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A N 
 
 INAUGURAL DISSERTATION 
 
 O N 
 
 COMPRESSION OF THE BRAIN FROM 
 CONCUSSION. 
 
 SUBMITTED TO THE PUBLIC EXAMINATION 
 OF THE 
 
 FACULTY OF PHYSIC, 
 
 UNDER THE AUTHORITY OF THE 
 
 TRUSTEES OF COLUMBIA COLLEGE 
 
 IN THE 
 
 STATE OF NEW-YORK: 
 WILLIAM SAMUEL JOHNSON, LL.D. Prefident; 
 
 FOR THE DEGREE OF 
 
 DOCTOR OF PHTSICi 
 
 ON THE THIRTIETH DAY OF APRIL, I793. 
 
 By JOHN B. HICKS, 
 
 Citizen of the State of New- York. 
 
 Experience and Obfervation, the Parents of the Healing Art. 
 
 Lzdsan. 
 
 NEW-YORK: 
 
 Printed by T. and J. Swordi, Printers to the Faculty of Phyfic of 
 Columbia College, No. i-j, William-Street. 
 
 —•793 — 
 
• 
 
 - 
 
 Imprimatur. 
 
 - 
 
 fin 
 
 Richard Bay ley, 
 
 
 H5.SL 
 
5 
 
 TO THE 
 
 MEDICAL SOCIETY 
 
 9 T II I 
 
 STATE OF NEW-YORK: 
 
 GENTLEMEN, 
 
 PERMIT me to addrefs this 
 INAUGURAL ESSAT, not as worthy of your 
 fanclion, but, as an evidence of ejleem, rejpecl, and 
 gratitude. 
 
 From your much obliged, 
 
 Humble Servant, 
 
 The AUTHOR; 
 
ISAAC ROOSEVELT, Prefident, 
 
 THEOPHILACT BACHE, Vice-Prefident, 
 JOHN MURRAY, Treafurer, 
 JOHN KEESE, Secretary, 
 
 HENRY HAYDOCK, 
 WILLIAM EDGAR, 
 SAMUEL FRANKLIN, 
 THOMAS PEARSALL, 
 JOHN MURRAY, Junior, 
 GEORGE BOWNE, 
 LAWRENCE EMBREE, 
 JACOB WATSON, 
 SAMUEL JONES, 
 THOMAS BUCHANAN, 
 GERARD WALTON, 
 HUGH GAINE, 
 ALEXANDER ROBERTSON, 
 ROBERT BOWNE, 
 RICHARD MORRIS, 
 JOHN LAWRENCE, 
 ROBERT R. LIVINGSTON, 
 JAMES WATSON, 
 CORNELIUS RAY, 
 MATTHEW CLARKSON, 
 SAMUEL OSGOOD, 
 MOSES ROGERS, 
 
 o 
 o 
 < 
 
 M 
 25 
 
 GENTLEMEN, 
 
 I OUR liberal exertions in fupport of the New- York Hospital 
 demand my approbation at a citizen, and gratitude as a child of the 
 inftitution. 
 
 Your judicious felecVion of medical officers not only effccluares 
 the public bounty to thofe viflims of difeafc who arc objects of the infti- 
 tution. 
 
C 6 ) 
 
 tutlon, but enables the patrons of the healing art to eftabliih one of 
 the firft PRACTICAL MEDICAL SCHOOLS on the Continent of 
 America. 
 
 You have combined in the fame body, a fource of balm to the afflicted, 
 and obfervation for the advancement of the moft noble of fciences } and 
 thus the remoteft parts of the habitable globe will participate the fruits 
 of your benevolence. 
 
 As men ftudious to promote the arts and fciences, permit me to fuggeft 
 the flourifliing ftate of medical education in this city. An infti- 
 tution recently adopted by Columbia College, nearly allied to, and 
 cheriflied by the one under your direction, though in its infancy, fupport- 
 ed by the Pillars of Literature, is now emerging from obfcurity, and will 
 foon mine confpicuous by its tendency to diffufe useful knowledge. 
 
 How pleafing the reflection, that, in this inftitution, Columbia 
 boafts of a youth of genius and erudition, unequalled in the hiftory of 
 fcience.* 
 
 May Providence continue to be your guide, and j r our future adml- 
 niftration be fuch as to merit a continuance of the confidence of thofe 
 whom you have the honour to reprefent. 
 
 I remain, 
 
 With much efleem and refpett, 
 
 Your obliged, 
 
 And very humble Servant, 
 
 The AUTHOR; 
 
 •Profeflbr Mit chill. 
 
 INTRODUCTION^ 
 
INTRODUCTION. 
 
 Ti 
 
 HE Scnforium Commune has attracted the atten- 
 tion of the ablefl Philofophers. Its phyjiology has eluded 
 the researches of ingenuity and induftry, is involved in 
 obfcurity, and hence the uncertainty of the -pathology. 
 We have to lament the impojfibility of exploring this hid- 
 den^ important, and inimitable machine of infinite 
 wisdom. 
 
 Though Surgery has rapidly improved for a few years 
 paft, fill, within its province cxift a variety of difeafes \ 
 the caufe, nature, and cure of which b affile the ingenui- 
 ty of Surgeons. 
 
 Although the obfervations which I now fubmit to 
 
 public fcrutiny conflitute my Inaugural Essay, they 
 
 were not compofed merely in compliance with the sta- 
 
 7 utes of the injlitution under whofe fanttion Ipublijh, 
 
 but from a full conviction of their -propriety ; for though 
 
 they have been f ub jells of "inv efl igat ion, fine e Surgery has 
 
 been cultivated as an art, we are inpoffeffion of nofatis- 
 
 ; information refpeSing them. 
 
 In 
 
C 8 ) 
 
 In profecuting thefe fubjefis, an inter efting queftion 
 offers for critical examination -, to wit, Are the difeafes 
 known infurgical authors, by concuffion and comgreffion 
 of the brain, ejfentially different ? 
 
 It is of infinite moment in practice to have difeafes 
 defined with accuracy ; for though modern indufiry has 
 unburthened Surgery of its ancient barbarity, yet, in 
 -many inftances, we are under the difagreeable neceffity of 
 obtaining the aid of painful and dangerous operations ; 
 and hence the quefiion fated has not only agitated and 
 perplexed our predeceffors, but the ablefi of our cotem- 
 poraries are embarraffed, and have fplit on this ground. 
 
