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                           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.




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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.



