR. The higher and drier the situation which is chosen +for the purpose of enjoying the benefit of this remedy, the better. +Situations exposed to the sea, should be carefully avoided; for it is +a singular fact, that while consumptive persons are benefited by the +sea-air, when they breathe it on the ocean, they are always injured by +that portion of it which they breathe on the sea-shore. To show its +influence, not only in aggravating consumptions, but in disposing to +them, and in adding to the mortality of another disease of the lungs, I +shall subjoin the following facts. From one fourth to one half of all +the adults who die in Great Britain, Dr. Willan says, perish with this +disease. In Salem, in the state of Massachusetts, which is situated +near the sea, and exposed, during many months in the year, to a moist +east wind, there died, in the year 1799, one hundred and sixty persons; +fifty-three died of the consumption, making in all nearly one third of +all the inhabitants of the town. Eight more died of what is called a +lung fever, probably of what is called in Pennsylvania the galloping +grade of that disease. Consumptions are more frequent in Boston, +Rhode-Island, and New-York, from their damp winds, and vicinity to +the sea-shore, than they are in Philadelphia. In the neighbourhood of +Cape May, which lies near the sea-shore of New-Jersey, there are three +religious societies, among whom the influenza prevailed in the year +1790. Its mortality, under equal circumstances, was in the exact ratio +to their vicinity to the sea. The deaths were most numerous in that +society which was nearest to it, and least so in that which was most +remote from it. These unfriendly effects of the sea air, in the above +pulmonary diseases, do not appear to be produced simply by its moisture. +Consumptions are scarcely known in the moist atmosphere which so +generally prevails in Lincolnshire, in England, and in the inland parts +of Holland and Ireland. + +I shall not pause to inquire, why a mixture of land and sea air is so +hurtful in the consumption, and at the same time so agreeable to persons +in health, and so medicinal in many other diseases, but shall dismiss +this head by adding a fact which was communicated to me by Dr. Matthew +Irvine, of South-Carolina, and that is, That those situations which +are in the neighbourhood of bays or rivers, where the salt and fresh +waters mix their streams together, are more unfavourable to consumptive +patients than the sea-shore, and therefore should be more carefully +avoided by them in exchanging city for country air. + +3. A CHANGE OF CLIMATE. It is remarkable that climates uniformly cold +or warm, which seldom produce consumptions, are generally fatal to +persons who visit them in that disease. Countries between the 30th and +40th degrees of latitude are most friendly to consumptive people. + +4. LOOSE DRESSES, AND A CAREFUL ACCOMMODATION OF THEM TO THE CHANGES +IN THE WEATHER. Many facts might be mentioned to show the influence of +compression and of tight ligatures of every kind, upon the different +parts of the body; also of too much, or too little clothing, in +producing, or increasing diseases of every kind, more especially those +which affect the lungs. Tight stays, garters, waistbands, and collars, +should all be laid aside in the consumption, and the quality of the +clothing should be suited to the weather. A citizen of Maryland informed +me, that he twice had a return of a cough and spitting of blood, by +wearing his summer clothes a week after the weather became cool in the +month of September. But it is not sufficient to vary the weight or +quality of dress with the seasons. It should be varied with the changes +which take place in the temperature of the air every day, even in the +summer months, in middle latitudes. I know a citizen of Philadelphia, +who has laboured under a consumptive diathesis near thirty years, who +believes that he has lessened the frequency and violence of pulmonic +complaints during that time, by a careful accommodation of his dress to +the weather. He has been observed frequently to change his waistcoat and +small clothes twice or three times in a day, in a summer month. + +A repetition of colds, and thereby an increase of the disease, will be +prevented by wearing flannel next to the skin in winter, and muslin in +the summer, either in the form of a shirt or a waistcoat: where these +are objected to, a piece of flannel, or of soft sheepskin, should be +worn next to the breast. They not only prevent colds, but frequently +remove chronic pains from that part of the body. + +5. ARTIFICIAL EVACUATIONS, by means of BLISTERS and ISSUES. I suspect +the usefulness of these remedies to be chiefly confined to the +inflammatory and hectic states of consumption. In the typhus state, the +system is too weak to sustain the discharges of either of them. Fresh +blisters should be preferred to such as are perpetual, and the issues, +to be useful, should be large. They are supposed to afford relief by +diverting a preternatural secretion and excretion of mucus or pus from +the lungs, to an artificial emunctory in a less vital part of the +body. Blisters do most service when the disease arises from repelled +eruptions, and when they are applied between the shoulders, and the +upper and internal parts of the arms. When it arises from rheumatism +and gout, the blisters should be applied to the joints, and such other +external parts of the body as had been previously affected by those +diseases. + +6. Certain FUMIGATIONS and VAPOURS. An accidental cure of a pulmonary +affection by the smoke of rosin, in a man who bottled liquors, raised +for a while the credit of fumigations. I have tried them, but without +much permanent effect. I think I have seen the pain in the breast +relieved by receiving the vapour from a mixture of equal parts of tar, +bran, and boiling water into the lungs. The sulphureous and saline air +of Stabiæ, between Mount Vesuvius and the Mediterranean Sea, and the +effluvia of the pine forests of Lybia, were supposed, in ancient times, +to be powerful remedies in consumptive complaints; but it is probable, +the exercise used in travelling to those countries, contributed chiefly +to the cures which were ascribed to foreign matters acting upon the +lungs. + +7. LOZENGES, SYRUPS, and DEMULCENT TEAS. These are too common and too +numerous to be mentioned. + +8. OPIATES. It is a mistake in practice, founded upon a partial +knowledge of the qualities of opium, to administer it only at night, +or to suppose that its effects in composing a cough depend upon its +inducing sleep. It should be given in small doses during the day, as +well as in larger ones at night. The dose should be proportioned to the +degrees of action in the arterial system. The less this action, the more +opium may be taken with safety and advantage. + +9. DIFFERENT POSITIONS OF THE BODY have been found to be more or less +favourable to the abatement of the cough. These positions should be +carefully sought for, and the body kept in that which procures the +most freedom from coughing. I have heard of an instance in which a +cough, which threatened a return of the hæmorrhage from the lungs, was +perfectly composed for two weeks, by keeping the patient nearly in +one posture in bed; but I have known more cases in which relief from +coughing was to be obtained only by an erect posture of the body. + +10. Considerable relief will often be obtained from the patient's +SLEEPING BETWEEN BLANKETS in winter, and on a MATTRASS in summer. The +former prevent fresh cold from night sweats; the latter frequently checks +them altogether. In cases where a sufficient weight of blankets to keep +up an agreeable warmth cannot be borne, without restraining easy and full +acts of inspiration, the patient should sleep under a light feather bed, +or an eider down coverlet. They both afford more warmth than double or +treble their weight of blankets. + +However comfortable this mode of producing warmth in bed may be, it does +not protect the lungs from the morbid effects of the distant points of +temperature of a warm parlour in the day time, and a cold bed-chamber +at night. To produce an equable temperature of air at all hours, I have +frequently advised my patients, when going to a warm climate was not +practicable, to pass their nights as well as days in an open stove room, +in which nearly the same degrees of heat were kept up at all hours. I +have found this practice, in several cases, a tolerable substitute for a +warm climate. + +11. The MODERATE use of the lungs, in READING, PUBLIC SPEAKING, +LAUGHING, and SINGING. The lungs, when debilitated, derive equal benefit +with the limbs, or other parts of the body, from moderate exercise. +I have mentioned, in another place[28], several facts which support +this opinion. But too much pains cannot be taken to inculcate upon our +patients to avoid all _excess_ in the use of the lungs, by _long_, or +_loud_ reading, speaking, or singing, or by sudden and violent _bursts_ +of laughter. I shall long lament the death of a female patient, who had +discovered many hopeful signs of a recovery from a consumption, who +relapsed, and died, in consequence of bursting a blood-vessel in her +lungs, by a sudden fit of laughter. + + [28] An Account of the Effects of Common Salt in the Cure of + Hæmoptysis. + +12. Are there any advantages to be derived from the excitement of +certain PASSIONS in the treatment of consumptions? Dr. Blane tells us, +that many consumptive persons were relieved, and that some recovered, in +consequence of the terror which was excited by a hurricane in Barbadoes, +in the year 1780. It will be difficult to imitate, by artificial +means, the accidental cures which are recorded by Dr. Blane; but we +learn enough from them to inspire the invigorating passions of hope +and confidence in the minds of our patients, and to recommend to them +such exercises as produce exertions of body and mind analogous to those +which are produced by terror. Van Sweiten and Smollet relate cures of +consumptions, by patients falling into streams of cold water. Perhaps, +in both instances, the cures were performed only by the fright and +consequent exertion produced by the fall. This is only one instance out +of many which might be mentioned, of partial and unequal action being +suddenly changed into general and equal excitement in every part of the +system. The cures of consumptions which have been performed by a camp +life[29], have probably been much assisted by the commotions in the +passions which were excited by the various and changing events of war. + + [29] Vol. I. p. 204. + +13. A SALIVATION has lately been prescribed in this disease with +success. An accident first suggested its advantages, in the Pennsylvania +hospital, in the year 1800[30]. Since that time, it has performed many +cures in different parts of the United States. It is to be lamented, +that in a majority of the cases in which the mercury has been given, +it has failed of exciting a salivation. Where it affects the mouth, it +generally succeeds in recent cases, which is more than can be said of +any, or of all other remedies in this disease. In its hectic state, a +salivation frequently cures, and even in its typhus and last stage, I +have more than once prescribed it with success. The same regard to the +pulse should regulate the use of this new remedy in consumption, that +has been recommended in other febrile diseases. It should never be +advised until the inflammatory diathesis of the system has been in a +great degree reduced, by the depleting remedies formerly mentioned. + + [30] Medical Repository of New-York. Vol. V. + +During the use of the above remedies, great care should be taken to +relieve the patient from the influence of all those debilitating and +irritating causes which induced the disease. I shall say elsewhere that +decayed teeth are one of them. These should be extracted where there is +reason to suspect they have produced, or that they increase the disease. + +I have hitherto said nothing of the digitalis as a palliative remedy in +pulmonary consumption. I am sorry to acknowledge that, in many cases in +which I have prescribed it, it has done no good, and in some it has done +harm. From the opposite accounts of physicians of the most respectable +characters of the effects of this medicine, I have been inclined to +ascribe its different issues, to a difference in the soil in which it +has been cultivated, or in the times of gathering, or in the manner +of preparing it, all of which we know influence the qualities of many +other vegetables. If the theory of consumption which I have endeavoured +to establish be admitted, that uncertain and unsafe medicine will be +rendered unnecessary by the remedies that have been enumerated, provided +they are administered at the times, and in the manner that has been +recommended. + +Before I proceed to speak of the radical cure of the consumption, it +will be necessary to observe, that by means of the palliative remedies +which have been mentioned, many persons have been recovered, and some +have had their lives prolonged by them for many years; but in most of +these cases I have found, upon inquiry, that the disease recurred as +soon as the patient left off the use of his remedies, unless they were +followed by necessary or voluntary exercise. + +It is truly surprising to observe how long some persons have lived +who have been affected by a consumptive diathesis, and by frequent +attacks of many of the most troublesome symptoms of this disease. Van +Sweiten mentions the case of a man, who had lived thirty years in this +state. Morton relates the history of a man, in whom the symptoms of +consumption appeared with but little variation or abatement from his +early youth till the 70th year of his age. The widow of the celebrated +Senac lived to be 84 years of age, thirty of which she passed in a +pulmonary consumption. Dr. Nicols was subject to occasional attacks of +this disease during his whole life, and he lived to be above eighty +years of age. Bennet says he knew an instance in which it continued +above sixty years. I prescribed for my first pupil, Dr. Edwards, in a +consumption in the year 1769. He lived until 1802, and seldom passed a +year without spitting blood, nor a week without a cough, during that +long interval of time. The fatal tendency of his disease was constantly +opposed by occasional blood-letting, rural exercises, a cordial, but +temperate diet, the Peruvian bark, two sea voyages, and travelling in +foreign countries. There are besides these instances of long protracted +consumptions, cases of it which appear in childhood, and continue for +many years. I have seldom known them prove fatal under puberty. + +I am led here to mention another instance of the analogy between +pneumony and the pulmonary consumption. We often see the same frequency +of recurrence of both diseases in habits which are predisposed to them. +I have attended a German citizen of Philadelphia, in several fits of the +pneumony, who has been confined to his bed eight-and-twenty times, by +the same disease, in the course of the same number of years. He has, for +the most part, enjoyed good health in the intervals of those attacks, +and always appeared, till lately, to possess a good constitution. In the +cases of the frequent recurrence of pneumony, no one has suspected the +disease to have originated exclusively in a morbid state of the lungs; +on the contrary, it appears evidently to be produced by the _sudden_ +influence of the same causes, which, by acting with less force, and +for a _longer_ time, produce the pulmonary consumption. The name of +pneumony is taken from the principal symptom of this disease, but it as +certainly belongs to the whole arterial system as the consumption; and +I add further, that it is as certainly produced by general predisposing +debility. The hardness and fulness of the pulse do not militate against +this assertion, for they are altogether the effects of a morbid +and convulsive excitement of the sanguiferous system. The strength +manifested by the pulse is moreover partial, for every other part of the +body discovers, at the same time, signs of extreme debility. + +It would be easy, by pursuing this subject a little further, to mention +a number of facts which, by the aid of principles in physiology and +pathology, which are universally admitted, would open to us a new theory +of fevers, but this would lead us too far from the subject before us. +I shall only remark, that all that has been said of the influence of +_general_ debilitating causes upon the lungs, both in pneumony and +consumption, and of the alternation of the consumption with other +general diseases, will receive great support from considering the lungs +only as a part of the whole external surface of the body, upon which +most of the remote and exciting causes of both diseases produce their +first effects. This extent of the surface of the body, not only to the +lungs, but to the alimentary canal, was first taken notice of by Dr. +Boerhaave; but was unhappily neglected by him in his theories of the +diseases of the lungs and bowels. Dr. Keil supposes that the lungs, +from the peculiar structure of the bronchial vessels, and air vesicles, +expose a surface to the action of the air, equal to the extent of the +whole external and visible surface of the body. + +Thus have I mentioned the usual palliative remedies for the +consumption. Many of these remedies, under certain circumstances, I have +said have cured the disease, but I suspect that most of these cures have +taken place only when the disease has partaken of an intermediate nature +between a pneumony and a true pulmonary consumption. Such connecting +shades, appear between the extreme points of many other diseases. In a +former essay[31], I endeavoured to account for the transmutation (if I +may be allowed the expression) of the pneumony into the consumption, +by ascribing it to the increase of the debilitating refinements of +civilized life. This opinion has derived constant support from every +observation I have made connected with this subject, since its first +publication, in the year 1772. + + [31] Inquiry into the Diseases and Remedies of the Indians of + North-America; and a comparative view of their diseases and + remedies with those of civilized nations. Vol. I. + +I come now to treat of the RADICAL REMEDIES for the pulmonary +consumption. + +In an essay formerly alluded to[32], I mentioned the effects of labour, +and the hardships of a camp or naval life, upon this disease. As there +must frequently occur such objections to each of those remedies, as to +forbid their being recommended or adopted, it will be necessary to seek +for substitutes for them in the different species of exercise. These +are, _active_, _passive_, and _mixed_. The _active_ includes walking, +and the exercise of the hands and feet in working or dancing. The +_passive_ includes rocking in a cradle, swinging, sailing, and riding in +carriages of different kinds. The _mixed_ is confined chiefly to riding +on horseback. + + [32] Thoughts on the Pulmonary Consumption. Vol. I. + +I have mentioned all the different species of exercise, not because +I think they all belong to the class of radical remedies for the +consumption, but because it is often necessary to use those which are +passive, before we recommend those of a mixed or active nature. That +physician does not err more who advises a patient to take physic, +without specifying its qualities and doses, than the physician does +who advises a patient, in a consumption, to use exercise, without +specifying its species and degrees. From the neglect of this direction, +we often find consumptive patients injured instead of being relieved by +exercises, which, if used with judgment, might have been attended with +the happiest effects. + +I have before suggested that the stimulus of every medicine, which +is intended to excite action in the system, should always be in an +exact ratio to its excitability. The same rule should be applied to +the stimulus of exercise. I have heard a well-attested case of a young +lady, upon whose consumption the first salutary impression was made by +rocking her in a cradle; and I know another case in which a young lady, +in the lowest state of that debility which precedes an affection of the +lungs, was prepared for the use of the mixed and active exercises, by +being first moved gently backwards and forwards in a chariot without +horses, for an hour every day. Swinging appears to act in the same +gentle manner. In the case of a gardener, who was far advanced in +a consumption, in the Pennsylvania hospital, I had the pleasure of +observing its good effects, in an eminent degree. It so far restored +him, as to enable him to complete his recovery by working at his former +occupation. + +In cases of extreme debility, the following order should be recommended +in the use of the different species of exercise. + +1. Rocking in a cradle, or riding on an elastic board, commonly called a +chamber-horse. + +2. Swinging. + +3. Sailing. + +4. Riding in a carriage. + +5. Riding on horseback. + +6. Walking. + +7. Running and dancing. + +In the use of each of those species of exercise great attention should +be paid to the _degree_ or _force_ of action with which they are applied +to the body. For example, in riding in a carriage, the exercise will be +less in a four-wheel carriage than in a single horse chair, and less +when the horses move in a walking, than a trotting gait. In riding on +horseback, the exercise will be less or greater according as the horse +walks, paces, canters, or trots, in passing over the ground. + +I have good reason to believe, that an English sea-captain, who was +on the verge of the grave with the consumption, in the spring of the +year 1790, owed his perfect recovery to nothing but the above gradual +manner, in which, by my advice, he made use of the exercises of riding +in a carriage and on horseback. I have seen many other cases of the +good effects of thus accommodating exercise to debility; and I am sorry +to add, that I have seen many cases in which, from the neglect of this +manner of using exercise, most of the species and degrees of it, have +either been useless, or done harm. However carelessly this observation +may be read by physicians, or attended to by patients, I conceive no +direction to be more necessary in the cure of consumptions. I have been +thus particular in detailing it, not only because I believe it to be +important, but that I might atone to society for that portion of evil +which I might have prevented by a more strict attention to it in the +first years of my practice. + +The more the arms are used in exercise the better. One of the +proprietary governors of Pennsylvania, who laboured for many years under +consumptive diathesis, derived great benefit from frequently rowing +himself in a small boat, a few miles up and down the river Schuylkill. +Two young men, who were predisposed to a consumption, were perfectly +cured by working steadily at a printing press in this city. A French +physician in Martinique cured this disease, by simply rubbing the arms +between the shoulders and the elbows, until they inflamed. The remedy is +strongly recommended, by the recoveries from pulmonary consumption which +have followed abscesses in the arm-pits. Perhaps the superior advantages +of riding on horseback, in this disease, may arise in part from the +constant and gentle use of the arms in the management of the bridle and +the whip. + +Much has been said in favour of sea voyages in consumptions. In the +mild degrees of the disease they certainly have done service, but I +suspect the relief given, or the cures performed by them, should be +confined chiefly to seafaring people, who add to the benefits of a +constant change of pure air, a share of the invigorating exercises of +navigating the ship. I have frequently heard of consumptive patients +reviving at sea, probably from the transient effects of sea sickness +upon the whole system, and growing worse as soon as they came near +the end of their voyage. It would seem as if the mixture of land and +sea airs was hurtful to the lungs, in every situation and condition +in which it could be applied to them. Nor are the peculiar and morbid +effects of the first operation of land and sea airs upon the human body, +in sea voyages, confined only to consumptive people. I crossed the +Atlantic ocean, in the year 1766, with a sea captain, who announced to +his passengers the agreeable news that we were near the British coast, +before any discovery had been made of our situation by sounding, or by a +change in the colour of the water. Upon asking him upon what he founded +his opinion, he said, that he had been sneezing, which, he added, was +the sign of an approaching cold, and that, in the course of upwards of +twenty years, he had never made the land (to use the seaman's phrase) +without being affected in a similar manner. I have visited many sick +people in Philadelphia, soon after their arrival from sea, who have +informed me, that they had enjoyed good health during the greatest part +of their voyage, and that they had contracted their indispositions after +they came within sight of the land. I mention these facts only to show +the necessity of advising consumptive patients, who undertake a sea +voyage for the recovery of their health, not to expose themselves upon +deck in the morning and at night, after they arrive within the region in +which the mixture of the land and sea airs may be supposed to take place. + +I subscribe, from what I have observed, to the bold declaration of Dr. +Sydenham, in favour of the efficacy of riding on horseback, in the cure +of consumption. I do not think the existence of an abscess, when broken, +or even tubercles in the lungs, when recent, or of a moderate size, +the least objection to the use of this excellent remedy. An abscess in +the lungs is not necessarily fatal, and tubercles have no malignity in +them which should render their removal impracticable by this species of +exercise. The first question, therefore, to be asked by a physician who +visits a patient in this disease should be, not what is the state of his +lungs, but, is he able to ride on horseback. + +There are two methods of riding for health in this disease. The first +is by short excursions; the second is by long journies. In slight +consumptive affections, and after a recovery from an acute illness, +short excursions are sufficient to remove the existing debility; but in +the more advanced stages of consumption, they are seldom effectual, and +frequently do harm, by exciting an occasional appetite without adding +to the digestive powers. They, moreover, keep the system constantly +vibrating by their unavoidable inconstancy, between distant points +of tone and debility[33], and they are unhappily accompanied at all +times, from the want of a succession of fresh objects to divert the +mind, by the melancholy reflection that they are the sad, but necessary +conditions of life. + + [33] The bad effects of _inconstant_ exercise have been taken notice of + in the gout. Dr. Sydenham says, when it is used only by fits and + starts in this disease, it does harm. + +In a consumption of long continuance or of great danger, long journies +on horseback are the most effectual modes of exercise. They afford a +constant succession of fresh objects and company, which divert the +mind from dwelling upon the danger of the existing malady; they are +moreover attended by a constant change of air, and they are not liable +to be interrupted by company, or transient changes in the weather, by +which means appetite and digestion, action and power, all keep pace +with each other. It is to be lamented that the use of this excellent +remedy is frequently opposed by indolence and narrow circumstances +in both sexes, and by the peculiarity of situation and temper in the +female sex. Women are attached to their families by stronger ties than +men. They cannot travel alone. Their delicacy, which is increased by +sickness, is liable to be offended at every stage; and, lastly, they +sooner relax in their exertions to prolong their lives than men. Of +the truth of the last observation, sir William Hamilton has furnished +us with a striking illustration. He tells us, that in digging into +the ruins produced by the late earthquake in Calabria, the women who +perished in it, were all found with their arms folded, as if they had +abandoned themselves immediately to despair and death; whereas, the men +were found with their arms extended, as if they had resisted their fate +to the last moment of their lives. It would seem, from this fact, and +many others of a similar nature which might be related, that a capacity +of bearing pain and distress with fortitude and resignation, was the +distinguishing characteristic of the female mind; while a disposition to +resist and overcome evil, belonged in a more peculiar manner to the mind +of man. I have mentioned this peculiarity of circumstances and temper +in female patients, only for the sake of convincing physicians that it +will be necessary for them to add all the force of eloquence to their +advice, when they recommend journies to women in preference to all other +remedies, for the recovery of their health. + +Persons, moreover, who pursue active employments, frequently object to +undertaking journies, from an opinion that their daily occupations are +sufficient to produce all the salutary effects we expect from artificial +exercise. It will be highly necessary to correct this mistake, by +assuring such persons that, however useful the habitual exercise of an +active, or even a laborious employment may be to _preserve_ health, it +must always be exchanged for one which excites new impressions, both +upon the mind and body, in every attempt to _restore_ the system from +that debility which is connected with pulmonary consumption. + +As travelling is often rendered useless, and even hurtful in this +disease, from being pursued in an improper manner, it will be necessary +to furnish our patients with such directions as will enable them to +derive the greatest benefit from their journies. I shall, therefore, in +this place, mention the substance of the directions which I have given +in writing for many years to such consumptive patients as undertake +journies by my advice. + +1. To avoid fatigue. Too much cannot be said to enforce this direction. +It is the hinge on which the recovery or death of a consumptive patient +frequently turns. I repeat it again, therefore, that patients should be +charged over and over when they set off on a journey, as well as when +they use exercise of any kind, to avoid fatigue. For this purpose they +should begin by travelling only a few miles in a day, and increase the +distance of their stages, as they increase their strength. By neglecting +this practice, many persons have returned from journies much worse than +when they left home, and many have died in taverns, or at the houses of +their friends on the road. Travelling in stage-coaches is seldom safe +for a consumptive patient. They are often crowded; they give too much +motion; and they afford by their short delays and distant stages, too +little time for rest, or for taking the frequent refreshment which was +formerly recommended. + +2. To avoid travelling too soon in the morning, and after the going +down of the sun in the evening, and, if the weather be hot, never to +travel in the middle of the day. The sooner a patient breakfasts after +he leaves his bed the better; and in no case should he leave his morning +stage with an empty stomach. + +3. If it should be necessary for a patient to lie down, or to sleep in +the day time, he should be advised to undress himself, and to cover his +body between sheets or blankets. The usual ligatures of garters, stocks, +knee-bands, waistcoats, and shoes, are very unfriendly to sound sleep; +hence persons who lie down with their clothes on, often awake from an +afternoon's nap in terror from dreams, or in a profuse sweat, or with +a head-ach or sick stomach; and generally out of humour. The surveyors +are so sensible of the truth of this remark, that they always undress +themselves when they sleep in the woods. An intelligent gentleman of +this profession informed me, that he had frequently seen young woodsmen, +who had refused to conform to this practice, so much indisposed in the +morning, that, after the experience of a few nights, they were forced to +adopt it. + +Great care should be taken in sleeping, whether in the day time or at +night, never to lie down in damp sheets. Dr. Sydenham excepts the danger +from this quarter, when he speaks of the efficacy of travelling on +horseback in curing the consumption. + +4. Patients who travel for health in this disease should avoid all +large companies, more especially evening and night parties. The air +of a contaminated room, phlogisticated by the breath of fifteen or +twenty persons, and by the same number of burning candles, is poison +to a consumptive patient. To avoid impure air from every other source, +he should likewise avoid sleeping in a crowded room, or with curtains +around his bed, and even with a bed-fellow. + +5. Travelling, to be effectual in this disease, should be conducted +in such a manner as that a patient may escape the extremes of heat +and cold. For this purpose he should pass the winter, and part of the +spring, in Georgia or South-Carolina, and the summer in New-Hampshire, +Massachusetts, or Vermont, or, if he pleases, he may still more +effectually shun the summer heats, by crossing the lakes, and travelling +along the shores of the St. Laurence to the city of Quebec. He will +thus escape the extremes of heat and cold, particularly the less +avoidable one of heat; for I have constantly found the hot month of +July to be as unfriendly to consumptive patients in Pennsylvania, as +the variable month of March. By these means too he will enjoy nearly an +equable temperature of air in every month of the year; and his system +will be free from the inconvenience of the alternate action of heat +and cold upon it. The autumnal months should be spent in New-Jersey or +Pennsylvania. + +In these journies from north to south, or from south to north, he +should be careful, for reasons before mentioned, to keep at as great +a distance as possible from the sea coast. Should this inquiry fall +into the hands of a British physician, I would beg leave to suggest +to him, whether more advantages would not accrue to his consumptive +patients from advising them to cross the Atlantic ocean, and afterwards +to pursue the tour which I have recommended, than by sending them +to Portugal, France, or Italy. Here they will arrive with such a +mitigation of the violence of the disease, in consequence of the length +of their sea voyage, as will enable them immediately to begin their +journies on horseback. Here they will be exposed to fewer temptations +to intemperance, or to unhealthy amusements, than in old European +countries. And, lastly, in the whole course of this tour, they will +travel among a people related to them by a sameness of language and +manners, and by ancient or modern ties of citizenship. Long journies +for the recovery of health, under circumstances so agreeable, should +certainly be preferred to travelling among strangers of different +nations, languages, and manners, on the continent of Europe. + +6. To render travelling on horseback effectual in a consumption, it +should be continued with moderate intervals from _six to twelve months_. +But the cure should not be rested upon a single journey. It should be +repeated every _two_ or _three years_, till our patient has passed +the consumptive stages of life. Nay, he must do more; he must acquire +a _habit_ of riding constantly, both at home and abroad; or, to use +the words of Dr. Fuller, "he must, like a Tartar, learn to live on +horseback, by which means he will acquire in time the constitution of a +Tartar[34]." + + [34] Medicina Gymnastica, p. 116. + +Where benefit is expected from a change of climate, as well as from +travelling, patients should reside at least two years in the place +which is chosen for that purpose. I have seldom known a residence for a +shorter time in a foreign climate do much service. + +To secure a perfect obedience to medical advice, it would be extremely +useful if consumptive patients could always be accompanied by a +physician. Celsus says, he found it more easy to cure the dropsy in +slaves than in freemen, because they more readily submitted to the +restraints he imposed upon their appetites. Madness has become a curable +disease in England, since the physicians of that country have opened +private mad-houses, and have taken the entire and constant direction +of their patients into their own hands. The same successful practice +would probably follow the treatment of consumptions, if patients were +constantly kept under the eye and authority of their physicians. The +keenness of appetite, and great stock of animal spirits, which those +persons frequently possess, hurry them into many excesses which defeat +the best concerted plans of a recovery; or, if they escape these +irregularities, they are frequently seduced from our directions by every +quack remedy which is recommended to them. Unfortunately the cough +becomes a signal of their disease, at every stage of their journey, +and the easy or pleasant prescriptions of even hostlers and ferrymen, +are often substituted to the self-denial and exertion which have been +imposed by physicians. The love of life in these cases seems to level +all capacities; for I have observed persons of the most cultivated +understandings to yield in common with the vulgar, to the use of these +prescriptions. + +In a former volume I mentioned the good effects of accidental LABOUR in +pulmonary consumptions. The reader will find a particular account in the +first volume of Dr. Coxe's Medical Museum, of a clergyman and his wife, +in Virginia, being cured by the voluntary use of that remedy. + +The following circumstances and symptoms, indicate the longer or shorter +duration of this disease, and its issue in life and death: + +The consumption from gout, rheumatism, and scrophula, is generally of +long duration. It is more rapid in its progress to death, when it arises +from a half cured pleurisy, or neglected colds, measles, and influenza. +It is of shorter duration in persons under thirty, than in those who are +more advanced in life. + +It is always dangerous in proportion to the length of time, in which +the debilitating causes, that predisposed to it, have acted upon the +body. + +It is more dangerous when a predisposition to it has been derived from +ancestors, than when it has been acquired. + +It is generally fatal when accompanied with a bad conformation of the +breast. + +Chilly fits occurring in the forenoon, are more favourable than when +they occur in the evening. They indicate the disease to partake a little +of the nature of an intermittent, and are a call for the use of the +remedies proper in that disease. + +Rheumatic pains, attended with an abatement of the cough, or pains in +the breast, are always favourable; so are + +Eruptions, or an abscess on the external parts of the body, if they +occur before the last stage of the disease. + +A spitting of blood, in the early, or forming stage of the disease, is +favourable, but after the lungs become much obstructed, or ulcerated, it +is most commonly fatal. + +A pleurisy, occurring in the low state of the disease, generally kills, +but I have seen a case in which it suddenly removed the cough and hectic +fever, and thus became the means of prolonging the patient's life for +several years. + +The discharge of calculi from the lungs by coughing and spitting, and +of a thin watery liquid, with a small portion of pus swimming on its +surface, are commonly signs of an incurable consumption. + +No prediction unfavourable to life can be drawn from pus being +discharged from the lungs. We see many recoveries after it has taken +place, and many deaths where that symptom has been absent. Large +quantities of pus are discharged in consumptions attended with +abscesses, and yet few die of them, where they have not been preceded +by long continued debility of the whole system. No pus is expectorated +from tubercles, and how generally fatal is the disease, after they are +formed in the lungs! It is only after they ulcerate that they discharge +pus, and it is only after ulcers are thus formed, that the consumption +probably becomes uniformly fatal. I suspect these ulcers are sometimes +of a cancerous nature. + +A sudden cessation of the cough, without a supervening diarrh[oe]a, +indicates death to be at hand. + +A constant vomiting in a consumption, is generally a bad sign. + +Feet obstinately cold, also a swelling of the feet during the day, and +of the face in the night, commonly indicate a speedy and fatal issue of +the disease. + +Lice, and the falling off of the hair, often precede death. + +A hoarseness, in the beginning of the disease, is always alarming, but +it is more so in its last stage. + +A change of the eyes from a blue, or dark, to a light colour, similar +to that which takes place in very old people, is a sign of speedy +dissolution. + +I have never seen a recovery after an apthous sore throat took place. + +Death from the consumption comes on in some or more than one, of the +following ways: + +1. With a diarrh[oe]a. In its absence, + +2. With wasting night sweats. + +3. A rupture of an abscess. + +4. A rupture of a large blood-vessel in the lungs, attended with +external or internal hæmorrhage. _Sudden_ and _unexpected_ death in a +consumption is generally induced by this, or the preceding cause. + +5. Madness. The cough and expectoration cease with this disease. It +generally carries off the patient in a week or ten days. + +6. A pleurisy, brought on by exposure to cold. + +7. A typhus fever, attended with tremors, twitchings of the tendons, and +a dry tongue. + +8. Swelled hands, feet, legs, thighs, and face. + +9. An apthous sore throat. + +10. Great and tormenting pains, sometimes of a spasmodic nature in the +limbs. + +In a majority of the fatal cases of consumption, which I have seen, the +passage out of life has been attended with pain; but I have seen many +persons die with it, in whom all the above symptoms were so lenient, +or so completely mitigated by opium, that death resembled a quiet +transition from a waking, to a sleeping state. + +I cannot conclude this inquiry without adding, that the author of it +derived from his paternal ancestors a predisposition to the pulmonary +consumption, and that between the 18th and 43d years of his age, he has +occasionally been afflicted with many of the symptoms of that disease +which he has described. By the constant and faithful use of many of the +remedies which he has recommended, he now, in the 61st year of his age, +enjoys nearly an uninterrupted exemption from pulmonary complaints. +In humble gratitude, therefore, to that BEING, who condescends to be +called the preserver of men, he thus publicly devotes this result of his +experience and inquiries to the benefit of such of his fellow-creatures +as may be afflicted with the same disease, sincerely wishing that they +may be as useful to them, as they have been to the author. + + + + + OBSERVATIONS + + ON + + THE SYMPTOMS AND CURE + + OF + + _DROPSIES_. + + +Whether we admit the exhaling and absorbing vessels to be affected in +general dropsies by preternatural debility, palsy, or rupture, or by a +retrograde motion of their fluids, it is certain that their exhaling and +absorbing power is materially affected by too much, or too little action +in the arterial system. That too little action in the arteries should +favour dropsical effusions, has been long observed; but it has been +less obvious, that the same effusions are sometimes promoted, and their +absorption prevented, by too much action in these vessels. That this +fact should have escaped our notice is the more remarkable, considering +how long we have been accustomed to seeing serous swellings in the +joints in the acute rheumatism, and copious, but partial effusions of +water in the form of sweat, in every species of inflammatory fever. + +It is nothing new that the healthy action of one part, should depend +upon the healthy action of another part of the system. We see it in +many of the diseases of the nerves and brain. The tetanus is cured by +exciting a tone in the arterial system; madness is cured by lessening +the action of the arteries by copious blood-letting; and epilepsy and +hysteria are often mitigated by the moderate use of the same remedy. + +By too much action in the arterial system, I mean a certain morbid +excitement in the arteries, accompanied by preternatural force, which is +obvious to the sense of touch. It differs from the morbid excitement of +the arteries, which takes place in common inflammatory fevers, in being +attended by less febrile heat, and with little or no pain in the head +or limbs. The thirst is nearly the same in this state of dropsy, as in +inflammatory fevers. I include here those dropsies only in which the +whole system is affected by what is called a hydropic diathesis. + +That debility should, under certain circumstances, dispose to excessive +action, and that excessive action should occur in one part of the body, +at the same time that debility prevailed in every other, are abundantly +evident from the history and phenomena of many diseases. Inflammatory +fever, active hæmorrhages, tonic gout, asthma, apoplexy, and palsy, +however much they are accompanied by excessive action in the arterial +system, are always preceded by original debility, and are always +accompanied by obvious debility in every other part of the system. + +But it has been less observed by physicians that an undue force or +excess of action occurs in the arterial system in certain dropsies, and +that the same theory which explains the union of predisposing and nearly +general debility, with a partial excitement and preternatural action in +the arterial system, in the diseases before-mentioned, will explain the +symptoms and cure of certain dropsies. + +That debility predisposes to every state of dropsy, is evident from +the history of all the remote and occasional causes which produce them. +It will be unnecessary to mention these causes, as they are to be found +in all our systems of physic. Nor will it be necessary to mention any +proofs of the existence of debility in nearly every part of the body. +It is too plain to be denied. I shall only mention the symptoms which +indicate a morbid excitement and preternatural action of the arterial +system. These are, + +1. A _hard_, _full_, and _quick_ pulse. This symptom, I believe, is more +common in dropsies than is generally supposed, for many physicians visit +and examine patients in these diseases, without feeling the pulse. Dr. +Home mentions the _frequency_ of the pulse, in the patients whose cures +he has recorded[35], but he takes no notice of its force except in two +cases. Dr. Zimmerman, in his account of the dropsy which terminated +the life of Frederick II, of Prussia, tells us that he found his pulse +_hard_ and _full_. I have repeatedly found it full and hard in every +form of dropsy, and more especially in the first stage of the disease. +Indeed I have seldom found it otherwise in the beginning of the dropsy +of the breast. + + [35] Medical Facts. + +2. _Sizy blood._ This has been taken notice of by many practical +writers, and has very justly been ascribed, under certain circumstances +of blood-letting, to an excessive action of the vessels upon the blood. + +3. _Alternation of dropsies with certain diseases which were evidently +accompanied by excess of action in the arterial system._ I have seen +anasarca alternate with vertigo, and both ascites and anasarca alternate +with tonic madness. A case of nearly the same kind is related by Dr. +Mead. Dr. Grimes, of Georgia, informed me that he had seen a tertian +fever, in which the intermissions were attended with dropsical swellings +all over the body, which suddenly disappeared in every accession of a +paroxysm of the fever. + +4. _The occasional connection of certain dropsies with diseases +evidently of an inflammatory