 'Though I am bold to relinquifh the beaten tracl, and 
 controvert the theory and pratlice of eminent Surgeons, 
 Iprefume Ifhall not be impeached with a thirft for no- 
 velty or a fpirit of controverfy. If I have advanced 
 opinions repugnant to eftablifhed pratlice and great au- 
 thority, it has been with all deference ; from a convitHon 
 of their propriety, and a dejire of alleviating the cala- 
 mities attendant on mortality. 
 
 The ignorant, illiberal, and rafh may charge me with 
 vain per fumption; but the wife, candid, and deliberate 
 will applaud my independence. 
 
 This difparity of fentiment is not peculiar to the 
 healing feience ; but we are not equally inter eft ed and 
 
 folicitous 
 
( 9 ) 
 
 felicitous for the purity of etich: On-one the health and 
 lives of fociety are depending ; the others are more the 
 inquiries of curious fpeculation than real utility. I am 
 an advocate for lenity ; but when I contemplate the 
 nature and importance of the fubjecl, I fpurn at the 
 degeneracy of authors. 
 
 'The imperfecl Jlate of this part of fcience has arifen, 
 in fome degree, from its intricacy, fervile and fuperfli- 
 tious veneration for authority ; but depravity of prin- 
 ciple has had its influence •, and thus the light of truth 
 has been obfcured by the fhadow of the imagination •, and 
 to ejiablifh a favourite hypo the/is, fatls have been coined^ 
 and wanton cruelties praclifed. 
 
 We are rejlrainedby humanity > and prohibited by the 
 laws of civil fociety, from fporting with the calamities 
 and lives of the human creation; and hence the propriety 
 of the obligationmakzs every confideration fubordinate 
 to the welfare of th e patient. This, however humiliat- 
 ing, and painful to the reflection, is too frequently aban- 
 doned, and inter ejl and ambition predominate. 
 
 JB fciq 
 
A N 
 
 INAUGURAL DISSERTATION, &c. 
 
 AT is almoft unneceflary to remark, that this dif- 
 eafe is not peculiar to any feafon or climate j every 
 part of the habitable globe, both fexes, all ages, 
 and every variety of conftitution are the objects of 
 its vengeance. A complete or imperfect, general 
 or partial fufpcnfion of the intellectual operation, 
 (cnfo, and voluntary motion, from external violence, 
 with the continuance of refpiration and circulation, 
 is a definition fufficiently clear and diftinct, and 
 plainly enough directing the indications of cure. 
 But in obedience to cuftom, and further, becaufe 
 the variety marked has contributed to give rife to 
 an opinion and method of cure which, in the fub- 
 fequent part of this efTay, I fliall take the liberty to 
 controvert ; I proceed to mark, with precision, the 
 hiftory in particular. 
 
 When 
 
( ?* ) 
 
 When the violence is inflicted the following is the 
 order of fymptoms. 
 
 The perfon being thrown to the ground, lies ap- 
 parently lifelefs to the moft accurate examination. 
 The body, face, and extremities are pale and cold ; 
 the eyes lofe their fprightlinefs, become languid, 
 and afiume a deadly appearance; the action of the 
 heart and arteries, and the function of refpiration, are 
 not perceptible, or extremely obfcure. 
 
 In this fituation he continues for a longer or 
 fhorter time, and too frequently ends his exiftence : 
 But generally the involuntary organs recover their 
 fufpended operations, 
 
 The breathing is deep, fonorous, laborious, and 
 flow j the pulfe irregular, labouring, and opprefTed ; 
 but, fometimes the lungs play with freedom and 
 eafe, the pulfe is free, foft, regular, and full ; and, 
 in fhort, the ftate of the vital functions correfponds 
 to that of Jleep, 
 
 The face is flufhed, and often livid; the eyes tur- 
 gid, and the pupils dilated ; the ftomach is affected 
 with naufea, ficknefs, and vomiting •, inteftines con- 
 ftipated ; and thefe fymptoms are frequently accom- 
 panied with an efFufion of blood from the nofe, 
 ears, and eyes. 
 
 The 
 
( *3 ) 
 
 The mufcles, fubfervient to the will, are vari- 
 oufly convulfed -, particularly the mufcles of one fide 
 are violently agitated with alternate contractions and 
 relaxations, while thofe of the oppofite are in a ftate 
 of perfect paralyfis. 
 
 Thefe convulsions are often extremely obfeure, 
 the mufcles being affected fimply with tremor, efpe- 
 cially manifeft in the distortion of the features of 
 the face. 
 
 Thus Situated for an unlimited time, fufpended 
 between hope and defpair, we have no certainty of 
 approaching death, nor evidence to warrant a con- 
 jecture of probable recovery. 
 
 At length the fymptoms are mitigated; the 
 breathing becomes more free and eafy ; the pulfe re- 
 gular, full, more quick and frequent ; fenfibility in 
 fome degree returns •, he is reftlefs, awake to active 
 ftimuli, is fenfible to light ; the pupils contract, the 
 eyes exhibit the appearance of intoxication, " and 
 he 'talks incoherently." 
 
 Thus, gradually, he verges from the jaws of 
 death, again to exercife the functions of life, and 
 exhibit health, that ineftimable blefling. Some 
 degree of fatuity continues for a fhort time; and 
 we have inftances of its continuing for life, accom- 
 panied with paralyfis. 
 
 Our 
 
( H ) 
 
 Our efforts to obtain this falutary termination are" 
 frequently baffled ; the difeafe purfues a different 
 courfe-, and inftead of the fymptoms laffc detailed, 
 thofe of an oppofite complexion take place. The 
 breathing is Fmall, flow, and very obfcure; the pa- 
 tient is abfolutely infenfible ; his pupils remain fixed 
 and dilated when expofed to the ftrongefi light ; his 
 face and extremities are pale and cold; pulfe fmall, 
 very flow, weak, and intermittent; the urine and 
 fasces pafs involuntarily - 3 and now all hopes of cure 
 are precluded, and death is at hand. At length 
 general convulfions fupervene and conclude this 
 painful fcene. 
 
 REMOTE CAUSES. 
 
 AUTHORS have generally coniidered the divi- 
 sion of the remote caufes into occafional and predif- 
 pofing, as fuperfiuous; becaufe (fay they) the excit- 
 ing never requires the aid of predifpofition, and the 
 difeafe always arifes from their power alone. 
 
