The Practice of Physick by Alexander Gordon: On Being a Physician - and a Patient - in the 18Th Century

By Peter Bennett

This remarkable book never got to see the light of day when it was written two centuries ago. Its author, a Georgian doctor produced this examination of 18th century medicine at the same time as publishing an extremely controversial book on infection. Alexander Gordon had proved conclusively that puerperal (child-bed) fever was passed between patients by midwives. The idea met with outrage and hostility and saw him forced to leave his native city of Aberdeen, leaving behind hundreds of carefully penned pages of The Practise of Physick, a near-complete general text of medicine. Incredibly the final page of the original script even stops in mid-sentence as if the writer had fled there and then. Gordons remarkable unseen work has lain practically untouched ever since. Now painstakingly reworked by Doctor Peter Bennett, himself a medical author of international reputation, it gives a vivid account of medicine in the late 18th century. It was a time of enormous change; the industrial revolution was getting underway, and we were deep in the period of the Enlightenment. The medical profession was alive with new and unsubstantiated theory. Medical dogma that had held sway for two millennia was being challenged but the discoveries of the 19th century were but a speck on the horizon. In the 1790s doctors were still cupping, bleeding and leeching. Medications often contained the highly toxic mercury; Tar Water enjoyed a completely unjustified reputation as a universal remedy; effective drugs were prescribed indiscriminately. The book helps to explain the thinking behind practices which we would now regard as mystifying but were thought of as entirely rational at the time. Gordon's words provide a graphic and colourful account of life as a physician [and as a patient] two centuries ago. Arguably he lost his rightful place alongside the luminaries of medical history. Perhaps the book you hold in your hand will do something finally to redress the balance.

• Language: English
• Publisher: AuthorHouse UK
• Release date: Oct 11, 2011
• ISBN: 9781467892575

Peter Bennett

Peter Bennett is the co-author of a number of books, one of which has been translated into 8 languages. Based in the UK he normally immerses himself in the world of medicinal drug use. He was an advisor to the World Health Organization on the testing of drugs and his book on drugs in breast milk is used in hospitals across the world. Almost 50 years ago as a graduate of the University of Aberdeen he knew of the work of Alexander Gordon on child-bed fever but only more recently became aware of the remarkable manuscript which had lain practically unopened for 220 years. That document, a detailed and vivid account of the practices and medicine in the late 18th century was written by a Georgian physician who was forced to leave his home city for the audacity of his theories on the transmission of infection between patients. Long after his death they eerily proved to be valid. Peter Bennett, now retired, lives in Bath, UK where he has practiced medicine and raised his family for the last thirty years. This book is the result of an impelling desire to see a fellow physicians notes and observations on 18th century diagnosis and treatment finally recognized by their just place in the history of medical writing.

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First published by AuthorHouse 09/16/2011

ISBN: 978-1-4567-7505-6 (sc)

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Contents

Preface

Introduction

The Practice of Physick

Glossary and Notes

Endnotes:

Peter Bennett is the co-author of a number of books, one of which has been translated into 8 languages. Based in the UK he normally immerses himself in the world of medicinal drug use. He was an advisor to the World Health Organization on the testing of drugs and his book on drugs in breast milk is used in hospitals across the world. Almost 50 years ago as a graduate of the University of Aberdeen he knew of the work of Alexander Gordon on child-bed fever but only more recently became aware of the remarkable manuscript which had lain practically unopened for 220 years. That document, a detailed and vivid account of the practices and medicine in the late 18th century was written by a Georgian physician who was forced to leave his home city for the audacity of his theories on the transmission of infection between patients. Long after his death they eerily proved to be valid. Peter Bennett, now retired, lives in Bath where he has practiced medicine and raised his family for the last thirty years. This book is the result of an impelling desire to see a fellow physician’s notes and observations on 18th century diagnosis and treatment finally recognized by their just place in the history of medical writing.

Preface

The original manuscripts of this book were, according to the record, presented to King’s College Library of the University of Aberdeen in 1913 ‘by Miss Harvey, a descendant of the noted medical Harvey family of Aberdeen, into which Gordon married.’ For more than a century prior to this, the volumes had been in the possession of his family.