nature_, particularly pneumony, rheumatism, +and gout. + +5. Spontaneous _hæmorrhages_ from the lungs, hæmorrhodial vessels, and +nose, cases of which shall be mentioned hereafter, when we come to treat +of the cure of dropsies. + +6. _The appearance of dropsies in the winter and spring, in habits +previously affected by the intermitting fever._ The debility produced by +this state of fever, frequently disposes to inflammatory diathesis, as +soon as the body is exposed to the alternate action of heat and cold, +nor is this inflammatory diathesis always laid aside, by the transition +of the intermitting fever into a dropsy, in the succeeding cold weather. + +7. _The injurious effects of stimulating medicines in certain dropsies_, +prove that there exists in them, at times, too much action in the +blood-vessels. Dr. Tissot, in a letter to Dr. Haller, "De Variolis, +apoplexia, et hydrope," condemns, in strong terms, the use of opium +in the dropsy. Now the bad effects of this medicine in dropsies, must +have arisen from its having been given in cases of too much action in +the arterial system; for opium, we know, increases, by its stimulating +qualities, the action and tone of the blood-vessels, and hence we find, +it has been prescribed with success in dropsies of too little action in +the system. + +8. _The termination of certain fevers in dropsies in which +blood-letting was not used._ This has been ascertained by many +observations. Dr. Wilkes relates[36], that after "an epidemical fever, +which began in Kidderminster, in 1728, and soon afterwards spread, not +only over Great Britain, but all Europe, more people died dropsical +in three years, than did perhaps in twenty or thirty years before," +probably from the neglect of bleeding in the fever. + + [36] Historical Essay on the Dropsy, p. 326. + +But the existence of too much action in the arterial system in certain +dropsies, will appear more fully from the history of the effects of the +remedies which have been employed either by design or accident in the +cure of these diseases. I shall first mention the remedies which have +been used with success in tonic or inflammatory dropsies; and afterwards +mention those which have been given with success in dropsies of a weak +action in the arteries. I have constantly proposed to treat only of the +theory and cure of dropsies in general, without specifying any of the +numerous names it derives from the different parts of the body in which +they may be seated; but in speaking of the remedies which have been used +with advantage in both the tonic and atonic states, I shall occasionally +mention the name or seat of the dropsy in which the remedy has done +service. + +The first remedy that I shall mention for dropsies is _blood-letting_. +Dr. Hoffman and Dr. Home both cured dropsies accompanied by pulmonic +congestion by means of this remedy. Dr. Monroe quotes a case of dropsy +from Sponius, in which bleeding succeeded, but not till after it had +been used twenty times[37]. Mr. Cruikshank relates a case[38] of +accidental bleeding, which confirms the efficacy of blood-letting in +these diseases. He tells us that he attended a patient with dropsical +swellings in his legs, who had had a hoarseness for two years. One +morning, in stooping to buckle his shoes, he bursted a blood-vessel +in his lungs, from which he lost a quart of blood; in consequence of +which, both the swellings and the hoarseness went off gradually, and +he continued well two years afterwards. I have known one case in which +spontaneous hæmorrhages from the hæmorrhodial vessels, and from the +nose, suddenly reduced universal dropsical swellings. In this patient +there had been an uncommon tension and fulness in the pulse. + + [37] Treatise on the Dropsy. + + [38] Treatise on the Lymphatics. + +I could add the histories of many cures of anasarca and ascites, +performed by means of blood-letting, not only by myself, but by a number +of respectable physicians in the United States. Indeed I conceive this +remedy to be as much indicated by a tense and full pulse in those forms +of dropsy, as it is in a pleurisy, or in any other common inflammatory +disease. + +In those deplorable cases of hydrothorax, which do not admit of a +radical cure, I have given temporary relief, and thereby protracted +life, by taking away occasionally a few ounces of blood. Had Dr. +Zimmerman used this remedy in the case of the king of Prussia, I cannot +help thinking from the account which the doctor gives us of the diet and +pulse of his royal patient, that he would have lessened his sufferings +much more than by plentiful doses of dandelion; for I take it for +granted, from the candour and integrity which the doctor discovered in +all his visits to the king, that he did not expect that dandelion, or +any other medicine, would cure him. + +Although a _full_ and _tense_ pulse is always an indication of the +necessity of bleeding; yet I can easily conceive there may be such +congestions, and such a degree of stimulus to the arterial system, as to +produce a depressed, or a _low_ or _weak_ pulse. Two cases of this kind +are related by Dr. Monroe, one of which was cured by bleeding. The same +symptom of a low and weak pulse is often met with in the _first_ stage +of pneumony, and apoplexy, and is only to be removed by the plentiful +use of the same remedy. + +II. _Vomits_ have often been given with advantage in dropsies. Dr. Home +says, that squills were useful in these diseases only when they produced +a vomiting. By abstracting excitement and action from the arterial +system, it disposes the lymphatics to absorb and discharge large +quantities of water. The efficacy of vomits in promoting the absorption +of stagnating fluids is not confined to dropsies. Mr. Hunter was once +called to visit a patient in whom he found a bubo in such a state that +he purposed to open it the next day. In the mean while, the patient went +on board of a vessel, where he was severely affected by sea-sickness and +vomiting; in consequence of which the bubo disappeared, and the patient +recovered without the use of the knife. + +Mr. Cruikshank further mentions a case[39] of a swelling in the knee +being nearly cured by a patient vomiting eight and forty hours, in +consequence of his taking a large dose of the salt of tartar instead of +soluble tartar. + + [39] Letter to Mr. Clare, p. 166. + +III. _Purges._ The efficacy of this remedy, in the cure of dropsies, +has been acknowledged by physicians in all ages and countries. Jalap, +calomel, scammony, and gamboge, are often preferred for this purpose; +but I have heard of two cases of ascites being cured by a table +spoonful of sweet oil taken every day. It probably acted only as a +gentle laxative. The cream of tartar, so highly commended by Dr. Home, +seems to act _chiefly_ in the same way. Gherlius, from whom Dr. Home +learned the use of this medicine, says, that all the persons whom he +cured by it were in the vigour of life, and that their diseases had +been only of a few months continuance. From these two circumstances, +it is most probable they were dropsies of great morbid action in the +arterial system. He adds further, that the persons who were cured by +this medicine, were reduced very low by the use of it. Dr. Home says +that it produced the same effect upon the patients whom he cured by it, +in the infirmary of Edinburgh. Dr. Sydenham prefers gentle to drastic +purges, and recommends the exhibition of them every day. Both drastic +and gentle purges act by diminishing the action of the arterial system, +and thereby promote the absorption and discharge of water. That purges +promote absorption, we learn not only from their effects in dropsies, +but from an experiment related by Mr. Cruikshank[40], of a man who +acquired several ounces of weight after the operation of a purge. The +absorption in this case was from the atmosphere. So great is the effect +of purges in promoting absorption, that Mr. Hunter supposes the matter +of a gonorrh[oe]a, or of topical venereal ulcers to be conveyed by them +in some instances into every part of the body. + + [40] Letter to Mr. Clare, p. 117. + +IV. _Certain medicines_, which, by lessening the _action of the +arterial system_, favour the absorption and evacuation of water. The +only medicines of this class which I shall name are _nitre_, _cream of +tartar_, and _foxglove_. + +1. Two ounces of nitre dissolved in a pint of water, and a wine-glass +full of it taken three times a-day have performed perfect cures, in two +cases of ascites, which have come under my notice. I think I have cured +two persons of anasarca, by giving one scruple of the same medicine +three times a-day for several weeks. The two last cures were evidently +dropsies of violent action in the arterial system. Where nitre has been +given in atonic dropsies it has generally been useless, and sometimes +done harm. I have seen one instance of an incurable diarrh[oe]a after +tapping, which I suspected arose from the destruction of the tone of the +stomach and bowels, by large and long continued doses of nitre, which +the patient had previously taken by the advice of a person who had been +cured by that remedy. To avoid this, or any other inconvenience from the +use of nitre in dropsies, it should be given at first in small doses, +and should always be laid aside, if it should prove ineffectual after +having been given two or three weeks. + +2. I can say nothing of the efficacy of _cream of tartar_ in dropsies +from my own experience, where it has not acted as a purge. Perhaps +my want of decision upon this subject has arisen only from my not +having persisted in the use of it for the same length of time which is +mentioned by Dr. Home. + +3. There are different opinions concerning the efficacy of foxglove in +dropsies. From the cases related by Dr. Withering, it appears to have +done good; but from those related by Dr. Lettsom[41] it seems to have +done harm. I suspect the different accounts of those two gentlemen have +arisen from their having given it in different states of the system, +or perhaps from a difference in the quality of the plant from causes +mentioned in another place[42]. I am sorry to add further, that after +many trials of this medicine I have failed in most of the cases in which +I have given it. I have discharged the water in three instances by it, +but the disease returned, and my patients finally died. I can ascribe +only one complete cure to its use, which was in the year 1789, in a +young man in the Pennsylvania hospital, of five and thirty years of age, +of a robust habit, and plethoric pulse. + + [41] Medical Memoirs, vol. II. + + [42] Inquiry into the Causes and Cure of Pulmonary Consumption. + +Where medicines have once been in use, and afterwards fall into +disrepute, as was the case with the foxglove, I suspect the cases in +which they were useful, to have been either few or doubtful, and that +the cases in which they had done harm, were so much more numerous and +unequivocal, as justly to banish them from the materia medica. + +V. _Hard labour_, or exercise in such a degree as to produce fatigue, +have, in several instances, cured the dropsy. A dispensary patient, +in this city, was cured of this disease by sawing wood. And a patient +in an ascites under my care in the Pennsylvania hospital, had his +belly reduced seven inches in circumference in one day, by the labour +of carrying wood from the yard into the hospital. A second patient +belonging to the Philadelphia dispensary was cured by walking to +Lancaster, 66 miles from the city, in the middle of winter. The efficacy +of travelling in this disease, in cold weather, is taken notice of by +Dr. Monroe, who quotes a case from Dr. Holler, of a French merchant, who +was cured of a dropsy by a journey from Paris to England, in the winter +season. It would seem, that in these two cases, the _cold_ co-operated +as a sedative with the fatigue produced by labour or exercise, in +reducing the tone of the arterial system. + +VI. _Low diet._ I have heard of a woman who was cured of a dropsy by +eating nothing but boiled beans for three weeks, and drinking nothing +but the water in which they had been boiled. Many other cases of the +good effects of low diet in dropsies are to be found in the records of +medicine. + +VII. _Thirst._ This cruel remedy acts by debilitating the system in two +ways: 1st, by abstracting the stimulus of distention; and, 2dly, by +preventing a supply of fresh water to replace that which is discharged +by the ordinary emunctories of nature. + +VIII. _Fasting._ An accidental circumstance, related by sir John +Hawkins, in the life of Dr. Johnson, first led me to observe the +good effects of fasting in the dropsy. If the fact alluded to stood +alone under the present head of this essay, it would be sufficient +to establish the existence of too much action, and the efficacy of +debilitating remedies in certain dropsies. I am the more disposed to lay +a good deal of stress upon this fact, as it was the clue which conducted +me out of the labyrinth of empirical practice, in which I had been +bewildered for many years, and finally led me to adopt the principles +and practice which I am now endeavouring to establish. The passage which +contains this interesting fact is as follows: "A few days after (says +sir John) he [meaning Dr. Johnson] sent for me, and informed me, that +he had discovered in himself the symptoms of a dropsy, and, indeed, his +very much increased bulk, and the swollen appearance of his legs, seemed +to indicate no less. It was on Thursday that I had this conversation +with him; in the course thereof he declared, that he intended to devote +the whole of the next day to _fasting_, humiliation, and such other +devotional exercises as became a man in his situation. On the Saturday +following I made him a visit, and, upon entering his room, I observed +in his countenance such a serenity as indicated, that some remarkable +crisis of his disease had produced a change in his feelings. He told me +that, pursuant to the resolution he had mentioned to me, he had spent +the preceding day in an abstraction from all worldly concerns; that to +prevent interruption he had in the morning ordered _Frank_ [his servant] +not to admit any one to him, and, the better to enforce the charge, +had added these awful words, _for your master is preparing himself to +die_. He then mentioned to me, that in the course of this exercise he +found himself relieved from the disease which had been growing upon him, +and was becoming very oppressive, viz. the _dropsy_, by the gradual +evacuation of water, to the amount of _twenty pints_, a like instance +whereof he had never before experienced." Sir John Hawkins ascribes this +immense discharge of water to the influence of Dr. Johnson's prayers; +but he neglects to take notice, that these prayers were answered, in +this instance, as they are in many others, in a perfect consistence with +the common and established laws of nature. + +To satisfy myself that this discharge of water, in the case of Dr. +Johnson, was produced by the fasting only, I recommended it, soon after +I read the above account, to a gentlewoman whom I was then attending in +an ascites. I was delighted with the effects of it. Her urine, which for +some time before had not exceeded half a pint a-day, amounted to _two +quarts_ on the day she fasted. I repeated the same prescription once a +week for several weeks, and each time was informed of an increase of +urine, though it was considerably less in the last experiments than in +the first. Two patients in an ascites, to whom I prescribed the same +remedy, in the Pennsylvania hospital, the one in the winter of 1790, +and the other in the winter of 1792, exhibited proofs in the presence +of many of the students of the university, equally satisfactory of the +efficacy of fasting in suddenly increasing the quantity of urine. + +IX. _Fear._ This passion is evidently of a debilitating nature, and, +therefore, it has frequently afforded an accidental aid in the cure of +dropsies, of too much action. I suspect, that the fear of death, which +was so distinguishing a part of the character of Dr. Johnson, added a +good deal to the efficacy of fasting, in procuring the immense discharge +of water before-mentioned. In support of the efficacy of fear simply +applied, in discharging water from the body in dropsies, I shall mention +the following facts. + +In a letter which I received from Dr. John Pennington, dated Edinburgh, +August 3, 1790, I was favoured with the following communication. "Since +the conversation I had with you on the subject of the dropsy, I feel +more and more inclined to adopt your opinion. I can furnish you with +a fact which I learned from a Danish sailor, on my passage to this +country, which is much in favour of your doctrine. A sailor in an +ascites, fell off the end of the yard into the sea; the weather being +calm, he was taken up unhurt, but, to use the sailor's own words, who +told me the story, he was _frightened half to death_, and as soon as he +was taken out of the water, he discharged a gallon of urine or more. +A doctor on board ascribed this large evacuation to sea bathing, and +accordingly ordered the man to be dipped in the sea every morning, much +against his will, for, my informant adds, that he had not forgotten his +fall, and that in four weeks he was perfectly well. I think this fact +can only be explained on your principles. The sedative operation of +_fear_ was, no doubt, the cause of his cure." + +There is an account of an ascites being cured by a fall from an +open chaise, recorded in the third volume of the Medical Memoirs, by +M. Lowdell. I have heard of a complete recovery from dropsy, having +suddenly followed a fall from a horse. In both these cases, the cures +were probably the effects of fear. + +Dr. Hall, of York-town, in Pennsylvania, informed me, that he had been +called to visit a young woman of 19 years of age, who had taken all the +usual remedies for ascites without effect. He at once proposed to her +the operation of tapping. To this she objected, but so great was the +_fear_ of this operation, which the proposal of it suddenly excited in +her mind, that it brought on a plentiful discharge of urine, which in a +few days perfectly removed her disease. + +On the 27th of August, 1790, I visited a gentlewoman in this city with +the late Dr. Jones, in an ascites. We told her for the first time, +that she could not be relieved without being tapped. She appeared to +be much terrified upon hearing our opinion, and said that she would +consider of it. I saw her two days afterwards, when she told me, with +a smile on her countenance, that she hoped she should get well without +tapping, for that she had discharged two quarts of water in the course +of the day after we had advised her to submit to that operation. For +many days before, she had not discharged more than two or three gills in +twenty-four hours. The operation, notwithstanding, was still indicated, +and she submitted to be tapped a few days afterwards. + +I tapped the same gentlewoman a second time, in January, 1791. She was +much terrified while I was preparing for the operation, and fainted +immediately after the puncture was made. The second time that I visited +her after the operation was performed, she told me (without being +interrogated on that subject), that she had discharged a pint and a +half of urine, within twenty minutes after I left the room on the day I +tapped her. What made this discharge the more remarkable was, she had +not made more than a table spoonful of water in a day, for several days +before she was tapped. + +I have seen similar discharges of urine in two other cases of tapping +which have come under my notice, but they resembled so nearly those +which have been mentioned, that it will be unnecessary to record them. + +But the influence of fear upon the system, in the dropsy, extends far +beyond the effects which I have ascribed to it. Dr. Currie, of this +city, informed me that he called, some years ago, by appointment, to +tap a woman. He no sooner entered the room than he observed her, as he +thought, to faint away. He attempted to recover her, but to no purpose. +She died of a sudden paroxysm of fear. + +It is a matter of surprise, that we should have remained so long +ignorant of the influence of fear upon the urinary organs in dropsies, +after having been so long familiar with the same effect of that passion +in the hysteria. + +X. _A recumbent posture of the body._ It is most useful when the dropsy +is seated in the lower limbs. I have often seen, with great pleasure, +the happiest effects from this prescription in a few days. + +XI. _Punctures._ These, when made in the legs and feet, often discharge +in eight and forty hours the water of the whole body. I have never +seen a mortification produced by them. As they are not followed by +inflammation, they should be preferred to blisters, which are sometimes +used for the same purpose. + +I cannot dismiss the remedies which discharge water from the body +through the urinary passages, without taking notice, that they furnish +an additional argument in favour of blood-letting in dropsies, for they +act, not by discharging the stagnating water, but by creating such a +plentiful secretion in the kidneys from the serum of the circulating +blood, as to make room for the absorption and conveyance of the +stagnating water into the blood-vessels. + +Now the same effect may be produced in all tonic or inflammatory +dropsies, with more certainty and safety, by means of blood-letting. + +In recommending the antiphlogistic treatment of certain dropsies, I +must here confine myself to the dropsies of such climates as dispose to +diseases of great morbid action in the system. I am satisfied that it +will often be proper in the middle and eastern states of America; and +I have lately met with two observations, which show that it has been +used with success at Vienna, in Germany. Dr. Stoll tells us, that, in +the month of January, 1780, "Hydropic and asthmatic patients discovered +more or less marks of inflammatory diathesis, and that blood was drawn +from them with a sparing hand with advantage;" and in the month of +November, of the same year, he says, "The stronger diuretics injured +dropsical patients in this season; but an antiphlogistic drink, composed +of a quart of the decoction of grass, with two ounces of simple oxymel, +and nitre and cream of tartar, of each a drachm, did service[43]." It +is probable that the same difference should be observed between the +treatment of dropsies in warm and cold climates that is observed in the +treatment of fevers. The tonic action probably exists in the system in +both countries. In the former it resembles the tides which are suddenly +produced by a shower of rain, and as suddenly disappear; whereas, in the +latter, it may be compared to those tides which are produced by the flow +and gradual addition of water from numerous streams, and which continue +for days and weeks together to exhibit marks of violence in every part +of their course. + + [43] Ratio Medendi Nosocomio Practico Vindobonensi, vol. iv. p. 56 and + 99. + +I come now to say a few words upon atonic dropsies, or such as are +accompanied with a feeble morbid action in the blood-vessels. This +morbid action is essential to the nature of dropsies, for we never +see them take place without it. This is obvious from the absence of +swellings after famine, marasmus, and in extreme old age, in each of +which there exists the lowest degree of debility, but no morbid action +in the blood-vessels. These atonic or typhus dropsies may easily be +distinguished from those which have been described, by occurring in +habits naturally weak; by being produced by the operation of chronic +causes; by a weak and quick pulse; and by little or no preternatural +heat or thirst. + +The remedies for atonic dropsies are all such stimulating substances as +increase the action of the arterial system, or determine the fluids to +the urinary organs. These are, + +I. _Bitter_ and _aromatic substances_ of all kinds, exhibited in +substance or in infusions of wine, spirit, beer, or water. + +II. _Certain acrid vegetables_, such as scurvy-grass, horse-radish, +mustard, water-cresses, and garlic. I knew an old man who was perfectly +cured of an anasarca, by eating water-cresses, on bread and butter. + +III. _Opium._ The efficacy of this medicine in dropsies has been +attested by Dr. Willis, and several other practical writers. It seems to +possess almost an exclusive power of acting alike upon the arterial, the +lymphatic, the glandular, and the nervous systems. + +IV. _Metallic tonics_, such as chalybeate medicines of all kinds, and +the mild preparations of copper and mercury. I once cured an incipient +ascites and anasarca by large doses of the rust of iron; and I have +cured many dropsies by giving mercury in such quantities as to excite a +plentiful salivation. I have, it is true, often given it without effect, +probably from my former ignorance of the violent action of the arteries, +which so frequently occurs in dropsies, and in which cases mercury must +necessarily have done harm. + +V. _Diuretics_, consisting of alkaline salts, nitre, and the oxymels +of squills and colchicum. It is difficult to determine how far these +medicines produce their salutary effects by acting directly upon the +kidneys. It is remarkable that these organs are seldom affected in +dropsies, and that their diseases are rarely followed by dropsical +effusions in any part of the body. + +VI. _Generous diet_, consisting of animal food, rendered cordial by +spices; also sound old wine. + +VII. _Diluting drinks_ taken in such large quantities as to excite the +action of the vessels by the stimulus of distention. This effect has +been produced, sir George Baker informs us, by means of large draughts +of simple water, and of cyder and water[44]. The influence of distention +in promoting absorption is evident in the urinary and gall bladders, +which frequently return their contents to the blood by the lymphatics, +when they are unable to discharge them through their usual emunctories. +Is it not probable that the distention produced by the large quantities +of liquids which we are directed to administer after giving the +foxglove, may have been the means of performing some of those cures of +dropsies, which have been ascribed to that remedy? + + [44] The remark upon this fact by sir George, is worthy of notice, and + implies much more than was probably intended by it. "When common + means have failed, success has sometimes followed a method + _directly contrary_ to the established practice." Medical + Transactions, vol. II. + +VIII. _Pressure._ Bandages bound tightly around the belly and limbs, +sometimes prevent the increase or return of dropsical swellings. The +influence of pressure upon the action of the lymphatics appears in the +absorption of bone which frequently follows the pressure of contiguous +tumours, also in the absorption of flesh which follows the long pressure +of certain parts of the body upon a sick bed. + +IX. _Frictions_, either by means of a dry, or oiled hand, or with linen +or flannel impregnated with volatile and other stimulating substances. +I have found evident advantages from following the advice of Dr. +Cullen, by rubbing the lower extremities _upwards_, and that only in +the _morning_. I have been at a loss to account for the manner in which +sweet oil acts, when applied to dropsical swellings. If it act by what +is improperly called a sedative power upon the blood-vessels, it will +be more proper in tonic than atonic dropsies; but if it act by closing +the pores, and thereby preventing the absorption of moisture from the +air, it will be very proper in the state of dropsy which is now under +consideration. It is in this manner that Dr. Cullen supposes that sweet +oil, when applied to the body, cures that state of diabetes in which +nothing but insipid water is discharged from the bladder. + +X. _Heat_, applied either separately or combined with moisture in +the form of warm or vapour baths, has been often used with success in +dropsies of too little action. Dampier, in his voyage round the world, +was cured of a dropsy by means of a copious sweat, excited by burying +himself in a bed of warm sand. Warm fomentations to the legs, rendered +moderately stimulating by the addition of saline or aromatic substances, +have often done service in the atonic dropsical swellings of the lower +extremities. + +XI. The _cold bath_. I can say nothing in favour of the efficacy of this +remedy in dropsies, from my own experience. Its good effects seem to +depend wholly on its increasing the excitability of the system to common +stimuli, by the diminution of its excitement. If this be the case, I +would ask, whether _fear_ might not be employed for the same purpose, +and thus become as useful in atonic, as it was formerly proved to be in +tonic dropsies? + +XII. _Wounds_, whether excited by cutting instruments or by fire, +provided they excite inflammation and action in the arteries, frequently +cure atonic dropsies. The good effects of inflammation and action in +these cases, appear in the cure of hydrocele by means of the needle, or +the caustic. + +XIII. _Exercise._ This is probably as necessary in the atonic dropsy, +as it is in the consumption, and should never be omitted when a patient +is able to take it. The passive exercises of swinging, and riding in +a carriage, are most proper in the lowest stage of the disease; but +as soon as the patient's strength will admit of it, he should ride on +horseback. A journey should be preferred, in this disease, to short +excursions from home. + +XIV. A _recumbent posture of the body_ should always be advised during +the intervals of exercise, when the swellings are seated in the lower +extremities. + +XV. _Punctures in the legs and feet_ afford the same relief in general +dropsy, accompanied with a weak action in the blood-vessels, that has +been ascribed to them in dropsies of an opposite character. + +In the application of each of the remedies which have been mentioned, +for the cure of both tonic and atonic dropsies, great care should be +taken to use them in such a manner, as to accommodate them to the +strength and excitability of the patient's system. The most powerful +remedies have often been rendered _hurtful_, by being given in too large +doses in the beginning, and _useless_, by being given in too small doses +in the subsequent stages of the disease. + +I have avoided saying any thing of the usual operations for discharging +water from different parts of the body, as my design was to treat only +of the symptoms and cure of those dropsies which affect the whole +system. I shall only remark, that if tapping and punctures have been +more successful in the early, than in the late stage of these diseases, +it is probably because the sudden or gradual evacuation of water takes +down that excessive action in the arterial system, which is most common +in their early stage, and thereby favours the speedy restoration of +healthy action in the exhaling or lymphatic vessels. + +Thus have I endeavoured to prove, that two different states of action +take place in dropsies, and have mentioned the remedies which are proper +for each of them under separate heads. But I suspect that dropsies are +often connected with a certain _intermediate_ or mixed action in the +arterial system, analogous to the typhoid action which takes place in +certain fevers. I am led to adopt this opinion, not only from having +observed mixed action to be so universal in most of the diseases of the +arterial and nervous system, but because I have so frequently observed +dropsical swellings to follow the scarlatina, and the puerperile fever, +two diseases which appear to derive their peculiar character from a +mixture of excessive and moderate _force_, combined with irregularity of +action in the arterial system. In dropsies of mixed action, where too +much force prevails in the action of some, and too little in the action +of other of the arterial fibres, the remedies must be debilitating or +stimulating, according to the greater or less predominance of tonic or +atonic diathesis in the arterial system. + +I shall conclude this history of dropsies, and of the different and +opposite remedies which have cured them, by the following observations. + +1. We learn, in the first place, from what has been said, the +impropriety and even danger of prescribing stimulating medicines +indiscriminately in every case of dropsy. + +2. We are taught, by the facts which have been mentioned, the reason +why physicians have differed so much in their accounts of the same +remedies, and why the same remedies have operated so differently in +the hands of the same physicians. It is because they have been given +without a reference to the different states of the system, which have +been described. Dr. Sydenham says, that he cured the first dropsical +patient he was called to, by frequent purges. He began to exult in +the discovery, as he thought, of a certain cure for dropsies, but his +triumph was of short duration. The same remedy failed in the next case +in which he prescribed it. The reason probably was, the dropsy in the +first case was of a tonic, but in the second of an atonic nature; for +the latter was an ascites from a quartan ague. It is agreeable, however, +to discover, from the theory of dropsies which has been laid down, +that all the different remedies for these diseases have been proper in +their nature, and improper only in the state of the system in which +they have been given. As the discovery of truth in religion reconciles +the principles of the most opposite sects, so the discovery of truth +in medicine reconciles the most opposite modes of practice. It would +be happy if the inquirers after truth in medicine should be taught, by +such discoveries, to treat each other with tenderness and respect, and +to wait with patience till accident, or time, shall combine into one +perfect and consistent system, all the contradictory facts and opinions, +about which physicians have been so long divided. + +3. If a state of great morbid action in the arteries has been +demonstrated in dropsies, both from its symptoms and remedies, and if +these dropsies are evidently produced by previous debility, who will +deny the existence of a similar action in certain hæmorrhages, in +gout, palsy, apoplexy, and madness, notwithstanding they are all the +offspring of predisposing debility? And who will deny the efficacy of +bleeding, purges, and other debilitating medicines in certain states +of those diseases, that has seen the same medicines administered with +success in certain dropsies? To reject bleeding, purging, and the other +remedies for violent action in the system, in any of the above diseases, +because that action was preceded by general debility, will lead us to +reject them in the most acute inflammatory fevers, for these are as much +the offspring of previous debility as dropsies or palsy. The previous +debility of the former differs from that of the latter diseases, only in +being of a more acute, or, in other words, of a shorter duration. + +4. From the symptoms of tonic dropsy which have been mentioned, it +follows, that the distinction of apoplexy into serous and sanguineous, +affords no rational indication for a difference in the mode of treating +that disease. If an effusion of serum in the thorax, bowels, or limbs, +produce a hard and full pulse, it is reasonable to suppose that the same +symptom will be produced by the effusion of serum in the brain. But the +dissections collected by Lieutaud[45] place this opinion beyond all +controversy. They prove that the symptoms of great and feeble morbid +action, as they appear in the pulse, follow alike the effusion of serum +and blood in the brain. This fact will admit of an important application +to the disease, which is to be the subject of the next inquiry. + + [45] Historia Anatomica Medica, vol. II. + +5. From the influence which has been described, of the different states +of action of the arterial system, upon the lymphatic vessels, in +dropsies, we are led to reject the indiscriminate use of bark, mercury, +and salt water, in the scrophula. When the action of the arteries is +weak, those remedies are proper; but when an opposite state of the +arterial system occurs, and, above all, when scrophulous tumours are +attended with inflammatory ulcers, stimulating medicines of all kinds +are hurtful. By alternating the above remedies with a milk and vegetable +diet, according to the tonic, or atonic states of the arterial system, +I have succeeded in the cure of a case of scrophula, attended by large +ulcers in the inguinal glands, which had for several years resisted the +constant use of the three stimulating remedies which have been mentioned. + +6. Notwithstanding I have supposed dropsies to be connected with a +peculiar state of force in the blood-vessels, yet I have not ventured +to assert, that dropsies may not exist from an exclusive affection of +the exhaling and absorbing vessels. I conceive this to be as possible, +as for a fever to exist from an exclusive affection of the arteries, or +a hysteria from an exclusive affection of the nervous system. Nothing, +however, can be said upon this subject, until physiology and pathology +have taught us more of the structure and diseases of the lymphatic +vessels. Nor have I ventured further to assert, that there are not +medicines which may act specifically upon the lymphatics, independently +of the arteries. This I conceive to be as possible as for asaf[oe]tida +to act chiefly upon the nerves, or ipecacuanha and jalap upon the +alimentary canal, without affecting other parts of the system. Until +such medicines are discovered, it becomes us to avail ourselves of the +access to the lymphatics, which is furnished us through the medium of +the arteries, by means of most of the remedies which have been mentioned. + +7. If it should appear hereafter, that we have lessened the mortality +of certain dropsies by the theory and practice which have been proposed, +yet many cases of dropsy must still occur in which they will afford +us no aid. The cases I allude to are dropsies from enclosing cysts, +from the ossification of certain arteries, from schirri of certain +viscera from large ruptures of exhaling or lymphatic vessels, from a +peculiar and corrosive acrimony of the fluids, and, lastly, from an +exhausted state of the whole system. The records of medicine furnish us +with instances of death from each of the above causes. But let us not +despair. It becomes a physician to believe, that there is no disease +necessarily incurable; and that there exist in the womb of time, certain +remedies for all those morbid affections, which elude the present limits +of the healing art. + + + + + AN INQUIRY + + INTO THE + + _CAUSES AND CURE_ + + OF THE + + INTERNAL DROPSY OF THE BRAIN. + + +Having, for many years, been unsuccessful in all the cases, except two, +of internal dropsy of the brain, which came under my care, I began to +entertain doubts of the common theory of this disease, and to suspect +that the effusion of water should be considered only as the effect of a +primary disease in the brain. + +I mentioned this opinion to my colleague, Dr. Wistar, in the month of +June, 1788, and delivered it the winter following in my lectures. The +year afterwards I was confirmed in it, by hearing that the same idea +had occurred to Dr. Quin. I have since read Dr. Quin's treatise on the +dropsy of the brain with great pleasure, and consider it as the first +dawn of light which has been shed upon it. In pursuing this subject, +therefore, I shall avail myself of Dr. Quin's discoveries, and endeavour +to arrange the facts and observations I have collected in such a manner, +as to form a connected theory from them, which I hope will lead to a new +and more successful mode of treating this disease. + +I shall begin this inquiry by delivering a few general propositions. + +1. The internal dropsy of the brain is a disease confined chiefly to +children. + +2. In children the brain is larger in proportion to other parts of the +body, than it is in adults; and of course a greater proportion of blood +is sent to it in childhood, than in the subsequent periods of life. The +effects of this determination of blood to the brain appear in the mucous +discharge from the nose, and in the sores on the head and behind the +ears, which are so common in childhood. + +3. In all febrile diseases, there is a preternatural determination of +blood to the brain. This occurs in a more especial manner in children: +hence the reason why they are so apt to be affected by convulsions in +the eruptive fever of the small-pox, in dentition, in the diseases from +worms, and in the first paroxysm of intermitting fevers. + +4. In fevers of every kind, and in every stage of life, there is a +disposition to effusion in that part to which there is the greatest +determination. Thus, in inflammatory fever, effusions take place in the +lungs and in the joints. In the bilious fever they occur in the liver, +and in the gout in every part of the body. The matter effused is always +influenced by the structure of the part in which it takes place. + +These propositions being premised, I should have proceeded to mention +the remote causes of this disease; but as this inquiry may possibly +fall into the hands of some gentlemen who may not have access to the +description of it as given by Dr. Whytt, Dr. Fothergill, and Dr. Quin, I +shall introduce a history of its symptoms taken from the last of those +authors. I prefer it to the histories by Dr. Whytt and Dr. Fothergill, +as it accords most with the ordinary phenomena of this disease in the +United States. + +"In general, the patient is at first languid and inactive, often +drowsy and peevish, but at intervals cheerful and apparently free +from complaint. The appetite is weak, a nausea, and, in many cases, a +vomiting, occurs once or twice in the day, and the skin is observed to +be hot and dry towards the evenings: soon after these symptoms have +appeared, the patient is affected with a sharp head-ach, chiefly in the +fore-part, or, if not there, generally in the crown of the head: it is +sometimes, however, confined to one side of the head, and, in that case, +when the posture of the body is erect, the head often inclines to the +side affected. We frequently find, also, that the head-ach alternates +with the affection of the stomach; the vomiting being less troublesome +when the pain is most violent, and _vice versâ_; other parts of the body +are likewise subject to temporary attacks of pain, viz. the extremities, +or the bowels, but more constantly the back of the neck, and between the +scapulæ; in all such cases the head is more free from uneasiness. + +"The patient dislikes the light at this period; cries much, sleeps +little, and when he does sleep, he grinds his teeth, picks his nose, +appears to be uneasy, and starts often, screaming as if he were +terrified; the bowels are in the majority of cases very much confined, +though it sometimes happens that they are in an opposite state: the +pulse in this early stage of the disorder, does not usually indicate any +material derangement. + +"When the symptoms above-mentioned have continued for a few days, +subject as they always are in this disease to great fluctuation, the +axis of one eye is generally found to be turned in towards the nose; +the pupil on this side is rather more dilated than the other; and when +both eyes have the axes directed inwards (which sometimes happens), +both pupils are larger than they are observed to be in the eyes of +healthy persons: the vomiting becomes more constant, and the head-ach +more excruciating; every symptom of fever then makes its appearance, +the pulse is frequent, and the breathing quick; exacerbations of the +fever take place towards the evening, and the face is occasionally +flushed; usually one cheek is much more affected than the other; +temporary perspirations likewise break forth, which are not followed by +any alleviation of distress; a discharge of blood from the nose, which +sometimes appears about this period, is equally inefficacious. + +"Delirium, and that of the most violent kind, particularly if the +patient has arrived at the age of puberty, now takes place, and with +all the preceding symptoms of fever, continues for a while to increase, +until about fourteen days, often a much shorter space of time, shall +have elapsed since the appearance of the symptoms, which were first +mentioned in the above detail. + +"The disease then undergoes that remarkable change, which sometimes +suddenly points out the commencement of what has been called its second +stage: the pulse becomes slow but unequal, both as to its strength, +and the intervals between the pulsations; the pain of the head, or of +whatever part had previously been affected, seems to abate, or at least +the patient becomes apparently less sensible of it; the interrupted +slumbers, or perpetual restlessness which prevailed during the earlier +periods of the disorder, are now succeeded by an almost lethargetic +torpor, the strabismus, and dilatation of the pupil increase, the +patient lies with one, or both eyes half closed, which, when minutely +examined, are often found to be completely insensible to light; the +vomiting ceases; whatever food or medicine is offered is usually +swallowed with apparent voracity; the bowels at this period generally +remain obstinately costive. + +"If every effort made by art fails to excite the sinking powers of +life, the symptoms of what has been called the second stage are soon +succeeded by others, which more certainly announce the approach of +death. The pulse again becomes equal, but so weak and quick, that it +is almost impossible to count it; a difficulty of breathing, nearly +resembling the _stertor apoplecticus_, is often observed; sometimes the +eyes are suffused with blood, the flushing of the face is more frequent +than before, but of shorter duration, and followed by a deadly paleness; +red spots, or blotches, sometimes appear on the body and limbs; +deglutition becomes difficult, and convulsions generally close the +scene. In one case, I may observe, the jaws of a child of four years of +age were so firmly locked for more than a day before death, that it was +impossible to introduce either food or medicine into his mouth; and, in +another case, a hemiplegia, attended with some remarkable circumstances, +occurred during the two days preceding dissolution. + +"Having thus given as exact a history of _apoplexia hydrocephalica_ +as I could compile from the writings of others, and from my own +observations, I should think myself guilty of imposition on my readers, +if I did not caution them that it must be considered merely as a general +outline: the human brain seems to be so extremely capricious (if the +expression may be allowed) in the signals it gives to other parts of the +system, of the injury it suffers throughout the course of this disease, +that although every symptom above-mentioned does occasionally occur, and +indeed few cases of the disease are to be met with, which do not exhibit +many of them; yet it does not appear to me, that any one of them is +constantly and inseparably connected with it." + +To this history I shall add a few facts, which are the result of +observations made by myself, or communicated to me by my medical +brethren. These facts will serve to show that there are many deviations +from the history of the disease which has been given, and that it is +indeed, as Dr. Quin has happily expressed it, of "a truly proteiform" +nature. + +I have not found the dilated and insensible pupil, the puking, the +delirium, or the strabismus, to attend universally in this disease. + +I saw one case in which the appetite was unimpaired from the first to +the last stage of the disease. + +I have met with one case in which the disease was attended by blindness, +and another by double vision. + +I have observed an uncommon acuteness in hearing to attend two cases of +this disease. In one of them the noise of the sparks which were +discharged from a hiccory fire, produced great pain and startings which +threatened convulsions. + +I have seen three cases in which the disease terminated in hemiplegia. +In two of them it