 That this is generally the cafe will not be denied. 
 But, I will rifle an opinion, that inftances have oc- 
 curred where the difeafe has been avoided from the 
 abfence of predifpofition, and in every occurrence 
 is aggravated thereby. 
 
 The 
 
( m ) 
 
 The neceflity of this further appears, and is par- 
 ticularly enforced by its influence in determining the 
 prognosis, and directing the indications of cure. 
 
 OCCASIONAL CAUSE. 
 
 COMMOTION or concuflion of the brain. 
 
 PREDISPOSITION. 
 
 THIS I hold to confift in a phlethorie ftate of the 
 fyftem in general, and of the head in particular. 
 General phlethora may arife from original ftamina, 
 a liberal ufe of animal food and fpirituous liquors; 
 frequent intoxication, iedentary life, imbecility in the 
 intellectual operation, interruption or fuppreflion of 
 the fecretions, fuppreflion of accuftomed evacuations ; 
 and, we are told that frequent bleeding will have the 
 fame effect:. 
 
 Phlethora of the head, in particular, may depend 
 on original conformation. 
 
 A large head, fliort neck, contracted thorax, and 
 a conftitutionally lefs capacity of the lungs in pro- 
 portion to the other parts of the body. 
 
 Corpulent 
 
( 16 ) 
 
 Corpulent habit, oflincation of the valves of the 
 heart, and debility of the fame. 
 
 Caufes referred to the lungs, varioufly interrupt- 
 ing, impeding, and retarding the minor circulation. 
 
 Effufions of blood, ferum and extrication of air 
 in the cellular fubftance of the lungs. 
 
 Hydrops pericardii, hydrothorax, fpafms, rigi- 
 dity, and tremors j tympanites, aneurifms, afcites, 
 amputation \ youth, old age; and, in fhort, what- 
 ever will increafe the determination to, or prevent 
 the return of blood from the head, will produce 
 a phlethora of the fame. 
 
 PROXIMATE CAUSE. 
 
 THE queftion which I am now to difcufs, is as 
 interefting to the Patient, intricate and perplex- 
 ing to the Practitioner, as any within the jurifdiction 
 of Surgery. . . 
 
 Surgeons have agreed on the caufe, nature, and 
 cure of compreflion of the brain from external vio- 
 lence •, imputing the difeafe to compremon, depend- 
 ing on extravation, congestion, depreffion of bone, 
 and the introduction of foreign fubftances: But 
 
 the 
 
( i7 ) 
 
 the fancy of modern inquifitors has invented a new 
 fpecies of difeafe, entitled Concuflion of the Brain ; 
 though of a nature diametrically opposite, in the 
 character fo nearly allied to compreflion, that the 
 diftinction would elude the penetration of a Newton* 
 
 With all deference to fuch authorities, I believe 
 the fame to have no exiftence in nature, and to be 
 a phantom of the imagination only. 
 
 This diftinction was firft fuggefted by the French,* 
 who are unbounded in ambition, enthufiafts in no- 
 velty, happy at invention, and fond of the marvel- 
 lous. 
 
 Like contagion it has diffufed its noxious in- 
 fluence, aflimilated the Surgeons of the adjacent and 
 remoter!: countries ; and to this caufe too many owe 
 their diflblution. 
 
 Authors of a more recent date, unfatisfied with 
 the obfervations of their predeceflbrs, have refined 
 on refinement-, the former having denied the exift- 
 ence of compreflion in concuflion, to which the latter 
 have added debility as the proximate caufe, and 
 attributed to concuflion a direct fedative operation, 
 analogous to contagion, cold, fear, and other known 
 fedative^. \ What a ftrctch of the imagination ! 
 
 C I have 
 
 * Sharp'i Ciiiical Inquiry. 
 -) 1541'; SyfUm of Suigery, 
 
( i« ) 
 
 f have attentively weighed, and revolved in my 
 mind, in the moil favourable point of view, the ar- 
 guments urged in iupport of concuffion independent 
 of compreffion, and I am forry to fay, I have not 
 been able to difcover a rational foundation •, and no 
 doubt exifts with me as to the fallacy of their ob- 
 fervations, 
 
 Upon the whole, I prefume I fhall clearly main- 
 tain, that the variety of the phaenomena marked in 
 the hiftory of compreffion, and other circumftances, 
 on which the doctrine of concuffion has been found- 
 ed, may be referred to a difference in the predifpofi- 
 tion, &c. which gives no effential difference, implies 
 an analogous operation in the occasional caufe, marks 
 a variety only, and mews the deception of experi- 
 ence. 
 
 Though I have rejected the idea of excluding 
 compreffion in what authors denominate concuffion, 
 I admit that debility is induced, is to be fought 
 for to explain many phenomena, and is of infinite 
 moment in the method of cure. 
 
 This debility I hold to be indirect, the refult of 
 exceffive ftimulus, and not the immediate effect of 
 direct fedative powers. 
 
 From 
 
( i9 ) 
 
 From this consideration only we can explain the 
 inftantaneous fufpenfion of life, and immediate re- 
 ftoration of the fame, when the brain is fubjected 
 to violent concufliorj. 
 
 That debility, and not compreflion, is the caufe 
 of the phasnomena in this inftance, is obvious from 
 the following reflections. 
 
 What reafon can be given why the functions of 
 life, after a complete fufpenfion, inftantly return to 
 exercife with their ufual energy ? 
 
 Abforption is a tedious, laborious procefs, and 
 no one acquainted with the laws of the animal ceco- 
 iiomy can conceive extravafation and abforption in 
 the inftance mentioned ; and it is equally improbable 
 that congeftion exifted. 
 
 All caufes, fo far as they have a mechanical opera- 
 tion, are, to the human body, direct ftimulants. 
 By comparing the phasnomena of concufllon with 
 the morbid effects of electricity, joy, anger and 
 pain, the moft perfect analogy muft ftrike the un- 
 prejudiced and enlightened mind. 
 
 As the phasnomena of concufllon have the ftricteft 
 refcmblance to thofe of electricity, &c. it is unphi- 
 
 iofophic;i! 
 
( 20 } 
 
 lofophical to fay, that the fame effects refult from 
 oppofite caufes.* 
 
 Haying refuted the idea of direct, and eftablifhed, 
 upon invulnerable ground, the exiftence of indirect 
 debility, it remains to mew the exiftence of com- 
 preffion in concuffion, 
 
 This I conceive a difficult tafk, more fuited to age, 
 experience and obfervation, than calculated as an 
 exercife for a youth yet an infant in his profeflion. 
 