In converting Gordon’s manuscript to print form, I have sought as far as possible to preserve the integrity of the original writing. Irregular spellings, capitalisations and punctuations [consistent with his time] are presented as he put them down, save where I thought clarification of meaning was necessary, in which case, I have added punctuation marks, or text placed within brackets. We are left with the words almost as they were spoken by Gordon in his lectures, giving an account of what it was like to practise medicine in the United Kingdom some two centuries ago.

My hope is that Gordon’s book will be appeal to readers with a general interest in the history of medicine as well as historians, and it is with the former in mind that I have added the Glossary and Notes, to provide some background and explain words and terms with which they may not be familiar. Similarly, much of the Introduction was written with the general reader in mind.

I wish to record my appreciation of the cooperation I have received from Siobhan Convery, Head of the Special Library and Archives and from Michelle Gait, librarian, King’s College Library, in the provision of manuscript photocopies and for general advice and support. Indeed, it was Michelle Gait who initially suggested that I explore The Practice of Physick.

For the most part, Gordon’s original script is thankfully easy to read but it does contain some puzzling words and phrases and I am grateful for the assistance I received from Professor RT Parfitt and Judy Parfitt in clarifying some of these and in particular for comments on the Glossary and Notes.

Peter Bennett, Bath UK, 2011

Introduction

The manuscript of The Practice of Physick lay virtually undisturbed for over 200 years. It was written probably between 1786, when Alexander Gordon began his practice in Aberdeen and 1795, the year of his abrupt departure from the city. Thereafter it remained in the possession of his family until 1913 when it was gifted by a descendent to the library of King’s College at the University of Aberdeen. Why the work remained unpublished is a captivating tale.

The son of a tenant farmer, Gordon was born in the hamlet of Milton of Drum near Aberdeen on the north-east coast of Scotland. He completed an arts degree at Marischal College, Aberdeen in 1773 and, deciding on a career in medicine, studied for 6 months at the medical faculty of the University of Leiden in the Netherlands, for long the Mecca of aspiring young physicians from all over Europe. Some time between 1776 and 1780 he attended lectures at the school of medicine in Edinburgh, by then a firmly established institution and the most noted centre for medical teaching in Great Britain and beyond. After a period of service as a ship’s surgeon with the Royal Navy, Gordon elected to develop further expertise. He spent about a year in London as a resident pupil at the Middlesex and Store Street lying-in hospitals and attending lectures in obstetrics, and also dissections and lectures in surgery and at the Westminster Hospital. Early in 1786, with an education gained in premier medical centres, he returned to medical practice in his native city.

There occurred in Aberdeen in the period 1789-92, an epidemic of puerperal fever, a bacterial infection of the birth passages that can develop in the days following delivery and, when the invading organism is the haemolytic streptococcus, it is highly infectious. Hence it tended to arise in the closed communities of lying-in hospitals where death could result in 70-80% of those affected. The circumstances in Aberdeen were different, for the ‘fever’ occurred not in a hospital but in the city and surrounding villages. Furthermore, Gordon was the only local physician with a recent obstetric training and, from his time in London, recognised the disease as puerperal fever and that it had the proportions of an epidemic.

There was lively debate within medicine as to whether puerperal fever passed between patients by some noxious element in the atmosphere or was a contagion. The locations of the Aberdeen epidemic ranged from villages 3 miles south to 6 miles north-west of the city and Gordon soon reasoned that the notion of transmission by a constituent of the atmosphere in a region subject to on-shore and off-shore breezes was not tenable. Secondly, he observed that mothers living in the villages tended to get the fever if they were in the charge of midwives from the city; mothers cared for by country midwives were likely to be spared. In an action that was unusual for the time, he constructed a table that registered the appearance of fever cases in date-order, the mothers’ place of residence, its outcome and, crucially, the name of the person who attended the birth. It was immediately apparent that cases of fever began in date-sequence after visits by particular midwives and Gordon himself, compelling evidence that puerperal fever was transmitted by the medical attendants. His discovery was made well before of those by Oliver Wendell Holmes [1843] and Ignaz Semmelweiss [1847], the names commonly associated with uncovering the contagious nature of puerperal fever. By instituting hygiene measures including hand washing, fumigation of rooms, burning soiled apparel Gordon was able to claim a substantial reduction in mortality amongst affected women; the notion of hygiene in the management of infectious disease also figures recurrently in the present book.