proved fatal in a few days; in the third it continued +for nearly eighteen months. + +I have met with one case in which no preternatural slowness or +intermission was ever perceived in the pulse. + +I have seen the disease in children of nearly all ages. I once saw it +in a child of six weeks old. It was preceded by the cholera infantum. +The sudden deaths which we sometimes observe in infancy, I believe, are +often produced by this disease. Dr. Stoll is of the same opinion. He +calls it, when it appears in this form, "apoplexia infantalis[46]." + + [46] Prælectiones, vol. I. p. 254. + +In the month of March, 1771, I obtained a gill of water from the +ventricles of the brain of a negro girl of nine years of age, who died +of this disease, who complained in no stage of it of a pain in her head +or limbs, nor of a sick stomach. The disease in this case was introduced +suddenly by a pain in the breast, a fever, and the usual symptoms of a +catarrh. + +Dr. Wistar informed me, that he had likewise met with a case of internal +dropsy of the brain, in which there was a total absence of pain in the +head. + +Dr. Carson informed me, that he had attended a child in this disease +that discovered, for some days before it died, the symptom of +hydrophobia. + +Dr. Currie obtained, by dissection, seven ounces of water from the +brain of a child which died of this disease; in whom, he assured me, no +dilatation of the pupil, strabismus, sickness, or loss of appetite had +attended, and but very little head-ach. + +The causes which induce this disease, act either _directly_ on the +brain, or _indirectly_ upon it, through the medium of the whole system. + +The causes which act _directly_ on the brain are falls or bruises upon +the head, certain positions of the body, and childish plays which bring +on congestion or inflammation, and afterwards an effusion of water in +the brain. I have known it brought on in a child by falling into a +cellar upon its feet. + +The _indirect_ causes of this disease are more numerous, and more +frequent, though less suspected, than those which have been mentioned. +The following diseases of the whole system appear to act indirectly in +producing an internal dropsy of the brain. + +1. _Intermitting_, _remitting_, and _continual_ fevers. Of the effects +of these fevers in inducing this disease, many cases are recorded by +Lieutaud[47]. + + [47] Historia Anatomica-Medica, vol. II. + +My former pupil, Dr. Woodhouse, has furnished me with a dissection, +in which the disease was evidently the effect of the remitting fever. +That state of continual fever which has been distinguished by the name +of typhus, is often the remote cause of this disease. The languor and +weakness in all the muscles of voluntary motion, the head-ach, the +inclination to rest and sleep, and the disposition to be disturbed, or +terrified by dreams, which are said to be the precursors of water in +the brain, I believe are frequently symptoms of a typhus fever which +terminates in an inflammation, or effusion of water in the brain. The +history which is given of the typhus state of fever in children by Dr. +Butter[48], seems to favour this opinion. + + [48] Treatise on the Infantile Remitting Fever. + +2. The _rheumatism_. Of this I have known two instances. Dr. Lettsom has +recorded a case from the same cause[49]. The pains in the limbs, which +are supposed to be the effect, I suspect are frequently the cause of the +disease. + + [49] Medical Memoirs, vol. I. p. 174. + +3. The _pulmonary consumption_. Of the connection of this disease with +an internal dropsy of the brain, Dr. Percival has furnished us with the +following communication[50]: "Mr. C----'s daughter, aged nine years, +after labouring under the phthisis pulmonalis four months, was affected +with unusual pains in her head. These rapidly increased, so as to +occasion frequent screamings. The cough, which had before been extremely +violent, and was attended with stitches in the breast, now abated, and +in a few days ceased almost entirely. The pupils of the eyes became +dilated, a strabismus ensued, and in about a week death put an end to +her agonies. Whether this affection of the head arose from the effusion +of water or of blood, is uncertain, but its influence on the state of +the lungs is worthy of notice." Dr. Quin likewise mentions a case from +Dr. Cullen's private practice, in which an internal dropsy of the brain +followed a pulmonary consumption. Lieutaud mentions three cases of the +same kind[51], and two, in which it succeeded a catarrh[52]. + + [50] Essays, Medical, Philosophical, and Experimental, vol. II. p. 339, + 340. + + [51] Historia Anatomica-Medica, vol. II. lib. tertius. obs. 380, 394, + 1121. + + [52] Obs. 383, 431. + +4. _Eruptive fevers._ Dr. Odier informs us[53], that he had seen four +cases in which it had followed the small-pox, measles, and scarlatina. +Dr. Lettsom mentions a case in which it followed the small-pox[54], +and I have seen one in which it was obviously the effects of debility +induced upon the system by the measles. + + [53] Medical Journal. + + [54] Medical Memoirs, vol. I. p. 171. + +5. _Worms._ Notwithstanding the discharge of worms gives no relief in +this disease, yet there is good reason to believe, that it has, in some +instances, been produced by them. The morbid action continues in the +brain, as in other cases of disease, after the cause which induced it, +has ceased to act upon the body. + +6. From the dissections of Lieutaud, Quin, and others, it appears +further, that the internal dropsy of the brain has been observed +to succeed each of the following diseases, viz. the colic, palsy, +melancholy, dysentery, dentition, insolation, and scrophula, also the +sudden healing of old sores. I have seen two cases of it from the last +cause, and one in which it was produced by the action of the vernal sun +alone upon the system. + +From the facts which have been enumerated, and from dissections to be +mentioned hereafter, it appears, that the disease in its first stage is +the effect of causes which produce a less degree of that morbid action +in the brain which constitutes phrenitis, and that its second stage is +the effect of a less degree of that effusion, which produces serous +apoplexy in adults. The former partakes of the nature of the chronic +inflammation of Dr. Cullen, and of the asthenic inflammation of Dr. +Brown. I have taken the liberty to call it _phrenicula_, from its being +a diminutive species or state of phrenitis. It bears the same relation +to phrenitis, when it arises from indirect causes, which pneumonicula +does to pneumony; and it is produced nearly in the same manner as the +pulmonary consumption, by debilitating causes which act primarily on +the whole system. The peculiar size and texture of the brain seem to +invite the inflammation and effusions which follow debility, to that +organ in childhood, just as the peculiar structure and situation of +the lungs invite the same morbid phænomena to them, after the body has +acquired its growth, in youth and middle life. In the latter stage which +has been mentioned, the internal dropsy of the brain partakes of some +of the properties of apoplexy. It differs from it in being the effect +of a _slow_, instead of a _sudden_ effusion of water or blood, and in +being the effect of causes which are of an acute instead of a chronic +nature. In persons advanced beyond middle life, who are affected by +this disease, it approaches to the nature of the common apoplexy, by a +speedy termination in life or death. Dr. Cullen has called it simply by +the name of "apoplexia hydrocephalica." I have preferred for its last +stage the term of _chronic apoplexy_, for I believe with Dr. Quin, that +it has no connection with a hydropic diathesis of the whole system. I am +forced to adopt this opinion, from my having rarely seen it accompanied +by dropsical effusions in other parts of the body, nor a general dropsy +accompanied by an internal dropsy of the brain. No more occurs in this +disease than takes place when hydrothorax follows an inflammation of +the lungs, or when serous effusions follow an inflammation of the +joints. I do not suppose that both inflammation and effusion always +attend in this disease; on the contrary, dissections have shown some +cases of inflammation, with little or no effusion, and some of effusion +without inflammation. Perhaps this variety may have been produced by the +different stages of the disease in which death and the inspection of +the brain took place. Neither do I suppose, that the two stages which +have been mentioned, always succeed each other in the common order of +inflammation and effusion. In every case where the full tense, slow and +intermitting pulse occurs, I believe there is inflammation; and as this +state of the pulse occurs in most cases in the beginning of the disease, +I suppose the inflammation, in most cases, to precede the effusion of +water. I have met with only one case in which the slow and tense pulse +was absent; and out of six dissections of patients whom I have lost by +this disease, the brains of four of them exhibited marks of inflammation. + +Mr. Davis discovered signs of inflammation, after death from this +disease, to be universal. In eighteen or twenty dissections, he tells +us, he found the pia mater always distended with blood[55]. Where signs +of inflammation have not occurred, the blood-vessels had probably +relieved themselves by the effusion of serum, or the morbid action of +the blood-vessels had exceeded that grade of excitement, in which only +inflammation can take place. I have seen one case of death from this +disease, in which there was not more than a tea-spoonful of water in the +ventricles of the brain. Dr. Quin mentions a similar case. Here death +was induced by simple excess of excitement. The water which is found in +the ventricles of the brain refuses to coagulate by heat, and is always +pale in those diseases, in which the serum of the blood, in every other +part of the body, is of a yellow colour. + + [55] Medical Journal, vol. VIII. + +In addition to these facts, in support of the internal dropsy of the +brain being the effect of inflammation, I shall mention one more, +communicated to me in a letter, dated July 17th, 1795, by my former +pupil, Dr. Coxe, while he was prosecuting his studies in London. "It +so happened (says my ingenious correspondent), that at the time of my +receiving your letter, Dr. Clark was at the hospital. I read to him that +part which relates to your success in the treatment of hydrocephalus +internus. He was much pleased with it, and mentioned to me a fact which +strongly corroborates your idea of its being a primary inflammation of +the brain. This fact was, that upon opening, not long since, the head of +a child that had died of this disease, he found between three and four +ounces of water in the ventricles of the brain; also an inflammatory +crust on the optic nerves, as thick as he had ever observed it on the +intestines in a state of inflammation. The child lost its sight before +it died. The crust accounted in a satisfactory manner for its blindness. +Perhaps something similar may always be noticed in the dissections of +such as die of this disease, in whom the eyes are much affected." + +Having adopted the theory of this disease, which I have delivered, I +resolved upon such a change in my practice as should accord with it. The +first remedy indicated by it was + +I. _Blood-letting._ I shall briefly mention the effects of this remedy +in a few of the first cases in which I prescribed it. + + + CASE I. + +On the 15th of November, 1790, I was called to visit the daughter +of William Webb, aged four years, who was indisposed with a cough, a +pain in her bowels, a coma, great sensibility of her eyes to light, +costiveness, and a suppression of urine, a slow and irregular, but +tense pulse, dilated pupils, but no head-ach. I found, upon inquiry, +that she had received a hurt on her head by a fall, about seven weeks +before I saw her. From this information, as well as from her symptoms, +I had no doubt of the disease being the internal dropsy of the brain. I +advised the loss of five ounces of blood, which gave her some relief. +The blood was sizy. The next day she took a dose of jalap and calomel, +which operated twelve times. On the 18th she lost four ounces more of +blood, which was more sizy than that drawn on the 15th. From this time +she mended rapidly. Her coma left her on the 20th, and her appetite +returned; on the 21st she made a large quantity of turbid dark coloured +urine. On the 22d her pulse became again a little tense, for which she +took a gentle puke. On the 23d she had a natural stool. On the 24th her +pupils appeared to be contracted to their natural size, and on the 30th +I had the pleasure of seeing her seated at a tea-table in good health. +Her pulse notwithstanding, was a little more active and tense than +natural. + + + CASE II. + +On the 24th of the same month, I was called to visit the son of John +Cypher, in South-street, aged four years, who had been hurt about a +month before, by a wound on his forehead with a brick-bat, the mark of +which still appeared. He had been ill for near two weeks with coma, +head-ach, colic, vomiting, and frequent startings in his sleep. His +evacuations by stool and urine were suppressed; he had discharged three +worms, and had had two convulsion fits just before I saw him. The pupil +of the right eye was larger than that of the left. His pulse was full, +tense, and slow, and intermitted every _fourth_ stroke. The symptoms +plainly indicated an internal dropsy of the brain. I ordered him to lose +four or five ounces of blood. But three ounces of blood were drawn, +which produced a small change in his pulse. It rendered the intermission +of a pulsation perceptible only after every tenth stroke. On the 25th +he lost five ounces of blood, and took a purge of calomel and jalap. On +the 26th he was better. On the 27th the vomiting was troublesome, and +his pulse was still full and tense, but regular. I ordered him to lose +four ounces of blood. On the 28th his puking and head-ach continued; +his pulse was a little tense, but regular; and his right pupil less +dilated. On the 29th his head-ach and puking ceased, and he played +about the room. On the 4th of December he grew worse; his head-ach and +puking returned, with a hard pulse, for which I ordered him to lose five +ounces of blood. On the 5th he was better, but on the 6th his head-ach +and puking returned. On the 7th I ordered his forehead to be bathed +frequently with vinegar, in which ice had been dissolved. On the 8th he +was much better. On the 9th his pulse became soft, and he complained but +little of head-ach. After appearing to be well for near three weeks, +except that he complained of a little head-ach, on the 29th his pulse +became again full and tense, for which I ordered him to lose six ounces +of blood, which for the first time discovered a buffy coat. After this +last bleeding, he discharged a large quantity of water. From this time +he recovered slowly, but his pulse was a little fuller than natural on +the 19th of January following. He afterwards enjoyed good health. + + + CASES III. AND IV. + +In the month of March, 1792, I attended two children of three years of +age, the one the daughter of William King, the other the daughter of +William Blake: each of whom had most of the symptoms of the inflammatory +stage of the internal dropsy of the brain. I prescribed the loss of four +ounces of blood, and a smart purge in both cases, and in the course of a +few days had the pleasure of observing all the symptoms of the disease +perfectly subdued in each of them. + + + CASE V. + +In the months of July and August, 1792, I attended a female slave of +Mrs. Oneal, of St. Croix, who had an obstinate head-ach, coma, vomiting, +and a tense, full, and _slow_ pulse. I believed it to be the phrenicula, +or internal dropsy of the brain, in its inflammatory stage. I bled her +five times in the course of two months, and each time with obvious +relief of all the symptoms of the disease. Finding that her head-ach, +and a disposition to vomit, continued after the tension of her pulse +was nearly reduced, I gave her as much calomel as excited a gentle +salivation, which in a few weeks completed her cure. + + + CASE VI. + +The daughter of Robert Moffat, aged eight years, in consequence of the +suppression of a habitual discharge from sores on her head, in the +month of April, 1793, was affected by violent head-ach, puking, great +pains and weakness in her limbs, and a full, tense, and _slow_ pulse. +I believed these symptoms to be produced by an inflammation of the +brain. I ordered her to lose six or seven ounces of blood, and gave her +two purges of jalap and calomel, which operated very plentifully. I +afterwards applied a blister to her neck. In one week from the time of +my first visit to her she appeared to be in perfect health. + + + CASE VII. + +A young woman of eighteen years of age, a hired servant in the family +of Mrs. Elizabeth Smith, had been subject to a head-ach every spring for +several years. The unusually warm days which occurred in the beginning +of April, 1793, produced a return of this periodical pain. On the eighth +of the month, it was so severe as to confine her to her bed. I was +called to visit her on the ninth. I found her comatose, and, when awake, +delirious. Her pupils were unusually dilated, and insensible to the +light. She was constantly sick at her stomach, and vomited frequently. +Her bowels were obstinately costive, and her pulse was full, tense, and +so slow as seldom to exceed, for several days, from 56 to 60 strokes in +a minute. I ordered her to lose ten ounces of blood every day, for three +days successively, and gave her, on each of those days, strong doses of +jalap and aloes. The last blood which was drawn from her was sizy. The +purges procured from three to ten discharges every day from her bowels. +On the 12th, she appeared to be much better. Her pulse was less tense, +and beat 80 strokes in a minute. On the 14th, she had a fainting fit. On +the 15th, she sat up, and called for food. The pupils of her eyes now +recovered their sensibility to light, as well as their natural size. Her +head-ach left her, and, on the 17th, she appeared to be in good health. +Her pulse, however, continued to beat between 50 and 60 strokes in a +minute, and retained a small portion of irregular action for several +days after she recovered. + +I am the more disposed to pronounce the cases which have been described +to have been internal dropsy of the brain, from my having never been +deceived in a single case in which I have examined the brains of +patients whom I have suspected to have died of it. + +I could add many other cases to those which have been related, but +enough, I hope, have been mentioned to establish the safety and efficacy +of the remedies that have been recommended. + +I believe, with Dr. Quin, that this disease is much more frequent +than is commonly supposed. I can recollect many cases of anomalous +fever and head-ach in children, which have excited the most distressing +apprehensions of an approaching internal dropsy of the brain, but which +have yielded in a few days to bleeding, or to purges and blisters. I +think it probable, that some, or perhaps most of these cases, might have +terminated in an effusion of water in the brain, had they been left +to themselves, or not been treated with the above remedies. I believe +further, that it is often prevented by all those physicians who treat +the first stage of febrile diseases in children with evacuations, just +as the pulmonary consumption is prevented by bleeding, and low diet, in +an inflammatory catarrh. + +Where blood-letting has failed of curing this disease, I am disposed +to ascribe it to its being used less copiously than the disease +required. If its relation to pneumonicula be the same in its cure, +that I have supposed it to be in its cause, then I am persuaded, that +the same excess in blood-letting is indicated in it, above what is +necessary in phrenitis, that has been practised in pneumonicula, above +what is necessary in the cure of an acute inflammation of the lungs. +The continuance, and, in some instances, the increase of the appetite +in the internal dropsy of the brain, would seem to favour this opinion +no less in this disease, than in the inflammatory state of pulmonary +consumption. The extreme danger from the effusion of water into the +ventricles of the brain, and the certainty of death from its confinement +there, is a reason likewise why more blood should be drawn in this +disease, than in diseases of the same force in other parts of the body, +where the products of inflammation have a prompt, or certain outlet from +the body. Where the internal dropsy is obviously the effect of a fall, +or of any other cause which acts _directly_ on the brain, there can be +no doubt of the safety of very plentiful bleeding; all practical writers +upon surgery concur in advising it. The late Dr. Pennington favoured +me with an extract from Mr. Cline's manuscript lectures upon anatomy, +delivered in London in the winter of 1792, which places the advantage +of blood-letting, in that species of inflammation which follows a local +injury of the brain, in a very strong point of light. "I know (says he) +that several practitioners object to the use of evacuations as remedies +for concussions of the brain, because of the weakness of the pulse; but +in these cases the pulse is _depressed_. Besides, experience shows, +that evacuations are frequently attended with very great advantages. I +remember a remarkable case of a man in this [St. Thomas's] hospital, who +was under the care of Mr. Baker. He lay in a comatose state for three +weeks after an injury of the head. During that time he was bled _twenty_ +times, that is to say, he was bled once every day upon an average. He +was bled twice a day _plentifully_, but towards the conclusion he was +bled more sparingly, and only every other day; but at each bleeding, +there were taken, upon an average, about sixteen ounces of blood. In +consequence of this treatment, the man perfectly recovered his health +and reason." + +Local bleeding by cups, leaches, scarifications, or arteriotomy, should +be combined with venesection, or preferred to it, where the whole +arterial system does not sympathize with the disease in the brain. + +II. A second remedy to be used in the second stage of this disease is +_purges_. I have constantly observed all the patients whose cases have +been related, to be relieved by plentiful and repeated evacuations from +the bowels. I was led to the use of frequent purges, by having long +observed their good effects in palsies, and other cases of congestion +in the brain, where blood-letting was unsafe, and where it had been +used without benefit. In the Leipsic Commentaries[56], there is an +account of a case of internal dropsy of the brain, which followed the +measles, being cured by no other medicines than purges and diuretics. I +can say nothing in favour of the latter remedy, in this disease, from +my own experience. The foxglove has been used in this city by several +respectable practitioners, but, I believe, in no instance with any +advantage. + + [56] Vol. xxix. p. 139. + +III. _Blisters_ have been uniformly recommended by all practical writers +upon this disease. I have applied them to the head, neck, and temples, +and generally with obvious relief to the pain in the head. They should +be omitted in no stage of the disease; for even in its inflammatory +stage, the discharge they occasion from the vessels of the head, greatly +overbalances their stimulating effects upon the whole system. + +IV. _Mercury_ was long considered as the only remedy, which gave the +least chance of a recovery from a dropsy of the brain. Out of all the +cases in which I gave it, before the year 1790, I succeeded in but two: +one of them was a child of three years old, the other was a young woman +of twenty-six years of age. I am the more convinced that the latter +case was internal dropsy of the brain, from my patient having relapsed, +and died between two or three years afterwards, of the same disease. +Since I have adopted the depleting remedies which have been mentioned, +I have declined giving mercury altogether, except when combined with +some purging medicine, and I have given it in this form chiefly with a +view of dislodging worms. My reasons for not giving it as a sialagogue +are the uncertainty of its operation, its frequent inefficacy when +it excites a salivation, and, above all, its disposition to produce +gangrene in the tender jaws of children. Seven instances of its inducing +death from that cause, in children between three and eight years of +age, and with circumstances of uncommon distress, have occurred in +Philadelphia since the year 1795. + +V. _Linen cloths_, wetted with cold vinegar, or water, and applied to +the forehead, contribute very much to relieve the pain in the head. In +the case of Mr. Cypher's son[57], the solution of ice in the vinegar +appeared to afford the most obvious relief of this distressing symptom. + + [57] Case II. + +A puncture in the brain has been proposed by some writers to discharge +the water from its ventricles. If the theory I have delivered be true, +the operation promises nothing, even though it could always be performed +with perfect safety. In cases of local injuries, or of inflammation from +any cause, it must necessarily increase the disease; and in cases of +effusion only, the debilitated state of the whole system forbids us to +hope for any relief from such a local remedy. + +Bark, wine, and opium promise much more success in the last stage of +the disease. I can say nothing in their favour from my own experience; +but from the aid they afford to mercury in other diseases, I conceive +they might be made to accompany it with advantage. + +Considering the nature of the indirect causes which induce the disease, +and the case of a relapse, which has been mentioned, after an interval +of near three years, as well as the symptoms of slow convalescence, +manifested by the pulse, which occurred in the first and seventh cases, +I submit it to the consideration of physicians, whether the use of +moderate exercise, and the cold bath, should not be recommended to +prevent a return of the disease in every case, where it has yielded to +the power of medicine. + +I have great pleasure in adding, that the theory of this disease, +which I have delivered, has been adopted by many respectable physicians +in Philadelphia, and in other parts of the United States, and that it +has led to the practice that has been recommended, particularly to +copious blood-letting; in consequence of which, death from a dropsy of +the brain is not a more frequent occurrence, than from any other of the +acute febrile diseases of our country. + + + + + OBSERVATIONS + + UPON + + THE NATURE AND CURE + + OF THE + + _GOUT_. + + +In treating upon the gout, I shall deliver a few preliminary +propositions. + +1. The gout is a disease of the whole system. It affects the ligaments, +blood-vessels, stomach, bowels, brain, liver, lymphatics, nerves, +muscles, cartilages, bones, and skin. + +2. The gout is a primary disease, only of the solids. Chalk-stones, +abscesses, dropsical effusions into cavities, and cellular membrane, and +eruptions on the skin, are all the effects of a morbid action in the +blood-vessels. The truth of this proposition has been ably proved by Dr. +Cullen in his First Lines. + +3. It affects most frequently persons of a sanguineous temperament; but +sometimes it affects persons of nervous and phlegmatic temperaments. +The idle and luxurious are more subject to it, than the labouring and +temperate part of mankind. Women are said to be less subject to it than +men. I once believed, and taught this opinion, but I now retract it. +From the peculiar delicacy of the female constitution, and from the thin +covering they wear on their feet and limbs, the gout is less apt to fall +upon those parts than in men, but they exhibit all its other symptoms, +perhaps more frequently than men, in other parts of the body. The remote +causes of gout moreover to be mentioned presently, act with equal force +upon both sexes, and more of them I believe upon women, than upon men. + +It generally attacks in those periods of life, and in those countries, +and seasons of the year, in which inflammatory diseases are most common. +It seldom affects persons before puberty, or in old age, and yet I have +heard of its appearing with all its most characteristic symptoms in this +city in a child of 6, and in a man above 80 years of age. Men of active +minds are said to be most subject to it, but I think I have seen it as +frequently in persons of slender and torpid intellects, as in persons of +an opposite character. I have heard of a case of gout in an Indian at +Pittsburg, and I have cured a fit of it in an Indian in this city. They +had both been intemperate in the use of wine and fermented liquors. + +4. It is in one respect a hereditary disease, depending upon the +propagation of a similar temperament from father to son. When a +predisposition to the gout has been derived from ancestors, less force +in exciting causes will induce it than in those habits where this has +not been the case. This predisposition sometimes passes by children, +and appears in grand-children. There are instances likewise in which it +has passed by the males, and appeared only in the females of a family. +It even appears in the descendants of families who have been reduced +to poverty, but not often where they have been obliged to labour for a +subsistence. It generally passes by those children who are born before +the gout makes its appearance in a father. It is curious to observe +how extensively the predisposition pervades some families. An English +gentleman, who had been afflicted with the gout, married a young woman +in Philadelphia many years ago, by whom he had one daughter. His wife +dying three weeks after the birth of this child, he returned to England, +where he married a second wife, by whom he had six children, all of whom +except one died with the gout before they attained to the usual age of +matrimony in Great Britain. One of them died in her 16th year. Finally +the father and grandfather died with the same disease. The daughter whom +this afflicted gentleman left in this city, passed her life subject to +the gout, and finally died under my care in the year 1789, in the 68th +year of her age. She left a family of children, two of whom had the +gout. One of them, a lady, has suffered exquisitely from it. + +5. The gout is always induced by general predisposing debility. + +6. The remote causes of the gout which induce this debility, are, +indolence, great bodily labour, long protracted bodily exercise, +intemperance in eating, and in venery, acid aliments and drinks, strong +tea and coffee, public and domestic vexation, the violent, or long +continued exercise of the understanding, imagination, and passions +in study, business, or pleasure, and, lastly, the use of ardent, and +fermented liquors. The last are absolutely necessary to produce that +form of gout which appears in the ligaments and muscles. I assert this, +not only from my own observations, but from those of Dr. Cadogan, and +Dr. Darwin, who say they never saw a case of gout in the limbs in any +person who had not used spirits or wine in a greater or less quantity. +Perhaps this may be another reason why women, who drink less of those +liquors than men, are so rarely affected with this disease in the +extreme parts of their bodies. Wines of all kinds are more disposed +to produce this form of gout than spirits. The reason of this must +be resolved into the less stimulus in the former, than in the latter +liquors. Wine appears to resemble, in its action upon the body, the +moderate stimulus of miasmata which produce a common remitting fever, or +intermitting fever, while spirits resemble that violent action induced +by miasmata which passes by the blood-vessels, ligaments, and muscles, +and invades at once the liver, bowels, and brain. There is one symptom +of the gout in the extremities which seems to be produced exclusively +by ardent spirits, and that is a burning in the palms of the hands, +and soles of the feet. This is so uniform, that I have sometimes been +able to convict my patients of intemperance in the use of spirits, when +no other mark of their having taken them in _excess_, appeared in the +system. + +I have enumerated among the remote causes of the gout, the use of +strong tea. I infer its predisposing quality to that disease, from its +frequency at Japan, where tea is used in large quantities, and from the +gout being more common among that sex in our country who drink the most, +and the strongest tea. + +7. The exciting causes of the gout are frequently a greater degree, +or a sudden application of its remote and predisposing causes. They +act upon the accumulated excitability of the system, and by destroying +its equilibrium of excitement, and regular order of actions, produce +convulsion, or irregular morbid and local excitement. These exciting +causes are either of a stimulating, or of a sedative nature. The former +are violent exercise, of body or mind, night-watching, and even sitting +up late at night, a hearty meal, a fit of drunkenness, a few glasses +of claret or a draught of cyder, where those liquors have not been +habitual to the patient, a sudden paroxysm of joy, anger, or terror, +a dislocation of a bone, straining of a joint, particularly of the +ankle, undue pressure upon the foot, or leg, from a tight shoe or boot, +an irritated corn, and the usual remote causes of fever. The latter +exciting causes are sudden inanition from bleeding, purging, vomiting, +fasting, cold, a sudden stoppage of moisture on the feet, fear, grief, +excess in venery, and the debility left upon the system by the crisis +of a fever. All these causes act more certainly when they are aided by +the additional debility induced upon the system in sleep. It is for this +reason that the gout generally makes its first attack in the night, +and in a part of the system most remote from the energy of the brain, +and most debilitated by exercise, viz. in the great toe, or in some +part of the foot. In ascribing a fit of the gout to a cause which is +of a sedative nature, the reader will not suppose that I have departed +from the simplicity and uniformity of a proposition I have elsewhere +delivered, that disease is the effect of stimulus. The abstraction +of a natural and habitual impression of any kind, by increasing the +force of those which remain, renders the production of morbid and +excessive actions in the system as much the effect of preternatural or +disproportioned stimulus, as if they were induced by causes that are +externally and evidently stimulating. It is thus in many other of the +operations of nature, opposite causes produce the same effects. + +8. The gout consists simply in morbid excitement, accompanied with +irregular action, or the absence of all action from the force of +stimulus. There is nothing specific in the morbid excitement and actions +which take place in the gout different from what occur in fevers. It is +to be lamented that a kind of metastasis of error has taken place in +pathology. The rejection of a specific acrimony as the cause of each +disease, has unfortunately been followed by a belief in as many specific +actions as there are different forms and grades of disease, and thus +perpetuated the evils of our ancient systems of medicine. However varied +morbid actions may be by their causes, seats, and effects, they are +all of the same nature, and the time will probably come when the whole +nomenclature of morbid actions will be absorbed in the single name of +disease. + +I shall now briefly enumerate the symptoms of the gout, as they appear +in the ligaments, the blood-vessels, the viscera, the nervous system, +the alimentary canal, the lymphatics, the skin, and the bones of the +human body, and here we shall find that it is an epitome of all disease. + +I. The ligaments which connect the bones are the seats, of what is +called a legitimate or true gout. They are affected with pain, swelling, +and inflammation. The pain is sometimes so acute as to be compared +to the gnawing of a dog. We perceive here the sameness of the gout +with the rheumatism. Many pages, and indeed whole essays, have been +composed by writers to distinguish them, but they are exactly the same +disease while the morbid actions are confined to this part of the body. +They are, it is true, produced by different remote causes, but this +constitutes no more difference in their nature, than is produced in +a coal of fire, whether it be inflamed by a candle, or by a spark of +electricity. The morbid actions which are induced by the usual causes +of rheumatism affect, though less frequently, the lungs, the trachea, +the head, the bowels, and even the heart, as well as the gout. Those +actions, moreover, are the means of a fluid being effused, which is +changed into calcareous matter in the joints and other parts of the +body, exactly like that which is produced by the gout. They likewise +twist and dislocate the bones in common with the gout, in a manner to be +described hereafter. The only difference between what are called gouty, +and rheumatic actions, consists in their seats, and in the degrees of +their force. The debility which predisposes to the gout, being greater, +and more extensively diffused through the body than the debility which +precedes rheumatism, the morbid actions, in the former case, pass more +readily from external to internal parts, and produce in both more acute +and more dangerous effects. A simile derived from the difference in the +degrees of action produced in the system by marsh miasmata, made use of +upon a former occasion, will serve me again to illustrate this part of +our subject. A mild remittent, and a yellow fever, are different grades +of the same disease. The former, like the rheumatism, affects the bones +chiefly with pain, while the latter, like the gout, affects not only the +bones, but the stomach, bowels, brain, nerves, lymphatics, and all the +internal parts of the body. + +II. In the arterial system the gout produces fever. This fever appears +not only in the increased force or frequency of the pulse, but in morbid +affections of all the viscera. It puts on all the different grades of +fever, from the malignity of the plague, to the mildness of a common +intermittent. It has moreover its regular exacerbations and remissions +once in every four and twenty hours, and its crisis usually on the +fourteenth day, in violent cases. In moderate attacks, it runs on from +twenty to forty days in common with the typhus or slow chronic state +of fever. It is common for those persons who consider the gout as a +specific disease, when it appears in the above forms, to say, that it is +complicated with fever; but this is an error, for there can exist but +one morbid action in the blood-vessels at once, and the same laws are +imposed upon the morbid actions excited in those parts of the body by +the remote causes of the gout, as by the common causes of fever. I have +seen two instances of this disease appearing in the form of a genuine +hectic, and one in which it appeared to yield to lunar influence, in +the manner described by Dr. Balfour. In the highly inflammatory state +of the gout, the sensibility of the blood-vessels far exceeds what is +seen in the same state of fever from more common causes. I have known an +instance in which a translation of the gouty action to the eye produced +such an exquisite degree of sensibility, that the patient was unable +to bear the feeble light which was emitted from a few coals of fire in +his room, at a time too when the coldness of the weather would have +made a large fire agreeable to him. It is from the extreme sensibility +which the gout imparts to the stomach, that the bark is so generally +rejected by it. I knew a British officer who had nearly died from taking +a spoonful of the infusion of that medicine, while his arterial system +was in this state of morbid excitability, from a fit of the gout. It +is remarkable that the gout is most disposed to assume a malignant +character, during the prevalence of an inflammatory constitution of +the atmosphere. This has been long ago remarked by Dr. Huxham. Several +instances of it have occurred in this city since the year 1793. + +III. The gout affects most of the viscera. In the brain it produces +head-ach, vertigo, coma, apoplexy, and palsy. In the lungs it produces +pneumonia vera, notha, asthma, hæmoptysis, pulmonary consumption, and +a short hecking cough, first described by Dr. Sydenham. In the throat +it produces inflammatory angina. In the uterus it produces hæmorrhagia +uterina. It affects the kidneys with inflammation, strangury, diabetes, +and calculi. The position of the body for weeks or months on the +back, by favouring the compression of the kidneys by the bowels, is +the principal reason why those parts suffer so much in gouty people. +The strangury appears to be produced by the same kind of engorgement +or choking of the vessels of the kidneys, which takes place in the +small-pox and yellow fever. Four cases of it are described in the 3d +volume of the Physical and Literary Essays of Edinburgh, by Dr. David +Clerk. I have seen one instance of death in an old man from this cause. +The catheter brought no water from his bladder. The late Mr. John Penn, +formerly governor of Pennsylvania, I have been informed by one of his +physicians, died from a similar affection in his kidneys from gout. The +catheter was as ineffectual in giving him relief, as it was in the case +of my patient. The neck of the bladder sometimes becomes the seat of +the gout. It discovers itself by spasm, and a suppression of urine in +some cases, and occasionally by a habitual discharge of mucus through +the urethra. This disease has been called, by Lieutaud, "a catarrh of +the bladder." Dr. Stoll describes it, and calls it "hæmorrhoids of +the bladder." But of all the viscera, the liver suffers most from the +gout. It produces in it inflammation, suppuration, melena, schirrus, +gall-stones, jaundice, and a habitual increased secretion and excretion +of bile. These affections of the liver appear most frequently in +southern countries, and in female habits. They are substitutes for a +gout in the ligaments, and in the extremities of the body. They appear +likewise in drunkards from ardent spirits. It would seem that certain +stimuli act specifically upon the liver, probably for the wise purpose +of discharging such parts of the blood from the body, as are vitiated +by the rapidity of its circulation. I shall, in another place[58], +take notice of the action of marsh miasmata upon the livers of men and +beasts. It has been observed that hogs that live near brewhouses, and +feed upon the fermented grains of barley, always discover enlarged or +diseased livers. But a determination of the blood to the liver, and +an increased action of its vessels, are produced by other causes than +marsh miasmata, and fermented and distilled liquors. They appear in the +fever which accompanies madness and the malignant sore-throat, also in +contusions of the brain, and in the excited state of the blood-vessels +which is produced by anger and exercise. I have found an attention to +these facts useful in prescribing for diseases of the liver, inasmuch as +they have led me from considering them as idiopathic affections, but as +the effects only of morbid actions excited in other parts of the body. + + [58] Volume IV. + +IV. The gout sometimes affects the arterial and nervous systems +_jointly_, producing in the brain, coma, vertigo, apoplexy, palsy, loss +of memory, and madness, and in the _nerves_, hysteria, hypochondriasis, +and syncope. It is common to say the gout counterfeits all these +diseases. But this is an inaccurate mode of speaking. All those diseases +have but one cause, and they are exactly the same, however different the +stimulus may be, from which they are derived. Sometimes the gout affects +the brain and nerves exclusively, without producing the least morbid +action in the blood-vessels. I once attended a gentleman from Barbadoes +who suffered, from this affection of his brain and nerves, the most +intolerable depression of spirits. It yielded to large doses of wine, +but his relief was perfect, and more durable, when a pain was excited by +nature or art, in his hands or feet. + +The muscles are sometimes affected by the gout with spasm, with general +and partial convulsions, and lastly with great pain. Dr. Stoll describes +a case of opisthotonos from it. The angina pectoris, or a sudden +inability to breathe after climbing a hill, or a pair of stairs, and +after a long walk, is sometimes a symptom of the gout. There is a pain +which suddenly pervades the head, breast, and limbs, which resembles an +electric shock. I have known two instances of it in gouty patients, and +have taken the liberty of calling it the "aura arthritica." But the pain +which affects the muscles is often of a more permanent nature. It is +felt with most severity in the calves of the legs. Sometimes it affects +the muscles of the head, breast, and limbs, exciting in them large and +distressing swellings. But further; the gout in some cases seizes upon +the tendons, and twists them in such a manner as to dislocate bones in +the hands and feet. It even affects the cartilages. Of this I once saw +an instance in colonel Adams, of the state of Maryland. The external +parts of both his ears were so much inflamed in a fit of the gout, that +he was unable to lie on either of his sides. + +V. The gout affects the alimentary canal, from the stomach to its +termination in the rectum. Flatulency, sickness, acidity, indigestion, +pain, or vomiting, usually usher in a fit of the disease. The sick +head-ach, also dyspepsia, with all its train of distressing evils, are +frequently the effects of gout concentrated in the stomach. I have seen +a case in which the gout, by retreating to this viscus, produced the +same burning sensation which is felt in the yellow fever. The patient +who was the subject of this symptom died two days afterwards with a +black vomiting. It was Mr. Patterson, formerly collector of the port +of Philadelphia, under the British government. I was not surprised at +these two uncommon symptoms in the gout, for I had long been familiar +with its disposition to affect the biliary secretion, and the actions +of the stomach. The colic and dysentery are often produced by the gout +in the bowels. In the southern states of America, it sometimes produces +a chronic diarrh[oe]a, which is known in some places by the name of the +"downward consumption." The piles are a common symptom of gout, and +where they pour forth blood occasionally, render it a harmless disease. +I have known an instance in which a gouty pain in the rectum produced +involuntary stools in a gentleman in this city, and I have heard from +a southern gentleman, who had been afflicted with gouty symptoms, that +a similar pain was excited in the same part to such a degree, whenever +he went into a crowded room lighted by candles, as to oblige him to +leave it. In considering the effects of the gout upon this part, I +am led to take notice of a troublesome itching in the anus which has +been described by Dr. Lettsom, and justly attributed by him to this +disease[59]. I have known several cases of it. They always occurred +in gouty habits. A distressing collection of air in the rectum, which +renders frequent retirement from company necessary to discharge it, is +likewise a symptom of gout. It is accompanied with frequent, and small, +but hard stools. + + [59] Medical Memoirs, vol. III. + +Of the above morbid affections of the nerves, stomach, and bowels, the +hysteria, the sick head-ach, and the colic, appear much oftener in women +than in men. I have said that dyspepsia is a symptom of gout. Out of +more than 500 persons who were the patients of the Liverpool infirmary +and dispensary, in one year, Dr. Currie informs us, "a great majority +were females[60]." + + [60] Medical Reports on the Effects of Hot and Cold Water, p. 215. + +VI. The gout affects the glands