 Necellity needs no apology, and I afiume the ar- 
 duous undertaking with that diffidence becoming my 
 period of life. 
 
 I have already maintained the exiftence of debility 
 refulting from concuflion; it may feem paradoxical 
 now to urge the neceflity of compreflion, 
 
 I wiih to be clearly comprehended. The opinion 
 I have already advanced has a relation to circum- 
 ftances, feldom the objects of furgical obfervation. 
 
 No one is ignorant, that inftances daily occur, 
 where life is fufpended by falling from a height on the 
 feet, head, or other parts ; and on the moft accu- 
 rate examination, we have no evidence of folution 
 of continuity, conturlon, extrayafation, or congeftion. 
 
 We 
 
 * *.*. Identity of effefl: Implies identity of caufe." 
 
( %% ) 
 
 We have a more familiar example of this in the 
 impious and fhameful practice of boxing. We have all , 
 witneffed, and many have experienced what pugilifts 
 confider as an invariable rule, that a blow under the 
 ear, between the maftoid procefs of the temporal 
 bone and angle of the jaw, thrown the victim to the 
 ground, where he lies apparently inanimate-, but in a 
 few moments he is revived, renews the conteft, and 
 engages his antagonift with redoubled energy. 
 
 This (late of concumon is not what Surgeons are 
 contending about. When the intellectual faculties, 
 fenfe and voluntary motion are no more, and the 
 vital functions continue to difplay themfelves ; when 
 thefe exift to a considerable degree, and are of fome 
 duration, they conftitute what is to many fimple con- 
 cuflion, and to others complete compreffion. 
 
 I hold it as a principle in phyfiology, that a free 
 and uninterrupted ftate of the nervous power, (what- 
 ever that may be,) is necefTary to the exigence and 
 exercife of the intellectual faculties, fenfe and volun- 
 tary motion. 
 
 It is equally true, that the animal functions may 
 be fufpended, and the vital continue in action. It 
 appears, therefore, that a caufe capable of effecting 
 the firft, may be inadequate to the fecond; and that 
 in the difeafe now under confidcration, though an 
 
 injur/ 
 
( 22 ) 
 
 injury of iome kind has arretted the animal, the vital 
 organs are fupported by that ftate of the fenforium, or 
 nervous energy, which, though inefficient for the 
 former, is equal to the latter. I am aware of the 
 objection, that the phenomena which I have juft laid 
 down as depending on compreffion, are frequently 
 the effects of a ftate of the nervous Jyjfem, in which 
 we have^ (fay they) no caufe to fuipeet compreffion. 
 
 The firft of which is Jleep. 
 
 That this ftate is not produced by extravafation is 
 obvious ; but to me it is equally probable, that, though 
 compreffion is not the firft caufe of fleep, it completes 
 and preferves that ftate, and without which it would 
 never take place. 
 
 I am perftiaded of the truth of this from a variety 
 of confederations. 
 
 The mechanifm of the brain, which is calculated 
 to retard and accumulate the blood in this organ, 
 while no other ufe, equally probable, can be affigned, 
 (except giving a certain degree of energy to the ner- 
 vous fyft em)* is fufficient evidence, in a cafe intricate 
 as the prefent, to warrant the aflertion.-f- 
 
 " Befide 
 
 * On one, the mod fi-nple principle, nature accomplices two of the 
 moft important ends in the animal ceconomy, excitement and 
 
 COLLAPSE. 
 
 •J- This explanation of the sensorium does away what has hither- 
 to been considered a desideratum in physiology; to wit, a rcafon 
 
r 
 
 ( 23 ) 
 
 c * Bdide the caufes now mentioned occalioning 
 apoplexy by compreflion, I alledge there are other 
 caufes producing the fame difeafe, by directly deflroy- 
 ing the mobility of the nervous energy. Such 
 caufes feem to be mephitic air arifing from ferment- 
 ing 
 
 why a greater quantity of blood is distributed to this organ than is necefTary 
 for its nourishment. On this has been built the favourite hypothecs of 
 the nervous fluid. I f we re af on from analogy, (fay they,) the brain 
 is a gland, deftined for the fecretion of a peculiar fluid ; it being a fadt, 
 that, whenever a greater quantity of blood is fent to any organ than is re- 
 quired for its fupport, it is intended for fecerning from the circulating 
 mafs a certain fomething sui generis. To this rule there are obje&ions; 
 thespLElN, ^■■■tiiid ca?vl.£ sekales; in none of which 
 have we any evidence of their glandular ftruc"lure, no excretory duct 
 hiving been difcovered 5 nay, I may with propriety fay never will. 
 
 The explanation given is confiftent with the more remote caufes of fleep. 
 Exercife of the various functions of the body, by exhaufting the energy 
 of the fyftem, favours congeftion in the vefTels of the brain ; for, as the 
 velfels of this part forward their blcod by their own energy and the vifa- 
 tergo ; fo, in cafes of general debility, parts thus fituated, are molt rea- 
 dily furcharged ; and hence the head, thoracic, and abdominal 
 viscera are moll; frequently affeifted with congeftion. In this way Na- 
 ture compels the moft obuinate to yield, and enforces recreation. We 
 have a further illustration of this from the fomniferous effefts of cold. 
 We all know, that when expofed to a degree of extreme cold, we become 
 drowfy ; and, fcnlible of the impending evil, in vain we refill, fleep ap- 
 proaches, and, if the caufe continues, we expire without a fenfe of pain, 
 anxiety, or regret. I conceive that cold produces thefe effedts, by dimi- 
 nishing the energy of the fyitem ; the heart, unable to exert its ufual force, 
 propyls the blood with difficulty in the extreme parts, and, therefore, it 
 accumulates internally, but more particularly in the vefTels of the brain, 
 for the reafoni before given. ^ 
 
 A difficulty here arifej — if congestion is the caufe of deep, what folu- 
 tion will be given, why a perfon can be inflantly awoke? Compreffion 
 from eitrarafation, and that from congestion in the vefTels, are different 
 with refpeel to duration. In the firft, compreffion can only be relieved by 
 *bf .rpi.ion, wlnlr, in the latter, a relloration of adtion alone is all that ii 
 icqijifite j therefore, on the caufe of excitement being given, he is a woke ; 
 
( H ) 
 
 frig liquors, and from many other fources ; the fumes 
 arifing from burning charcoal ; the fumes of mercu* 
 ry, of Jead, and fome other metallic fubftancesj 
 opium, alcohal, and many other narcotic poifons i 
 To which I would add the power of cold, of con- 
 cuflion, of electricity, and of certain paftions of the 
 mind. 
 