Gordon published his work¹ but his Treatise had listed the names of all the patients and their medical attendants; the widowers were thus able to identify and then blame the midwives for the deaths of their wives, and for both groups to turn their wrath on Gordon himself. Certainly, he thereafter quit Aberdeen, in a departure that may have been hasty, for the words on last page of The Practice of Physick cease in mid-sentence, leaving the rest of the page blank [p 133]. He gave away his library [a significant act for a scholar] and never lived in his native city again. He also left behind the nearly-finished manuscript that is the subject of this volume.

A number of text-books of medicine were published in the latter half of the 18th century² and Gordon’s text compares favourably with these in the range and detail of the topics covered. Perceptibly, the tone of his manuscript conveys the feeling of words being delivered to an audience and, indeed, the text was based on lectures to students of medicine. The students urged Gordon to publish the work but his untimely death in 1799 thwarted this outcome.

Gordon’s lived his professional life in the last quarter of the 18th century, in the period of the Enlightenment. Medicine was casting off long-held beliefs to explore and sometimes adopt new ideas but had not yet gained the scientific insight that began in the 19th century. For many years, the medicine taught in European universities, and its practice by those styled the ‘learned and rational’ physicians, had been shaped by the precepts recorded in some 60 pieces of writing known as the Hippocratic corpus [dated 420-370 BC]. An important theme was that health depended on balance of the body’s humours [blood, phlegm, yellow bile and black bile]; in an integrated system each humour was associated with two of four primary qualities [hot or cold, wet or dry], one of the four seasons, temperaments, elements, ages of man, the months and the zodiacal constellations [see p. 134]; disease was the consequence of imbalanced humours. The system of humoural pathology was given sustained impetus by the teaching of the Graeco-Roman physician, Galen of Pergamum [129-c216]. Additionally, many diseases were held to be the result of some morbific influence having entered the body and manifestations such as fever, rash, vomiting and diarrhoea were taken as evidence of the body’s attempts to rid itself of the toxic element; the duty of the physician was to assist these processes by evacuating body fluids with measures such as emesis, catharsis and bleeding. There were other perceived external influences on health – the direction of the wind, phases of the Moon. The focus here was on the patient, with the particular combinations of humoural imbalance, location and environment, applying to that individual and correctable by equally patient-specific interventions.

Beginning in the 17th century, these long-held beliefs became the subject of challenges that are reflected in the sources Gordon quotes in his manuscript. Just for the record, he was well read, for he refers in total to the work of some 91 authors, both ancient and contemporary. In 1628, the English physician, William Harvey demonstrated the true nature of the circulation of the blood and of the pumping action of the heart³, challenging and replacing of the teaching of Galen. Later in the century, careful observations and case histories compiled during epidemics, led another English physician, Thomas Sydenham [1624-89], to conclude that diseases were not specific for the individual and that many people could suffer from the same disease, each epidemic having a characteristic, time course, crisis and responses to intervention. His work⁴ began a transformation of the medical perception of disease, a process continued by Giovanni Battista Morgagni [1682-1771] of Padua in a correlation of some 640 autopsies with case histories which established that symptoms corresponded with pathological lesions in particular organs.⁵ Gradually then, diseases became recognized as entities, with specific, identifiable features and interest shifted away from the patient and towards the illness itself.

With these developments there came a quest to understand the nature of disease. Giorgi Baglivi [1668-1707] of Rome offered a view of the body as a machine, arguing that the functioning of the human body should be explained in mathematical terms of numbers, weights and measures⁶. In an alternative approach, Hermann Boerhaave [1668-1738] of Leiden evolved an hydraulic model which saw health predicated upon the free movement of essential fluids around the body with disease being the consequence of obstructed flow. These mechanistic ideas were challenged by Georg Ernst Stahl [1660-1734] of Halle who sought to explain the nature of life as a God-given quality in all living organisms, in effect the anima [soul] which when misled, for example by emotions, produced illnesses. In Montpellier, Boissier de Sauvages [1706-67, also remembered for his detailed disease classification, see Glossary and Notes], postulated an intermediate view that stressed the inherent vitality of living bodies, a property quite distinct from body and soul. Albrecht von Haller [1708-77] in Göttingen added to the vitalist debate by drawing attention to the irritable and contractile properties of muscle and sensation carried by nerves, innate attributes that dispensed with the necessity to evoke a soul. The idea of life depending ultimately on nervous power was adopted and promoted by William Cullen [1710-90] of Edinburgh, a renowned teacher. Attention now turned to the nervous system as the seat of disease.