and lymphatics. It produced a +salivation of a profuse nature in major Pearce Butler, which continued +for two days. It produced a bubo in the groin in a citizen of +Philadelphia. He had never been infected with the venereal disease, of +course no suspicion was entertained by me of its being derived from that +cause. I knew a lady who had periodical swellings in her breasts, at the +same season of the year in which she had before been accustomed to have +a regular fit of the gout. The scrophula and all the forms of dropsy +are the effects in many cases of the disposition of the gout to attack +the lymphatic system. There is a large hard swelling without pain, of +one, or both the legs and thighs, which has been called a dropsy, but +is very different from the common disease of that name. It comes on, +and goes off suddenly. It has lately been called in England the _dumb_ +gout. In the spring of 1798 I attended colonel Innes, of Virginia, in +consultation with my Edinburgh friend and fellow-student, Dr. Walter +Jones, of the same state. The colonel had large anasarcous swellings in +his thighs and legs, which we had reason to believe were the effects of +an indolent gout. We made several punctures in his feet and ancles, and +thereby discharged a large quantity of water from his legs and thighs. +A day or two afterwards his ancles exhibited in pain and inflammation, +the usual form of gout in those parts. In the year 1794 I attended Mrs. +Lloyd Jones, who had a swelling of the same kind in her foot and leg. +Her constitution, habits, and the sober manners of her ancestors, gave +me no reason to suspect it to arise from the usual remote causes of +gout. She was feverish, and her pulse was tense. I drew ten ounces of +blood from her, and gave her a purge. The swelling subsided, but it was +succeeded by an acute rheumatic pain in the part, which was cured in a +few days. I mention these facts as an additional proof of the sameness +of the gout and rheumatism, and to show that the vessels in a simple +disease, as well as in malignant fevers, are often oppressed beyond that +point in which they emit the sensation of pain. + +Under this head I shall include an account of the mucous discharge +from the urethra, which sometimes takes place in an attack of the gout, +and which has ignorantly been ascribed to a venereal gonorrhæa. There +is a description of this symptom of the gout in the 3d volume of the +Physical and Literary Essays of Edinburgh, by Dr. Clark. It was first +taken notice of by Sauvages by the name of "gonorrhæa podagrica," in +a work entitled Pathologia Methodica. I have known three instances of +it in this city. In the visits which the gout pays to the genitals, +it sometimes excites great pain in the testicles. Dr. Whytt mentions +three cases of this kind. One of them was attended with a troublesome +itching of the scrotum. I have seen one case in which the testicles were +affected with great pain, and the penis with an obstinate priapism. They +succeeded a sudden translation of the gout from the bowels. + +From the occasional disposition of the gout to produce a mucous +discharge from the urethra in men, it is easy to conceive that it is the +frequent cause of the fluor albus in women, for in them, the gout which +is restrained from the feet, by a cause formerly mentioned, is driven to +other parts, and particularly to that part which, from its offices, is +more disposed to invite disease to it, than any other. The fluor albus +sometimes occurs in females, apparently of the most robust habits. In +such persons, more especially if they have been descended from gouty +ancestors, and have led indolent and luxurious lives, there can be no +doubt but the disease is derived from the gout, and should be treated +with remedies which act not only upon the affected part, but the whole +system. An itching similar to that I formerly mentioned in the anus, +sometimes occurs in the vagina of women. Dr. Lettsom has described it. +In all the cases I have known of it, I believe it was derived from the +usual causes of the gout. + +VII. There are many records in the annals of medicine of the gout +affecting the skin. The erysipelas, gangrene, and petechiæ are its +acute, and tetters, and running sores are its usual chronic forms when +it appears in this part of the body. I attended a patient with the late +Dr. Hutchinson, in whom the whole calf of one leg was destroyed by a +mortification which succeeded the gout. Dr. Alexander, of Baltimore, +informed me that petechiæ were among the last symptoms of this disease +in the Rev. Mr. Oliver, who died in the town of Baltimore, about two +years ago. In the disposition of the gout to attack external parts, it +sometimes affects the eyes and ears with the most acute and distressing +inflammation and pain. I hesitate the less in ascribing them both to the +gout, because they not only occur in gouty habits, but because they now +and then effuse a calcareous matter of the same nature with that which +is found in the ligaments of the joints. + +VIII. Even the bones are not exempted from the ravages of this +disease. I have before mentioned that the bones of the hands and feet +are sometimes dislocated by it. I have heard of an instance in which +it dislocated the thigh bone. It probably produced this effect by the +effusion of that part of the blood which constitutes chalk-stones, or +by an excrescence of flesh in the cavity of the joint. Two instances +have occurred in this city of its dislodging the teeth, after having +produced the most distressing pains in the jaws. The long protracted, +and acute pain in the face, which has been so accurately described by +Dr. Fothergill, probably arises wholly from the gout acting upon the +bones of the part affected. + +I have more than once hinted at the sameness of some of the states of +the gout, and the yellow fever. Who can compare the symptoms and seats +of both diseases, and not admit the unity of the remote and immediate +causes of fever? + +Thus have I enumerated proofs of the gout being a disease of the _whole_ +system. I have only to add under this proposition, that it affects +different parts of the body in different people, according to the nature +of their congenital or acquired temperaments, and that it often passes +from one part of the body to another in the twinkling of an eye. + +The morbid excitement, and actions of the gout, when seated in the +ligaments, the blood-vessels, and viscera, and left to themselves, +produce effects different in their nature, according to the parts in +which they take place. In the viscera they produce congestions composed +of all the component parts of the blood. From the blood-vessels which +terminate in hollow cavities and in cellular membrane, they produce +those effusions of serum which compose dropsies. From the same vessels +proceed those effusions which produce on the skin erysipelas, tetters, +and all the different kinds of eruptions. In the ligaments they produce +an effusion of coagulable lymph, which by stagnation is changed into +what are called chalk-stones. In the urinary organs they produce an +effusion of particles of coagulable lymph or red blood, which, under +certain circumstances, are changed into sand, gravel, and stone. All +these observations are liable to some exceptions. There are instances in +which chalk-stones have been found in the lungs, mouth, on the eye-lids, +and in the passages of the ears, and a preternatural flux of water and +blood has taken place from the kidneys. Pus has likewise been formed in +the joints, and air has been found in the cavity of the belly, instead +of water. + +Sometimes the gout is said to combine with the fevers which arise from +cold and miasmata. We are not to suppose from this circumstance, that +the system is under a twofold stimulus. By no means. The symptoms which +are ascribed to the gout, are the effects of morbid excitement excited +by the cold, or miasmata acting upon parts previously debilitated by the +usual remote causes of that disease. + +A bilious diathesis in the air so often excites the peculiar symptoms +of gout, in persons predisposed to it, that it has sometimes been said +to be epidemic. This was the case, Dr. Stoll says, in Vienna, in the +years 1782 and 1784. The same mixture of gouty and bilious symptoms was +observed by Dr. Hillary, in the fevers of Barbadoes. + +From a review of the symptoms of the gout, the impropriety of +distinguishing it from its various seats, by specific names, must be +obvious to the reader. As well might we talk of a yellow fever in the +brain, in the nerves, or in the groin, when its symptoms affect those +parts, as talk of _misplaced_ or _retrocedent_ gout. The great toe, and +the joints of the hands and feet, are no more its exclusive seats, than +the "stomach is the throne of the yellow fever." In short, the gout +may be compared to a monarch whose empire is unlimited. The whole body +crouches before it. + +It has been said as a reflection upon our profession, that physicians +are always changing their opinions respecting chronic diseases. For a +long while they were all classed under the heads of nervous, or bilious. +These names for many years afforded a sanctuary for the protection of +fraud and error in medicine. They have happily yielded of late years to +the name of gout. If we mean by this disease a primary affection of the +joints, we have gained nothing by assuming that name; but if we mean +by it a disease which consists simply of morbid excitement, invited by +debility, and disposed to invade every part of the body, we conform +our ideas to facts, and thus simplify theory and practice in chronic +diseases. + +I proceed now to treat of the METHOD OF CURE. + +Let not the reader startle when I mention curing the gout. It is not a +sacred disease. There will be no profanity in handling it freely. It has +been cured often, and I hope to deliver such directions under this head, +as will reduce it as much under the power of medicine, as a pleurisy or +an intermitting fever. Let not superstition say here, that the gout is +the just punishment of folly, and vice, and that the justice of Heaven +would be defeated by curing it. The venereal disease is more egregiously +the effect of vice than the gout, and yet Heaven has kindly directed +human reason to the discovery of a remedy which effectually eradicates +it from the constitution. This opinion of the gout being a curable +disease, is as humane as it is just. It is calculated to prompt to early +application for medical aid, and to prevent that despair of relief which +has contributed so much to its duration, and mortality. + +But does not the gout prevent other diseases, and is it not improper +upon this account to cure it? I answer, that it prevents other diseases, +as the daily use of drams prevents the intermitting fever. In doing +this, they bring on a hundred more incurable morbid affections. The +yellow fever carried off many chronic diseases in the year 1793, and yet +who would wish for, or admit such a remedy for a similar purpose? The +practice of encouraging, and inviting what has been called a "friendly +fit" of the gout as a cure for other diseases, resembles the practice +of school boys who swallow the stones of cherries to assist their +stomachs in digesting that delicate fruit. It is no more necessary to +produce the gout in the feet, in order to cure it, than it is to wait +for, or encourage abscesses or natural hæmorrhages, to cure a fever. +The practice originated at a time when morbific matter was supposed to +be the cause of the gout, but it has unfortunately continued under the +influence of theories which have placed the seat of the disease in the +solids. + +The remedies for the gout naturally divide themselves into the +following heads. + +I. Such as are proper in its approaching, or forming state. + +II. Such as are proper in _violent_ morbid action in the blood-vessels +and viscera. + +III. Such as are proper in a _feeble_ morbid action in the same parts of +the body. + +IV. Such as are proper to relieve certain local symptoms which are not +accompanied by general morbid action. And + +V. Such as are proper to prevent its recurrence, or, in other words, to +eradicate it from the system. + +I. The symptoms of an approaching fit of the gout are great languor, +and dulness of body and mind, doziness, giddiness, wakefulness, or +sleep disturbed by vivid dreams, a dryness, and sometimes a coldness, +numbness, and prickling in the feet and legs, a disappearance of pimples +in the face, occasional chills, acidity and flatulency in the stomach, +with an increased, a weak, or a defect of appetite. These symptoms are +not universal, but more or less of them usher in nearly every fit of the +gout. The reader will see at once their sameness with the premonitory +symptoms of fever from cold and miasmata, and assent from this proof, in +addition to others formerly mentioned, to the propriety of considering a +fit of the gout, as a paroxysm of fever. + +The system, during the existence of these symptoms, is in a state of +morbid depression. The disease is as yet unformed, and may easily be +prevented by the loss of a few ounces of blood, or, if this remedy be +objected to, by a gentle doze of physic, and afterwards by bathing the +feet in warm water, by a few drops of the spirit of hartshorn in a +little sage or camomile tea, by a draught of wine whey, or a common doze +of liquid laudanum, and, according to a late Portuguese physician, by +taking a few doses of bark. + +It is worthy of notice, that if these remedies are omitted, all the +premonitory symptoms that have been mentioned disappear as soon as the +arthritic fever is formed, just as lassitude and chilliness yield to a +paroxysm of fever from other causes. + +II. Of the remedies that are proper in cases of great morbid action in +the blood-vessels and viscera. + +I shall begin this head by repudiating the notion of a specific cure for +the gout existing in any single article of the materia medica. Every +attempt to cure it by elixirs, diet-drinks, pills, or boluses, which +were intended to act singly on the system, has been as unsuccessful +as the attempts to cure the whooping cough by spells, or tricks of +legerdemain. + +The first remedy that I shall mention for reducing great morbid action +in the blood-vessels and viscera, is _blood-letting_. I was first taught +the safety of this remedy in the gout by reading the works of Dr. +Lister, above thirty years ago, and I have used it ever since with great +advantage. It has the sanction of Dr. Hoffman, Dr. Cullen, and many +others of the first names in medicine in its favour. + +The usual objections to bleeding as a remedy, have been urged with +more success in the gout, than in any other disease. It has been +forbidden, because the gout is said to be a disease of debility. This +is an error. Debility is not a disease. It is only its predisposing +cause. Disease is preternatural strength in the state of the system +now under consideration, occasioned by the abstraction of excitement +from one part, and the accumulation of it in another part of the body. +Every argument in favour of bleeding in a pleurisy applies in the +present instance, for they both depend upon the same kind of morbid +action in the blood-vessels. Bleeding acts moreover alike in both cases +by abstracting the excess of excitement from the blood-vessels, and +restoring its natural and healthy equality to every part of the system. + +It has been further said, that bleeding disposes to more frequent +returns of the gout. This objection to the lancet has been urged by +Dr. Sydenham, who was misled in his opinion of it, by his theory of +the disease being the offspring of morbific matter. The assertion +is unfounded, for bleeding in a fit of the gout has no such effect, +provided the remedies to be mentioned hereafter are used to prevent it. +But a fit of the gout is not singular in its disposition to recur after +being once cured. The rheumatism, the pleurisy, and the intermitting +fever are all equally disposed to return when persons are exposed to +their remote and exciting causes, and yet we do not upon this account +consider them as incurable diseases, nor do we abstain from the usual +remedies which cure them. + +The inflammatory or violent state of the gout is said most commonly to +affect the limbs. But this is far from being the case. It frequently +makes its first attack upon the head, lungs, kidneys, stomach, and +bowels. The remedies for expelling it from the stomach and bowels are +generally of a stimulating nature. They are as improper in full habits, +and in the recent state of the disease, as cordials are to drive the +small-pox from the vitals to the skin. Hundreds have been destroyed by +them. Bleeding in these cases affords the same speedy and certain relief +that it does in removing pain from the stomach and bowels in the first +stage of the yellow fever. Colonel Miles owes his life to the loss of 60 +ounces of blood in an attack of the gout in his bowels, in the winter of +1795, and major Butler derived the same benefit from the loss of near 30 +ounces, in an attack of the gout in his stomach in the spring of 1798. + +I could add many more instances of the efficacy of the lancet in the +gout when it affects the viscera, from my own experience, but I prefer +mentioning one only from sir John Floyer, which is more striking than +any I have met with in its favour. He tells us, sir Henry Coningsby +was much disposed to the palsy from the gout when he was 30 years old. +By frequent bleedings, and the use of the cold bath, he recovered, and +lived to be 88. During his old age, he was bled every three months. + +I have said, in the history of the symptoms of the gout, that it +sometimes appeared in the form of a hectic fever. I have prescribed +occasional bleedings in a case of this kind accompanied with a tense +pulse, with the happiest effects. It confined the disease for several +years wholly to the blood-vessels, and it bid fair in time to eradicate +it from the system. + +The state of the pulse, as described in another place[61], should govern +the use of the lancet in this disease. Bleeding is required as much +in its depressed, as in its full and chorded state. Colonel Miles's +pulse, at the time he suffered from the gout in his bowels, was scarcely +perceptible. It did not rise till after a second or third bleeding. + + [61] Defence of Blood-letting, vol. IV. + +Some advantage may be derived from examining the blood. I have once +known it to be dissolved; but for the most part I have observed it, with +Dr. Lister, to be covered with the buffy coat of common inflammation. + +The arguments made use of in favour of bleeding in the diseases of +old people in a former volume, apply with equal force to its use in +the gout. The inflammatory state of this disease frequently occurs in +the decline of life, and bleeding is as much indicated in such cases +as in any other inflammatory fever. The late Dr. Chovet died with an +inflammation in his liver from gout, in the 86th year of his age. He was +twice bled, and his blood each time was covered with a buffy coat. + +Where the gout affects the head with obstinate pain, and appears to be +seated in the muscles, cupping and leeches give great relief. This mode +of bleeding should be trusted in those cases only in which the morbid +action is confined chiefly to the head, and appears in a feeble state in +the rest of the arterial system. + +The advantages of bleeding in the gout, when performed under all the +circumstances that have been mentioned, are as follow: + +1. It removes or lessens pain. + +2. It prevents those congestions and effusions which produce apoplexy, +palsy, pneumonia notha, calculi in the kidneys and bladder, and +chalk-stones in the hands and feet. The gravel and stone are nine times +in ten, I believe, the effects of an effusion of lymph or blood from +previous morbid action in the kidneys. If this disease were narrowly +watched, and cured as often as it occurs, by the loss of blood, we +should have but little gravel or stone among gouty people. A citizen of +Philadelphia died a few years ago, in the 96th year of his age, who had +been subject to the strangury the greatest part of his life. His only +remedy for it was bleeding. He lived free from the gravel and stone; +and died, or rather appeared to fall asleep in death, from old age. Dr. +Haller mentions a similar case in his Bibliotheca Medicinæ, in which +bleeding had the same happy effects. + +3. It prevents the system from wearing itself down by fruitless pain and +sickness, and thereby inducing a predisposition to frequent returns of +the disease. + +4. It shortens the duration of a fit of gout, by throwing it, not into +the feet, but out of the system, and thus prevents a patient's lying +upon his back for two or three months with a writhing face, scolding a +wife and family of children, and sometimes cursing every servant that +comes near enough to endanger the touch of an inflamed limb. Besides +preventing all this parade of pain and peevishness, it frequently, when +assisted with other remedies to be mentioned presently, restores a man +to his business and society in two or three days: a circumstance this +of great importance in the public as well as private pursuits of men; +for who has not read of the most interesting affairs of nations being +neglected or protracted, by the principal agents in them being suddenly +confined to their beds, or chairs, for weeks or months, by a fit of the +gout? + +2. A second remedy in the state of the gout which has been mentioned, is +_purging_. Sulphur is generally preferred for this purpose, but castor +oil, cream of tartar, sena, jalap, rhubarb, and calomel, may all be used +with equal safety and advantage. The stomach and habits of the patient +should determine the choice of a suitable purge in every case. Salts are +generally offensive to the stomach. They once brought on a fit of the +gout in Dr. Brown. + +3. _Vomits_ may be given in all those cases where bleeding is objected +to, or where the pulse is only moderately active. Mr. Small, in an +excellent paper upon the gout, in the 6th volume of the Medical +Observations and Inquiries, p. 205, containing the history of his own +case, tells us that he always took a vomit upon the first attack of the +gout, and that it never failed of relieving all its symptoms. The matter +discharged by this vomit indicated a morbid state of the liver, for it +was always a dark greenish bile, which was insoluble in water. A British +lieutenant, whose misfortunes reduced him to the necessity of accepting +a bed in the poor-house of this city, informed the late Dr. Stuben, that +he had once been much afflicted with the gout, and that he had upon many +occasions strangled a fit of it by the early use of an emetic. Dr. Pye +adds his testimony to those which have been given in favour of vomits, +and says further, that they do most service when they discharge an +acid humour from the stomach. They appear to act in part by equalizing +the divided excitement of the system, and in part by discharging the +contents of the gall-bladder and stomach, vitiated by the previous +debility of those organs. Care should be taken not to exhibit this +remedy where the gout attacks the stomach with symptoms of inflammation, +or where it has a tendency to fix itself upon the brain. + +4. _Nitre_ may be given with advantage in cases of inflammatory action, +where the stomach is not affected. + +5. A fifth remedy is _cool_ or _cold air_. This is as safe and useful +in the gout as in any other inflammatory state of fever. The affected +limbs should be kept out of bed, _uncovered_. In this way Mr. Small says +he moderated the pains of the gout in his hands and feet[62]. I have +directed the same practice with great comfort, as well as advantage +to my patients. Even cold water has been applied with good effects +to a limb inflamed by the gout. Mr. Blair M'Clenachan taught me the +safety and benefit of this remedy, by using it upon himself without the +advice of a physician. It instantly removed his pain, nor was the gout +translated by it to any other part of his body. It was removed in the +same manner, Dr. Heberden tells us, by the celebrated Dr. Harvey from +his own feet. Perhaps it would be best in most cases to prefer cool, or +cold air, to cold water. The safety and advantages of both these modes +of applying cold to the affected limbs, show the impropriety of the +common practice of wrapping them in flannel. + + [62] Medical Observations and Inquiries, vol VI. p. 201. + +6. _Diluting liquors_, such as are prescribed in common inflammatory +fevers, should be given in such quantities as to dispose to a gentle +perspiration. + +7. _Abstinence from wine, spirits, and malt liquors_, also from such +aliments as afford much nourishment or stimulus, should be carefully +enjoined. Sago, panada, tapioca, diluted milk with bread, and the pulp +of apples, summer fruits, tea, coffee, weak chocolate, and bread soaked +in chicken water or beef tea, should constitute the principal diet of +patients in this state of the gout. + +8. _Blisters_ are an invaluable remedy in this disease, when used at +a proper time, that is, after the reduction of the morbid actions in +the system by evacuations. They should be applied to the joints of the +feet and wrists in general gout, and to the neck and sides, when it +attacks the head or breast. A strangury from the gout is no objection +to their use. So far from increasing this complaint, Dr. Clark and Dr. +Whytt inform us, that they remove it[63]. But the principal advantage of +blisters is derived from their collecting and concentrating scattered +and painful sensations, and conveying them out of the system, and thus +becoming excellent substitutes for a tedious fit of the gout. + + [63] Physical and Literary Essays, vol. III. p. 469. + +9. _Fear_ and _terror_ have in some instances cured a paroxysm of this +disease. A captain of a British ship of war, who had been confined for +several weeks to his cabin, by a severe fit of the gout in his feet, +was suddenly cured by hearing the cry of fire on board his ship. This +fact was communicated to me by a gentleman who was a witness of it. Many +similar cases are upon record in books of medicine. I shall in another +place insert an account of one in which the cure effected by a fright, +eradicated the disease from the system so completely, as ever afterwards +to prevent its return. + +Thus have I enumerated the remedies which are proper in the gout when +it affects the blood-vessels and viscera with great morbid action. Most +of those remedies are alike proper when the morbid actions are seated +in the muscular fibres, whether of the bowels or limbs, and whether +they produce local pain, or general convulsion, provided they are of a +violent nature. + +There are some remedies under this head of a doubtful nature, on which I +shall make a few observations. + +_Sweating_ has been recommended in this state of the gout. All the +objections to it in preference to other modes of depletion, mentioned +in another place[64], apply against its use in the inflammatory state +of the gout. It is not only less safe than bleeding, purging, and +abstinence, but it is often an impracticable remedy. The only sudorific +medicine to be trusted in this state of the disease is the Seneka +snake-root. It promotes all the secretions and excretions, and exerts +but a feeble stimulus upon the arterial system. + + [64] Defence of Blood-letting. + +Many different preparations of _opium_ have been advised in this state +of the gout. They are all hurtful if given before the morbid action of +the system is nearly reduced. It should then be given in small doses +accommodated to the excitability of the system. + +Applications of various kinds to the affected limbs have been used in +a fit of the gout, and some of them with success. The late Dr. Chalmers +of South-Carolina used to meet the pain of the gout as soon as it fixed +in any of his limbs, with a blister, and generally removed it by that +means in two or three days. I have imitated this practice in several +cases, and always with success, nor have I ever seen the gout thrown +upon any of the viscera by means of this remedy. Caustics have sometimes +been applied to gouty limbs with advantage. The moxa described and used +by sir William Temple, which is nothing but culinary fire, has often +not only given relief to a pained limb, but carried off a fit of the +gout in a few hours. These powerful applications may be used with equal +advantage in those cases in which the gout by falling upon the head +produces coma, or symptoms of apoplexy. A large caustic to the neck +roused Mr. John M. Nesbit from a coma in which he had lain for three +days, and thereby appeared to save his life. Blisters, and cataplasms of +mustard, had been previously used to different parts of his body, but +without the least effect. In cases of moderate pain, where a blister has +been objected to, I have seen a cabbage leaf afford considerable relief. +It produces a moisture upon the part affected, without exciting any +pain. An old sea captain taught me to apply molasses to a limb inflamed +or pained by the gout. I have frequently advised it, and generally with +advantage. All volatile and stimulating liniments are improper, for +they not only endanger a translation of the morbid excitement to the +viscera, but where they have not this effect, they increase the pain and +inflammation of the part affected. + +The sooner a patient exercises his lower limbs by walking, after +a fit of the gout, the better. "I made it a constant rule (says Mr. +Small) to walk abroad as soon as the inflammatory state of the gout was +past, and though by so doing, I often suffered great pain, I am well +convinced that the free use I now enjoy of my limbs is chiefly owing +to my determined perseverance in the use of that exercise; nor am I +less persuaded that nine in ten of gouty cripples owe their lameness +more to indolence, and fear of pain, than to the genuine effects of the +gout[65]." Sir William Temple confirms the propriety of Mr. Small's +opinion and practice, by an account of an old man who obviated a fit of +the gout as often as he felt it coming in his feet, by walking in the +open air, and afterwards by going into a warm bed, and having the parts +well rubbed where the pain began. "By following this course (he says) he +was never laid up with the gout, and before his death recommended the +same course to his son if ever he should fall into that accident." Under +a conviction of the safety of this practice the same author concludes +the history of his own case in the following words: "I favoured it [viz. +the swelling in my feet] all this while more than I needed, upon the +common opinion, that walking too much might draw down the humour, which +I have since had reason to conclude is a great mistake, and that if I +had walked as much as I could from the first day the pain left me, the +swelling might have left me too in a much less time[66]." + + [65] Medical Observations and Inquiries, vol. vi. p. 220. + + [66] Essay upon the Cure of the Gout by Moxa, vol. i. folio edition, + p. 143 and 141. + +III. I come now to mention the remedies which are proper in that state +of the gout in which a _feeble_ morbid action takes place in the +blood-vessels and viscera. + +I shall begin this head, by remarking, that this state of the gout is +often created, like the typhus state of fever, by the neglect, or too +scanty use of evacuations in its first stage. When the prejudices which +now prevent the adoption of those remedies in their proper time, are +removed, we shall hear but little of the low state of the arthritic +fever, nor of the numerous diseases from obstruction which are produced +by the blood-vessels disorganizing the viscera, by repeated and violent +attacks of the disease. + +To determine the character of a paroxysm of gout and the remedies +proper to relieve it, the climate, the season of the year, the +constitution of the atmosphere, and the nature of the prevailing +epidemic, should be carefully attended to by a physician. But his +principal dependence should be placed upon the state of the pulse. If +it do not discover the marks which indicate bleeding formerly referred +to, but is weak, quick, and soft, the remedies should be such as are +calculated to produce a more vigorous, and equable action in the +blood-vessels and viscera. They are, + +1. _Opium._ It should at first be given in small doses, and afterwards +increased, as circumstances may require. + +2. _Madeira_ or _Sherry wine_ alone, or diluted with water, or in the +form of whey, or rendered more cordial by having any agreeable spice +infused in it. It may be given cold or warm, according to the taste of +the patient, or the state of his stomach. If this medicine be rejected +in all the above forms, + +3. _Porter_ should be given. It is often retained when no other liquor +will lie upon the stomach. I think I once saved the life of Mr. Nesbit +by this medicine. It checked a vomiting, from the gout, which seemed +to be the last symptom of his departing life. If porter fail of giving +relief, + +4. _Ardent spirits_ should be given, either alone, or in the form +of grog, or toddy. Cases have occurred in which a pint of brandy has +been taken in the course of an hour with advantage. Great benefit has +sometimes been found from Dr. Warner's tincture, in this state of the +gout. As these observations may fall into the hands of persons who may +not have access to Dr. Warner's book, I shall here insert the receipt +for preparing it. + +Of raisins, sliced and stoned, half a pound. + +Rhubarb, one ounce. + +Sena, two drachms. + +Coriander and fennel seeds, of each one drachm. + +Cochineal, saffron, and liquorice root, each half a drachm. + +Infuse them for ten days in a quart of French brandy, then strain it, +and add a pint more of brandy to the ingredients, afterwards strain it, +and mix both tinctures together. Four table spoons full of this cordial +are to be taken every hour, mixed with an equal quantity of water, until +relief be obtained. + +Ten drops of laudanum may be added to each dose in those cases in which +the cordial does not produce its intended effects, in two or three +hours. If all the different forms of ardent spirits which have been +mentioned fail of giving relief, + +5. From 30 drops to a tea spoonful of _æther_ should be given in any +agreeable vehicle. Also, + +6. _Volatile alkali._ From five to ten grains of this medicine should be +given every two hours. + +7. _Aromatic substances_, such as alspice, ginger, Virginia snake-root, +cloves, and mace in the form of teas, have all been useful in this state +of the gout. + +All these remedies are indicated in a more especial manner when the +gout affects the stomach. They are likewise proper when it affects the +bowels. The laudanum in this case should be given by way of glyster. +After the vomiting was checked in Mr. Nesbit by means of porter, he was +afflicted with a dull and distressing pain in his bowels, which was +finally removed by two anodyne glysters injected daily for two or three +weeks. + +8. Where the gout produces spasmodic or convulsive motions, the _oil of +amber_ may be given with advantage. I once saw it remove for a while a +convulsive cough from the gout. + +9. In cases where the stomach will bear the _bark_, it should be given +in large and frequent doses. It does the same service in this state of +gout, that it does in the slow, or low states of fever from any other +cause. Where the gout appears in the form of an intermittent, the bark +affords the same relief that it does in the same disease from autumnal +exhalations. Mr. Small found great benefit from it after discharging the +contents of his stomach and bowels by a dose of tartar emetic. "I do not +call (says this gentleman) a fit of the gout a paroxysm, for there are +several paroxysms in the fit, each of which is ushered in with a rigour, +sickness at stomach, and subsequent heat. In this the gout bears a +resemblance to an irregular intermittent, at least to a remitting fever, +and hence perhaps the efficacy of the bark in removing the gout[67]." + + [67] Medical Observations and Inquiries, vol. vi. p. 220. + +10. The _warm bath_ is a powerful remedy in exciting a regular and +healthy action in the sanguiferous system. Where the patient is too weak +to be taken out of bed, and put into a bathing tub, his limbs and body +should be wrapped in flannels dipped in warm water. In case of a failure +of all the above remedies, + +11. A _salivation_ should be excited as speedily as possible, by means +of mercury. Dr. Cheyne commends it in high terms. I have once used it +with success. The mercury, when used in this way, brings into action an +immense mass of latent excitement, and afterwards diffuses it equally +through every part of the body. + +12. Besides these internal remedies, frictions with brandy, and volatile +liniment, should be used to the stomach and bowels. Blisters should be +applied to parts in which congestion or pain is seated, and stimulating +cataplasms should be applied to the lower limbs. The flour of mustard +has been justly preferred for this purpose. It should be applied to the +upper part of the foot. + +The reader will perceive, in the account I have given of the remedies +proper in the feeble state of chronic fever, that they are the same +which are used in the common typhus, or what is called nervous fever. +There is no reason why they should not be the same, for the supposed two +morbid states of the system are but one disease. + +It is agreeable in medical researches to be under the direction of +principles. They render unnecessary, in many instances, the slow and +expensive operations of experience, and thus multiply knowledge, by +lessening labour. The science of navigation has rested upon this basis, +since the discovery of the loadstone. A mariner who has navigated a +ship to one distant port, is capable of conducting her to every port +on the globe. In like manner, the physician who can cure one disease +by a knowledge of its principles, may by the same means cure all the +diseases of the human body, for their causes are the same. Judgment is +required, only in accommodating the force of remedies to the force of +each disease. The difference in diseases which arises from their seats, +from age, sex, habit, season, and climate, may be known in a short time, +and is within the compass of very moderate talents. + +IV. Were I to enumerate all the local symptoms of gout which occur +without fever, and the remedies that are proper to relieve them, I +should be led into a tedious digression. The reader must consult +practical books for an account of them. I shall only mention the +remedies for a few of them. + +The theory of the gout which has been delivered, will enable us to +understand the reason why a disease which properly belongs to the +whole system, should at any time be accompanied only with local morbid +affection. The whole body is a unit, and hence morbid impressions which +are resisted by sound parts are propagated to such as are weak, where +they excite those morbid actions we call disease. + +The _head-ach_ is a distressing symptom of the gout. It yields to +depleting or tonic remedies, according to the degree of morbid action +which accompanies it. I have heard an instance of an old man, who was +cured of an obstinate head-ach by throwing aside his nightcap, and +sleeping with his bare head exposed to the night air. The disease in +this case was probably attended with great morbid action. In this +state of the vessels of the brain, cupping, cold applications to the +head, purges, a temperate diet, and blisters behind the ears, are all +proper remedies, and should be used together, or in succession, as the +nature of the disease may require. Many persons have been cured of the +same complaint by sleeping in woollen nightcaps. The morbid action in +these cases is always of a feeble nature. With this remedy, tonics, +particularly the bark and cold bath, will be proper. I have once known +a chronic gouty pain in the head cured by an issue in the arm, after +pounds of bark, and many other tonic remedies, had been taken to no +purpose. + +The _ophthalmia_ from gout should be treated with the usual remedies +for that disease when it arises from other causes, with the addition of +such local applications to other and distant parts of the body, as may +abstract the gouty action from the eyes. + +_Dull but constant pains in the limbs_ yield to frictions, volatile +liniments, muslin and woollen worn next to the skin, electricity, a +salivation, and the warm and cold bath. A gentleman who was afflicted +with a pain of this kind for three years and a half in one of his arms, +informed me, that he had been cured by wearing a woollen stocking that +had been boiled with sulphur in water, for two weeks upon the affected +limb. He had previously worn flannel upon it, but without receiving any +benefit from it. I have known wool and cotton, finely carded, and made +into small mats, worn upon the hips, when affected by gout, with great +advantage. In obstinate sciatic pains, without fever or inflammation, +Dr. Pitcairn's remedy, published by Dr. Cheyne, has performed many +cures. It consists in taking from one to four tea-spoons full of the +fine spirit of turpentine every morning, for a week or ten days, in +three times the quantity of honey, and afterwards in drinking a large +quantity of sack whey, to settle it on the stomach, and carry it into +the blood. An anodyne should be taken every night after taking this +medicine. + +A _gouty diarrh[oe]a_ should be treated with the usual astringent +medicines of the shops. Blisters to the wrists and ankles, also a +salivation, have often cured it. I have heard of its being checked, +after continuing for many years, by the patient eating large quantities +of alspice, which he carried loose in his pocket for that purpose. + +The _angina pectoris_, which I have said is a symptom of the gout, +generally comes on with fulness and tension in the pulse. After these +are reduced by two or three bleedings, mineral tonics seldom fail of +giving relief. + +_Spasms in the stomach_, and _pains in the bowels_, often seize gouty +people in the midst of business or pleasure, or in the middle of the +night. My constant prescription for these complaints is ten drops of +laudanum every half hour, till relief be obtained. If this medicine +be taken in the forming state of these pains, a single dose generally +removes the disease. It is preferable to spiced wine and spirits, +inasmuch as it acts quicker, and leaves no disposition to contract a +love for it when it is not required to ease pain. + +The _pain in the rectum_ which has been described, yields to the common +remedies for the piles. Cold water applied to the part, generally gives +immediate relief. + +For a _preternatural secretion and excretion of bile_, gentle laxatives, +and abstinence from oily food, full meals, and all violent exercises of +the body and mind, are proper. + +The _itching in the anus_, which I have supposed to be a symptom of +gout, has yielded in one instance that has come within my knowledge to +mercurial ointment applied to the part affected. Dr. Lettsom recommends +fomenting the part with a decoction of poppy heads and hemlock, and +advises lenient purges and a vegetable diet as a radical cure for the +disease[68]. + + [68] Medical Memoirs, vol. III. + +For the _itching in the vagina_ I have found a solution of the sugar +of lead in water to be an excellent palliative application. Dr. Lettsom +recommends as a cure for it, the use of bark in delicate habits, and +occasional bleeding, with a light and moderate diet, if it occur about +the time of the cessation of the menses. + +Obstinate _cutaneous eruptions_, which are the effects of gout, have +been cured by gentle physic, a suitable diet, issues, and applications +of the unguentum citrinum to the parts affected. + +The _arthritic gonorrh[oe]a_ should be treated with the same remedies as +a gonorrh[oe]a from any other cause. + +In the treatment of all the local symptoms that have been enumerated, +it will be of great consequence to inquire, before we attempt to cure +them, whether they have not succeeded general gout, and thereby relieved +the system from its effects in parts essential to life. If this have +been the case, the cure of them should be undertaken with caution, +and the danger of a local disease being exchanged for a general one, +should be obviated by remedies that are calculated to eradicate the +gouty diathesis altogether from the system. The means for this purpose, +agreeably to our order, come next under our consideration. Before I +enter upon this head, I shall premise, that I do not admit of the +seeds of the gout remaining in the body to be eliminated by art after +a complete termination of one of its paroxysms, any more than I admit +of the seeds of a pleurisy or intermitting fever remaining in the body, +after they have been cured by blood-letting or bark. A predisposition +only remains in the system to a return of the gout, from its usual +remote and exciting causes. The contrary idea took its rise in those +ages of medicine in which morbific matter was supposed to be the +proximate cause of the gout, but it has unfortunately continued since +the rejection of that theory. Thus in many cases we see wrong habits +continue long after the principles have been discarded, from which they +were derived. + +I have known several instances in which art, and I have heard and read +of others in which accidental suffering from abstinence, pain, and +terror have been the happy means of overcoming a predisposition to the +gout. A gentleman from one of the West-India islands, who had been for +many years afflicted with the gout, was perfectly cured of it by living +a year or two upon the temperate diet of the jail in this city, into +which he was thrown for debt by one of his creditors. A large hæmorrhage +from the foot, inflamed and swelled by the gout, accidentally produced +by a penknife which fell upon it, effected in an Irish gentleman +a lasting cure of the disease. Hildanus mentions the history of a +gentleman, whom he knew intimately, who was radically cured of a gout +with which he had been long afflicted, by the extreme bodily pain he +suffered innocently from torture in the canton of Berne. He lived to be +an old man, and ever afterwards enjoyed good health[69]. The following +letter from my brother contains the history of a case in which terror +suddenly eradicated the gout from the system. + + [69] Observat. Chirurg. Cent. 1. Obs. 79. + + + "_Reading_, _July 27th, 1797_. + +"DEAR BROTHER, + +"WHEN I had the pleasure of seeing you last week, I mentioned an +extraordinary cure of the gout in this town, by means of a _fright_. In +compliance with your request, I now send an exact narration of the facts. + +"Peter Fether, the person cured, is now alive, a householder in +Reading, seventy-three years of age, a native of Germany, and a very +hearty man. The first fit of the gout he ever had, was about the year +1773; and from that time till 1785, he had a regular attack in the +spring of every year. His feet, hands, and elbows were much swollen and +inflamed; the fits lasted long, and were excruciating. In particular, +the last fit in 1785 was so severe, as to induce an apprehension, that +it would inevitably carry him off, when he was suddenly relieved by the +following accident. + +"As he lay in a small back room adjoining the yard, it happened that +one of his sons, in turning a waggon and horses, drove the tongue of +the waggon with such force against the window, near which the old man +lay stretched on a bed, as to beat in the sash of the window, and to +scatter the pieces of broken glass all about him. To such a degree was +he alarmed by the noise and violence, that he instantly leaped out of +bed, forgot that he had ever used crutches, and eagerly inquired what +was the matter. His wife, hearing the uproar, ran into the room, where, +to her astonishment, she found her husband on his feet, bawling against +the author of the mischief, with the most passionate vehemence. From +_that_ moment, he has been entirely exempt from the gout, has never had +the slightest touch of it, and _now_ enjoys perfect health, has a good +appetite, and