 " None of thefe poifons, or noxious powers, feem 
 to kill by acting on the organs of refpiration, or 
 fanguiferous fyftemj and I believe their immediate 
 and direct operation to be on tWiwUPoiis power, 
 deftroying its mobility •, becaufe thefe poifons fhew 
 their power in deftroying the irritability of mufcles, 
 and of the nerves connected with them, when both 
 thefe are entirely feparated from the reft of the body. 
 
 " With refpect, however, to the circumftances 
 which may appear on diflection of perfons dead of 
 
 apoplexy, 
 
 but even this is not immediately, for frequently he continues in a ftate of 
 femi-watching for fome time ; and when he is revived, on withdrawing the 
 caufe, he (inks in the fame ftate ; and if he does not, it is only after 
 fome time that the watching ftate is completed. 
 
 I conceive, however, that the caufes principally to be noticed in explain- 
 ing the phaenomenon of fleep, j£a peculiar organization and habit. We 
 have a beauf iful illuftration of this in the organ of voice : here the moft 
 ^ftonifhing phenomena in the animal machine depend on peculiarity of 
 organization, and a facility of action in the mufcles fubfervient, acquired 
 by repetition : fo the fame caufes referred to the sensorium, may produce 
 congestion and inanition not to be expected a priori ; and hence the caufe 
 of children fleeping ia much more than adults, and as they advance. t» 
 puberty of its gradually dimlnilhin j. 
 
( H 7 
 
 apoplexy, there may be fome fallacy in judging from 
 thofe of the caufe of the difeafe. Whatever takes off, 
 or diminishes the mobility of the nervous power, may 
 very much retard the motion of the blood in the vef- 
 fels of the brain, and perhaps to a degree of increasing 
 exhalation, or even of occasioning rupture and effu- 
 fion i fo that, in fuch cafes, the marks of compreflion 
 may appear upon diflection, though the difeafe had. 
 truly depended on caufes destroying the mobility of 
 the nervous power. This feems to be illuftrated 
 and confirmedhfrom what occurs in many cafes of 
 epilepfy : in fome of thefe, after a repetition of fits, 
 recovered from in the ufual manner, a fatuity is in- 
 duced, which commonly depends upon a watery in- 
 undation of the brain i and in other cafes of epilepfy, 
 when fits have been often repeated without any per- 
 manent confequences, there happens at length a fatal 
 paroxifm ; and, upon diSTedion, it appears that an 
 effufion of blood had happened. This, I think, is 
 to be considered as a caufe of death, not a caufe of 
 the difeafe-, for, in fuch cafes, the difeafe had dimi- 
 nifhed the action of the veffels of the brain, and 
 thereby given occafion to a Stagnation, which pro- 
 duced the appearances mentioned. And, I appre- 
 hend the fame reafoning will apply to the retro- 
 cedent gout, which, by deftroying the energy of the 
 brain, may occafion fuch a ftagnation as will produce 
 D rupture, 
 
( 26 ) 
 
 rupture, effufion, and death ; and in fuch cafes the 
 appearances might lead us to think that the apoplexy 
 had depended entirely on compreflion." 
 
 In thefe quotations we have the authority of Doc- 
 tor Cullen, together with extreme plausibility, to 
 fhew, that concuffion, though it produces debility in 
 the nervous fyftem, is attended with compreflion. 
 
 This the Doctor will not admit as a caufe of the 
 cfifeafe, but as an effect of death, for, what reafon I 
 am at a lofs to fay. 
 
 1 might with equal propriety contend, that ex- 
 travafation or depreffion of bone from external vio- 
 lence, were not the caufes of an apoplexy in fuch in* 
 fiances, becaufe they were occafioned by external 
 violence -, and, therefore, the force applied is the 
 caufe, and extravafation or depreffion of bone, the 
 effect of death : For what is the difference, whether 
 the effufion or extravafation is the effect of rupture 
 by violence, or rupture and effufion from a want of 
 energy in the vefiels ? 
 
 In the former the apoplexy evidently depends up- 
 on extravafation and deprefled bone ; and it is equally 
 true, that, in the latter, though debility of the ner- 
 vous energy occafioned the rupture and effufion, de- 
 bility independent of that would not produce the 
 
 apoplectic 
 
( 27 ) 
 
 apoplectic ftate; for, if it Would, a reftoration of 
 energy would be the cure : this is contrary to fact, 
 and therefore debility is the remote, and compreffion 
 thQ proximate caufe, and not the effect of death. 
 
 The fact which I am now to lay down as invariably 
 the cafe in every inftance, and for the truth of which I 
 appeal to every Practitioner experienced in Surgery, 
 that when concuffion of the brain is of duration 
 fufficient to fall under the obfervation of Surgeons 
 and Phyficians, it will be found, that the animal and 
 v\tal functions were extinguifhed at the inftant of 
 concuffion, and that this is momentary : For though 
 the animal functions continue in a ftate of fufpenfion, 
 the vital renew their action ; and in this ftate the 
 perfon remains for an unlimited time^ 
 
 If concuffion, independent of compreffion, flip- 
 ports the difeafe under the circumftances I have men- 
 tioned, I a(k a reafon why the animal as well as the 
 vital functions were not reftored. 
 
 A reply to this queftlon I conceive will be diffi- 
 cult, and a rational folution only can be given on the 
 principle of compreffion. 
 
 That debility alone docs not exhibit the phenome- 
 na, I conclude from hence, that if it did, there would 
 
 be 
 
( 28 ) 
 
 be no paufe at the vital, and the animal functions 
 would be reftored in the fame progreflion : This, 
 however, is otherwife ; for the animal functions do 
 not proceed to a reftoration of action in the fame 
 progreflion, but remain in a ftate of abolition for a 
 confiderable time, and at length frequently end in. 
 death. 
 
 This is a ftubborn objection to the dodrine of 
 concuflion independent of compreflion, and we muft 
 purfue fome other courfe to arrive at the truth. J 
 would attempt it in this way : Violence of excitement 
 from concuflion terminates in & ftate of collapfe 
 analogous to fyncope from joy. 
 