Gordon’s text reflects the tensions between these changing ideas. He makes repeated allusions to ‘Ancient’ that is, humoral medicine; he acknowledges phlegmatic, sanguineous, bilious and melancholic temperaments and constitutions; he uses ‘humoural’ words such as ‘acrimony’ and ‘concoction’ in respect of fluids [see Glossary and Notes]; he gives detailed indications for the use of different forms of evacuation including by emesis, catharsis, sweating, taking blood, cupping; he refers to the effects on the course on illnesses of climate, weather, the phases of the Moon. Yet, reading the manuscript, it becomes clear that what influences and directs Gordon’s thinking most profoundly, is evidence from recorded observations, his own and those of others; indeed the author he quotes most frequently [26 times in the text] is the one person most closely associated with conclusions made from recorded clinical experience, Thomas Sydenham. Gordon emerges from the pages as an individual whose scepticism of unsubstantiated theory is matched only by his belief in the value of personal scrutiny, as evidenced by his many references to evidence from post-mortem dissections. He both dismisses aspects of Boerhaave’s work as ‘hypothesis’, and makes reference to evidence of ‘obstructed viscera’, acknowledging Dutch physician’s theory. Gordon’s questioning attitude is well expressed thus:

The piece of Theory that has made People keep the Patient close [i.e. confined] during the Eruptive Fever, is an opinion that the Fever is employed by Nature to expel the Variolous Matter, but this is a mere Hypothesis; if it were true, it should be the Business of the Physician to keep up the Fever, but the experience and Observation show, that the Fever is really to be considered as Nature’s grateful Enemy, therefore it is his Business to subdue it as much as possible. [p. 162]

In more constructive vein, much of Gordon’s writing is concerned with enquiry into the nature of illness and its source or ‘seat’; it is notable that a list of causes with differing strengths of association [proximate, predisponent, occasional, exciting, antecedent] accompanies his account of each disease. Where no convincing cause is apparent and in tune with the thinking of the time, Gordon resorts to Cullen’s teaching, writing that As therefore the Proximate Cause of fever, is neither in the solids or fluids, we naturally seek for it in the Nervous System. [p. 50]

In common with the other text-books of medicine of the time, the first volume of Gordon’s manuscript comprises a lengthy account of different types of fever and their management. The subject provides an insight of what was a deepening understanding of transmissible disease. That biological agents could be carried from person to person was certainly understood in the case of infestation with worms which, of course, were clearly visible to the naked eye. On another scale, he recognizes scabies as a topical infectious disease for, as he puts it, there is great reason to think it is owing to Animalculae [p. 303] and the causative agent, Scarcoptes scabii, is visible by hand lens and microscope which would have been available to him. There may also have been an understanding that imperceptible agents can pass from person to person to cause some febrile illnesses. Gordon was alert to the possibility of such transmission from his experience of puerperal fever, for he comments in his Treatise that the infection of puerperal fever gains access to the birth passages, enters the lymphatic system and then the blood. Although not in the specific context of infection, he refers to Fractastoro who, in the 16th century, evolved a remarkably accurate form of germ theory [see Glossary and Notes]. Moreover, he writes of the fomites [see Glossary and Notes] and putrid particles with the implication that these can transmit disease, and counsels the physician who has seen a patient with severe fever to return home and change and fumigate his clothes. But medical advance was slow and a full century would elapse before the formulation of the modern idea of germ theory by Louis Pasteur and Robert Koch.

While The Practice of Physick was written two centuries ago, Gordon’s approach and analysis of problems sometimes resonate with a modern view. In a general statement on the use of medicines, for example, he sets out a policy which would sit well in any modern text of therapeutics [p. 34]:

Few medicines are to be prescribed, and these with the greatest simplicity. They ought not to be often changed, till a fair tryal is made of their Efficacy. By prescribing a Multitude of Remedies, and those too compounded, it is impossible to say to which the Cure is owing, and this is the Cause, why medicines lie so much in obscurity. A Physician I think should prescribe but one single medicine, unless he can give a reason for making an Addition such as to cover nauseousness, to make a Medicine sit easily on the Stomach, to prevent a Cathartic’s griping etc. In such cases one or perhaps two Additions are necessarily.