says he was never heartier in his life. This is probably +the more remarkable, when I add, that he has always been used to the +hard work of a farm, and _since_ the year 1785 has frequently mowed in +his own meadow, which I understand is low and wet. I am well informed, +in his mode of living, he has been temperate, occasionally indulging +in a glass of wine, after the manner of the German farmers, but not to +excess. + +"To you, who have been long accustomed to explore diseases, I leave the +task of developing the principles, on which this mysterious restoration +from the lowest decrepitude and bodily wretchedness, to a state of +perfect health, has been accomplished. I well know that tooth-achs, +head-achs, hiccoughs, &c. are often removed by the sudden impression of +fear, and that they return again. But to see a debilitated gouty frame +instantly restored to vigour; to see the whole system in a moment, as it +were, undergo a perfect and entire change, and the most inveterate and +incurable disease _radically_ expelled, is surely a _different_ thing, +and must be acknowledged a very singular and marvellous event. If an old +man, languishing under disease and infirmity, had _died_ of mere fright, +nobody would have been surprised at it; but that he should be absolutely +cured, and his constitution renovated by it, is a most extraordinary +fact, which, while I am compelled to believe by unexceptionable +evidence, I am totally at a loss to account for. + + I am your sincerely + affectionate brother, + JACOB RUSH." + +These facts, and many similar ones which might be mentioned, afford +ample encouragement to proceed in enumerating the means which are proper +to prevent the recurrence of the gout, or, in other words, to eradicate +it from the system. + +V. I shall first mention the means of preventing the return of that +state of the disease which is accompanied with _violent_ action, and +afterwards take notice of the means of preventing the return of that +state of it, in which a _feeble_ morbid action takes place in the +blood-vessels. The means for this purpose consist in avoiding all the +remote, exciting, and predisposing causes of the gout which have been +mentioned. I shall say a few words upon the most important of them, in +the order that has been proposed. + +I. The first remedy for obviating the _violent_ state of gout is, + +1. _Temperance._ This should be regulated in its degrees by the age, +habits, and constitution of the patient. A diet consisting wholly of +milk, vegetables, and simple water, has been found necessary to prevent +the recurrence of the gout in some cases. But, in general, fish, eggs, +the white meats and weak broths may be taken in small quantities once +a day, with milk and vegetables at other times. A little salted meat, +which affords less nourishment than fresh, may be eaten occasionally. +It imparts vigour to the stomach, and prevents dyspepsia from a diet +consisting chiefly of vegetables. The low and acid wines should be +avoided, but weak Madeira or sherry wine and water, or small beer, may +be drunken at meals. The latter liquor was the favourite drink of Dr. +Sydenham in his fits of the gout. Strong tea and coffee should not be +tasted, where there is reason to believe the habitual use of them has +contributed to bring on the disease. + +From the disposition of the gout to return in the spring and autumn, +greater degrees of abstinence in eating and drinking will be necessary +at those seasons than at any other time. With this diminution of +aliment, gentle purges should be taken, to obviate an attack of the +gout. In persons above fifty years of age, an abstemious mode of living +should be commenced with great caution. It has sometimes, when entered +upon suddenly, and carried to its utmost extent, induced fits of the +gout, and precipitated death. In such persons, the abstractions from +their usual diet should be small, and our dependence should be placed +upon other means to prevent a return of the disease. + +2. _Moderate labour_ and _gentle exercise_ have frequently removed +that debility and vibratility in the blood-vessels, on which a +predisposition to the gout depends. Hundreds of persons who have been +reduced by misfortunes to the necessity of working for their daily +bread, have thrown off a gouty diathesis derived from their patents, or +acquired by personal acts of folly and intemperance. The employments +of agriculture afford the most wholesome labour, and walking, the most +salutary exercise. To be useful, they should be moderate. The extremes +of indolence and bodily activity meet in a point. They both induce +debility, which predisposes to a recurrence of a fit of the gout. +Riding in a carriage, and on horseback, are less proper as a means of +preventing the disease than walking. Their action upon the body is +partial. The lower limbs derive no benefit from it, and on these the +violent state of gout generally makes its first attack. In England, +many domestic exercises have been contrived for gouty people, such as +shuttle-cock, bullets, the chamber-horse, and the like, but they are +all trifling in their effects, compared with labour, and exercise in +the open air. The efficacy of the former of those prophylactic remedies +will appear in a strong point of light, when we consider, how much the +operation of the remote and exciting causes of the gout which act more +or less upon persons in the humblest ranks of society, are constantly +counteracted in their effects, by the daily labour which is necessary +for their subsistence. + +3. To prevent the recurrence of the gout, cold should be carefully +avoided, more especially when it is combined with moisture. Flannel +should be worn next to the skin in winter, and muslin in summer, in +order to keep up a steady and uniform perspiration. Fleecy hosiery +should be worn in cold weather upon the breast and knees, and the feet +should be kept constantly warm and dry by means of socks and cork-soaled +shoes. It was by wetting his feet, by standing two or three hours upon +the damp ground, that colonel Miles produced the gout in his stomach and +bowels which had nearly destroyed him in the year 1795. + +4. Great moderation should be used by persons who are subject to the +gout in the exercise of their understandings and passions. Intense +study, fear, terror, anger, and even joy, have often excited the disease +into action. It has been observed, that the political and military +passions act with more force upon the system, than those which are of a +social and domestic nature; hence generals and statesmen are so often +afflicted with the gout, and that too, as was hinted in another place, +in moments the most critical and important to the welfare of a nation. +The combination of the exercises of the understanding, and the passion +of avarice in gaming, have often produced an attack of this disease. + +These facts show the necessity of gouty people subjecting their minds, +with all their operations, to the government of reason and religion. The +understanding should be exercised only upon light and pleasant subjects. +No study should ever be pursued till it brings on fatigue; and, above +all things, midnight, and even late studies should be strictly avoided. +A gouty man should always be in bed at an early hour. This advice has +the sanction of Dr. Sydenham's name, and experience proves its efficacy +in all chronic diseases. + +5. The venereal appetite should be indulged with moderation. And, + +6. Costiveness should be prevented by all persons who wish to escape +a return of violent fits of the gout. Sulphur is an excellent remedy +for this purpose. Dr. Cheyne commends it in high terms. His words are, +"Sulphur is one of the best remedies in the intervals of the gout. In +the whole extent of the materia medica, I know not a more safe and +active medicine[70]." Two cases have come within my knowledge, in which +it has kept off fits of the gout for several years, in persons who had +been accustomed to have them once or twice a year. Rhubarb in small +quantities chewed, or in the form of pills, may be taken to obviate +costiveness, by persons who object to the habitual use of sulphur. +Dr. Cheyne, who is lavish in his praises of that medicine as a gentle +laxative, says, he "knew a noble lord of great worth and much gout, who, +by taking from the hands of a quack a drachm of rhubarb, tinged with +cochineal to disguise it, every morning for six weeks, lived in health, +for four years after, without any symptom of it[71]." + + [70] Essay on the Nature and True Method of Treating the Gout, p. 36. + + [71] Page 30. + +I have said that abstinence should be enjoined with more strictness in +the spring and autumn, than at any other time, to prevent a return of +the gout. From the influence of the weather at those seasons in exciting +febrile actions in the system, the loss of a pint of blood will be +useful in some cases for the same purpose. It will be the more necessary +if the gout has not paid its habitual visits to the system. The late Dr. +Gregory had been accustomed to an attack of the gout every spring. Two +seasons passed away without his feeling any symptoms of it. He began to +flatter himself with a hope that the predisposition to the disease had +left him. Soon afterwards he died suddenly of an apoplexy. The loss of +a few ounces of blood at the usual time in which the gout affected him, +would probably have protracted his life for many years. In the year +1796, in visiting a patient, I was accidentally introduced into a room +where a gentleman from the Delaware state had been lying on his back +for near six weeks with an acute fit of the gout. He gave me a history +of his sufferings. His pulse was full and tense, and his whole body +was covered with sweat from the intensity of his pain. He had not had +his bowels opened for ten days. I advised purging and bleeding in his +case. The very names of those remedies startled him, for he had adopted +the opinion of the salutary nature of a fit of the gout, and therefore +hugged his chains. After explaining the reason of my prescriptions, he +informed me, in support of them, that he had escaped the gout but two +years in twenty, and that in one of these two years he had been bled for +a fall from his horse, and, in the other, his body had been reduced by a +chronic fever, previously to the time of the annual visit of his gout. + +As a proof of the efficacy of active, or passive depletion, in +preventing the gout, it has been found that persons who sweat freely, +either generally or partially, or who make a great deal of water, are +rarely affected by it. + +An epitome of all that has been said upon the means of preventing a +return of the gout, may be delivered in a few words. A man who has had +one fit of it, should consider himself in the same state as a man who +has received the seeds of a malignant fever into his blood. He should +treat his body as if it were a Florence flask. By this means he will +probably prevent, during his life, the re-excitement of the disease. + +Are _issues_ proper to prevent the return of the violent state of gout? +I have heard of an instance of an issue in the leg having been effectual +for this purpose; but if the remedies before-mentioned be used in the +manner that has been directed, so unpleasant a remedy can seldom be +necessary. + +Are _bitters_ proper to prevent a return of this state of gout? It will +be a sufficient answer to this question to mention, that the duke of +Portland's powder, which is composed of bitter ingredients, excited a +fatal gout in many people who used it for that purpose. I should as soon +expect to see gold produced by the operations of fire upon copper or +lead, as expect to see the gout prevented or cured by any medicine that +acted upon the system, without the aid of more or less of the remedies +that have been mentioned. + +II. We come now, in the last place, to mention the remedies which are +proper to prevent a return of that state of gout which is attended with +a _feeble_ morbid action in the blood-vessels and viscera. + +This state of gout generally occurs in the evening of life, and in +persons of delicate habits, or in such as have had their constitutions +worn down by repeated attacks of the disease. + +The remedies to prevent it are, + +1. A _gently stimulating diet_, consisting of animal food well +cooked, with sound old Madeira or sherry wine, or weak spirit and +water. Salted, and even smoked meat may be taken, in this state of the +system, with advantage. It is an agreeable tonic, and is less disposed +to create plethora than fresh meat. Pickles and vinegar should seldom +be tasted. They dispose to gouty spasms in the stomach and bowels. +Long intervals between meals should be carefully avoided. The stomach, +when overstretched or empty, is always alike predisposed to disease. +There are cases in which the evils of inanition in the stomach will be +prevented, by a gouty patient eating in the middle of the night. + +2. The use of _chalybeate medicines_. These are more safe when used +habitually, than bitters. I have long been in the practice of giving +the different preparations of iron in large doses, in chronic diseases, +and in that state of debility which disposes to them. A lady of a weak +constitution informed Dr. Cheyne, that she once asked Dr. Sydenham how +long she might safely take steel. His answer was, that "she might take +it for thirty years, and then begin again if she continued ill[72]." + + [72] Essay on the Nature, and True Method of Treating the Gout, p. 69. + +Water impregnated with iron, either by nature or art, may be taken +instead of the solid forms of the metal. It will be more useful if it be +drunken in a place where patients will have the benefit of country air. + +3. The habitual use of the _volatile tincture of gum guiacum_, and +of other cordial and gently stimulating medicines. A clove of garlic +taken once or twice a day, has been found useful in debilitated habits +predisposed to the gout. It possesses a wonderful power in bringing +latent excitement into action. It moreover acts agreeably upon the +nervous system. + +Mr. Small found great benefit from breakfasting upon a tea made of half +a drachm of ginger cut into small slices, in preventing occasional +attacks of the gout in his stomach. Sir Joseph Banks was much relieved +by a diet of milk, with ginger boiled in it. The root of the sassafras +of our country might probably be used with advantage for the same +purpose. Aurelian speaks of certain remedies for the gout which he +calls "annalia[73]." The above medicines belong to this class. To be +effectual, they should be persisted in, not for one year only, but for +many years. + + [73] Morborum Chronicorum. Lib. v. Cap. 2. + +4._ Warmth_, uniformly applied, by means of suitable dresses, and +sitting rooms, to every part of the body. + +5. The _warm bath_ in winter, and the _temperate_, or _cold bath_ in +summer. + +6. _Exercise._ This may be in a carriage, or on horseback. The viscera +being debilitated in this state of predisposition to the gout, are +strengthened in a peculiar manner by the gentle motion of a horse. Where +this or other modes of passive exercise cannot be had, frictions to the +limbs and body should be used every day. + +7. _Costiveness_ should be avoided by taking occasionally one or two +table spoons full of Dr. Warner's purging tincture prepared by infusing +rhubarb, orange peel, and caraway seeds, of each an ounce, for three +days in a quart of Madeira, or any other white wine. If this medicine be +ineffectual for opening the bowels, rhubarb may be taken in the manner +formerly mentioned. + +8. The understanding and passions should be constantly employed in +agreeable studies and pursuits. Fatigue of mind and body should be +carefully avoided. + +9. A warm climate often protracts life in persons subject to this state +of gout. The citizens of Rome who had worn down their constitutions by +intemperance, added many years to their lives, by migrating to Naples, +and enjoying there, in a warmer sun, the pure air of the Mediterranean, +and sir William Temple says the Portuguese obtain the same benefit by +transporting themselves to the Brazils, after medicine and diet cease to +impart vigour to their constitutions in their native country. + +Thus have I enumerated the principal remedies for curing and preventing +the gout. Most of them are to be met with in books of medicine, but +they have been administered by physicians, or taken by patients with so +little regard to the different states of the system, that they have in +many instances done more harm than good. Solomon places all wisdom, in +the management of human affairs, in finding out the proper times for +performing certain actions. Skill in medicine, consists in an eminent +degree in timing remedies. There is a time to bleed, and a time to +withhold the lancet. There is a time to give physic, and a time to trust +to the operations of nature. There is a time to eat meat, and there is +a time to abstain from it. There is a time to give tonic medicines, and +a time to refrain from them. In a word, the cure of the gout depends +wholly upon two things, viz. _proper_ remedies, in their proper _times_, +and _places_. + +I shall take leave of this disease, by comparing it to a deep and +dreary cave in a new country, in which ferocious beasts and venomous +reptiles, with numerous ghosts and hobgoblins, are said to reside. The +neighbours point at the entrance of this cave with horror, and tell of +the many ravages that have been committed upon their domestic animals, +by the cruel tenants which inhabit it. At length a school-boy, careless +of his safety, ventures to enter this subterraneous cavern, when! to +his great delight, he finds nothing in it but the same kind of stones +and water he left behind him upon the surface of the earth. In like +manner, I have found no other principles necessary to explain the cause +of the gout, and no other remedies necessary to cure it, than such as +are admitted in explaining the causes, and in prescribing for the most +simple and common diseases. + + + + + OBSERVATIONS + + UPON + + THE NATURE AND CURE + + OF THE + + _HYDROPHOBIA_. + + +In entering upon the consideration of this formidable disease, I feel +myself under an involuntary impression, somewhat like that which was +produced by the order the king of Syria gave to his captains when he +was conducting them to battle: "Fight not with small or great, save +only with the king of Israel[74]." In whatever light we contemplate the +hydrophobia, it may be considered as pre-eminent in power and mortality, +over all other diseases. + + [74] II. Chron. xviii. 30. + +It is now many years since the distress and horror excited by it, +both in patients and their friends, led me with great solicitude to +investigate its nature. I have at length satisfied myself with a theory +of it, which, I hope, will lead to a rational and successful mode of +treating it. + +For a history of the symptoms of the disease, and many interesting +facts connected with it, I beg leave to refer the reader to Dr. Mease's +learned and ingenious inaugural dissertation, published in the year 1792. + +The remote and exciting causes of the hydrophobia are as follow: + +1. The bite of a rabid animal. Wolves, foxes, cats, as well as dogs, +impart the disease. It has been said that blood must be drawn in order +to produce it, but I have heard of a case in Lancaster county, in +Pennsylvania, in which a severe contusion, by the teeth of the rabid +animal, without the effusion of a drop of red blood, excited the +disease. Happily for mankind, it cannot be communicated by blood, or +saliva falling upon sound parts of the body. In Maryland, the negroes +eat with safety the flesh of hogs that have perished from the bite of +mad dogs; and I have heard of the milk of a cow, at Chestertown, in +the same state, having been used without any inconvenience by a whole +family, on the very day in which she was affected by this disease, and +which killed her in a few hours. Dr. Baumgarten confirms these facts by +saying, that "the flesh and milk of rabid animals have been eaten with +perfect impunity[75]." + + [75] Medical Commentaries, Philadelphia edition, vol. 7. p. 409. + +In the following observations I shall confine myself chiefly to the +treatment of the hydrophobia which arises from the bite of a rabid +animal, but I shall add in this place a short account of all its other +causes. + +2. Cold night air. Dr. Arthaud, late president of the society of +Philadelphians in St. Domingo, has published several cases in which it +was produced in negroes by sleeping all night in the open air. + +3. A wound in a tendinous part. + +4. Putrid and impure animal food. + +5. Worms. + +6. Eating beech nuts. + +7. Great thirst. + +8. Exposure to intense heat. + +9. Drinking cold water when the body was very much heated. + +10. A fall. + +11. Fear. + +12. Hysteria. + +13. Epilepsy. + +14. Tetanus. + +15. Hydrocephalus. Of the presence of hydrophobia in the hydrocephalic +state of fever, there have been several instances in Philadelphia. + +16. An inflammation of the stomach. + +17. The dysentery. + +18. The typhus fever. Dr. Trotter mentions the hydrophobia as a symptom +which frequently occurred in the typhus state of fever in the British +navy[76]. + + [76] Medicina Nautica, p. 301. + +19. It is taken notice of likewise in a putrid fever by Dr. Coste[77]; +and Dr. Griffitts observed it in a high degree in a young lady who died +of the yellow fever, in 1793. + + [77] Medical Commentaries, Dobson's edition, vol. II. p. 476. + +20. The bite of an angry, but not a diseased animal. + +21. An involuntary association of ideas. + +Cases of spontaneous hydrophobia from all the above causes are to be met +with in practical writers, and of most of them in M. Audry's learned +work, entitled, "Recherches sur la Rage." + +The dread of water, from which this disease derives its name, has five +distinct grades. 1. It cannot be drunken. 2. It cannot be touched. 3. +The sound of it pouring from one vessel to another, 4. the sight of +it, and 5. even the naming of it, cannot be borne, without exciting +convulsions. But this symptom is not a universal one. Dr. Mead mentions +three cases in which there was no dread of water, in persons who +received the disease from the bite of a rabid animal. It is unfortunate +for this disease, as well as many others, that a single symptom should +impose names upon them. In the present instance it has done great harm, +by fixing the attention of physicians so exclusively upon the dread of +water which occurs in it, that they have in a great measure overlooked +every other circumstance which belongs to the disease. The theory of +the hydrophobia, which an examination of its causes, symptoms, and +accidental cures, with all the industry I was capable of, has led me to +adopt, is, that it is a _malignant state of fever_. My reasons for this +opinion are as follow: + +1. The disease in all rabid animals is a fever. This is obvious in dogs +who are most subject to it. It is induced in them by the usual causes +of fever, such as scanty or putrid aliment[78], extreme cold, and the +sudden action of heat upon their bodies. Proofs of its being derived +from each of the above causes are to be met with in most of the authors +who have written upon it. The animal matters which are rendered morbid +by the action of the above causes upon them, are determined to the +saliva, in which a change seems to be induced, similar to that which +takes place in the perspirable matter of the human species from the +operation of similar causes upon it. This matter, it is well known, is +the remote cause of the jail fever. No wonder the saliva of a dog should +produce a disease of the same kind, after being vitiated by the same +causes, and thereby disposed to produce the same effects. + + [78] "Animal food, in a state of putridity, is amongst the most + frequent causes of canine madness." + + "Canine madness chiefly arises from the excessive number of + ill-kept and ill-fed dogs." + YOUNG'S ANNUALS, vol. XVII. p. 561. + +2. The disease called canine madness, prevails occasionally among +dogs at those times in which malignant fevers are epidemic. This will +not surprise those persons who have been accustomed to observe the +prevalence of the influenza and bilious fevers among other domestic +animals at a time when they are epidemic among the human species. + +3. Dogs, when they are said to be mad, exhibit the usual symptoms of +fever, such as a want of appetite, great heat, a dull, fierce, red, or +watery eye, indisposition to motion, sleepiness, delirium, and madness. +The symptom of madness is far from being universal, and hence many dogs +are diseased and die with this malignant fever, that are inoffensive, +and instead of biting, continue to fawn upon their masters. Nor is the +disposition of the fever to communicate itself by infection universal +among dogs any more than the same fever in the human species, and this I +suppose to be one reason why many people are bitten by what are called +mad dogs, who never suffer any inconvenience from it. + +4. A dissection of a dog, by Dr. Cooper, that died with this fever, +exhibited all the usual marks of inflammation and effusion which take +place in common malignant fevers. I shall in another place mention a +fifth argument in favour of the disease in dogs being a malignant fever, +from the efficacy of one of the most powerful remedies in that state of +fever, having cured it in two instances. + +II. The disease produced in the human species by the bite of a rabid +animal, is a _malignant_ fever. This appears first from its symptoms. +These, as recorded by Aurelian, Mead, Fothergill, Plummer, Arnold, +Baumgarten, and Morgagni, are chills, great heat, thirst, nausea, a +burning sensation in the stomach, vomiting, costiveness; a small, +quick, tense, irregular, intermitting, natural, or slow pulse; a cool +skin, great sensibility to cold air, partial cold and clammy sweats on +the hands, or sweats accompanied with a warm skin diffused all over +the body, difficulty of breathing, sighing, restlessness, hiccup, +giddiness, head-ach, delirium, coma, false vision, dilatation of the +pupils, dulness of sight, blindness, glandular swellings, heat of urine, +priapism, palpitation of the heart, and convulsions. I know that there +are cases of hydrophobia upon record, in which there is said to be a +total absence of fever. The same thing has been said of the plague. +In both cases the supposed absence of fever is the effect of stimulus +acting upon the blood-vessels with so much force as to suspend morbid +action in them. By abstracting a part of this stimulus, a fever is +excited, which soon discovers itself in the pulse and on the skin, and +frequently in pains in every part of the body. The dread of water, +and the great sensibility of the system to cold air, are said to give +a specific character to the hydrophobia; but the former symptom, it +has been often seen, occurs in diseases from other causes, and the +latter has been frequently observed in the yellow fever. It is no more +extraordinary that a fever excited by the bite of a rabid animal should +excite a dread of water, than that fevers from other causes should +produce aversion from certain aliments, from light, and from sounds +of all kinds; nor is it any more a departure from the known laws of +stimulants, that the saliva of a mad dog should affect the fauces, than +that mercury should affect the salivary glands. Both stimuli appear to +act in a specific manner. + +2. The hydrophobia partakes of the character of a malignant fever, in +appearing at different intervals from the time in which the infection +is received into the body. These intervals are from one day to five or +six months. The small-pox shows itself in intervals from eight to twenty +days, and the plague and yellow fever from the moment in which the +miasmata are inhaled, to nearly the same distance of time. This latitude +in the periods at which infectious and contagious matters are brought +into action in the body, must be resolved into the influence which the +season of the year, the habits of the patients, and the passion of fear +have upon them. + +Where the interval between the time of being bitten, and the appearance +of a dread of water, exceeds five or six months, it is probable it may +be occasioned by a disease derived from another cause. Such a person is +predisposed in common with other people to all the diseases of which +the hydrophobia is a symptom. The recollection of the poisonous wound +he has received, and its usual consequences, is seldom absent from his +mind for months or years. A fever, or an affection of his nerves from +their most common causes, cannot fail of exciting in him apprehensions +of the disease which usually follows the accident to which he has been +exposed. His fears are then let loose upon his system, and produce in +a short time a dread of water which appears to be wholly unconnected +with the bite of a rabid animal. Similar instances of the effects of +fear upon the human body are to be met with in books of medicine. The +pains produced by fear acting upon the imagination in supposed venereal +infections, are as real and severe as they are in the worst state of +that disease. + +3. Blood drawn in the hydrophobia exhibits the same appearances which +have been remarked in malignant fevers. In Mr. Bellamy, the gentleman +whose case is so minutely related by Dr. Fothergill, the blood +discovered with "slight traces of size, _serum_ remarkably _yellow_." +It was uncommonly sizy in a boy of Mr. George Oakley whom I saw, and +bled for the first time, on the fourth day of his disease, in the +beginning of the year 1797. His pulse imparted to the fingers the same +kind of quick and tense stroke which is common in an acute inflammatory +fever. He died in convulsions the next day. He had been bitten by a mad +dog on one of his temples, three weeks before he discovered any signs +of indisposition. There are several other cases upon record, of the +blood exhibiting, in this disease, the same appearances as in common +malignant and inflammatory fevers. + +4. The hydrophobia accords exactly with malignant fevers in its +duration. It generally terminates in death, according to its violence, +and the habit of the patient, in the first, second, third, fourth, or +fifth day, from the time of its attack, and with the same symptoms which +attend the last stage of malignant fevers. + +5. The body, after death from the hydrophobia, putrifies with the same +rapidity that it does after death from a malignant fever in which no +depletion has been used. + +6. Dissections of bodies which have died of the hydrophobia, exhibit the +same appearances which are observed in the bodies of persons who have +perished of malignant fevers. These appearances, according to Morgagni +and Tauvry[79], are marks of inflammation in the throat, [oe]sophagus, +trachea, brain, stomach, liver, and bowels. Effusions of water, and +congestions of blood in the brain, large quantities of dark-coloured +or black bile in the gall-bladder and stomach, mortifications in the +bowels and bladder, livid spots on the surface of the body, and, above +all, the arteries filled with fluid blood, and the veins nearly empty. +I am aware, that two cases of death from hydrophobia are related by Dr. +Vaughan, in which no appearance of disease was discovered by dissection +in any part of the body. Similar appearances have occasionally been met +with in persons who have died of malignant fevers. In another place I +hope to prove, that we err in placing disease in inflammation, for it +is one of its primary effects only, and hence, as was before remarked, +it does not take place in many instances in malignant fevers, until the +arteries are so far relaxed by two or three bleedings, as to be able to +relieve themselves by effusing red blood into serous vessels, and thus +to produce that error loci which I shall say hereafter is essential to +inflammation[80]. The existence of this grade of action in the arteries +may always be known by the presence of sizy blood, and by the more +obvious and common symptoms of fever. + + [79] Bibliotheque Choisie de Medecine, tome XV. p. 210. + + [80] In the 6th volume of the Medical Observations and Inquiries, there + is an account of a dissection of a person who had been destroyed + by taking opium. "No morbid appearance (says Mr. Whateley, the + surgeon who opened the body) was found in any part of the body, + except that the villous coat of the stomach was very slightly + inflamed." The stimulus of the opium in this case either produced + an action which transcended inflammation, or destroyed action + altogether by its immense force, by which means the more common + morbid appearances which follow disease in a dead body could not + take place. + +The remedies for hydrophobia, according to the principles I have +endeavoured to establish, divide themselves naturally into two kinds. + +I. Such as are proper to prevent the disease, after the infection of the +rabid animal is received into the body. + +II. Such as are proper to cure it when formed. + +The first remedy under the first general head is, abstracting or +destroying the virus, by cutting or burning out the wounded part, or by +long and frequent effusions of water upon it, agreeably to the advice +of Dr. Haygarth, in order to wash the saliva from it. The small-pox +has been prevented, by cutting out the part in which the puncture was +made in the arm with variolous matter. There is no reason why the same +practice should not succeed, if used in time, in the hydrophobia. Where +it has failed of success, it has probably been used after the poison has +contaminated the blood. The wound should be kept open and running for +several months. In this way a servant girl, who was bitten by the same +cat that bit Mr. Bellamy, is supposed by Dr. Fothergill to have escaped +the disease. Dr. Weston of Jamaica believes that he prevented the +disease by the same means, in two instances. Perhaps an advantage would +arise from exciting a good deal of inflammation in the wound. We observe +after inoculation, that the more inflamed the puncture becomes, and the +greater the discharge from it, the less fever and eruption follow in the +small-pox. + +A second preventive is a low diet, such as has been often used with +success to mitigate the plague and yellow fever. The system, in this +case, bends beneath the stimulus of the morbid saliva, and thus obviates +or lessens its effects at a future day. + +During the use of these means to prevent the disease, the utmost +care should be taken to keep up our patient's spirits, by inspiring +confidence in the remedies prescribed for him. + +Mercury has been used in order to prevent the disease. There are many +well-attested cases upon record, of persons who have been salivated +after being bitten by mad animals, in whom the disease did not show +itself, but there are an equal number of cases to be met with, in which +a salivation did not prevent it. From this it would seem probable, that +the saliva did not infect in the cases in which the disease was supposed +to have been prevented by the mercury. At the time calomel was used to +prepare the body for the small-pox, a salivation was often induced by +it. The affection of the salivary glands in many instances lessened the +number of pock, but I believe in no instance prevented the eruptive +fever. + +I shall say nothing here of the many other medicines which have been +used to prevent the disease. No one of them has, I believe, done any +more good, than the boasted specifics which have been used to eradicate +the gout, or to procure old age. They appear to have derived their +credit from some of the following circumstances accompanying the bite of +the animal. + +1. The animal may have been angry, but not diseased with a malignant +fever such as I have described. + +2. He may have been diseased, but not to such a degree as to have +rendered his saliva infectious. + +3. The saliva, when infectious, may have been so washed off in passing +through the patient's clothes, as not to have entered the wound made in +the flesh. And + +4. There may have been no predisposition in the patient to receive the +fever. This is often observed in persons exposed to the plague, yellow +fever, small-pox, and to the infection of the itch, and the venereal +disease. + +The hydrophobia, like the small-pox, generally comes on with some +pain, and inflammation in the part in which the infection was infused +into the body, but to this remark, as in the small-pox, there are some +exceptions. As soon as the disease discovers itself, whether by pain or +inflammation in the wounded part, or by any of the symptoms formerly +mentioned, the first remedy indicated is _blood-letting_. All the facts +which have been mentioned, relative to its cause, symptoms, and the +appearances of the body after death, concur to enforce the use of the +lancet in this disease. Its affinity to the plague and yellow fever in +its force, is an additional argument in favour of that remedy. To be +effectual, it should be used in the most liberal manner. The loss of +100 to 200 ounces of blood will probably be necessary in most cases to +effect a cure. The pulse should govern the use of the lancet as in other +states of fever, taking care not to be imposed upon by the absence of +_frequency_ in it, in the supposed absence of fever, and of _tension_ +in affections of the stomach, bowels, and brain. This practice, in the +extent I have recommended it, is justified not only by the theory of the +disease, but by its having been used with success in the following cases. + +Dr. Nugent cured a woman by two copious bleedings, and afterwards by the +use of sweating and cordial medicines. + +Mr. Wrightson was encouraged by Dr. Nugent's success to use the same +remedies with the same happy issue in a boy of 15 years of age[81]. + + [81] Medical Transactions, vol. ii. p. 192. + +Mr. Falconer cured a young woman of the name of Hannah Moore, by +"a copious bleeding," and another depleting remedy to be mentioned +hereafter[82]. + + [82] Ditto, p. 222. + +Mr. Poupart cured a woman by bleeding until she fainted, and Mr. Berger +gives an account of a number of persons being bitten by a rabid animal, +all of whom died, except two who were saved by bleeding[83]. + + [83] Bibliotheque Choisie de Medecine, tome xv. p. 212. + +In the 40th volume of the Transactions of the Royal Society of London, +there is an account of a man being cured of hydrophobia by Dr. Hartley, +by the loss of 120 ounces of blood. + +Dr. Tilton cured this disease in a woman in the Delaware state by very +copious bleeding. The remedy was suggested to the doctor by an account +taken from a London magazine of a dreadful hydrophobia being cured by an +accidental and profuse hæmorrhage from the temporal artery[84]. + + [84] Medical Essays of Edinburgh, vol. i. p. 226. + +A case is related by Dr. Innes[85], of the loss of 116 ounces of blood +in seven days having cured this disease. In the patient who was the +subject of this cure, the bleeding was used in the most depressed, and +apparently weak state of the pulse. It rose constantly with the loss of +blood. + + [85] Medical Commentaries, vol. iii. p. 496. + +The cases related by Dr. Tilton and Dr. Innes were said to be of a +spontaneous nature, but the morbid actions were exactly the same in +both patients with those which are derived from the bite of a rabid +animal. There is but one remote cause of disease, and that is stimulus, +and it is of no consequence in the disease now under consideration, +whether the dread of water be the effect of the saliva of a rabid animal +acting upon the fauces, or of a morbid excitement determined to those +parts by any other stimulus. The inflammation of the stomach depends +upon the same kind of morbid action, whether it be produced by the +miasmata of the yellow fever, or the usual remote and exciting causes +of the gout. An apoplexy is the same disease when it arises from a +contusion by external violence, that it is when it arises spontaneously +from the congestion of blood or water in the brain. A dropsy from +obstructions in the liver induced by strong drink, does not differ in +its proximate cause from the dropsy brought on by the obstructions in +the same viscus which are left by a neglected, or half cured bilious +fever. These remarks are of extensive application, and, if duly attended +to, would deliver us from a mass of error which has been accumulating +for ages in medicine: I mean the nomenclature of diseases from their +remote causes. It is the most offensive and injurious part of the +rubbish of our science. + +I grant that bleeding has been used in some instances in hydrophobia +without effect, but in all such cases it was probably used out of time, +or in too sparing a manner. The credit of this remedy has suffered in +many other diseases from the same causes. I beg it may not be tried in +this disease, by any physician who has not renounced our modern systems +of nosology, and adopted, in their utmost extent, the principles and +practice of Botallus and Sydenham in the treatment of malignant fevers. + +Before I quit the subject of blood-letting in hydrophobia, I have to +add, that it has been used with success in two instances in dogs that +had exhibited all the usual symptoms of what has been called madness. +In one case, blood was drawn by cutting off the tail, in the other, +by cutting off the ears of the diseased animal. I mention these facts +with pleasure, not only because they serve to support the theory and +practice which I have endeavoured to establish in this disease, but +because they will render it unnecessary to destroy the life of a useful +and affectionate animal in order to prevent his spreading it. By curing +it in a dog by means of bleeding, we moreover beget confidence in the +same remedy in persons who have been bitten by him, and thus lessen +the force of the disease, by preventing the operation of fear upon the +system. + +2. Purges and glysters have been found useful in the hydrophobia. They +discharge bile which is frequently vitiated, and reduce morbid action in +the stomach and blood-vessels. Dr. Coste ascribes the cure of a young +woman in a convent wholly to glysters given five or six times every day. + +3. Sweating after bleeding completed the cure of the boy whose case is +mentioned by Mr. Wrightson. Dr. Baumgarten speaks highly of this mode +of depleting, and says further, that it has never been cured "but by +evacuations of some kind." + +4. All the advantages which attend a salivation in common malignant +fevers, are to be expected from it in the hydrophobia. It aided +blood-letting in two persons who were cured by Mr. Falconer and Dr. Le +Compt. + +There are several cases upon record in which musk and opium have +afforded evident relief in this disease. + +A physician in Virginia cured it by large doses of bark and wine. I have +no doubt of the efficacy of these remedies when the disease is attended +with a moderate or feeble morbid action in the system, for I take it for +granted, it resembles malignant fevers from other causes in appearing +in different grades of force. In its more violent and common form, +stimulants of all kinds must do harm, unless they are of such a nature, +and exhibited in such quantities, as to exceed in their force the +stimulus of the disease; but this is not to be expected, more especially +as the stomach is for the most part so irritable as sometimes to reject +the mildest aliments as well as the most gentle medicines. + +After the morbid actions in the system have been weakened, tonic +remedies would probably be useful in accelerating the cure. + +Blisters and stimulating cataplasms, applied to the feet, might probably +be used with the same advantage in the declining state of the disease, +that they have been used in the same stage of other malignant fevers. + +The cold bath, also long immersion in cold water, have been frequently +used in this disease. The former aided the lancet, in the cure of the +man whose case is related by Dr. Hartley. There can be no objection +to the cold water in either of the above forms, provided no dread is +excited by it in the mind of the patient. + +The reader will perceive here that I have deserted an opinion which I +formerly held upon the cause and cure of the tetanus. I supposed the +hydrophobia to depend upon debility. This debility I have since been +led to consider as partial, depending upon abstraction of excitement +from some, and a morbid accumulation of it in other parts of the +body. The preternatural excitement predominates so far, in most cases +of hydrophobia, over debility, that depleting remedies promise more +speedily and safely to equalize, and render it natural, than medicines +of an opposite character. + +In the treatment of those cases of hydrophobia which are not derived +from the bite of a rabid animal, regard should always be had to its +remote and exciting causes, so as to accommodate the remedies to them. + +The imperfection of the present nomenclature of medicine has become the +subject of general complaint. The mortality of the disease from the bite +of a rabid animal, has been increased by its name. The terms hydrophobia +and canine madness, convey ideas of the symptoms of the disease only, +and of such of them too as are by no means universal. If the theory I +have delivered, and the practice I have recommended, be just, it ought +to be called the hydrophobic state of fever. This name associates it at +once with all the other states of fever, and leads us to treat it with +the remedies which are proper in its kindred diseases, and to vary them +constantly with the varying state of the system. + +In reviewing what has been said of this disease, I dare not say that I +have not been misled by the principles of fever which I have adopted; +but if I have, I hope the reader will not be discouraged by my errors +from using his reason in medicine. By contemplating those errors, he +may perhaps avoid the shoals upon which I have been wrecked. In all his +researches, let him ever remember that there is the same difference +between the knowledge of a physician who prescribes for diseases as +limited by genera and species, and of one who prescribes under the +direction of just principles, that there is between the knowledge we +obtain of the nature and extent of the sky, by viewing a few feet of it +from the bottom of a well, and viewing from the top of a mountain the +whole canopy of heaven. + +Since the first edition of the foregoing observations, I have seen a +communication to the editors of the Medical Repository[86], by Dr. +Physick, which has thrown new light upon this obscure disease, and +which, I hope, will aid the remedies that have been proposed, in +rendering them more effectual for its cure. The doctor supposes death +from hydrophobia to be the effect of a sudden and spasmodic constriction +of the glottis, inducing suffocation, and that it might be prevented +by creating an artificial passage for air into the lungs, whereby life +might be continued long enough to admit of the disease being cured +by other remedies. The following account of a dissection is intended +to show the probability of the doctor's proposal being attended with +success. + + [86] Volume V. + +On the 13th of September, 1802, I was called, with Dr. Physick, to +visit, in consultation with Dr. Griffitts, the son of William Todd, +Esq. aged five years, who was ill with the disease called hydrophobia, +brought on by the bite of a mad dog, on the 6th of the preceding month. +The wound was small, and on his cheek, near his mouth, two circumstances +which are said at all times to increase the danger of wounds from rabid +animals. From the time he was bitten, he used the cold bath daily, and +took the infusion, powder, and seeds of the anagallis, in succession, +until the 9th of September, when he was seized with a fever which +at first resembled the remittent of the season. Bleeding, purging, +blisters, and the warm bath were prescribed for him, but without +success. The last named remedy appeared to afford him some relief, which +he manifested by paddling and playing in the water. At the time I saw +him he was much agitated, had frequent twitchings, laughed often; but, +with this uncommon excitement in his