 I confefs, that, in this ftate, the neceflity of com- 
 preflion does not appear ; I prefume at the fame 
 time, that extravafation accompanies the excitement, 
 or, that congeftion in the yeflels takes place at the 
 time of collapfe. 
 
 If fyncope from joy does not terminate in a ftate 
 of irrecoverable collapfe, it in a few moments difap- 
 pears, and excitement returns; fo, in cafe of col- 
 lapfe from concuflion, the fame takes place, except 
 with this difference, that in fyncope excitement is 
 reftored to the whole fyftem •, whereas, in concuflion, 
 to the vital funffiqns only. 
 
 The 
 
( 29 ) 
 The following is the reafon. 
 
 I have ftated it as a principle in phyjiology, that 
 a caufe, capable of fufpending the animal, may be 
 inadequate to produce the fame effect on the vital 
 organs : Now, I conceive, that in the inftance of con- 
 cuflion, life is fufpended from collapfe only, and the 
 excitement is reftored to the vital functions -, becaufe 
 extravafation or congestion in the veflels producing 
 compreflion, exifts at the fame time j and though 
 inadequate to any manifeft injury on the vital, is com- 
 petent to a lofs of the animal f Millions. 
 
 Bell, in his Syftem of Surgery, fays, " So far as 
 my obfervation goes, the mod material difference 
 which occurs between the fymptoms produced by 
 theft two caufes, concuflion and compreflion, is met 
 with in the pulfe and in the breathing. 
 
 " In a compreffed ftate of the brain, the breathing 
 is commonly deep and oppreffed, fimilar to what 
 moft frequently takes place in apoplexy-, whereas, 
 ill patients labouring under commotion or concuflion, 
 the breathing is in general free and eafy, and the 
 patient lies as if he was in a found and natural flecp. 
 The pulfe is commonly foft and equal, and not 
 irregular and flow, as it ufually is found to be when 
 the brain is compreffed. 
 
 "In 
 
( 3° ) 
 
 " In cafe of comprefled brain too, although little 
 or no relief may be obtained from blood-letting, 
 yet no harm is obferved to accrue from it; for in 
 fuch circumftances it may be prefcribed in moderate 
 quantities, without reducing either the frequency or 
 ftrength of the pulfe ; whereas, in real concuflion of 
 the brain, the pulfe, as we have already remarked, 
 will frequently fink, and become more feeble on the 
 difcharge of only eight or ten ounces of blood." 
 
 Thefe obfervations, on the circumftances of the 
 two difeafes, may induce an inattentive obferver m 
 adopt the diftinction \ but, I apprehend I mail be 
 able to account for the variety quoted, and admit 
 the exiftence of compreflion. 
 
 There is a ftate of the arterial fyftem which pa- 
 thologists have named phlethora ad vires ; and we all 
 know the exiftence of inanition produces an oppo- 
 site ftate-, the compreflion being given, thefe two 
 ftates of the fanguiferous fyftem will give the variety : 
 For inftance, if a phlethora ad vires fhould exift; in 
 one, and inanition in another, the firft will prefent 
 the fymptoms of compreflion; the fecond will exhibit 
 the phenomena of concuflion. — In fupport of this 
 an explanation may be required. 
 
 The 
 
( 3* ) 
 
 The pulfe in phlethora ad vires is irregular, flow 
 and opprefled, and correfponds to that of compref- 
 fion. This does not arife from a want of energy in 
 the nervous fyfiem, but from the equilibrium be- 
 tween the arteries and their contents being deftroyed, 
 from the predominancy of the latter. 
 
 The fame consideration accounts for the deep and 
 oppreffed breathing ; for, as this organ is a mixture 
 of voluntary and involuntary, and as the animal 
 functions are fufpended, the mufcles, fubfervient to 
 the organ of refpiration, refufe their afliftance ; 
 and hence the ftate of refpiration in compreffion* 
 Further, the blood is accumulated in the right au- 
 ricle and ventricle of the heart, from the flownefs of 
 refpiration, the diminifhed energy of the heart and 
 phlethora ; and, therefore, a deep infpiration is ne- 
 cefTary to the tranfmimon of the accumulated blood. 
 
 The breathing is free and eafy, the pulfe foft and 
 equal in concumon, and anfwers to that of fleep. 
 
 I have no doubt but Practitioners have been de- 
 ceived by thofe circumftances of the breathing and 
 pulfe, bccaufe I mall now prove them to depend up- 
 on com preflion. 
 
 The cavity of the crarium being given, and always 
 the fame, at different times it will be more or lefs 
 
 completely 
 
( 32 J 
 
 completely filled, according to the ftate of the vejfels of 
 the brain. If two perfons of unequal ftates of pble- 
 thora fhould have accumulated in the fcull the fame 
 quantity of matter, one may receive comprefnon 
 equal to a complete ftate of apoplexy ', and the other 
 mall receive no injury, or if he does it will be in a 
 lefs degree ; for the accumulation being given, the 
 comprefnon will be in proportion to the phlethoric 
 fiate of the brain. 
 
 A more lnconfiderable accumulation and ftate of 
 inanition of the vejfels, will explain why a foft, equal 
 pulfe, and a free, eafy refpiration takes place in this 
 Inftance and not in the other. As refpiration is iii 
 fome degree under the influence of the will, it Will be 
 impaired in proportion to the lofs of the fame ; and 
 as the degree of refpiration required will be in pro- 
 portion to the quantity of blood to be circulated by 
 the lungs, we have < a reafon, without the neceffity of a 
 comment, why the ftate of the vital organs corref- 
 ponds to a ftate of Jleep, having previoufly fhewn 
 this phenomenon to depend on comprefnon. 
 
 DifTeclion, fb frequently the refource of Surgeons, 
 Is often fallacious. 
 
 We have it roundly afterted in books of furgery, 
 that after the moft attentive examination of many 
 
 who 
 
( 33 ') 
 
 who died of concuffion, they were not able to dif- 
 cover the leaft veftige of compreffion. 
 
 It would be illiberal to charge the authors of 
 fuch direction with wilful mifreprefentations of the 
 refult of their inquiries; but, I may with the 
 ftricteft propriety obferve, that it. did exift in every 
 fuch inftance, though it eluded the eyes of thofe 
 blinded by prejudice. 
 
 I mail anticipate the reply to this obfervation, that 
 the fame refult has attended the purfuits of the 
 warmeft advocates for compreffion: I admit the 
 fact, but deny the force of this as an objection. 
 