And further [p. 35]:

In all Chronic diseases, were the System seems to be affected, and the general Mass of fluids vitiated, those things which operate slowly, but have a constant effect upon the Constitution, are particularly to be attended to. These are the Circumstances of diet, Air, exercise, mineral waters, and an easy cheerful state of mind, all which in general come under the head of Regimen, and are often of more consequence, than any drugs whatever.

Gordon’s work originally comprised 4 volumes but the second volume was lost and the final volume is incomplete. Nevertheless, it is possible to deduce what was in the missing pages and also to conclude that the book was nearly finished. The initial topic headings of Gordon’s work follow those of John Gregory’s Elements of the Practise of Physic [1773]. The scope of the latter work was curtailed by Gregory’s death but, fortunately, the manuscript notes of Gregory’s pupil, Thomas Gilchrist are available [Aberdeen University Library MS 2784] and show topic headings that coincide exactly with Gregory’s published version. Furthermore, Gilchrist’s notes proceed to show what would have been covered had Gregory completed his book. Comparing Gordon’s headings with those of Gilchrist shows, first that the missing sections of Gordon’s book would have included text on infectious disease, for example plague, phrenitis and ophthalmia and secondly that Gordon’s work was near it end, for the final section of his manuscript describes Diseases of Women which is also the concluding section of Gilchrist’s notes.

In any event, the 683 pages of The Practice of Physick that are the substance of this book describe the practice of medicine almost exactly as Alexander Gordon would have spoken it, over two centuries ago. In these words, an intelligent, well-educated and widely read individual brings to life what it was like to be a physician in the late 18th century and, turning the coin, what it was like to be a patient.

The Practice of Physick

The Business of my Profession is to give a History of all the diseases incident to the Human body, and the proper Method of Cure; but neither the Pathology, or Therapeutics, come within my plan—These I must suppose already known—

It is necessary before I begin my proper Subject, to explain some general division of Disease and the general Principles I proceed upon in the Cure of them.

Every Animal has a certain external and internal structure and parts, and certain functions allotted to it. When this Structure is in the Condition natural to that species, and the functions performed in a lively and vigorous manner, then the Animal is said to be in health, any deviation from this condition, forms a Disease, a Disease is therefore a Deviation of the Human Constitutional from its natural State. This Definition of a Disease includes in it whatever belongs to a Physician to Cure. My Reasons for making the Definition so general, is, that I may take in the Deformitates and Vitia, many of which cannot be included in Dr Boerhaave’s Definition. Taking in the Causes into the Definition I also think improper, as Dr Hoffman does. A Disease—does not consist of any single morbid Symptom or Appearance, but of many conjoined, the Concourse of these forming the Disease and separately, they are called Symptoms. The Definition of a Disease, should, I think, be taken from these and from these alone, which most commonly attend Disease. The Proximate Causes ought not to be taken in, as this creates disputes, than which nothing is more foolish. There are some Cases however in which I think it is necessary even to take in the Proximate Cause, but these are where it is so obvious, as to create no Disputes. As Sauvage follows this Method, and is more full than most of the Authors, I shall generally follow his Definition. Diseases are distinguished in the first place from their Origin and again subdivided into many branches.

I Such as are hereditary, as the Phthisis Pulmonalis, Apoplexy, Madness, Gout, Scrofula [by the by, it is remarkable that the Scrofula seldom appears after the Age of Puberty], Stone, certain Cutaneous Diseases, and a very great sensibility of the Nervous System; a disposition to have a bad kind of small Pox, but tho’ this is frequently the case, yet there are numerous Exceptions to it.

These brake out at different Periods of Life, some in Childhood, as the Scrofula particularly. A Disease of this kind does not seize all the Children of a Parent, some escape, and sometimes it passes the Children, and again appears in the Grand Children.—The Causes of these are generally unknown, we can give no more Account of it than the resemblance of the features of a Child to its Parent, or likeness in Disposition, some of them indeed dependent upon an external Conformation of parts, as in the Apoplexy, Phthisis Pulmonalis etc.

It has been said of these diseases, which appear at certain periods of Life, are transmitted to Children when begotten, but I think there is little foundation for this. Congenital diseases are different from hereditary, they mean such Diseases as a Child may be infected with in its Mother’s Womb, as the Small Pox, Measles, which are different from hereditary Diseases—Hereditary Diseases are generally very difficult or impossible to cure. What we ought to do is to Moderate the Symptoms so as to hinder the hereditary disposition from being communicated to the Children of the patient, but even of this I know of no Instance in Medicine.