muscles and nerves, his mind was +unusually correct in all its operations. + +He discovered no dread of water, except in one instance, when he turned +from it with horror. He swallowed occasionally about a spoon full of +it at a time, holding the cup in his own hand, as if to prevent too +great a quantity being poured at once into his throat. The quick manner +of his swallowing, and the intervals between each time of doing so, +were such as we sometimes observe in persons in the act of dying of +acute diseases. Immediately after swallowing water, he looked pale, and +panted for breath. He spoke rapidly, and with much difficulty. This +was more remarkably the case when he attempted to pronounce the words +_carriage_, _water_, and _river_. After speaking he panted for breath +in the same manner that he did after drinking. He coughed and breathed +as patients do in the moderate grade of the cynanche trachealis. The +dog that had bitten him, Mr. Todd informed me, made a similar noise +in attempting to bark, a day or two before he was killed. We proposed +making an opening into his windpipe. To this his parents readily +consented; but while we were preparing for the operation, such a change +for the worse took place, that we concluded not to perform it. A cold +sweat, with a feeble and quick pulse, came on; and he died suddenly, at +12 o'clock at night, about six hours after I first saw him. He retained +his reason, and a playful humour, till the last minute of his life. An +instance of the latter appeared in his throwing his handkerchief at +his father just before he expired. The parents consented to our united +request to examine his body. Dr. Griffitts being obliged to go into the +country, and Dr. Physick being indisposed, I undertook this business +the next morning; and, in the presence of Dr. John Dorsey (to whom I +gave the dissecting knife), and my pupil Mr. Murduck, I discovered the +following appearances. All the muscles of the neck had a livid colour, +such as we sometimes observe, after death, in persons who have died of +the sore throat. The muscles employed in deglutition and speech were +suffused with blood. The epiglottis was inflamed, and the glottis so +thickened and contracted, as barely to admit a probe of the common size. +The trachea below it was likewise inflamed and thickened, and contained +a quantity of mucus in it, such as we observe, now and then, after +death from cynanche trachealis. The [oe]sophagus exhibited no marks +of disease; but the stomach had several inflamed spots upon it, and +contained a matter of a brown appearance, and which emitted an offensive +odour. + +From the history of this dissection, and of many others, in which much +fewer marks appeared of violent disease, in parts whose actions are +essential to life, it is highly probable death is not induced in the +ordinary manner in which malignant fevers produce it, but by a sudden +or gradual suffocation. It is the temporary closure of this aperture +which produces the dread of swallowing liquids: hence the reason why +they are swallowed suddenly, and with intervals, in the manner that has +been described; for, should the glottis be closed during the time of +two swallows, in the highly diseased state of the system which takes +place in this disease, suffocation would be the immediate and certain +consequence. The same difficulty and danger attend the swallowing +saliva, and hence the symptom of spitting, which has been so often +taken notice of in hydrophobia. Solids are swallowed more easily than +fluids, only because they descend by intervals, and because a less +closure of the glottis is sufficient to favour their passage into the +stomach. This remark is confirmed by the frequent occurrence of death +in the very act of swallowing, and that too with the common symptoms of +suffocation. To account for death from this cause, and in the manner +that has been described, it will be necessary to recollect, that fresh +air is more necessary to the action of the lungs in a fever than in +health, and much more so in a fever of a malignant character, such +as the hydrophobia appears to be, than in fevers of a milder nature. +An aversion from swallowing liquids is not peculiar to this disease. +It occurs occasionally in the yellow fever. It occurs likewise in +the disease which has prevailed among the cats, both in Europe and +America, and probably, in both instances, from a dread of suffocation +in consequence of the closure of the glottis, and sudden abstraction of +fresh air. + +The seat of the disease, and the cause of death, being, I hope, +thus ascertained, the means of preventing death come next under +our consideration. Tonic remedies, in all their forms, have been +administered to no purpose. The theory of the disease would lead us +to expect a remedy for it in blood-letting. But this, though now and +then used with success, is not its cure, owing, as we now see, to the +mortal seat of the disease being so far removed from the circulation, as +not to be affected by the loss of blood in the most liberal quantity. +As well might we expect the inflammation and pain of a paronychia, or +what is called a felon on the finger, to be removed by the same remedy. +Purging and sweating, though occasionally successful, have failed in +many instances; and even a salivation, when excited (which is rarely the +case), has not cured it. An artificial aperture into the windpipe alone +bids fair to arrest its tendency to death, by removing the symptom which +generally induces it, and thereby giving time for other remedies, which +have hitherto been unsuccessful, to produce their usual salutary effects +in similar diseases[87]. In removing faintness, in drawing off the water +in ischuria, in composing convulsions, and in stopping hæmorrhages in +malignant fever, we do not cure the disease, but we prevent death, and +thereby gain time for the use of the remedies which are proper to cure +it. Laryngotomy, according to Fourcroy's advice, in diseases of the +throat which obstruct respiration, should be preferred to tracheotomy, +and the incision should be made in the triangular space between the +thyroid and cricoid cartilages. Should this operation be adopted, in +order to save life, it will not offer near so much violence to humanity +as many other operations. We cut through a large mass of flesh into the +bladder in extracting a stone. We cut into the cavity of the thorax in +the operation for the empyema. We perforate the bones of the head in +trepanning; and we cut through the uterus, in performing the Cæsarian +operation, in order to save life. The operation of laryngotomy is much +less painful and dangerous than any of them; and besides permitting +the patient to breathe and to swallow, it is calculated to serve the +inferior purpose of lessening the disease of the glottis by means of +local depletion. After an aperture has been thus made through the +larynx, the remedies should be such as are indicated by the state of +the system, particularly by the state of the pulse. In hot climates it +is, I believe, generally a disease of feeble re-action, and requires +tonic remedies; but in the middle and northern states of America it +is more commonly attended with so much activity and excitement of the +blood-vessels, as to require copious blood-letting and other depleting +remedies. + + [87] The hoarse barking, or the total inability of mad dogs to bark, + favours still further the idea that the mortal seat of the + disease is in the glottis, and that the remedy which has been + proposed is a rational one. + +Should this new mode of attacking this furious disease be adopted, and +become generally successful, the discovery will place the ingenious +gentleman who suggested it in the first rank of the medical benefactors +of mankind. + +I have only to add a fact upon this subject which may tend to increase +confidence in a mode of preventing the disease which has been +recommended by Dr. Haygarth, and used with success in several instances. +The same dog which bit Mr. Todd's son, bit, at the same time, a cow, a +pig, a dog, and a black servant of Mr. Todd's. The cow and pig died; +the dog became mad, and was killed by his master. The black man, who +was bitten on one of his fingers, exposed the wound for some time, +immediately after he received it, to a stream of pump water, and washed +it likewise with soap and water. He happily escaped the disease, and +is now in good health. That his wound was poisoned is highly probable, +from its having been made eight hours after the last of the above +animals was bitten, in which time there can be but little doubt of such +a fresh secretion of saliva having taken place as would have produced +the hydrophobia, had it not been prevented by the above simple remedy. I +am not, however, so much encouraged by its happy issue in this case as +to advise it in preference to cutting out the wounded part. It should +only be resorted to where the fears of a patient, or his distance from a +surgeon render it impossible to use the knife. + + + + + AN ACCOUNT + + OF + + _THE MEASLES_, + + AS THEY + + APPEARED IN PHILADELPHIA, + + IN THE SPRING OF 1789. + + +The weather in December, 1788, and in January, 1789, was variable, but +seldom very cold. On the first of February, 1789, at six o'clock in the +morning, the mercury in Fahrenheit's thermometer fell 5° below 0, in the +city of Philadelphia. At twenty miles from the city, on the Schuylkill, +it fell 12° below 0, at the same hour. On the 19th and 20th of this +month, there fell a quantity of snow, the depth of which, upon an +average, was supposed to be about eight or ten inches. On the 23d, 24th, +25th, and 27th, the weather was very cold. The mercury fluctuated during +these days between 4° and 10° above 0. + +In the intervals between these cold days, the weather frequently +moderated, so that the Delaware was frozen and thawed not less than +four times. It was not navigable till the 8th of March. There were in +all, during the winter and month of March, sixteen distinct falls of +snow. + +In April and May there were a few warm days; but upon the whole, it was +a very cold and backward spring. The peaches failed almost universally. +There were no strawberries or cherries on the 24th of May, and every +other vegetable product was equally backward. A country woman of 84 +years of age informed me, that it was the coldest spring she had ever +known. It was uncomfortable to sit without fire till the first of June. + +The measles appeared first in the Northern Liberties, in December. +They spread slowly in January, and were not universal in the city till +February and March. + +This disease, like many others, had its _precursor_. It was either a +gum-boil, or a sore on the tongue. They were both very common, but not +universal. They occurred, in some instances, several days before the +fever, but in general they made their appearance during the eruptive +fever, and were a sure mark of the approaching eruption of the measles. +I was first led to observe this fact, from having read Dr. Quin's +accurate account of the measles in Jamaica. I shall now proceed to +mention the symptoms of the measles as they appeared in the different +parts of the body. + +1. In the _head_, they produced great pain, swelling of the eye-lids, so +as to obstruct the eye-sight, tooth-ach, bleeding at the nose, tinnitus +aurium, and deafness; also coma for two days, and convulsions. I saw the +last symptom only in one instance. It was brought on by a stoppage of a +running from the ear. + +2. In the _throat_ and _lungs_, they produced a soreness and hoarseness, +acute or dull pains in the breast and sides, and a painful or +distressing cough. In one case, this cough continued for two hours +without any intermission, attended by copious expectoration. In two +cases, I saw a constant involuntary discharge of phlegm and mucus from +the mouth, without any cough. One of them terminated fatally. Spitting +of blood occurred in several instances. The symptoms of pneumonia +vera notha and typhoides were very common. I saw two fatal cases from +pneumonia notha, in both of which the patients died with the trunk of +the body in an erect posture. I met with two cases in which there was +no cough till the eruption made its appearance on the fourth day, and +one which was accompanied by all the usual symptoms of the cynanche +trachealis. + +3. In the _stomach_ the measles produced, in many instances, sickness +and vomiting. And + +4. In the _bowels_, griping, diarrh[oe]a, and, in some instances, bloody +stools. The diarrh[oe]a occurred in every stage of the disease, but it +was bloody and most painful in its decline. I attended a black girl who +discharged a great many worms, but without the least relief of any of +her symptoms. + +There was a great variety in this disease. 1. In the _time_ of the +attack of the fever, from the _time_ of the reception of the contagion. +In general the interval was fourteen days, but it frequently appeared +before, and sometimes later than that period. + +2. In the _time of the eruption_, from the beginning of the fever. It +generally appeared on the third and fourth days. In one case, Dr. Waters +informed me, it did not appear till the eighth day. + +3. In the _abatement_ or _continuance_ of the fever after the eruption. + +4. In the _colour_ and _figure_ of the eruption. In some it put on +a _pale_ red, in others a _deep_, and in a few a _livid_ colour, +resembling an incipient mortification. In some there appeared red +blotches, in others an equally diffused redness, and in a few, eruptions +like the small-pox, called by Dr. Cullen, rubiola varioloides. + +5. In the _duration_ of the eruption on the skin. It remained in most +cases only three or four days; but in one, which came under my care, it +remained nine days. + +6. In the _manner of its retrocession_. I saw very few cases of its +leaving the branny appearance so generally spoken of by authors on the +skin. + +7. In _not affecting_ many persons, and even families who were exposed +to it. + +The symptoms which continued in many after the retrocession of the +measles, were cough, hoarseness, or complete aphonia, which continued +in two cases for two weeks; also diarrh[oe]a, opthalmy, a bad taste in +the mouth, a defect or excess of appetite, and a fever, which in some +instances was of the intermitting kind, but which in more assumed the +more dangerous form of the typhus mitior. Two cases of internal dropsy +of the brain followed them. One was evidently excited by a fall. They +both ended fatally. + +During the prevalence of the disease I observed several persons (who had +had the measles, and who were closely confined to the rooms of persons +ill with them) to be affected with a slight cough, sore throat, and even +sores in the mouth. I find a similar fact taken notice of by Dr. Quier. + +But I observed further, many children to be affected by a fever, +cough, and all the other symptoms of the measles which have been +mentioned, except a general eruption, for in some there was a trifling +efflorescence about the neck and breast. I observed the same thing +in 1773 and 1783. In my note book I find the following account of +the appearance of this disease in children in the year 1773. "The +measles appeared in March; a catarrh (for by that name I then called +it) appeared at the same time, and was often mistaken for them, the +symptoms being nearly the same in both. In the catarrh there was in some +instances a trifling eruption. A lax often attended it, and some who had +it had an extremely sore mouth." + +I was the more struck with this disease, from finding it was taken +notice of by Dr. Sydenham. He calls it a morbillous fever. I likewise +find an account of it in the 2d article of the 5th volume of the +Edinburgh Medical Essays. The words of the author, who is anonymous, +are as follow. "During this measly season, several persons, who never +had the measles, had all the symptoms of measles, which went off in a +few days without any eruptions. The same persons had the measles months +or years afterwards." Is this disease a common fever, marked by the +reigning epidemic, and produced in the same manner, and by the same +causes, as the variolous fever described by Dr. Sydenham, which he says +prevailed at the same time with the small-pox? I think it is not. My +reasons for this opinion are as follow. + +1. I never saw it affect any but children, in the degree that has been +mentioned, and such only as had never had the measles. + +2. It affected whole families at the same time. It proved fatal to one +of three children whom it affected on the same day. + +3. It terminated in a pulmonary consumption in a boy of ten years old, +with all the symptoms which attend that disease when it follows the +regular measles. + +4. It affected a child in one family, on the same day that two other +members of the same family were affected by the genuine measles. + +5. It appeared on the usual days of the genuine measles, from the time +the persons affected by it were exposed to its contagion. And, + +6. It communicated the disease in one family, in the usual time in which +the disease is taken from the genuine measles. + +The measles, then, appear to follow the analogy of the small-pox, which +affects so superficially as to be taken a second time, and which produce +on persons who have had them what are called the nurse pock. They follow +likewise the analogy of another disease, viz. the scarlatina anginosa. +In the account of the epidemic for 1773, published in the third volume +of the Edinburgh Medical Essays, we are told, that such patients as had +previously had the scarlet fever without sore throats, took the sore +throat, and had no eruption, while those who had previously had the sore +throat had a scarlet eruption, but the throat remained free from the +distemper. All other persons who were affected had both. + +From these facts, I have taken the liberty of calling it the _internal +measles_, to distinguish it from those which are _external_. I think +the discovery of this new state of this disease of some application to +practice. + +1. It will lead us to be cautious in declaring any disease to be the +external measles, in which there is not a general eruption. From +my ignorance of this, I have been led to commit several mistakes, +which were dishonourable to the profession. I was called, during the +prevalence of the measles in the above-named season, to visit a girl +of twelve years old, with an eruption on the skin. I called it the +measles. The mother told me it was impossible, for that I had in 1783 +attended her for the same disease. I suspect the anonymous author +before-mentioned has fallen into the same error. He adds to the account +before quoted the following words. "Others, who had undergone the +measles formerly, had _at this time_ a fever of the erysipelatous kind, +with eruptions like to which nettles cause, and all the _previous_ and +concomitant symptoms of the measles, from the beginning to the end of +the disease." + +2. If inoculation, or any other mode of lessening the violence of the +disease, should be adopted, it will be of consequence to know what +persons are secure from the attacks of it, and who are still exposed to +it. + +I shall now add a short account of my method of treating this disease. + +Many hundred families came through the disease without the help of a +physician. But in many cases it was attended with peculiar danger, and +in some with death. I think it was much more fatal than in the years +1773 and 1783, probably owing to the variable weather in the winter, +and the coldness and dampness of the succeeding spring. Dr. Huxham +says, he once saw the measles attended with peculiar mortality, during +a late cold and damp spring in England. It was much more fatal (cæteris +paribus) to adults than to young people. + +The remedies I used were, + +1. _Bleeding_, in all cases where great pain and cough with a hard pulse +attended. In some I found it necessary to repeat this remedy. But I met +with many cases in which it was forbidden by the weakness of the pulse, +and by other marks of a feeble action in the blood-vessels. + +2. _Vomits._ These were very useful in removing a nausea; they likewise +favoured the eruption of the measles. + +3. _Demulcent_ and _diluting drinks_. These were barley water, bran, +and flaxseed tea, dried cherry and raw apple water, also beverage, and +cyder and water. The last drink I found to be the most agreeable to my +patients of any that have been mentioned. + +4. _Blisters_ to the neck, sides, and extremities, according to the +symptoms. They were useful in every stage of the disease. + +5. _Opiates._ These were given not only at night, but in small doses +during the day, when a troublesome cough or diarrh[oe]a attended. + +6. Where a catarrhal fever ensued, I used bleeding and blisters. In +those cases in which this fever terminated in an intermittent, or in a +mild typhus fever, I gave the bark with evident advantage. In that case +of measles, formerly mentioned, which was accompanied by symptoms of +cynanche trachealis, I gave calomel with the happiest effects. In the +admission of _fresh air_ I observed a medium as to its temperature, and +accommodated it to the degrees of action in the system. In different +parts of the country, in Pennsylvania and New-Jersey, I heard with great +pleasure of the _cold air_ being used as freely and as successfully in +this disease, as in the inflammatory small-pox. The same people who +were so much benefited by _cool air_, I was informed, drank plentifully +of cold water during every stage of the fever. One thing in favour of +this country practice deserves to be mentioned, and that is, evident +advantage arose in all the cases which I attended, from patients leaving +their beds in the febrile state of this disease. But this was practised +only by those in whom inflammatory diathesis prevailed, for these alone +had strength enough to bear it. + +The convalescent state of this disease required particular attention. + +1. _A diarrh[oe]a_ often continued to be troublesome after other +symptoms had abated. I relieved it by opiates and demulcent drinks. +Bleeding has been recommended for it, but I did not find it necessary in +a single case. + +2. An _opthalmia_ which sometimes attended, yielded to astringent +collyria and blisters. + +3. Where a cough or fever followed so slight as not to require bleeding, +I advised a milk and vegetable diet, country air, and moderate warmth; +for whatever might have been the relation of the lungs in the beginning +of the disease to cold air, they were now evidently too much debilitated +to bear it. + +4. It is a common practice to prescribe purges after the measles. After +the asthenic state of this disease they certainly do harm. In all +cases, the effects of them may be better obviated by diet, full or low, +suitable clothing, and gentle exercise, or country air. I omitted them +in several cases, and no eruption or disease of any kind followed their +disuse. + +I shall only add to this account of the measles, that in several +families, I saw evident advantages from preparing the body for the +reception of the contagion, by means of a vegetable diet. + + + + + AN ACCOUNT + + OF + + _THE INFLUENZA_, + + AS IT APPEARED + + IN PHILADELPHIA, + + IN THE AUTUMN OF 1789, IN THE SPRING OF 1790, AND IN THE WINTER OF + 1791. + + +The latter end of the month of August, in the summer of 1789, was so +very cool that fires became agreeable. The month of September was cool, +dry, and pleasant. During the whole of this month, and for some days +before it began, and after it ended, there had been no rain. In the +beginning of October, a number of the members of the first congress, +that had assembled in New-York, under the present national government, +arrived in Philadelphia, much indisposed with colds. They ascribed +them to the fatigue and night air to which they had been exposed in +travelling in the public stages; but from the number of persons who +were affected, from the uniformity of their complaints, and from the +rapidity with which it spread through our city, it soon became evident +that it was the disease so well known of late years by the name of the +influenza. + +The symptoms which ushered in the disease were generally a hoarseness, +a sore throat, a sense of weariness, chills, and a fever. After the +disease was formed, it affected more or less the following parts of the +body. Many complained of acute pains in the _head_. These pains were +frequently fixed between the eye-balls, and, in three cases which came +under my notice, they were terminated by abscesses in the frontal sinus, +which discharged themselves through the nose. The pain, in one of these +cases, before the rupture of the abscess, was so exquisite, that my +patient informed me, that he felt as if he should lose his reason. Many +complained of a great itching in the _eye-lids_. In some, the eye-lids +were swelled. In others, a copious effusion of water took place from +the _eyes_; and in a few, there was a true ophthalmia. Many complained +of great pains in one _ear_, and some of pains in both _ears_. In some, +these pains terminated in abscesses, which discharged for some days +a bloody or purulent matter. In others, there was a swelling behind +each ear, without a suppuration.--_Sneezing_ was a universal symptom. +In some, it occurred not less than fifty times in a day. The matter +discharged from the nose was so acrid as to inflame the nostrils and +the upper lip, in such a manner as to bring on swellings, sores, and +scabs in many people. In some, the nose discharged drops, and in a +few, streams of blood, to the amount, in one case, of twenty ounces. +In many cases, it was so much obstructed, as to render breathing +through it difficult. In some, there was a total defect of _taste_. In +others, there was a bad taste in the mouth, which frequently continued +through the whole course of the disease. In some, there was a want of +_appetite_. In others, it was perfectly natural. Some complained of +a soreness in their mouths, as if they had been inflamed by holding +pepper in them. Some had _swelled jaws_, and many complained of the +_tooth-ach_. I saw only one case in which the disease produced a _coma_. + +Many were affected with pains in the _breast_ and _sides_. A difficulty +of breathing attended in some, and a _cough_ was universal. Sometimes +this cough alternated with a pain in the _head_. Sometimes it +preceded this pain, and sometimes it followed it. It was at all times +distressing. In some instances, it resembled the chin-cough. One person +expired in a fit of coughing, and many persons spat blood in consequence +of its violence. I saw several patients in whom the disease affected +the trachea chiefly, producing great difficulty of breathing, and, in +one case, a suppression of the voice, and I heard of another in which +the disease, by falling on the trachea, produced a cynanche trachealis. +In most of the cases which terminated fatally, the patients died of +pneumonia notha. + +The _stomach_ was sometimes affected by nausea and vomiting; but this +was far from being a universal symptom. + +I met with four cases in which the whole force of the disease fell upon +the _bowels_, and went off in a diarrh[oe]a; but in general the bowels +were regular or costive. + +The _limbs_ were affected with such acute pains as to be mistaken for +the rheumatism, or for the break-bone-fever of 1780. The pains were most +acute in the back and thighs. + +_Profuse sweats_ appeared in many over the whole body in the beginning, +but without affording any relief. It was in some instances accompanied +by erysipelatous, and in four cases which came to my knowledge, it was +followed by miliary eruptions. + +The _pulse_ was sometimes tense and quick, but seldom full. In a great +majority of those whom I visited it was quick, weak, and soft. + +There was no appearance in the urine different from what is common in +all fevers. + +The disease had evident remissions, and the fever seldom continued above +three or four days; but the cough, and some other troublesome symptoms, +sometimes continued two or three weeks. + +In a few persons, the fever terminated in a tedious and dangerous typhus. + +In several pregnant women it produced uterine hæmorrhages and abortions. + +It affected adults of both sexes alike. A few old people escaped it. It +passed by children under eight years old with a few exceptions. Out of +five and thirty maniacs in the Pennsylvania hospital, but three were +affected by it. No profession or occupation escaped it. The smell of +tar and tobacco did not preserve the persons who worked in them from +the disease, nor did the use of tobacco, in snuff, smoking, or chewing, +afford a security against it.[88] + + [88] Mr. Howard informs us that the use of tobacco is not a + preservative against the plague, as has formerly been supposed; + of course that apology for the use of an offensive weed should + not be admitted. + +Even previous and existing diseases did not protect patients from it. It +insinuated into sick chambers, and blended itself with every species of +chronic complaint. + +It was remarkable that persons who worked in the open air, such as +sailors, and 'long-shore-men, (to use a mercantile epithet) had it much +worse than tradesmen who worked within doors. A body of surveyors, in +the eastern woods of Pennsylvania, suffered extremely from it. Even the +vigour of constitution which is imparted by the savage life did not +mitigate its violence. Mr. Andrew Ellicott, the geographer of the United +States, informed me that he was a witness of its affecting the Indians +in the neighbourhood of Niagara with peculiar force. The cough which +attended this disease was so new and so irritating a complaint among +them, that they ascribed it to witchcraft. + +It proved most fatal on the sea-shore of the United States. + +Many people who had recovered, were affected a second time with all the +symptoms of the disease. I met with a woman, who, after recovering from +it in Philadelphia, took it a second time in New-York, and a third time +upon her return to Philadelphia. + +Many thousand people had the disease who were not confined to their +houses, but transacted business as usual out of doors. A perpetual +coughing was heard in every street of the city. Buying and selling were +rendered tedious by the coughing of the farmer and the citizen who met +in market places. It even rendered divine service scarcely intelligible +in the churches. + +A few persons who were exposed to the disease escaped it, and some had +it so lightly as scarcely to be sensible of it. Of the persons who were +confined to their houses, not a fourth part of them kept their beds. + +It proved fatal (with few exceptions) only to old people, and to +persons who had been previously debilitated by consumptive complaints. +It likewise carried of several hard drinkers. It terminated in asthma +in three persons whose cases came under my notice, and in pulmonary +consumption, in many more. I met with an instance in a lady, who was +much relieved of a chronic complaint in her liver; and I heard of +another instance of a clergyman whose general health was much improved +by a severe attack of this disease. + +It was not wholly confined to the human species. It affected two cats, +two house-dogs, and one horse, within the sphere of my observations. One +of the dogs disturbed his mistress so much by coughing at night, that +she gave him ten drops of laudanum for several nights, which perfectly +composed him. One of the cats had a vomiting with her cough. The horse +breathed as if he had been affected by the cynanche trachealis. + +The scarlatina anginosa, which prevailed during the summer, disappeared +after the first of October; but appeared again after the influenza left +the city. Nor was the remitting fever seen during the prevalence of the +reigning epidemic. + +I inoculated about twenty children for the small-pox during this +prevalence of the influenza, and never saw that disease exhibit a more +favourable appearance. + +In the treatment of the influenza I was governed by the state of the +system. Where inflammatory diathesis discovered itself by a full or +tense pulse, or where great difficulty of breathing occurred, and the +pulse was low and weak in the beginning of the disease, I ordered +moderate bleeding. In a few cases in which the symptoms of pneumony +attended, I bled a second time with advantage. In all these instances +of inflammatory affection, I gave the usual antiphlogistic medicines. +I found that vomits did not terminate the disease, as they often do a +common catarrh, in the course of a day, or of a few hours. + +In cases where no inflammatory action appeared in the system, I +prescribed cordial drinks and diet, and forbad every kind of evacuation. +I saw several instances of persons who had languished for a week or two +with the disease, who were suddenly cured by eating a hearty meal, or +by drinking half a pint of wine, or a pint of warm punch. In all these +cases of weak action in the blood-vessels, liquid laudanum gave great +relief, not only by suspending the cough, but by easing the pains in the +bones. + +I met with a case of an old lady who was suddenly and perfectly cured of +her cough by a fright. + +The duration of this epidemic in our city was about six weeks. It spread +from New-York and Philadelphia in all directions, and in the course of +a few months pervaded every state in the union. It was carried from the +United States to several of the West-India islands. It prevailed in +the island of Grenada in the month of November, 1789, and it was heard +of in the course of the ensuing winter in the Spanish settlements in +South-America. + +The following winter was unusually mild, insomuch that the navigation +of the Delaware was not interrupted during the whole season, only from +the 7th to the 24th of February. The weather on the 3d and 4th days of +March was very cold, and on the 8th and 9th days of the same month, +the mercury in Fahrenheit's thermometer stood at 4° at 7 o'clock in +the morning. On the 10th and 11th, there fell a deep snow. The weather +during the remaining part of the month was cold, rainy, and variable. It +continued to be variable during the month of April. About the middle of +the month there fell an unusual quantity of rain. The showers which fell +on the night of the 17th will long be connected in the memories of the +citizens of Philadelphia with the time of the death of the celebrated +Dr. Franklin. Several pleurisies appeared during this month; also a few +cases of measles. In the last week of the month the influenza made its +appearance. It was brought to the city from New-England, and affected, +in its course, all the intermediate states. Its symptoms were nearly the +same as they were in the preceding autumn, but in many people it put +on some new appearances. Several persons who were affected by it had +symptoms of madness, one of whom destroyed himself by jumping out of a +window. Some had no cough, but very acute pains in the back and head. +It was remarked that those who had the disease chiefly in the breast +the last year, complained now chiefly of their heads, while those whose +heads were affected formerly, now complained chiefly of their breasts. +In many it put on the type of an intermitting fever. Several complained +of constant chills, or constant sweats; and some were much alarmed by +an uncommon blue and dark colour in their hands. I saw one case of +ischuria, another of an acute pain in the rectum, a third of anasarca, +and a fourth of a palsy in the tongue and arms; all of which appeared +to be anomalous symptoms of the influenza. Sneezing, and pains in the +ears and frontal sinus, were less common now than they were in the +fall; but a pain in the eye-balls was a universal symptom. Some had a +pain in the one eye only, and a few had sore eyes, and swellings in the +face. Many women who had it, were affected by an irregular appearance +of the catamenia. In two persons whom I saw, the cough was incessant +for three days, nor could it be composed by any other remedy than +plentiful bleeding. A patient of Dr. Samuel Duffield informed me, after +his recovery, that he had had no other symptom of the disease than an +efflorescence on his skin, and a large swelling in his groin, which +terminated in a tedious abscess. + +The prisoners in the jail who had it in the autumn, escaped it this +spring. + +During the prevalence of this disease, I saw no sign of any other +epidemic. + +It declined sensibly about the first week in June, and after the 12th +day of this month I was not called to a single patient in it. + +The remedies for it were the same as were used in the fall. + +I used bleeding in several cases on the second, third, and fourth days +of the disease, where it had appeared to be improper in its first stage. +The cases which required bleeding were far from being general. I saw two +instances of syncope of an alarming nature, after the loss of ten ounces +of blood; and I heard of one instance of a boy who died in half an hour +after this evacuation. + +I remarked that purges of all kinds worked more violently than usual in +this disease. + +The convalescence from it was very slow, and a general languor appeared +to pervade the citizens for several weeks after it left the city. + +The month of December, 1790, was extremely and uniformly cold. In the +beginning of the month of January, 1791, the weather moderated, and +continued to be pleasant till the 17th, on which day the navigation +of the Delaware, which had been completely obstructed by the ice, +was opened so as to admit of the arrival of several vessels. During +the month of December many people complained of _colds_; but they +were ascribed wholly to the weather. In January four or five persons +in a family were affected by colds at the same time; which created +a suspicion of a return of the influenza. This suspicion was soon +confirmed by accounts of its prevailing in the neighbouring counties of +Chester and Montgomery, in Pennsylvania, and in the distant states of +Virginia and Rhode-Island. It did not affect near so generally as in the +two former times of appearance. There was no difference in the method of +treating it. While the common inflammatory diseases of the winter bore +the lancet as usual, it was remarked that patients who were attacked by +the influenza, did not bear bleeding in a greater proportion, or in a +larger quantity, than in the two former times of its appearance in the +city. + +I shall conclude this account of the influenza by the following +observations: + +1. It exists independently of the sensible qualities of the air, and in +all kinds of weather. Dr. Patrick Russel has proved the plague to be +equally independent of the influence of the sensible qualities of the +atmosphere, to a certain degree. + +2. The influenza passes with the utmost rapidity through a country, and +affects the greatest number of people, in a given time, of any disease +in the world. + +3. It appears from the histories of it which are upon record, that +neither climate, nor the different states of society, have produced any +_material_ change in the disease. This will appear from comparing the +account I have given, with the histories of it which have lately been +given by Dr. Grey, Dr. Hamilton, Dr. A. Fothergill, Mr. Chisholm, and +other modern physicians. It appears further, that even time itself has +not been able materially to change the type of this disease. This is +evident, from comparing modern accounts of it with those which have been +handed down to us by ancient physicians. + +I have hinted in a former essay at the _diminutives_ of certain +diseases. There is a state of influenza, which is less violent and more +local, than that which has been described. It generally prevails in the +winter season. It seems to originate from a morbid matter, generated +in crowded and heated churches, and other assemblies of the people. I +have seen a cold, or influenza, frequently universal in Philadelphia, +which I have distinctly traced to this source. It would seem as if the +same species of diseases resembled pictures, and that while some of them +partook of the deep and vivid nature of mosaic work, others appeared +like the feeble and transient impressions of water colours. + + + + + AN INQUIRY + + INTO THE + + _CAUSE OF ANIMAL LIFE_. + + IN THREE LECTURES, + + DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. + + LECTURE I. + + +GENTLEMEN, + +My business in this chair is to teach the institutes of medicine. They +have been divided into physiology, pathology, and therapeutics. The +objects of the first are, the laws of the human body in its healthy +state. The second includes the history of the causes and seats of +diseases. The subjects of the third are the remedies for those diseases. +In entering upon the first part of our course, I am met by a remark +delivered by Dr. Hunter in his introductory lectures to his course of +anatomy. "In our branch (says the doctor) those teachers who study to +captivate young minds with ingenious speculations, will not leave a +reputation behind them that will outlive them half a century. When they +cease from their labours, their labours will be buried along with them. +There never was a man more followed and admired in physiology, than Dr. +Boerhaave. I remember the veneration in which he was held. And now, in +the space of forty years, his physiology is---- it shocks me to think in +what a light it appears[89]." Painful as this premonition may be to the +teachers of physiology, it should not deter them from speculating upon +physiological subjects. Simple anatomy is a mass of dead matter. It is +physiology which infuses life into it. A knowledge of the structure of +the human body occupies only the memory. Physiology introduces it to the +higher and more noble faculties of the mind. The component parts of the +body may be compared to the materials of a house, lying without order +in a yard. It is physiology, like a skilful architect, which connects +them together, so as to form from them an elegant and useful building. +The writers against physiology resemble, in one particular, the writers +against luxury. They forget that the functions they know and describe +belong to the science of physiology; just as the declaimers against +luxury forget that all the conveniences which they enjoy beyond what are +possessed in the most simple stage of society, belong to the luxuries of +life. The anatomist who describes the circulation of the blood, acts +the part of a physiologist, as much as he does, who attempts to explain +the functions of the brain. In this respect Dr. Hunter did honour to +our science; for few men ever explained that subject, and many others +equally physiological, with more perspicuity and eloquence, than that +illustrious anatomist. Upon all new and difficult subjects there must +be pioneers. It has been my lot to be called to this office of hazard +and drudgery; and if in discharging its duties I should meet the fate +of my predecessors, in this branch of medicine, I shall not perish in +vain. My errors, like the bodies of those who fall in forcing a breach, +will serve to compose a bridge for those who shall come after me, in +our present difficult enterprise. This consideration, aided by just +views of the nature and extent of moral obligation, will overbalance the +evils anticipated by Dr. Hunter, from the loss of posthumous fame. Had +a prophetic voice whispered in the ear of Dr. Boerhaave in the evening +of his life, that in the short period of forty years, the memory of +his physiological works would perish from the earth, I am satisfied, +from the knowledge we have of his elevated genius and piety, he would +have treated the prediction with the same indifference that he would +have done, had he been told, that in the same time, his name should be +erased from a pane of glass, in a noisy and vulgar country tavern. + + [89] Lect. xi. p. 198. + +The subjects of the lectures I am about to deliver, you will find in a +syllabus which I have prepared and published, for the purpose of giving +you a succinct view of the extent and connection of our course. Some of +these subjects will be new in lectures upon the institutes of medicine, +particularly those which relate to morals, metaphysics, and theology. +However thorny these questions may appear, we must approach and handle +them; for they are intimately connected with the history of the +faculties and operations of the human mind; and these form an essential +part of the animal economy. Perhaps it is because physicians have +hitherto been restrained from investigating, and deciding upon these +subjects, by an erroneous belief that they belong exclusively to another +profession, that physiology has so long been an obscure and conjectural +science. + +In beholding the human body, the first thing that strikes us, is its +_life_. This, of course, should be the first object of our inquiries. +It is a most important subject; for the end of all the studies of a +physician is to preserve life; and this cannot be perfectly done, until +we know in what it consists. + +I include in animal life, as applied to the human body, _motion_, +_sensation_, and _thought_. These three, when united, compose perfect +life. It may exist without thought, or sensation; but neither sensation, +nor thought, can exist without motion. The lowest grade of life, +probably exists in the absence of even motion, as I shall mention +hereafter. I have preferred the term _motion_ to those of oscillation +and vibration, which have been employed by Dr. Hartley in explaining the +laws of animal matter; because I conceived it to be more simple, and +better adapted to common apprehension. + +In treating upon this subject, I shall first consider animal life as it +appears in the waking and sleeping states in a healthy adult, and shall +afterwards inquire into the modification of its causes in the f[oe]tal, +infant, youthful, and middle states of life, in certain diseases, in +different states of society, in different climates, and in different +animals. + +I shall begin by delivering three general propositions. + +I. Every part of the human body (the nails and hair excepted) is endowed +with sensibility, or excitability, or with both of them. By sensibility +is meant the power of having sensation excited by the action of +impressions. Excitability denotes that property in the human body, by +which motion is excited by means of impressions. This property has been +called by several other names, such as irritability, contractility, +mobility, and stimulability. + +I shall make use of the term excitability, for the most part, in +preference to any of them. I mean by it, a capacity of imperceptible, +as well as obvious motion. It is of no consequence to our present +inquiries, whether this excitability be a quality of animal matter, or a +substance. The latter opinion has been maintained by Dr. Girtanner, and +has some probability in its favour. + +II. The whole human body is so formed and connected, that impressions +made in the healthy state upon one part, excite motion, or sensation, +or both, in every other part of the body. From this view, it appears +to be a unit, or a simple and indivisible quality, or substance. Its +capacity for receiving motion, and sensation, is variously modified by +means of what are called the senses. It is external, and internal. The +impressions which act upon it shall be ennumerated in order. + +III. Life is the _effect_ of certain stimuli acting upon the sensibility +and excitability which are extended, in different degrees, over every +external and internal part of the body. These stimuli are as necessary +to its existence, as air is to flame. Animal life is truly (to use the +words of Dr. Brown) "a forced state." I have said the _words_ of Dr. +Brown; for the opinion was delivered by Dr. Cullen in the university of +Edinburgh, in the year 1766, and was detailed by me in this school, many +years before the name of Dr. Brown was known as teacher of medicine. +It is true, Dr. Cullen afterwards deserted it; but it is equally true, +I never did; and the belief of it has been the foundation of many of +the principles and modes of practice in medicine which I have since +adopted. In a lecture which I delivered in the year 1771, I find the +following words, which are taken from a manuscript copy of lectures +given by Dr. Cullen upon the institutes of medicine. "The human body +is not an automaton, or self-moving machine; but is kept alive and in +motion, by the constant action of stimuli upon it." In thus ascribing +the discovery of the cause of life which I shall endeavour to establish, +to Dr. Cullen, let it not be supposed I mean to detract from the genius +and merit of Dr. Brown. To his intrepidity in reviving and propagating +it, as well as for the many other truths contained in his system of +medicine, posterity, I have no doubt, will do him ample justice, after +the errors that are blended with them have been corrected, by their +unsuccessful application to the cure of diseases. + +Agreeably to our last proposition, I proceed to remark, that the action +of the brain, the diastole and systole of the heart, the pulsation of +the arteries, the contraction of the muscles, the peristaltic motion of +the bowels, the absorbing power of the lymphatics, secretion, excretion, +hearing, seeing, smelling, taste, and the sense of touch, nay more, +thought itself, are all the effects of stimuli acting upon the organs +of sense and motion. These stimuli have been divided into external and +internal. The external are light, sound, odours, air, heat, exercise, +and the pleasures of the senses. The internal stimuli are food, drinks, +chyle, the blood, a certain tension of the glands, which contain +secreted liquors, and the exercises of the faculties of the mind; each +of which I shall treat in the order in which they have been mentioned. + +1. Of external stimuli. The first of these is light. It is remarkable +that the progenitor of the human race was not brought into existence +until all the luminaries of heaven were created. Light acts chiefly +through the medium of the organs of vision. Its influence upon animal +life is feeble, compared with some other stimuli to be mentioned +hereafter; but it has its proportion of force. Sleep has been said +to be a tendency to death; now the absence of light we know invites +to sleep, and the return of it excites the waking state. The late Mr. +Rittenhouse informed me, that for many years he had constantly awoke +with the first dawn of the morning light, both in summer and winter. Its +influence upon the animal spirits strongly demonstrates its connection +with animal life, and hence we find a cheerful and a depressed state of +mind in many people, and more especially in invalids, to be intimately +connected with the presence or absence of the rays of the sun. The +well-known pedestrian traveller, Mr. Stewart, in one of his visits to +this city, informed me, that he had spent a summer in Lapland, in the +latitude of 69°, during the greatest part of which time the sun was +seldom out of sight. He enjoyed, he said, during this period, uncommon +health and spirits, both of which he ascribed to the long duration, and +invigorating influence of light. These facts will surprise us less when +we attend to the effects of light upon vegetables. Some of them lose +their colour by being deprived of it; many of them discover a partiality +to it in the direction of their flowers; and all of them discharge their +pure air only while they are exposed to it[90]. + + [90] "Organization, sensation, spontaneous motion, and life, exist + only at the surface of the earth, and in places exposed to + _light_. We might affirm the flame of Prometheus's torch was + the expression of a philosophical truth that did not escape + the ancients. Without light, nature was lifeless, inanimate, + and dead. A benevolent God, by producing life, has spread + organization, sensation, and thought over the surface of the + earth."