 Compreffion from external violence has hitherto 
 been confidered as produced by extravafation, de- 
 preffied bone, and the introduction of foreign fub- 
 ftances : was this a fact, I mould be in fome meafure 
 defeated by the energy of their difTection3: but, 
 compreffion from concuffion is frequently the effect 
 of congestion in the veffels of the brain. 
 
 Again, though extravafation mould exift, in thofe 
 inftanccs in which we are told diffiection has dif- 
 proved, I fay, I can eafily conceive, that the moft 
 accurate and liberal diflcctors may have been de- 
 ceived j for the extravafated matter neceflary to 
 produce this effect under particular circumftances, 
 
 E is 
 
( 34 ) 
 
 is tod inconfiderable to ftrike the fenfes, unlefs the 
 fame be fubjecled to the mod: fufpicious examination. 
 
 The circumftance I have juft mentioned is not 
 the only caufe of error in fuch cafes ; for the feat 
 of compreflion has generally been considered as 
 exifting between the duramater and crarium, the 
 former and pia mater, or the latter and brain: I 
 conceive, however, that extravafation may with 
 equal facility take place in the fubftance of the 
 brain, or fome other internal part, as thofe for- 
 merly mentioned.* 
 
 Further* extravafation of blood is not a neceflary 
 confequence of rupture of the veflels of the brain from 
 concuflion ; for ferum only may be, and frequently 
 is efFufed, and proves a caufe of compreflion. 
 
 Now, from the facts which I have juft mention- 
 ed ; to wit, a falfe idea of the feat of compreflion, 
 a partial knowledge of the caufes, and from the 
 inconfiderable quantity of extravafated matter ne- 
 ceflary to produce this effecT:, it is probable, that 
 diflection has done little more than nourifti an ab- 
 furd preconceived opinion. 
 
 As congeftion in the veflels of the brain is the 
 caufe in many inftances of compreflion from concuf- 
 
 fion, 
 
 * Pott'e Surgery. 
 
( 35 ) 
 
 fion, the reafon is obvious, why difTectors have 
 been fo often baffled in difcovering a caufe of com- 
 preflion. 
 
 If they had no fufpicion of the exigence of fuch 
 a caufe, is it probable that if it did exift, it would 
 fall under their obfervation ? I anfwer no j becaufe 
 the nature of congeftion may be, and generally is 
 fuch, as to render its exiftence ambiguous to thofe 
 who contend for its prefence. 
 
 The celebrated Bromfield and others found, from 
 long extennve experience and much obfervation, 
 that the afthenic plan was too rigidly obfervedj and 
 therefore, without a knowledge of the caufe of the 
 inefficacy of their practice, empirically ventured to 
 relinquifh the fame, and fubmit to fudorifes in fuch 
 cafes.* 
 
 I have no doubt that the indifcriminate practice of 
 venefetlion'm concuflion is. often injurious ; and lam 
 equally certain, that fudorifies, cathartics, and every 
 other part of the ajlhenic plan, are no lefs ambiguous 
 under particular circumftances. 
 
 I am led to believe, both from theory and practice, 
 that the fatality of this difeafe is owing to the pre- 
 judice in favour of fyftcm, whereby, practicing from 
 general indications, many and infuperable errors are 
 
 committed. 
 
 If 
 
 * Bomfield's Surgery. 
 
C 36 ) 
 
 If the mortality of this difeafe has abated fince 
 Surgeons and Phyficians have fufpe&ed the propri- 
 ety of bleeding in every inftance, and all ftages of 
 the difeafe, we have reafon to conclude, that, if for 
 the afihenic they had fubmitted the Jlbenic, the pro- 
 portion of deaths in fuch inftances would have much 
 diminished. 
 
 I am at a'lofs to fay, why the author of the pre- 
 fent Syftem of Surgery has advanced the experience 
 and obfervations of Bromfield, in fupport of his ri- 
 diculous hypothecs on the proximate caufe of con- 
 cufTion.* I admit that it is evidence of the exist- 
 ence of debility -, but this I mall fhew is not a caufe, 
 but a necefTary confequence of that fliate of the brain. 
 
 The exercife of the intellectual faculties^ fenfe-f 
 voluntary motion and refpiration, are direct ftimulants 
 to the fyftem, and th,e only caufe and fupport of its 
 
 activity, 
 
 It is now a notorious fact, that refpiration is a 
 procefs analogous to combuftion ; and that the of- 
 fice of the minor circulation is to impregnate the blood 
 with wh~t, in the new nomenclature of the French 
 chemifts, is known by oxigene, and to prove the 
 fource of animal heat. 
 
 It 
 
 f Bell's Syftem of Surgery, 
 
( 37 ) 
 
 It is equally weil eftablifhed, that the exigence 
 and exercife of this fun ^i on is efiential to animal life: 
 it appears further, that the prefence of oxigene is 
 necefTary to the action of the heart and arteries, it be- 
 ing the natural and only famulus capable of fupport- 
 ing the fame. 
 
 Now, whoever will reflect calmly On what has 
 been fubmitted on the animal and vital functions, 
 may eafily conceive from the fubduction of flimulus, 
 that in every cafe of compreffion of any duration, 
 debility muft be the refult. 
 
 In this way I prefume the difeafe proves fatal. 
 
 In all inftances of inanition, exifting at the time 
 of extravafation or congeflion, in confequence of 
 concuffion, I fay, bleeding is an ambiguous remedy, 
 becaufe the indication is to take off compreffion by 
 the removal of extra vafated or infarcted matter : this 
 can only be effected by abforption and a reftoration 
 of energy to the infarcted vefTels. 
 
 A queftion here arifes, Is venefection adequate to, 
 or compatible with the indication ? 
 
 This is a fubject equal to an Inaugural Eflay, and 
 improper to be difcufled at prefent^ I mail only re- 
 
 jr.ark, that ;n my opinion it is. 
 
 The 
 
( 3« ) 
 
 The fuccefs of Bromfield's practice appears to be 
 the refult not of judicious prefcriptions, but a leffer 
 degree of improper practice. 
 
 We adduce, from their own experience, the moft 
 invincible evidence of the non-exiftence of debility, 
 as the proximate caufe, 
 
 All the champions for this favourite hypothecs 
 fpeak favourably of the ufe of cathartics, as affording 
 lingular relief. 
 