II. Diseases distinguished from their Origin are also subdivided into primary and secondary. A Secondary disease is where it depends upon another Disease, as the Primary. Thus in a Dropsy, depending upon a schirrous Liver, is the Primary, the Dropsy the secondary disease. Secondary Diseases really differ from Symptoms, but the Distinction is not always easily made.

III. Into Diseases seizing a great number of People from any common Cause, called Pandemic, these again are subdivided into Endemic and Epidemic Diseases.

Endemic, are certain Diseases, peculiar to the People of any Country, arising from Circumstances of Climate and Situation. Thus Intermittent Fevers are Endemic in all marshy Countries, and the Phthisis Pulmonalis, may be said to be so, in Great Britain, owing perhaps to the Vicissitudes of the Weather, which exposes the Inhabitants more to catching Cold.

Epidemics, seize a great number of people at once from some general Cause, the Nature of which is often unknown. They are generally believed to depend upon some Quality of the Air, tho’ I think it is often not to any sensible Quality of the Air, but that the Air is only the Medium, by which the Contagion is transmitted. At the same time, the sensible quality of the Air, has a great Effect upon these Epidemic diseases, in rendering them milder, or more violent. Thus most Putrid Epidemics are carried off in the Winter, and Vernal ones checked at the Approach of Summer. There is a very important Distinction betwixt Vernal and Autumnal Epidemics. The first are more generally attended with the Inflammatory Diatheses, the others have more of the Putrid. Epidemic Diseases have a great influence on the type of sporadic diseases prevailing at the same time, for Examples of which see Dr Sydenham. Epidemics may act either in consequence of Contagion in the air, or an Infection propagated from one Person to another by contact, tho’ this is not always to be known.—The 2nd way, there is great reason to think is the Case with the Plague—Epidemics too belong to the Class of Acute Diseases, or Fevers. There are scarcely any Instances of chronical Diseases being Epidemic. There are certain Circumstances in the Cure of Epidemic Acute Diseases, which require particular treatment, which you will see well illustrated in Dr Sydenham’s Practice. Dr Freind however makes very light of this matter but intirely from Theory. Most of the Epidemic Putrid Diseases appear to act in Consequence of an Assimulating firment, but more of this hereafter.

IV. Into Diseases particular to particular temperament, and Constitutions, as divided into the Phlegmatic, Sanguineous, Bilious, Melancholic⁷ and those that have a remarkable degree of Sensibility of the Nervous System.

V. Diseases peculiar to certain ways of Life, as to certain Mechanic Trades, see Ramazini de Morbis Artificium. These attack not only Artificers, but several other different ways of Life, have their particular diseases, as Studious People, Miners, According to the different Mineral they are employed about, those who live Luxuriously, have their diseases different from those who use much Exercise, and a very simple diet, and the treatment too is very different. A great Allowance is always to be made to habit.

VI. Diseases peculiar to certain periods of Life which distinction is always of great Consequence in Practice. Thus Children are liable to Affections of the head, hence subject to Epilepsies, runnings behind their Ears and different Eruptions on their heads. In Youth these morbid Congestions happen oftener in the Breast, whence spitting of Blood, Phthisis Pulmonalis, Asthmatic Disorders etc. In the decline of Life, they are more subject to morbid congestions in the Abdominal viscera. All Children have also naturally a Diarrhoea, and those who have not, their Constitutions are more ticklish. During teething also there is a greater Irritability of the Nervous System.

VII. Diseases are particular to the Sexes, from whence arises often a considerable variation in the Method of treatment. Thus most Female Disorders either proceed from obstruction of the Menses, their too great Quantity, or the Fluor Abus, which is a very common Complaint especially among Women of Fashion. Differences also arise from the State of Virginity, Pregnancy, Lying-in, Suckling and of the coming on or the ceasing of the Menses, which happens betwixt 40 and 50.

VIII. The last subdivision is into the Contagious Diseases, such as the Plague, Eruptive Fevers and Dysentery, which appear in general to be communicated from those who are infected to—those that are well. Some also are only propagated by immediate Contact, as the Itch and Lues Venerea. It is observed that almost no diseases are contagious but acute ones that are propagated by contact. It is also observed that the more of the Inflammatory Diatheses, Diseases have, the less Contagious they are; the more Putrid they are, the more Contagious, but this is no certain Rule. The Contagious Diseases of one Species of Animals, are not always contagious to a different Species, though sometimes the Contrary has been observed.