--_Lavoisier._ + +2. Sound has an extensive influence upon human life. Its numerous +artificial and natural sources need not be mentioned. I shall only take +notice, that the currents of winds, the passage of insects through +the air, and even the growth of vegetables, are all attended with an +emission of sound; and although they become imperceptible from habit, +yet there is reason to believe they all act upon the body, through +the medium of the ears. The existence of these sounds is established +by the reports of persons who have ascended two or three miles from +the earth in a balloon. They tell us that the silence which prevails +in those regions of the air is so new and complete, as to produce an +awful solemnity in their minds. It is not necessary that these sounds +should excite sensation or perception, in order to their exerting a +degree of stimulus upon the body. There are a hundred impressions +daily made upon it, which from habit are not followed by sensation. +The stimulus of aliment upon the stomach, and of blood upon the heart +and arteries, probably cease to be felt, only from the influence of +habit. The exercise of walking, which was originally the result of a +deliberate act of the will, is performed from habit without the least +degree of consciousness. It is unfortunate for this, and many other +parts of physiology, that we forget what passed in our minds the first +two or three years of our lives. Could we recollect the manner in +which we acquired our first ideas, and the progress of our knowledge +with the evolution of our senses and faculties, it would relieve us +from many difficulties and controversies upon this subject. Perhaps +this forgetfulness by children, of the origin and progress of their +knowledge, might be remedied by our attending more closely to the +first effects of impressions, sensation, and perception upon them, +as discovered by their little actions; all of which probably have a +meaning, as determined as any of the actions of men or women. + +The influence of sounds of a certain kind in producing excitement, and +thereby increasing life, cannot be denied. Fear produces debility, which +is a tendency to death. Sound obviates this debility, and thus restores +the system to the natural and healthy grade of life. The school-boy and +the clown invigorate their feeble and trembling limbs by whistling or +singing as they pass by a country church-yard, and the soldier feels +his departing life recalled in the onset of a battle by the noise +of the fife, and of the poet's "spirit stirring drum." Intoxication +is frequently attended with a higher degree of life than is natural. +Now sound we know will produce this with a very moderate portion of +fermented liquor; hence we find men are more easily and highly excited +by it at public entertainments where there is music, loud talking, +and hallooing, than in private companies where there is no auxiliary +stimulus added to that of the wine. I wish these effects of sound upon +animal life to be remembered; for I shall mention it hereafter as a +remedy for the weak state of life in many diseases, and shall relate +an instance in which a scream suddenly extorted by grief, proved the +means of resuscitating a person who was supposed to be dead, and who had +exhibited the usual recent marks of the extinction of life. + +I shall conclude this head by remarking, that persons who are destitute +of hearing and seeing possess life in a more languid state than other +people; and hence arise the dulness and want of spirits which they +discover in their intercourse with the world. + +3. Odours have a sensible effect in promoting animal life. The greater +healthiness of the country, than cities, is derived in part from the +effluvia of odoriferous plants, which float in the atmosphere in the +spring and summer months, acting upon the system, through the medium of +the sense of smelling. The effects of odours upon animal life appear +still more obvious in the sudden revival of it, which they produce in +cases of fainting. Here the smell of a few drops of hartshorn, or even +of a burnt feather, has frequently in a few minutes restored the system, +from a state of weakness bordering upon death, to an equable and regular +degree of excitement. + +4. Air acts as a powerful stimulus upon the system, through the medium +of the lungs. The component parts of this fluid, and its decomposition +in the lungs, will be considered in another place[91]. I shall only +remark here, that the circulation of the blood has been ascribed, by +Dr. Goodwin, exclusively to the action of air upon the lungs and heart. +Does the external air act upon any other part of the body besides those +which have been mentioned? It is probable it does, and that we lose +our sensation and consciousness of it by habit. It is certain children +cry, for the most part, as soon as they come into the world. May not +this be the effect of the sudden impression of air upon the tender +surface of their bodies? And may not the red colour of their skins be +occasioned by an irritation excited on them by the stimulus of the air? +It is certain it acts powerfully upon denudated animal fibres; for +who has not observed a sore, and even the skin when deprived of its +cuticle, to be affected, when long exposed to the air, with pain and +inflammation? The stimulus of air, in promoting the natural actions of +the alimentary canal, cannot be doubted. A certain portion of it seems +to be necessarily present in the bowels in a healthy state. + + [91] It is probable, the first impulse of life was imparted to the body + of Adam by the decomposition of air in his lungs. I infer this + from the account given by Moses of his creation, in Genesis, + chap. ii. v. 7. "And the Lord God formed man of the dust of the + ground, and breathed into his nostrils the breath of life," in + consequence of which, the verse adds, he became "a living soul." + This explanation of the origin of life in the father of the human + race, appears to accord more with reason, as well as the order + of the words which describe it, than the common opinion of his + having been animated by the infusion of a living soul into his + body. + +5. Heat is a uniform and active stimulus in promoting life. It is +derived, in certain seasons and countries, in part from the sun; but its +principal source is from the lungs, in which it appears to be generated +by the decomposition of pure air, and from whence it is conveyed, by +means of the circulation, to every part of the body. The extensive +influence of heat upon animal life, is evident from its decay and +suspension during the winter in certain animals, and from its revival +upon the approach and action of the vernal sun. It is true, life is +diminished much less in man, from the distance and absence of the sun, +than in other animals; but this must be ascribed to his possessing +reason in so high a degree, as to enable him to supply the abstraction +of heat, by the action of other stimuli upon his system. + +6. Exercise acts as a stimulus upon the body in various ways. Its first +impression is upon the muscles. These act upon the blood-vessels, and +they upon the nerves and brain. The necessity of exercise to animal life +is indicated, by its being kindly imposed upon man in paradise. The +change which the human body underwent by the fall, rendered the same +salutary stimulus necessary to its life, in the more active form of +labour. But we are not to suppose, that motion is excited in the body by +exercise or labour alone. It is constantly stimulated by the positions +of standing, sitting, and lying upon the sides; all of which act more or +less upon muscular fibres, and by their means, upon every part of the +system. + +7. The pleasures we derive from our senses have a powerful and extensive +influence upon human life. The number of these pleasures, and their +proximate cause, will form an agreeable subject for two or three future +lectures. + +We proceed next to consider the internal stimuli which produce animal +life. These are + +I. FOOD. This acts in the following ways. 1. Upon the tongue. Such are +the sensibility and excitability of this organ, and so intimate is its +connection with every other part of the body, that the whole system is +invigorated by aliment, as soon as it comes in contact with it. 2. By +mastication. This moves a number of muscles and blood-vessels situated +near the brain and heart, and of course imparts impressions to them. +3. By deglutition, which acts upon similar parts, and with the same +effect. 4. By its presence in the stomach, in which it acts by its +quantity and quality. Food, by distending the stomach, stimulates the +contiguous parts of the body. A moderate degree of distention of the +stomach and bowels is essential to a healthy excitement of the system. +Vegetable aliment and drinks, which contain less nourishment than animal +food, serve this purpose in the human body. Hay acts in the same manner +in a horse. Sixteen pounds of this light food in a day are necessary +to keep up such a degree of distension in the stomach and bowels of +this animal, as to impart to him his natural grade of strength and +life. The _quality_ of food, when of a stimulating nature, supplies +the place of its distension from its quantity. A single onion will +support a lounging highlander on the hills of Scotland for four and +twenty hours. A moderate quantity of salted meat, or a few ounces of +sugar, have supplied the place of pounds of less stimulating food. Even +indigestible substances, which remain for days, or perhaps weeks in the +stomach, exert a stimulus there which has an influence upon animal life. +It is in this way the tops of briars, and the twigs of trees, devoid +not only of nourishing matter, but of juices, support the camel in his +journies through the deserts of the eastern countries. Chips of cedar +posts moistened with water have supported horses for two or three weeks, +during a long voyage from Boston to Surinam; and the indigestible cover +of an old Bible preserved the life of a dog, accidentally confined in +a room at Newcastle upon Tyne, for twenty days. 5. Food stimulates the +whole body by means of the process of digestion which goes forward in +the stomach. This animal function is carried on by a process, in which +there is probably an extrication of heat and air. Now both these, it +has been remarked, exert a stimulus in promoting animal life. + +Drinks, when they consist of fermented or distilled liquors, stimulate +from their quality; but when they consist of water, either in its simple +state, or impregnated with any sapid substance, they act principally by +distention. + +II. The chyle acts upon the lacteals, mesenteric glands, and thoracic +duct, in its passage through them; and it is highly probable, its first +mixture with the blood in the subclavian vein, and its first action on +the heart, are attended with considerable stimulating effects. + +III. The blood is a very important internal stimulus. It has been +disputed whether it acts by its quality, or only by distending the +blood-vessels. It appears to act in both ways. I believe with Dr. +Whytt, that the blood stimulates the heart and arteries by a specific +action. But if this be not admitted, its influence in extending the +blood-vessels in every part of the body, and thereby imparting extensive +and uniform impressions to every animal fibre, cannot be denied. In +support of this assertion it has been remarked, that in those persons +who die of hunger, there is no diminution of the quantity of blood in +the large blood-vessels. + +IV. A certain _tension_ of the glands, and of other parts of the body, +contributes to support animal life. This is evident in the vigour which +is imparted to the system, by the fulness of the seminal vesicles and +gall bladder, and by the distension of the uterus in pregnancy. This +distension is so great, in some instances, as to prevent sleep for many +days and even weeks before delivery. It serves the valuable purpose of +rendering the female system less liable to death during its continuance, +than at any other time. By increasing the quantity of life in the body, +it often suspends the fatal issue of pulmonary consumption, and ensures +a temporary victory over the plague and other malignant fevers; for +death, from those diseases, seldom takes place, until the stimulus, from +the distension of the uterus, is removed by parturition. + +V. The exercises of the faculties of the mind have a wonderful influence +in increasing the quantity of human life. They all act by _reflection_ +only, after having been previously excited into action by impressions +made upon the body. This view of the _re-action_ of the mind upon the +body accords with the simplicity of other operations in the animal +economy. It is thus the brain repays the heart for the blood it conveys +to it, by re-acting upon its muscular fibres. The influence of the +different faculties of the mind is felt in the pulse, in the stomach, +and in the liver, and is seen in the face, and other external parts of +the body. Those which act most unequivocally in promoting life are the +understanding, the imagination, and the passions. Thinking belongs to +the understanding, and is attended with an obvious influence upon the +degree and duration of life. Intense study has often rendered the body +insensible to the debilitating effects of cold and hunger. Men of great +and active understandings, who blend with their studies temperance and +exercise, are generally long lived. In support of this assertion, a +hundred names might be added to those of Newton and Franklin. Its truth +will be more fully established by attending to the state of human life +in persons of an opposite intellectual character. The cretins, a race +of idiots in Valais, in Switzerland, travellers tell us, are all short +lived. Common language justifies the opinion of the stimulus of the +understanding upon the brain: hence it is common to say of dull men, +that they have scarcely ideas enough to keep themselves awake. + +The imagination acts with great force upon the body, whether its +numerous associations produce pleasure or pain. But the passions pour +a constant stream upon the wheels of life. They have been subdivided +into emotions and passions properly so called. The former have for their +objects present, the latter, future good and evil. All the objects of +the passions are accompanied with desire or aversion. To the former +belong chiefly, hope, love, ambition, and avarice; to the latter, +fear, hatred, malice, envy, and the like. Joy, anger, and terror, +belong to the class of emotions. The passions and emotions have been +further divided into stimulating and sedative. Our business at present +is to consider their first effect only upon the body. In the original +constitution of human nature, we were made to be stimulated by such +passions and emotions only as have moral good for their objects. Man +was designed to be always under the influence of hope, love, and joy. +By the loss of his innocence, he has subjected himself to the dominion +of passions and emotions of a malignant nature; but they possess, in +common with such as are good, a stimulus which renders them subservient +to the purpose of promoting animal life. It is true, they are like the +stimulus of a dislocated bone in their operation upon the body, compared +with the action of antagonist muscles stretched over bones, which +gently move in their natural sockets. The effects of the good passions +and emotions, in promoting health and longevity, have been taken notice +of by many writers. They produce a flame, gentle and pleasant, like oil +perfumed with frankincense in the lamp of life. There are instances +likewise of persons who have derived strength and long life from the +influence of the evil passions and emotions that have been mentioned. +Dr. Darwin relates the history of a man, who used to overcome the +fatigue induced by travelling, by thinking of a person whom he hated. +The debility induced by disease is often removed by a sudden change in +the temper. This is so common, that even nurses predict a recovery in +persons as soon as they become peevish and ill-natured, after having +been patient during the worst stage of their sickness. This peevishness +acts as a gentle stimulus upon the system in its languid state, and +thus turns the scale in favour of life and health. The famous Benjamin +Lay, of this state, who lived to be eighty years of age, was of a very +irascible temper. Old Elwes was a prodigy of avarice, and every court in +Europe furnishes instances of men who have attained to extreme old age, +who have lived constantly under the dominion of ambition. In the course +of a long inquiry which I instituted some years ago into the state +of the body and mind in old people, I did not find a single person +above eighty, who had not possessed an active understanding, or active +passions. Those different and opposite faculties of the mind, when in +excess, happily supply the place of each other. Where they unite their +forces, they extinguish the flame of life, before the oil which feeds it +is consumed. + +In another place I shall resume the influence of the faculties of the +mind upon human life, as they discover themselves in the different +pursuits of men. + +I have only to add here, that I see no occasion to admit, with the +followers of Dr. Brown, that the mind is active in sleep, in preserving +the motions of life. I hope to establish hereafter the opinion of Mr. +Locke, that the mind is always passive in sound sleep. It is true it +acts in dreams; but these depend upon a morbid state of the brain, and +therefore do not belong to the present stage of our subject, for I am +now considering animal life only in the healthy state of the body. I +shall say presently, that dreams are intended to supply the absence of +some natural stimulus, and hence we find they occur in those persons +most commonly, in whom there is a want of healthy action in the system, +induced by the excess or deficiency of customary stimuli. + +Life is in a languid state in the morning. It acquires vigour by the +gradual and successive application of stimuli in the forenoon. It is +in its most perfect state about mid-day, and remains stationary for +some hours. From the diminution of the sensibility and contractility +of the system to the action of impressions, it lessens in the evening, +and becomes again languid at bed-time. These facts will admit of an +extensive application hereafter in our lectures upon the practice of +physic. + + + LECTURE II. + +GENTLEMEN, + +The stimuli which have been enumerated, when they act collectively, and +within certain bounds, produce a healthy waking state. But they do not +always act collectively, nor in the determined and regular manner that +has been described. There is, in many states of the system, a deficiency +of some stimuli, and, in some of its states, an apparent absence of +them all. To account for the continuance of animal life under such +circumstances, two things must be premised, before we proceed to take +notice of the diminution or absence of the stimuli which support it. + +1. The healthy actions of the body in the waking state consist in a +proper degree of what has been called excitability and excitement. The +former is the medium on which stimuli act in producing the latter. In +an exact proportion, and a due relation of both, diffused uniformly +throughout every part of the body, consists good health. Disease is +the reverse of this. It depends _in part_ upon a disproportion between +excitement and excitability, and in a partial distribution of each of +them. In thus distinguishing the different states of excitement and +excitability in health and sickness, you see I dissent from Dr. Brown, +who supposes them to be (though disproportioned to each other) equably +diffused in the morbid, as well as the healthy state of the body. + +2. It is a law of the system, that the absence of one natural stimulus +is generally supplied by the increased action of others. This is more +certainly the case where a natural stimulus is abstracted _suddenly_; +for the excitability is thereby so instantly formed and accumulated, +as to furnish a highly sensible and moveable surface for the remaining +stimuli to act upon. Many proofs might be adduced in support of this +proposition. The reduction of the excitement of the blood-vessels, by +means of cold, prepares the way for a full meal, or a warm bed, to +excite in them the morbid actions which take place in a pleurisy or a +rheumatism. A horse in a cold stable eats more than in a warm one, and +thus counteracts the debility which would otherwise be induced upon his +system, by the abstraction of the stimulus of warm air. + +These two propositions being admitted, I proceed next to inquire into +the different degrees and states of animal life. The first departure +from its ordinary and perfect state which strikes us, is in + +I. Sleep. This is either natural or artificial. Natural sleep is induced +by a diminution of the excitement and excitability of the system, by +the continued application of the stimuli which act upon the body in +its waking state. When these stimuli act in a determined degree, that +is, when the same number of stimuli act with the same force, and for +the same time, upon the system, sleep will be brought on at the same +hour every night. But when they act with uncommon force, or for an +unusual time, it is brought on at an earlier hour. Thus a long walk +or ride, by persons accustomed to a sedentary life, unusual exercise +of the understanding, the action of strong passions or emotions, and +the continual application of unusual sounds seldom fail of inducing +premature sleep. It is recorded of pope Ganganelli, that he slept more +soundly, and longer than usual, the night after he was raised to the +papal chair. The effects of unusual sounds in bringing on premature +sleep, is further demonstrated by that constant inclination to retire +to bed at an early hour, which country people discover the first and +second days they spend in a city, exposed from morning till night to the +noise of hammers, files, and looms, or of drays, carts, waggons, and +coaches, rattling over pavements of stone. Sleep is further hastened +by the absence of light, the cessation of sounds and labour, and the +recumbent posture of the body on a soft bed. + +Artificial sleep may be induced at any time by certain stimulating +substances, particularly by opium. They act by carrying the system +beyond the healthy grade of excitement, to a degree of indirect +debility, which Dr. Brown has happily called the sleeping point. The +same point may be induced in the system at any time by the artificial +abstraction of the usual stimuli of life. For example, let a person shut +himself up at mid-day in a dark room, remote from noise of all kinds, +let him lie down upon his back upon a soft bed in a temperate state of +the atmosphere, and let him cease to think upon interesting subjects, +or let him think only upon one subject, and he will soon fall asleep. +Dr. Boerhaave relates an instance of a Dutch physician, who, having +persuaded himself that waking was a violent state, and sleep the only +natural one of the system, contrived, by abstracting every kind of +stimulus in the manner that has been mentioned, to sleep away whole +days and nights, until at length he impaired his understanding, and +finally perished in a public hospital in a state of idiotism. + +In thus anticipating a view of the cause of sleep, I have said nothing +of the effects of diseases of the brain in inducing it. These belong to +another part of our course. The short explanation I have given of its +cause was necessary in order to render the history of animal life, in +that state of the system, more intelligible. + +At the usual hour of sleep there is an abstraction of the stimuli of +light, sound, and muscular motion. The stimuli which remain, and act +with an increased force upon the body in sleep, are + +1. The heat which is discharged from the body, and confined by means of +bed-clothes. It is most perceptible when exhaled from a bed-fellow. Heat +obtained in this way has sometimes been employed to restore declining +life to the bodies of old people. Witness the damsel who lay for this +purpose in the bosom of the king of Israel. The advantage of this +external heat will appear further, when we consider how impracticable +or imperfect sleep is, when we lie under too light covering in cold +weather. + +2. The air which is applied to the lungs during sleep probably acts with +more force than in the waking state. I am disposed to believe that more +air is phlogisticated in sleep than at any other time, for the smell of +a close room in which a person has slept one night, we know, is much +more disagreeable than that of a room, under equal circumstances, in +which half a dozen people have sat for the same number of hours in the +day time. The action of decomposed air on the lungs and heart was spoken +of in a former lecture. An increase in its quantity must necessarily +have a powerful influence upon animal life during the sleeping state. + +3. Respiration is performed with a greater extension and contraction +of the muscles of the breast in sleep than in the waking state; and +this cannot fail of increasing the impetus of the blood in its passage +through the heart and blood-vessels. The increase of the fulness and +force of the pulse in sleep, is probably owing in part to the action +of respiration upon it. In another place I hope to elevate the rank of +the blood-vessels in the animal economy, by showing that they are the +fountains of power in the body. They derive this pre-eminence from the +protection and support they afford to every part of the system. They are +the perpetual centineals of health and life; for they never partake in +the repose which is enjoyed by the muscles and nerves. During sleep, +their sensibility seems to be converted into contractility, by which +means their muscular fibres are more easily moved by the blood than in +the waking state. The diminution of sensibility in sleep is proved by +many facts to be mentioned hereafter; and the change of sensibility into +contractility will appear, when we come to consider the state of animal +life in infancy and old age. + +4. Aliment in the stomach acts more powerfully in sleep than in the +waking state. This is evident from digestion going on more rapidly +when we are awake than when we sleep. The more slow the digestion, the +greater is the stimulus of the aliment in the stomach. Of this we have +many proofs in daily life. Labourers object to milk as a breakfast, +because it digests too soon; and often call for food in a morning, which +they can feel all day in their stomachs. Sausages, fat pork, and onions +are generally preferred by them for this purpose. A moderate supper is +favourable to easy and sound sleep; and the want of it, in persons who +are accustomed to that meal, is often followed by a restless night. The +absence of its stimulus is probably supplied by a full gall-bladder +(which always attends an empty stomach) in persons who are not in the +habit of eating suppers. + +5. The stimulus of the urine, accumulated in the bladder during +sleep, has a perceptible influence upon animal life. It is often so +considerable as to interrupt sleep; and it is one of the causes of our +waking at a regular hour in the morning. It is moreover a frequent cause +of the activity of the understanding and passions in dreams; and hence +we dream more in our morning slumbers, when the bladder is full, than we +do in the beginning or middle of the night. + +6. The fæces exert a constant stimulus upon the bowels in sleep. This +is so considerable as to render it less profound when they have been +accumulated for two or three days, or when they have been deposited in +the extremity of the alimentary canal. + +7. The partial and irregular exercises of the understanding and passions +in dreams have an occasional influence in promoting life. They occur +only where there is a deficiency of other stimuli. Such is the force +with which the mind acts upon the body in dreams, that Dr. Brambilla, +physician to the emperor of Germany, informs us, that he has seen +instances of wounds in soldiers being inflamed, and putting on a +gangrenous appearance in consequence of the commotions excited in their +bodies by irritating dreams[92]. The stimulating passions act through +the medium of the will; and the exercises of this faculty of the mind +sometimes extend so far as to produce actions in the muscles of the +limbs, and occasionally in the whole body, as we see in persons who walk +in their sleep. The stimulus of lust often awakens us with pleasure or +pain, according as we are disposed to respect or disobey the precepts +of our Maker. The angry and revengeful passions often deliver us, in +like manner, from the imaginary guilt of murder. Even the debilitating +passions of grief and fear produce an indirect operation upon the system +that is favourable to life in sleep, for they excite that distressing +disease called the night mare, which prompts us to speak, or halloo, and +by thus invigorating respiration, overcomes the languid circulation of +the blood in the heart and brain. Do not complain then, gentlemen, when +you are bestrode by this midnight hag. She is kindly sent to prevent +your sudden death. Persons who go to bed in good health, and are found +dead the succeeding morning, are said most commonly to die of this +disease. + + [92] A fever was excited in Cinna the poet, in consequence of his + dreaming that he saw Cæsar, the night after he was assassinated, + and was invited to accompany him to a dreary place, to which + he pointed, in order to sup with him. Convulsions and other + diseases, I believe, are often excited in the night, by + terrifying or distressing dreams. + _Plutarch's Life of M. Brutus._ + +I proceed now to inquire into the state of animal life in its different +stages. I pass over for the present its history in generation. It will +be sufficient only to remark in this place, that its first motion is +produced by the stimulus of the male seed upon the female ovum. This +opinion is not originally mine. You will find it in Dr. Haller[93]. The +pungent taste which Mr. John Hunter discovered in the male seed renders +it peculiarly fit for this purpose. No sooner is the female ovum thus +set in motion, and the f[oe]tus formed, than its capacity of life is +supported, + +1. By the stimulus of the heat which it derives from its connection with +its mother in the womb. + +2. By the stimulus of its own circulating blood. + +3. By its constant motion in the womb after the third month of +pregnancy. The absence of this motion for a few days is always a sign +of the indisposition or death of a f[oe]tus. Considering how early a +child is accustomed to it, it is strange that a cradle should ever have +been denied to it after it comes into the world. + + [93] "Novum f[oe]tum a seminis masculi _stimulo_ vitam + concepisse."--_Elementa Physiologiæ_, vol. viii. p. 177. + +II. In infants there is an absence of many of the stimuli which support +life. Their excretions are in a great measure deficient in acrimony, and +their mental faculties are too weak to exert much influence upon their +bodies. But the absence of stimulus from those causes is amply supplied + +1. By the very great excitability of their systems to those of light, +sound, heat, and air. So powerfully do light and sound act upon them, +that the Author of nature has kindly defended their eyes and ears from +an excess of their impressions by imperfect vision and hearing, for +several weeks after birth. The capacity of infants to be acted upon +by moderate degrees of heat is evident from their suffering less from +cold than grown people. This is so much the case, that we read, in Mr. +Umfreville's account of Hudson's Bay, of a child that was found alive +upon the back of its mother after she was frozen to death. I before +hinted at the action of the air upon the bodies of new-born infants in +producing the red colour of their skins. It is highly probable (from +a fact formerly mentioned) that the first impression of the atmosphere +which produces this redness is accompanied with pain, and this we know +is a stimulus of a very active nature. By a kind law of sensation, +impressions, that were originally painful, become pleasurable by +repetition or duration. This is remarkably evident in the impression now +under consideration, and hence we find infants at a certain age discover +signs of an increase of life by their delightful gestures, when they are +carried into the open air. Recollect further, gentlemen, what was said +formerly of excitability predominating over sensibility in infants. We +see it daily, not only in their patience of cold, but in the short time +in which they cease to complain of the injuries they meet with from +falls, cuts, and even severe surgical operations. + +2. Animal life is supported in infants by their sucking, or feeding, +nearly every hour in the day and night when they are awake. I explained +formerly the manner in which food stimulated the system. The action +of sucking supplies, by the muscles employed in it, the stimulus of +mastication. + +3. Laughing and crying, which are universal in infancy, have a +considerable influence in promoting animal life, by their action +upon respiration, and the circulation of the blood. Laughing exists +under all circumstances, independently of education or imitation. The +child of the negro slave, born only to inherit the toils and misery +of its parents, receives its master with a smile every time he enters +his kitchen or a negro-quarter. But laughing exists in infancy under +circumstances still more unfavourable to it; an instance of which is +related by Mr. Bruce. After a journey of several hundred miles across +the sands of Nubia, he came to a spring of water shaded by a few scrubby +trees. Here he intended to have rested during the night, but he had not +slept long before he was awakened by a noise which he perceived was made +by a solitary Arab, equally fatigued and half famished with himself, who +was preparing to murder and plunder him. Mr. Bruce rushed upon him, and +made him his prisoner. The next morning he was joined by a half-starved +female companion, with an infant of six months old in her arms. In +passing by this child, Mr. Bruce says, it laughed and crowed in his +face, and attempted to leap upon him. From this fact it would seem as +if laughing was not only characteristic of our species, but that it was +early and intimately connected with human life. The child of these Arabs +had probably never seen a smile upon the faces of its ferocious parents, +and perhaps had never (before the sight of Mr. Bruce) beheld any other +human creature. + +Crying has a considerable influence upon health and life in children. +I have seen so many instances of its salutary effects, that I have +satisfied myself it is as possible for a child to "cry and be fat," as +it is to "laugh and be fat." + +4. As children advance in life, the constancy of their appetites for +food, and their disposition to laugh and cry, lessen, but the diminution +of these stimuli is supplied by exercise. The limbs[94] and tongues of +children are always in motion. They continue likewise to eat oftener +than adults. A crust of bread is commonly the last thing they ask +for at night, and the first thing they call for in the morning. It +is now they begin to feel the energy of their mental faculties. This +stimulus is assisted in its force by the disposition to prattle, which +is so universal among children. This habit of converting their ideas +into words as fast as they rise, follows them to their beds, where we +often hear them talk themselves to sleep in a whisper, or to use less +correct, but more striking terms, by _thinking aloud_. + + [94] Niebuhr, in his Travels, says the children in Arabia are taught to + keep themselves constantly in motion by a kind of vibratory + exercise of their bodies. This motion counteracts the diminution + of life produced by the heat of the climate of Arabia. + +5. Dreams act at an early period upon the bodies of children. Their +smiles, startings, and occasional screams in their sleep appear to arise +from them. After the third or fourth year of their lives, they sometimes +confound them with things that are real. From observing the effects of +this mistake upon the memory, a sensible woman whom I once knew, forbad +her children to tell their dreams, lest they should contract habits of +lying, by confounding imaginary with real events. + +6. New objects, whether natural or artificial, are never seen by +children without emotions of pleasure which act upon their capacity +of life. The effects of novelty upon the tender bodies of children +may easily be conceived, by its friendly influence upon the health of +invalids who visit foreign countries, and who pass months or years in a +constant succession of new and agreeable impressions. + +III. From the combination of all the stimuli that have been enumerated, +human life is generally in excess from fifteen to thirty-five. It is +during this period the passions blow a perpetual storm. The most +predominating of them is the love of pleasure. No sooner does the system +become insensible to this stimulus, than ambition succeeds it in, + +IV. The middle stage of life. Here we behold man in his most perfect +physical state. The stimuli which now act upon him are so far regulated +by prudence, that they are seldom excessive in their force. The habits +of order the system acquires in this period, continue to produce good +health for many years afterwards; and hence bills of mortality prove +that fewer persons die between forty and fifty-seven, than in any other +seventeen years of human life. + +V. In old age, the senses of seeing, hearing, and touch are impaired. +The venereal appetite is weakened, or entirely extinguished. The pulse +becomes slow, and subject to frequent intermissions, from a decay in the +force of the blood-vessels. Exercise becomes impracticable, or irksome, +and the operations of the understanding are performed with languor and +difficulty. In this shattered and declining state of the system, the +absence and diminution of all the stimuli which have been mentioned are +supplied, + +1. By an increase in the quantity, and by the peculiar quality of the +food which is taken by old people. They generally eat twice as much as +persons in middle life, and they bear with pain the usual intervals +between meals. They moreover prefer that kind of food which is savoury +and stimulating. The stomach of the celebrated Parr, who died in the +one hundred and fiftieth year of his age, was found full of strong, +nourishing aliment. + +2. By the stimulus of the fæces, which are frequently retained for five +or six days in the bowels of old people. + +3. By the stimulus of fluids rendered preternaturally acrid by age. +The urine, sweat, and even the tears of old people, possess a peculiar +acrimony. Their blood likewise loses part of the mildness which is +natural to that fluid; and hence the difficulty with which sores heal in +old people; and hence too the reason why cancers are more common in the +decline, than in any other period of human life. + +4. By the uncommon activity of certain passions. These are either good +or evil. To the former belong an increased vigour in the operations of +those passions which have for their objects the Divine Being, or the +whole family of mankind, or their own offspring, particularly their +grand-children. To the latter passions belong malice, a hatred of the +manners and fashions of the rising generation, and, above all, avarice. +This passion knows no holidays. Its stimulus is constant, though varied +daily by the numerous means which it has discovered of increasing, +securing, and perpetuating property. It has been observed that weak +mental impressions produce much greater effects in old people than in +persons in middle life. A trifling indisposition in a grand-child, an +inadvertent act of unkindness from a friend, or the fear of losing a +few shillings, have, in many instances, produced in them a degree of +wakefulness that has continued for two or three nights. It is to this +highly excitable state of the system that Solomon probably alludes, when +he describes the grasshopper as burdensome to old people. + +5. By the passion for talking, which is so common, as to be one of the +characteristics of old age. I mentioned formerly the influence of this +stimulus upon animal life. Perhaps it is more necessary in the female +constitution than in the male; for it has long ago been remarked, that +women who are very taciturn, are generally unhealthy. + +6. By their wearing warmer clothes, and preferring warmer rooms, than in +the former periods of their lives. This practice is so uniform, that it +would not be difficult, in many cases, to tell a man's age by his dress, +or by finding out at what degree of heat he found himself comfortable in +a close room. + +7. By dreams. These are universal among old people. They arise from +their short and imperfect sleep. + +8. It has been often said, that "We are once men, and twice children." +In speaking of the state of animal life in infancy, I remarked that the +contractility of the animal fibres predominated over their sensibility +in that stage of life. The same thing takes place in old people, and it +is in consequence of the return of this infantile state of the system, +that all the stimuli which have been mentioned act upon them with much +more force than in middle life. This sameness, in the predominance of +excitability over sensibility in children and old people, will account +for the similarity of their habits with respect to eating, sleep, +exercise, and the use of fermented and distilled liquors. It is from +the increase of excitability in old people, that so small a quantity +of strong drink intoxicates them; and it is from an ignorance of this +change in their constitutions, that many of them become drunkards, after +passing the early and middle stages of life with sober characters. + +Life is continued in a less imperfect state in old age in women than +in men. The former sew, and knit, and spin, after they lose the use of +their ears and eyes; whereas the latter, after losing the use of those +senses, frequently pass the evening of their lives in a torpid state +in a chimney corner. It is from the influence of moderate and gently +stimulating employments, upon the female constitution, that more women +live to be old than men, and that they rarely survive their usefulness +in domestic life. + +Hitherto the principles I am endeavouring to establish have been applied +to explain the cause of life in its more common forms. Let us next +inquire, how far they will enable us to explain its continuance in +certain morbid states of the body, in which there is a diminution of +some, and an apparent abstraction of all the stimuli, which have been +supposed to produce animal life. + +I. We observe some people to be blind, or deaf and dumb from their +birth. The same defects of sight, hearing, and speech, are sometimes +brought on by diseases. Here animal life is deprived of all those +numerous stimuli, which arise from light, colours, sounds, and speech. +But the absence of these stimuli is supplied, + +1. By increased sensibility and excitability in their remaining senses. +The ears, the nose, and the fingers, afford a surface for impressions +in blind people, which frequently overbalances the loss of their +eye-sight. There are two blind young men, brothers, in this city, of +the name of Dutton, who can tell when they approach a post in walking +across a street, by a peculiar sound which the ground under their feet +emits in the neighbourhood of the post. Their sense of hearing is still +more exquisite to sounds of another kind. They can tell the names of a +number of tame pigeons, with which they amuse themselves in a little +garden, by only hearing them fly over their heads. The celebrated blind +philosopher, Dr. Moyse, can distinguish a black dress on his friends, +by its smell; and we read of many instances of blind persons who have +been able to perceive colours by rubbing their fingers upon them. One of +these persons, mentioned by Mr. Boyle, has left upon record an account +of the specific quality of each colour as it affected his sense of +touch. He says black imparted the most, and blue the least perceptible +sense of asperity to his fingers. + +2. By an increase of vigour in the exercises of the mental faculties. +The poems of Homer, Milton, and Blacklock, and the