Putrid Diseases acquire their greatest degree of putrescence, by crowding many such People together, when there is not a free Circulation of Air, Goals, Hospitals, Hospital Ships and I believe it would be a Means of saving the Lives of Numbers, were there no Hospitals in the Armys at all, even were the sick taken much less Care of. It is difficult to say whether all Contagious Diseases can be reduced to certain Classes. They are in general divided into Exanthematous, Catarrhal and Dysenteric. But I have known Instances of Inflammatory Diseases being Infectious, as Ophthalmiae and there are several Nervous Diseases infections which cannot I think be reduced to any of these Classes.

The Second division of Diseases, is from their Seat.

I The first Subdivision, is from internal and external, a distinction which is exceedingly vague, and of very little Consequence in Practice, except in some particular Cases.

II Into Diseases that are fixed and those that are wandering, as in certain Species of the Rheumatism and Gout.

III Into Idiopathic, and Symphatic Diseases, they are called Idiopathic, when the Cause of the Disease appears to be in the part affected—Symphatic when of the Cause is not there. Thus, a Headache, arising from a morbid affection of the Stomach, is Symphatic, but one proceeding from an encreased determination to the head itself, is called Idiopathic. This distinction, is often of a very great Consequence in Practice and often very difficult to establish. A Symphatic generally goes off with the Primary but sometimes it continues. Thus a Dropsy, proceeding from Schirrous Viscera, may continue after these are cured.

The words Symptomatical and Critical may relate also to Evacuations in Diseases, or to particular translations. It has been thought that Sympathetic Diseases are sometimes to be Accounted for, from the Communication of Nerves. I think there is such a connection between some parts of the Body, that when one is diseased, the other becomes so also, which some say is from having Nerves from the same Origin. But there are Cases of it, where there are no such Communication of Nerves. This is called Sympathy, and tho’ many Objections have been made to the Word, yet to explain a fact and not the Cause of it, I think it may be very well used. We have instances of this from a Carious Tooth’s occasioning swellings of the Submaxillary Glands, pains of the Ears, forehead and, without any pain in the Tooth itself, which one unacquainted with this Sympathy, would never imagine to be the Cause.

IV A 4th Subdivision on this head is into Diseases, that are universal, affecting the whole System, and those that are only Topical.

The Universal are again subdivided into those that are properly universal, as a common continued fever, and the improperly universal, such as fevers accompanied with local Inflammations, where the whole system is affected, along with a particular local Affection.

The Third General Division of Diseases, is according to their Course, which are subdivided

I Into those of short Continuance and those longer, called Chronical. If a Disease is short, severe, and dangerous it is called acute.

II Diseases as they are continued, or Intermittent, and another kind, called Remittent, all which may be illustrated from Fevers, as is well known—Intermittent and Remittents are also Regular, or Anomalous, when they return at certain regular and stated times, they are called Periodical. Remittent Fevers are those, where the Fever abates for a little, and then returns with as great violence as before. The periodical Diseases, are mostly reducible to the Class of fevers, Evacuations and Nervous Disorders. We have examples of the first in Intermittents, of the second Haemorrhages, and in the 3rd we have examples sometimes in Epilepsies and Madness.

The different parts of a disease, are the Invasion, or Symptoms first Appearing, when the disease attacks, the Augment, the State, and the Decline. In Periodical Fevers these are sometimes applied to the whole course of the Fever and sometimes to the particular Paroxysms.

The fourth general Division of Diseases is what is taken from their Nature and Genus.

I Subdivided in the first place into mild and severe diseases. The mild are instanced in certain slight Epidemical Catarrhal Fevers which keep the patient but for a few days and seldom requires a Physician. Severity is to be judged of from the whole course of the Symptoms.

II Into malignant Diseases, which Word has been exceedingly abused. The Three Senses it has been generally used are these, 1stly Diseases beginning with very mild Symptoms, and suddenly without any evident Cause becoming very violent, 2ndly Diseases attended by unusual Severity for a disease of that kind, 3rdly Diseases proving obstinate and refractory to all remedies. The Cases it is commonly applied to now are very dangerous Fevers of the Putrid kind, as the Goal and Hospital Fevers and some Species of the Angina, as the Gangrenous sore Throat.

III Diseases that are regular, sometimes called exquisite, which have the usual symptoms and natural Periods of that Disease—These anomalous Symptoms are very often owing to two different diseases, meeting in this same Person. Thus they frequently appear in Fevers, attacking Patients subject to nervous Complaints. They are also often owing to Worms.

IV The fourth Subdivision is into Diseases called active and Passive, a distinction of great Consequence in Practice. The active Diseases are such wherein Nature makes a sensible Effort, for the relief of the Patient, the Passive, where no such effort is made. We have an example of this in the common Inflammatory Fever, which is commonly carried off by some Critical Evacuations, and it is particularly remarkable, in the Eruptive Fevers, of the Passive Kind, are the Schrophula, Cancer and perhaps the Lues Venerea which may be said not to be cured without the assistance of art. In the active, it is the Business of the Physician to attend to the Efforts of Nature.

The Fifth general Division.

I Subdivided in to the Curable and Incurable, a distinction that is exceedingly vague. A Physician should never say that the disease is incurable, only that he can not cure it.

II Diseases which return more than once in a man’s Life time, and these we are only likely to be affected with once. These last are the small Pox, Measles, Iussis Convulsive and Plague, with regard to which last it is extremely uncertain, but in the others, Instances of return are very rare.

III The 3rd Subdivision, is a very important one. It is into Diseases to be considered as salutary, and those that are properly Diseases. Instances of this we have in the Gout, which on some particular Occasions, is not to be considered a Disease, as the cure of one. The same is to be said with regard to Intermittent Fevers particularly a vernal Tertian, also with regard to certain Evacuations, as bleeding of the Nose, Diarrhoeas, sweatings which in many cases, are very salutary. It is also sometimes the Case with common fevers. Certain Diseases also that are habitual to a Patient, it is dangerous to stop. This is the case with regard to every Evacuation becoming habitual and natural, as in universal and partial Sweating in the feet, it is the Case also with many subject to frequent Diarrhoeas and with the Cough attending Old People of gross and phlegmatic Habits.

IV The fourth Subdivision is into those that are terminated by a Crisis. This word was used in different Senses by the Ancients, sometimes any termination of the disease, was called a Crisis, but in general, it signified a Salutary one. A Crisis generally implies some Evacuation, but it may happen with any, but only by a Metastastis or translation to some other part of the Body, by way of Abscesses. These Evacuations are observed in most Fevers to happen on certain particular days, which have been called Critical days.

This Doctrine tho’ much contested, I apprehend is established in Nature, tho’ no doubt subject to many exceptions. In general, we may say, they are not so regular here, as in the more southern Climates. They are most remarkable in Eruptive Fevers, Inflammations and Wounds.

Diseases may be classed, according to their Occasional Causes or their proximate Causes. There is no Doubt, but that the last method would be most useful, but the great difficulty there, lies in our Ignorance of the Proximate Cause. The order that is most natural is from the External Symptoms, which was never done in any regular Plan before Sauvages time, for which I think he has a great merit, but even his method must labour under many defects, since I think it is impossible by this Method to have a compleat arrangement.

Sauvages gives an Artificial Order of diseases, as in the arrangement of Plants, and with the same design. The view in my Classification is different. It is to bring those Diseases together that resemble one another most in their Nature, that the consideration of one may throw light upon another. It often happens at the same time, that Sauvages Plan and mine coincide, and as I can follow his, I will Mine, is no design of a compleat artificial Arrangement of Diseases, but only some Attempt to a natural one. The Order of which I propose to treat Diseases is as follows.

Class 1. Febrile Disorders

Class II. The preternatural Evacuations

Class III. All Parallytic Diseases and disabilities

Class IV. Spasmodic Diseases

Class V. Diseases of the Mind and its functions

Class VI. Cachexia

There are other Diseases, which I chuse to treat separately by themselves, particularly the Calculous disorders, whether in the Urinary Passages and Ducts or in the Liver. Jaundice I also chuse to consider along with these, because it resembles them in the nature of its Proximate Cause, and often in the Method of Cure—worms also I consider by themselves, because in one point of View, they may be considered as the Proximate Cause of the Disease. I shall also here consider the Diseases that are the Effects of Poison, and under this head, the Hydrophobia also,