attainments of +Sanderson in mathematical knowledge, all discover how much the energy of +the mind is increased by the absence of impressions upon the organs of +vision. + +II. We sometimes behold life in idiots, in whom there is not only +an absence of the stimuli of the understanding and passions, but +frequently, from the weakness of their bodies, a deficiency of the +loco-motive powers. Here an inordinate appetite for food, or venereal +pleasures, or a constant habit of laughing, or talking, or playing with +their hands and feet, supply the place of the stimulating operations of +the mind, and of general bodily exercise. Of the inordinate force of the +venereal appetite in idiots we have many proofs. The cretins are much +addicted to venery; and Dr. Michaelis tells us that the idiot whom he +saw at the Passaic falls in New-Jersey, who had passed six and twenty +years in a cradle, acknowledged that he had venereal desires, and wished +to be married, for, the doctor adds, he had a sense of religion upon his +fragment of mind, and of course did not wish to gratify that appetite +in an unlawful manner. + +III. How is animal life supported in persons who pass many days, +and even weeks without food, and in some instances without drinks? +Long fasting is usually the effect of disease, of necessity, or of a +principle of religion. When it arises from the first cause, the actions +of life are kept up by the stimulus of disease[95]. The absence of +food when accidental, or submitted to as a means of producing moral +happiness, is supplied, + +1. By the stimulus of a full gall bladder. This state of the receptacle +of bile has generally been found to accompany an empty stomach. The +bile is sometimes absorbed, and imparts a yellow colour to the skin of +persons who suffer or die of famine. + +2. By increased acrimony in all the secretions and excretions of the +body. The saliva becomes so acrid by long fasting, as to excoriate the +gums, and the breath acquires not only a f[oe]tor, but a pungency so +active, as to draw tears from the eyes of persons who are exposed to it. + +3. By increased sensibility and excitability in the sense of touch. The +blind man mentioned by Mr. Boyle, who could distinguish colours by his +fingers, possessed this talent only after fasting. Even a draught of any +kind of liquor deprived him of it. I have taken notice, in my account of +the yellow fever in Philadelphia, in the year 1793, of the effects of a +diet bordering upon fasting for six weeks, in producing a quickness and +correctness in my perceptions of the state of the pulse, which I had +never experienced before. + +4. By an increase of activity in the understanding and passions. +Gamesters often improve the exercises of their minds, when they are +about to play for a large sum of money, by living for a day or two upon +roasted apples and cold water. Where the passions are excited into +preternatural action, the absence of the stimulus of food is scarcely +felt. I shall hereafter mention the influence of the desire of life +upon its preservation, under all circumstances. It acts with peculiar +force when fasting is accidental. But when it is submitted to as a +religious duty, it is accompanied by sentiments and feelings which +more than balance the abstraction of aliment. The body of Moses was +sustained, probably without a miracle, during an abstinence of forty +days and forty nights, by the pleasure he derived from conversing with +his Maker "face to face, as a man speaking with his friend[96]." + + [95] The stimulus of a disease sometimes supplies the place of food in + prolonging life. Mr. C. S----, a gentleman well known in + Virginia, who was afflicted with a palsy, which had resisted the + skill of several physicians, determined to destroy himself, by + abstaining from food and drinks. He lived _sixty_ days without + eating any thing, and the greatest part of that time without + tasting even a drop of water. His disease probably protracted his + life thus long beyond the usual time in which death is induced + by fasting. See a particular account of this case, in the first + number of the second volume of Dr. Coxe's Medical Museum. + + [96] Exodus xxxiii, 11. xxxiv, 28. + +I remarked formerly, that the veins discover no deficiency of blood in +persons who die of famine. Death from this cause seems to be less the +effect of the want of food, than of the combined and excessive operation +of the stimuli, which supply its place in the system. + +IV. We come now to a difficult inquiry, and that is, how is life +supported during the total abstraction of external and internal stimuli +which takes place in asphyxia, or in apparent death, from all its +numerous causes? + +I took notice, in a former lecture, that ordinary life consisted in +the excitement and excitability of the different parts of the body, +and that they were occasionally changed into each other. In apparent +death from violent emotions of the mind, from the sudden impression +of miasmata, or from drowning, there is a loss of excitement; but the +excitability of the system remains for minutes, and, in some instances, +for hours afterwards unimpaired, provided the accident which produced +the loss of excitement has not been attended with such exertions as are +calculated to waste it. If, for example, a person should fall suddenly +into the water, without bruising his body, and sink before his fears +or exertions had time to dissipate his excitability; his recovery +from apparent death might be effected by the gentle action of heat or +frictions upon his body, so as to convert his accumulated excitability +gradually into excitement. The same condition of the system takes place +when apparent death occurs from freezing, and a recovery is accomplished +by the same gentle application of stimuli, provided the organization +of the body be not injured, or its excitability wasted, by violent +exertions previously to its freezing. This excitability is the vehicle +of motion, and motion, when continued long enough, produces sensation, +which is soon followed by thought; and in these, I said formerly, +consists perfect life in the human body. + +For this explanation of the manner in which life is suspended and +revived, in persons apparently dead from cold, I am indebted to Mr. John +Hunter, who supposes, if it were possible for the body to be _suddenly_ +frozen, by an instantaneous abstraction of its heat, life might be +continued for many years in a suspended state, and revived at pleasure, +provided the body were preserved constantly in a temperature barely +sufficient to prevent re-animation, and never so great as to endanger +the destruction of any organic part. The resuscitation of insects, that +have been in a torpid state for months, and perhaps years, in substances +that have preserved their organization, should at least defend this bold +proposition from being treated as chimerical. The effusions even of the +imagination of such men as Mr. Hunter, are entitled to respect. They +often become the germs of future discoveries. + +In that state of suspended animation which occurs in acute diseases, and +which has sometimes been denominated a _trance_, the system is nearly in +the same excitable state that it is in apparent death from drowning and +freezing. Resuscitation, in these cases, is not the effect, as in those +which have been mentioned, of artificial applications made to the body +for that purpose. It appears to be spontaneous; but it is produced by +impressions made upon the ears, and by the operations of the mind in +dreams. Of the actions of these stimuli upon the body in its apparently +lifeless state, I have satisfied myself by many facts. I once attended +a citizen of Philadelphia, who died of a pulmonary disease, in the 80th +year of his age. A few days before his death, he begged that he might +not be interred until one week after the usual signs of life had left +his body, and gave as a reason for this request, that he had, when a +young man, died to all appearance of the yellow fever, in one of the +West-India islands. In this situation he distinctly heard the persons +who attended him, fix upon the time and place of burying him. The horror +of being put under ground alive, produced such distressing emotions in +his mind, as to diffuse motion throughout his body, and finally excited +in him all the usual functions of life. In Dr. Creighton's essay upon +mental derangement, there is a history of a case nearly of a similar +nature. A young lady (says the doctor), an attendant on the princess +of----, after having been confined to her bed for a great length of +time, with a violent nervous disorder, was at last, to all appearance, +deprived of life. Her lips were quite pale, her face resembled the +countenance of a dead person, and her body grew cold. She was removed +from the room in which _she died_, was laid in a coffin, and the day for +her funeral was fixed on. The day arrived, and according to the custom +of the country, funeral songs and hymns were sung before the door. Just +as the people were about to nail on the lid of the coffin, a kind of +perspiration was observed on the surface of her body. She recovered. +The following is the account she gave of her sensations: she said, "It +seemed to her as if in a dream, that she was really dead; yet she was +perfectly conscious of all that happened around her. She distinctly +heard her friends speaking and lamenting her death at the side of her +coffin. She felt them pull on the dead clothes, and lay her in it. This +feeling produced a mental anxiety which she could not describe. She +tried to cry out, but her mind was without power, and could not act on +her body. She had the contradictory feeling as if she were in her own +body, and not in it, at the same time. It was equally impossible for +her to stretch out her arm or open her eyes, as to cry, although she +continually endeavoured to do so. The internal anguish of her mind was +at its utmost height when the funeral hymns began to be sung, and when +the lid of the coffin was about to be nailed on. The thought that she +was to be buried alive was the first which gave activity to her mind, +and enabled it to operate on her corporeal frame." + +Where the ears lose their capacity of being acted upon by stimuli, the +mind, by its operations in dreams, becomes a source of impressions +which again sets the wheels of life in motion. There is an account +published by Dr. Arnold, in his observations upon insanity[97], of a +certain John Engelbreght, a German, who was believed to be dead, and who +was evidently resuscitated by the exercises of his mind upon subjects +which were of a delightful or stimulating nature. This history shall +be taken from Mr. Engelbreght's words. "It was on Thursday noon (says +he), about twelve o'clock, when I perceived that death was making his +approaches upon me from the lower parts upwards, insomuch that my whole +body became stiff. I had no feeling left in my hands and feet, neither +in any other part of my whole body, nor was I at last able to speak or +see, for my mouth now becoming very stiff, I was no longer able to open +it, nor did I feel it any longer. My eyes also broke in my head in such +a manner that I distinctly felt it. For all that, I understood what +they said, when they were praying by me, and I distinctly heard them +say, feel his legs, how stiff and cold they have become. This I heard +distinctly, but I had no perception of their touch. I heard the watchman +cry 11 o'clock, but at 12 o'clock my hearing left me." After relating +his passage from the body to heaven with the velocity of an arrow shot +from a cross bow, he proceeds, and says, that as he was twelve hours in +dying, so he was twelve hours in returning to life. "As I died (says +he) from beneath upwards, so I revived again the contrary way, from +above to beneath, or from top to toe. Being conveyed back from the +heavenly glory, I began to hear something of what they were praying for +me, in the same room with me. Thus was my hearing the _first_ sense I +recovered. After this I began to have a perception of my eyes, so that, +by little and little, my whole body became strong and sprightly, and no +sooner did I get a feeling of my legs and feet, than I arose and stood +firm upon them with a firmness I had never enjoyed before. The heavenly +joy I had experienced, invigorated me to such a degree, that people were +astonished at my rapid, and almost instantaneous recovery." + + [97] Vol. ii. p. 298. + +The explanation I have given of the cause of resuscitation in this +man will serve to refute a belief in a supposed migration of the +soul from the body, in cases of apparent death. The imagination, it +is true, usually conducts the whole mind to the abodes of happy or +miserable spirits, but it acts here in the same way that it does when it +transports it, in common dreams, to numerous and distant parts of the +world. + +There is nothing supernatural in Mr. Engelbreght being invigorated by +his supposed flight to heaven. Pleasant dreams always stimulate and +strengthen the body, while dreams which are accompanied with distress or +labour debilitate and fatigue it. + + + LECTURE III. + +GENTLEMEN, + +Let us next take a view of the state of animal life in the different +inhabitants of our globe, as varied by the circumstances of +civilization, diet, situation, and climate. + +I. In the Indians of the northern latitudes of America there is often +a defect of the stimulus of aliment, and of the understanding and +passions. Their vacant countenances, and their long and disgusting +taciturnity, are the effects of the want of action in their brains from +a deficiency of ideas; and their tranquillity under all the common +circumstances of irritation, pleasure, or grief, are the result of an +absence of passion; for they hold it to be disgraceful to show any +outward signs of anger, joy, or even of domestic affection. This account +of the Indian character, I know, is contrary to that which is given of +it by Rousseau, and several other writers, who have attempted to prove +that man may become perfect and happy without the aids of civilization +and religion. This opinion is contradicted by the experience of all +ages, and is rendered ridiculous by the facts which are well ascertained +in the history of the customs and habits of our American savages. In a +cold climate they are the most miserable beings upon the face of the +earth. The greatest part of their time is spent in sleep, or under the +alternate influence of hunger and gluttony. They moreover indulge in +vices which are alike contrary to moral and physical happiness. It is in +consequence of these habits that they discover so early the marks of old +age, and that so few of them are long-lived. The absence and diminution +of many of the stimuli of life in these people is supplied in part by +the violent exertions with which they hunt and carry on war, and by the +extravagant manner with which they afterwards celebrate their exploits, +in their savage dances and songs. + +II. In the inhabitants of the torrid regions of Africa there is a +deficiency of labour; for the earth produces spontaneously nearly all +the sustenance they require. Their understandings and passions are +moreover in a torpid state. But the absence of bodily and mental stimuli +in these people is amply supplied by the constant heat of the sun, by +the profuse use of spices in their diet, and by the passion for musical +sounds which so universally characterises the African nations. + +III. In Greenland the body is exposed during a long winter to such a +degree of cold as to reduce the pulse to 40 or 50 strokes in a minute. +But the effects of this cold in lessening the quantity of life are +obviated in part by the heat of close stove rooms, by warm clothing, +and by the peculiar nature of the aliment of the Greenlanders, which +consists chiefly of animal food, of dried fish, and of whale oil. They +prefer the last of those articles in so rancid a state, that it imparts +a f[oe]tor to their perspiration, which, Mr. Crantz says, renders even +their churches offensive to strangers. I need hardly add, that a diet +possessed of such diffusible qualities cannot fail of being highly +stimulating. It is remarkable that the food of all the northern nations +of Europe is composed of stimulating animal or vegetable matters, and +that the use of spiritous liquors is universal among them. + +IV. Let us next turn our eyes to the miserable inhabitants of those +eastern countries which compose the Turkish empire. Here we behold life +in its most feeble state, not only from the absence of physical, but of +other stimuli which operate upon the inhabitants of other parts of the +world. Among the poor people of Turkey there is a general deficiency +of aliment. Mr. Volney in his Travels tells us, "That the diet of the +Bedouins seldom exceeds six ounces a day, and that it consists of six +or seven dates soaked in butter-milk, and afterwards mixed with a little +sweet milk, or curds." There is likewise a general deficiency among them +of stimulus from the operations of the mental faculties; for such is +the despotism of the government in Turkey, that it weakens not only the +understanding, but it annihilates all that immense source of stimuli +which arises from the exercise of the domestic and public affections. +A Turk lives wholly to himself. In point of time he occupies only the +moment in which he exists; for his futurity, as to life and property, +belongs altogether to his master. Fear is the reigning principle of his +actions, and hope and joy seldom add a single pulsation to his heart. +Tyranny even imposes a restraint upon the stimulus which arises from +conversation, for "They speak (says Mr. Volney) with a slow feeble +voice, as if the lungs wanted strength to propel air enough through the +glottis to form distinct articulate sounds." The same traveller adds, +that "They are slow in all their motions, that their bodies are small, +that they have small evacuations, and that their blood is so destitute +of serosity, that nothing but the greatest heat can preserve its +fluidity." The deficiency of aliment, and the absence of mental stimuli +in these people is supplied, + +1. By the heat of their climate. + +2. By their passion for musical sounds and fine clothes. And + +3. By their general use of coffee, garlic[98], and opium. + + [98] Niebuhr's Travels. + +The more debilitated the body is, the more forcibly these stimuli act +upon it. Hence, according to Mr. Volney, the Bedouins, whose slender +diet has been mentioned, enjoy good health; for this consists not +in strength, but in an exact proportion being kept up between the +excitability of the body, and the number and force of the stimuli which +act upon it. + +V. Many of the observations which have been made upon the inhabitants +of Africa, and of the Turkish dominions, apply to the inhabitants of +China and the East-Indies. They want, in many instances, the stimulus of +animal food. Their minds are, moreover, in a state too languid to act +with much force upon their bodies. The absence and deficiency of these +stimuli are supplied by, + +1. The heat of the climate in the southern parts of those countries. + +2. By a vegetable diet abounding in nourishment, particularly rice and +beans. + +3. By the use of tea in China, and by a stimulating coffee made of the +dried and toasted seeds of the datura stramonium, in the neighbourhood +of the Indian coast. Some of these nations likewise chew stimulating +substances, as too many of our citizens do tobacco. + +Among the poor and depressed subjects of the governments of the +middle and southern parts of Europe, the deficiency of the stimulus +of wholesome food, of clothing, of fuel, and of liberty, is supplied, +in some countries, by the invigorating influence of the christian +religion upon animal life, and in others by the general use of tea, +coffee, garlic, onions, opium, tobacco, malt liquors, and ardent +spirits. The use of each of these stimuli seems to be regulated by the +circumstances of climate. In cold countries, where the earth yields +its increase with reluctance, and where vegetable aliment is scarce, +the want of the stimulus of distension which that species of food is +principally calculated to produce is sought for in that of ardent +spirits. To the southward of 40°, a substitute for the distension from +mild vegetable food is sought for in onions, garlic, and tobacco. But +further, a uniform climate calls for more of these artificial stimuli +than a climate that is exposed to the alternate action of heat and +cold, winds and calms, and of wet and dry weather. Savages and ignorant +people likewise require more of them than persons of civilized manners, +and cultivated understandings. It would seem from these facts that man +cannot exist without _sensation_ of some kind, and that when it is not +derived from natural means, it will always be sought for in such as are +artificial. + +In no part of the human species, is animal life in a more perfect state +than in the inhabitants of Great Britain[99], and the United States of +America. With all the natural stimuli that have been mentioned, they +are constantly under the invigorating influence of liberty. There is an +indissoluble union between moral, political, and physical happiness; and +if it be true, that elective and representative governments are most +favourable to individual, as well as national prosperity, it follows of +course, that they are most favourable to animal life. But this opinion +does not rest upon an induction derived from the relation, which truths +upon all subjects bear to each other. Many facts prove animal life to +exist in a larger quantity and for a longer time, in the enlightened +and happy state of Connecticut, in which republican liberty has existed +above one hundred and fifty years, than in any other country upon the +surface of the globe. + + [99] Haller's Elements Physiologiæ, vol. viii. p. 2. p. 107. + +It remains now to mention certain mental stimuli which act nearly alike +in the production of animal life, upon the individuals of all the +nations in the world. They are, + +1. The desire of life. This principle, so deeply and universally +implanted in human nature, acts very powerfully in supporting our +existence. It has been observed to prolong life. Sickly travellers by +sea and land, often live under circumstances of the greatest weakness, +till they reach their native country, and then expire in the bosom of +their friends. This desire of life often turns the scale in favour +of a recovery in acute diseases. Its influence will appear, from the +difference in the periods in which death was induced in two persons, +who were actuated by opposite passions with respect to life. Atticus, +we are told, died of voluntary abstinence from food in five days. In +sir William Hamilton's account of the earthquake at Calabria, we read +of a girl who lived eleven days without food before she expired. In +the former case, life was shortened by an aversion from it; in the +latter, it was protracted by the desire of it. The late Mr. Brissot, +in his visit to this city, informed me, that the application of animal +magnetism (in which he was a believer) had in no instance cured a +disease in a West-India slave. Perhaps it was rendered inert by its +not being accompanied by a strong desire of life; for this principle +exists in a more feeble state in slaves than in freemen. It is possible +likewise the wills and imaginations of these degraded people may have +become so paralytic by slavery, as to be incapable of being excited by +the impression of this fanciful remedy. + +2. The love of money sets the whole animal machine in motion. Hearts +which are insensible to the stimuli of religion, patriotism, love, +and even of the domestic affections, are excited into action by this +passion. The city of Philadelphia, between the 10th and 15th of August, +1791, will long be remembered by contemplative men, for having furnished +the most extraordinary proofs of the stimulus of the love of money upon +the human body. A new scene of speculation was produced at that time by +the scrip of the bank of the United States. It excited febrile diseases +in three persons who became my patients. In one of them, the acquisition +of twelve thousand dollars in a few minutes by a lucky sale, brought on +madness which terminated in death in a few days[100]. The whole city +felt the impulse of this paroxysm of avarice. The slow and ordinary +means of earning money were deserted, and men of every profession and +trade were seen in all our streets hastening to the coffee-house, where +the agitation of countenance, and the desultory manners, of all the +persons who were interested in this species of gaming, exhibited a truer +picture of a bedlam, than of a place appropriated to the transaction +of mercantile business. But further, the love of money discovers its +stimulus upon the body in a peculiar manner in the games of cards and +dice. I have heard of a gentleman in Virginia who passed two whole days +and nights in succession at a card table, and it is related in the life +of a noted gamester in Ireland, that when he was so ill as to be unable +to rise from his chair, he would suddenly revive when brought to the +hazard table, by hearing the rattling of the dice. + + [100] Dr. Mead relates, upon the authority of Dr. Hales, that more + of the successful speculators in the South-Sea scheme of 1720 + became insane, than of those who had been ruined by it. + +3. Public amusements of all kinds, such as a horse race, a cockpit, a +chase, the theatre, the circus, masquerades, public dinners, and tea +parties, all exert an artificial stimulus upon the system, and thus +supply the defect of the rational exercises of the mind. + +4. The love of dress is not confined in its stimulating operation to +persons in health. It acts perceptibly in some cases upon invalids. I +have heard of a gentleman in South-Carolina, who always relieved himself +of a fit of low spirits by changing his dress; and I believe there are +few people who do not feel themselves enlivened, by putting on a new +suit of clothes. + +5. Novelty is an immense source of agreeable stimuli. Companions, +studies, pleasures, modes of business, prospects, and situations, with +respect to town and country, or to different countries, that are _new_, +all exert an invigorating influence upon health and life. + +6. The love of fame acts in various ways; but its stimulus is most +sensible and durable in military life. It counteracts in many instances +the debilitating effects of hunger, cold, and labour. It has sometimes +done more, by removing the weakness which is connected with many +diseases. In several instances it has assisted the hardships of a camp +life, in curing pulmonary consumption. + +7. The love of country is a deep seated principle of action in the +human breast. Its stimulus is sometimes so excessive, as to induce +disease in persons who recently migrate, and settle in foreign +countries. It appears in various forms; but exists most frequently in +the solicitude, labours, attachments, and hatred of party spirit. All +these act forcibly in supporting animal life. It is because newspapers +are supposed to contain the measure of the happiness or misery of our +country, that they are so interesting to all classes of people. Those +vehicles of intelligence, and of public pleasure or pain, are frequently +desired with the impatience of a meal, and they often produce the same +stimulating effects upon the body[101]. + + [101] They have been very happily called by Mr. Green, in his poem + entitled Spleen, "the manna of the day." + +8. The different religions of the world, by the activity they excite +in the mind, have a sensible influence upon human life. Atheism is +the worst of sedatives to the understanding and passions. It is the +abstraction of thought from the most sublime, and of love from the most +perfect of all possible objects. Man is as naturally a religious, as he +is a social and domestic animal; and the same violence is done to his +mental faculties, by robbing him of a belief in a God, that is done by +dooming him to live in a cell, deprived of the objects and pleasures +of social and domestic life. The necessary and immutable connection +between the texture of the human mind, and the worship of an object of +some kind, has lately been demonstrated by the atheists of Europe, who, +after rejecting the true God, have instituted the worship of nature, of +fortune, and of human reason; and, in some instances, with ceremonies +of the most expensive and splendid kind. Religions are friendly to +animal life, in proportion as they elevate the understanding, and act +upon the passions of hope and love. It will readily occur to you, that +christianity, when believed and obeyed, according to its original +consistency with itself, and with the divine attributes, is more +calculated to produce those effects than any other religion in the +world. Such is the salutary operation of its doctrines and precepts +upon health and life, that if its divine authority rested upon no +other argument, this alone would be sufficient to recommend it to our +belief. How long mankind may continue to prefer substituted pursuits and +pleasures to this invigorating stimulus, is uncertain; but the time, we +are assured, will come, when the understanding shall be elevated from +its present inferior objects, and the luxated passions be reduced to +their original order. This change in the mind of man, I believe, will +be effected only by the influence of the christian religion, after all +the efforts of human reason to produce it, by means of civilization, +philosophy, liberty, and government, have been exhausted to no purpose. + +Thus far, gentlemen, we have considered animal life as it respects the +human species; but the principles I am endeavouring to establish require +that we should take a view of it in animals of every species, in all of +which we shall find it depends upon the same causes as in the human body. + +And here I shall begin by remarking, that if we should discover the +stimuli which support life in certain animals to be fewer in number, +or weaker in force than those which support it in our species, we +must resolve it into that attribute of the Deity which seems to have +delighted in variety in all his works. + +The following observations apply more or less to all the animals upon +our globe. + +1. They all possess either hearts, lungs, brains, nerves, or muscular +fibres. It is as yet a controversy among naturalists whether animal life +can exist without a brain; but no one has denied muscular fibres, and of +course contractility, or excitability, to belong to animal life in all +its shapes. + +2. They all require more or less air for their existence. Even the snail +inhales it for seven months under ground, through a pellicle which it +weaves out of slime, as a covering for its body. If this pellicle at any +time become too thick to admit the air, the snail opens a passage in it +for that purpose. Now air we know acts powerfully in supporting animal +life. + +3. Many of them possess heat equal to that of the human body. Birds +possess several degrees beyond it. Now heat, it was said formerly, acts +with great force in the production of animal life. + +4. They all feed upon substances more or less stimulating to their +bodies. Even water itself, chemistry has taught us, affords an aliment, +not only stimulating, but nourishing to many animals. + +5. Many of them possess senses, more acute and excitable, than the same +organs in the human species. These expose surfaces for the action of +external impressions, that supply the absence or deficiency of mental +faculties. + +6. Such of them as are devoid of sensibility, possess an uncommon +portion of contractility, or simple excitability. This is most evident +in the polypus. When cut to pieces, it appears to feel little or no pain. + +7. They all possess loco-motive powers in a greater or less degree, and +of course are acted upon by the stimulus of muscular motion. + +8. Most of them appear to feel a stimulus, from the gratification of +their appetites for food, and for venereal pleasures, far more powerful +than that which is felt by our species from the same causes. I shall +hereafter mention some facts from Spalanzani upon the subject of +generation, that will prove the stimulus, from venery, to be strongest +in those animals, in which other stimuli act with the least force. Thus +the male frog during its long connection with its female, suffers its +limbs to be amputated, without discovering the least mark of pain, and +without relaxing its hold of the object of its embraces. + +9. In many animals we behold evident marks of understanding and passion. +The elephant, the fox, and the ant exhibit strong proofs of thought; and +where is the school boy that cannot bear testimony to the anger of the +bee and the wasp? + +10. But what shall we say of those animals, which pass long winters in +a state in which there is an apparent absence of the stimuli of heat, +exercise, and the motion of the blood. Life in these animals is probably +supported, + +1. By such an accumulation of excitability, as to yield to impressions, +which to us are imperceptible. + +2. By the stimulus of aliment in a state of digestion in the stomach, or +by the stimulus of aliment restrained from digestion by means of cold; +for Mr. John Hunter has proved by an experiment on a frog, that cold +below a certain degree, checks that animal process. + +3. By the constant action of air upon their bodies. + +It is possible life may exist in these animals, during their +hybernation, in the total absence of impression and motion of every +kind. This may be the case where the torpor from cold has been +_suddenly_ brought upon their bodies. Excitability here is in an +accumulated, but quiescent state. + +11. It remains only under this head to inquire, in what manner is +life supported in those animals which live in a cold element, and +whose blood is sometimes but a little above the freezing point? It +will be a sufficient answer to this question to remark, that heat and +cold are relative terms, and that different animals, according to +their organization, require very different degrees of heat for their +existence. Thirty-two degrees of it are probably as stimulating to some +of these cold blooded animals (as they are called), as 70° or 80° are to +the human body. + +It might afford additional support to the doctrine of animal life, which +I have delivered, to point out the manner in which life and growth are +produced in vegetables of all kinds. But this subject belongs to the +professor of botany and natural history[102], who is amply qualified to +do it justice. I shall only remark, that vegetable life is as much the +offspring of stimuli as animal, and that skill in agriculture consists +chiefly in the proper application of them. The seed of a plant, like an +animal body, has no principle of life within itself. If preserved for +many years in a drawer, or in earth below the stimulating influence of +heat, air, and water, it discovers no sign of vegetation. It grows, like +an animal, only in consequence of stimuli acting upon its _capacity_ of +life. + + [102] Dr. Barton. + +From a review of what has been said of animal life in all its numerous +forms and modifications, we see that it as much an effect of impressions +upon a peculiar species of matter, as sound is of the stroke of a +hammer upon a bell, or music of the motion of the bow upon the strings +of a violin. I exclude therefore the intelligent principle of Whytt, +the medical mind of Stahl, the healing powers of Cullen, and the vital +principal of John Hunter, as much from the body, as I do an intelligent +principle from air, fire, and water. + +It is no uncommon thing for the simplicity of causes to be lost in the +magnitude of their effects. By contemplating the wonderful functions of +life we have strangely overlooked the numerous and obscure circumstances +which produce it. Thus the humble but true origin of power in the people +is often forgotten in the splendour and pride of governments. It is +not necessary to be acquainted with the precise nature of that form of +matter, which is capable of producing life from impressions made upon +it. It is sufficient for our purpose to know the fact. It is immaterial, +moreover, whether this matter derives its power of being acted upon +wholly from the brain, or whether it be in part inherent in animal +fibres. The inferences are the same in favour of life being the effect +of stimuli, and of its being as truly mechanical as the movements of a +clock from the pressure of its weights, or the passage of a ship in the +water from the impulse of winds and tide. + +The infinity of effects from similar causes, has often been taken +notice of in the works of the Creator. It would seem as if they had +all been made after one pattern. The late discovery of the cause of +combustion has thrown great light upon our subject. Wood and coal are +no longer believed to contain a principle of fire. The heat and flame +they emit are derived from an agent altogether external to them. They +are produced by a matter which is absorbed from the air, by means of +its decomposition. This matter acts upon the predisposition of the +fuel to receive it, in the same way that stimuli act upon the human +body. The two agents differ only in their effects. The former produces +the destruction of the bodies upon which it acts, while the latter +excite the more gentle and durable motions of life. Common language +in expressing these effects is correct, as far as it relates to their +cause. We speak of a coal of fire being _alive_, and of the _flame_ of +life. + +The causes of life which I have delivered will receive considerable +support by contrasting them with the causes of death. This catastrophe +of the body consists in such a change induced on it by disease or old +age, as to prevent its exhibiting the phenomena of life. It is brought +on, + +1. By the abstraction of all the stimuli which support life. Death from +this cause is produced by the same mechanical means that the emission of +sound from a violin is prevented by the abstraction of the bow from its +strings. + +2. By the excessive force of stimuli of all kinds. No more occurs +here than happens from too much pressure upon the strings of a violin +preventing its emitting musical tones. + +3. By too much relaxation, or too weak a texture of the matter which +composes the human body. No more occurs here than is observed in the +extinction of sound by the total relaxation, or slender combination of +the strings of a violin. + +4. By an error in the place of certain fluid or solid parts of the body. +No more occurs here than would happen from fixing the strings of a +violin upon its body, instead of elevating them upon its bridge. + +5. By the action of poisonous exhalations, or of certain fluids vitiated +in the body, upon parts which emit most forcibly the motions of life. No +more happens here than occurs from enveloping the strings of a violin in +a piece of wax. + +6. By the solution of continuity by means of wounds in solid parts of +the body. No more occurs in death from this cause than takes place when +the emission of sound from a violin is prevented by a rupture of its +strings. + +7. Death is produced by a preternatural rigidity, and in some instances +by an ossification of the solid parts of the body in old age, in +consequence of which they are incapable of receiving and emitting the +motions of life. No more occurs here, than would happen if a stick or +pipe-stem were placed in the room of catgut, upon the bridges of the +violin. But death may take place in old age without a change in the +texture of animal matter, from the stimuli of life losing their effect +by repetition, just as opium, from the same cause, ceases to produce its +usual effects upon the body. + +Should it be asked, what is that peculiar organization of matter, +which enables it to emit life, when acted upon by stimuli, I answer, +I do not know. The great Creator has kindly established a witness +of his unsearchable wisdom in every part of his works, in order to +prevent our forgetting him, in the successful exercises of our reason. +Mohammed once said, "that he should believe himself to be a God, if he +could bring down rain from the clouds, or give life to an animal." It +belongs exclusively to the true God to endow matter with those singular +properties, which enable it, under certain circumstances, to exhibit the +appearances of life. + +I cannot conclude this subject, without taking notice of its extensive +application to medicine, metaphysics, theology, and morals. + +The doctrine of animal life which has been taught, exhibits in the +first place, a new view of the nervous system, by discovering its origin +in the extremities of the nerves, on which impressions are made, and its +termination in the brain. This idea is extended in an ingenious manner +by Mr. Valli, in his treatise upon animal electricity. + +2. It discovers to us the true means of promoting health and longevity, +by proportioning the number and force of stimuli to the age, climate, +situation, habits, and temperament of the human body. + +3. It leads us to a knowledge of the causes of all diseases. These +consist in excessive or preternatural excitement in the whole, or a part +of the human body, accompanied _generally_ with irregular motions, and +induced by natural or artificial stimuli. The latter have been called, +very properly, by Mr. Hunter, _irritants_. The occasional absence of +motion in acute diseases is the effect only of the excess of impetus in +their remote causes. + +4. It discovers to us that the cure of all diseases depends simply upon +the abstraction of stimuli from the whole, or from a part of the body, +when the motions excited by them are in excess; and in the increase of +their number and force, when motions are of a moderate nature. For the +former purpose, we employ a class of medicines known by the name of +sedatives. For the latter, we make use of stimulants. Under these two +extensive heads, are included all the numerous articles of the materia +medica. + +5. It enables us to reject the doctrine of innate ideas, and to ascribe +all our knowledge of sensible objects to impressions acting upon an +_innate_ capacity to receive ideas. Were it possible for a child to +grow up to manhood without the use of any of its senses, it would not +possess a single idea of a material object; and as all human knowledge +is compounded of simple ideas, this person would be as destitute of +knowledge of every kind, as the grossest portion of vegetable or fossil +matter. + +6. The account which has been given of animal life, furnishes a striking +illustration of the origin of human actions, by the impression of +motives upon the will. As well might we admit an inherent principle of +life in animal matter, as a self-determining power in this faculty of +the mind. Motives are necessary, not only to constitute its _freedom_, +but its _essence_; for, without them, there could be no more a will, +than there could be vision without light, or hearing without sound. +It is true, they are often so obscure as not to be perceived, and +they sometimes become insensible from habit; but the same things have +been remarked in the operation of stimuli, and yet we do not upon this +account deny their agency in producing animal life. In thus deciding in +favour of the necessity of motives, to produce actions, I cannot help +bearing a testimony against the gloomy misapplication of this doctrine +by some modern writers. When properly understood, it is calculated to +produce the most comfortable views of the divine government, and the +most beneficial effects upon morals and human happiness. + +7. There are errors of an impious nature, which sometimes obtain a +currency, from being disguised by innocent names. The doctrine of animal +life that has been delivered is directly opposed to an error of this +kind, which has had the most baneful influence upon morals and religion. +To suppose a principle to reside necessarily and constantly in the human +body, which acted independently of external circumstances, is to ascribe +to it an attribute, which I shall not connect, even in language, with +the creature man. Self-existence belongs only to God. + +The best criterion of the truth of a philosophical opinion, is its +tendency to produce exalted ideas of the Divine Being, and humble views +of ourselves. The doctrine of animal life which has been delivered is +calculated to produce these effects in an eminent degree, for + +8. It does homage to the Supreme Being, as the governor of the +universe, and establishes the certainty of his universal and particular +providence. Admit a principle of life in the human body, and we open a +door for the restoration of the old Epicurean or atheistical philosophy, +which supposed the world to be governed by a principle called nature, +and which was believed to be inherent in every kind of matter. The +doctrine I have taught, cuts the sinews of this error; for by rendering +the _continuance_ of animal life, no less than its commencement, the +effect of the constant operation of divine power and goodness, it leads +us to believe that the whole creation is supported in the same manner. + +9. The view that has been given of the dependent state of man for the +blessing of life, leads us to contemplate, with very opposite and +inexpressible feelings, the sublime idea which is given of the Deity +in the scriptures, as possessing life "within himself." This divine +prerogative has never been imparted but to one being, and that is the +Son of God. This appears from the following declaration. "For as the +Father hath life in himself, so hath he given to the Son to have life +_within himself_."[103] To this plenitude of independent life, we are to +ascribe his being called the "life of the world," "the prince of life," +and "life" itself, in the New Testament. These divine epithets which are +very properly founded upon the manner of our Saviour's existence, exalt +him infinitely above simple humanity, and establish his divine nature +upon the basis of reason, as well as revelation. + + [103] John v. verse 26. + +10. We have heard that some of the stimuli which produce animal life, +are derived from the moral and physical evils of our world. From +beholding these instruments of death thus converted by divine skill into +the means of life, we are led to believe goodness to be the supreme +attribute of the Deity, and that it will appear finally to predominate +in all his works. + +11. The doctrine which has been delivered, is calculated to humble the +pride of man by teaching him his constant dependence upon his Maker for +his existence, and that he has no pre-eminence in his tenure of it, over +the meanest insect that flutters in the air, or the humblest plant that +grows upon the earth. What an inspired writer says of the innumerable +animals which inhabit the ocean, may with equal propriety be said of the +whole human race. "Thou sendest forth thy spirit, and they are created. +Thou takest away their breath--they die, and return to their dust." + +12. Melancholy indeed would have been the issue of all our inquiries, +did we take a final leave of the human body in its state of +decomposition in the grave. Revelation furnishes us with an elevating, +and comfortable assurance that this will not be the case. The precise +manner of its re-organization, and the new means of its future +existence, are unknown to us. It is sufficient to believe, the event +will take place, and that after it, the soul and body of man will be +exalted in one respect, to an equality with their Creator. They will be +immortal. + +Here, gentlemen, we close the history of animal life. I feel as if I +had waded across a rapid and dangerous stream. Whether I have gained +the opposite shore with my head clean, or covered with mud and weeds, I +leave wholly to your determination. + + + END OF VOL. II. + + + + + * * * * * + + + + +Transcriber's note: + +The original spelling and minor inconsistencies in the spelling and +formatting have been maintained. + +Obvious misprints have been corrected. + +Partly repeated chapter headings have been deleted. + + + +*** END OF THE PROJECT GUTENBERG EBOOK 58860 *** |