 It is almoft unnecerTary to remark, that the energy 
 of the brain depends upon a certain ftate of tenfion 
 in the veffels of the fame, as is obvious from deple- 
 tion producing fyncope : examples of which we have 
 in the removal of a ligature from the arm in venefec- 
 tion, paracentifis thoracis et abdominis, and parturition. 
 
 The indication of cure, (agreeable to Bell and 
 others) is to invigorate the fyji em. 
 
 Who can reflect: on fuch lingular inconfirtency 
 without difguft ! 
 
 What are the effects of cathartics? To debilitate. 
 
 How far they are calculated to fulfil the indica* 
 tion needs no comment. 
 
 I prefume we are now in poneflion of an incon- 
 trovertible fact, to fubvert the ftately edifice of bril- 
 liant and fertile imaginations. 
 
 Dees 
 
( 39 ) 
 
 Does not the invariable and fuccefsful practice 
 of purging in phrenitis, Jynocha, and all other 
 Jihenic difeafes, and the general averfion of Phyfi- 
 cians to their exhibition in the afthenic, fpeak a 
 plain language; to wit, that their falutary effects 
 in concuflion can never be reconciled to debility 
 as a caufe, and, therefore, is one of many in proof 
 of the non-exiftence of the fame ? 
 
 From the preceding reflections on the proximate 
 caufe, it mufl be obvious, that the theory of the 
 fame is the following. 
 
 When the brain is fubjected to violent commo- 
 tion, the fyftem is greatly excited; this terminates 
 in a ftate of collapfe analogous to fyncope from 
 joy, and generally is of mort duration ; for the per- 
 fon in a few moments recovers his ufual excitement : 
 Butfometimes the vital functions only recover their 
 action, and the animal continue in a ftate of fufpen- 
 fion. In this ftate of the difeafc, I prcfume indirect 
 debility to have no agency in producing the pheno- 
 mena, and that the difeafe is fupported by comprcf- 
 fion : Again, that direct debility arifcs from the fub- 
 duction of ftimulus, and in this way the difeafe 
 proves fatal. 
 
 METHOD 
 
I 40 ) 
 
 METHOD .*/ CURE, 
 
 "WE may amufe our fancy, and indulge our in- 
 genuity in vifionary fpeculations on the theory of 
 difeafes-y but, the interpofition of art.'m adminifter- 
 ing relief, is of too ferious a. nature for fuch ex- 
 ercife. 
 
 As I have dared to relinquish the beaten path, 
 and propofe a change in practice, it may be confi- 
 dered neceftary that I mould, in conformity to cuf- 
 tom, mew the fallacy and inefficacy of Xh&fyjiems of 
 our predeceilbrs and cotemporaries on this fubjecT:. 
 
 The limited nature of this eflay renders fuch an 
 undertaking impracticable: I prefume, however, 
 that the arguments I ihall adduce in fupport of my 
 own, will fufficiently evince the impropriety of thole 
 which have preceded. 
 
 The obfervations which Ihave previously fubmit- 
 ted on the fubjedte of concuffion and compreflion, 
 leave no doubt as to the nature of the proximate 
 caufe; and therefore, the indication refulting there- 
 from is obvious; but to effedt the fame is ambigu- 
 ous and difficult. 
 
 The indication is to take oif comprefiion. 
 
 As 
 
( 4i ) 
 
 As comprefiion in this inftance is produced and 
 fupported by congeftion in the vefTels of the brain, 
 or extravafation, we can only remove the immediate 
 caufe by abforption, or a reftoration of energy to 
 the vefTels. 
 
 It would be of advantage if we were in pofTeffion 
 of circumftances to enable us to diftinguiih fuch 
 cafes as are occasioned by extravafation, from thofe 
 depending on congefiion in the vefTels ; but as this is 
 impofTible, and as three fourths of the whole depend 
 on extravafation, we mull choofe the leafr. of two 
 evils — abforption therefore is what we have in view. 
 
 As I have confined my inquiries to that variety 
 of comprefTion which arifes from concuflion or com- 
 motion, no indication can prefent with refpecl to the 
 operation of the trepan* 
 
 F The 
 
 * We are directed by Bell, in his Syftem of Surgery, in all cafes of 
 comprbsskd brain, though we are in pofleflion of rro circumftances 
 to direct to the feat of the injury, to trypan every accellible part of the 
 
 CRANIUM. 
 
 If ever a ihirft for novelty led a man into a labyrinth of folly, we have 
 an inftance of it here. Would not a Phyfician be impeached with infj.- 
 nity, or charged with fporting with the life of his patient, who, in cafes of 
 apoplexy, ftiould direct the ufe of the tr ipan ? and is not the prox- 
 imate caufe of apoplexy the fame as that of comprefiion from concuf- 
 fion > If fo, hive we any one fact, which in comprefiion can require or 
 juftify an operation, more than in apopi. txv ? If the operation of the 
 trepan wa« unattended with |uin, and of fuch a nature that w<: nerd 
 apprehend no danger from it» ufe, I fay, under fudi citcunillaiiccs, if the 
 probiLlity . , ,iiiurciJion MM nut iujIC than one of 
 
( 42 ) 
 
 The remedy in which I repofe the greatest con- 
 fidence, to effect the indication, is venefetlion. 
 
 c Could I reconcile the idea, that depleting the fan- 
 guiferous fyfiem will increafe and invigorate the action 
 of the abforbent^ I Ihould with eafe furmount every 
 difficulty as to the propriety of the remedy : But, 
 as I am not in poiTeffion of fads for its fupport, 
 and as I have no defire to impofe, by fubtilty of 
 reafoning, on the minds of men, at the expence 
 of my patients, I mull relinquifh the idea, as wild, 
 vifionary and abfurd ; although adopting it would 
 greatly aid to enforce the fyftem of practice which 
 I wilh to eftablifh. 
 
 It may be aiked, what are the circumftances of 
 thisdifeafe, which indicate the ufe of the lancet? 
 
 To this I reply, that venefetlion is practifed on a 
 principle different from what it is in inftances of 
 -phlegmafia •, in the latter we have in view the pro- 
 duction of debility, while in the former, my object 
 is to deplete until the fymptoms of compreflion 
 vanifh without inducing debility. 
 
 Whether 
 
 a thoufand, the operation would be warranted : But, as the operation Is 
 tedious and laborious to the Surgeon, and painful and dangerous to the 
 patient, it is injudicious, wicked and cruel, and will be avoided by all 
 wife, prudent and honeft Practitioners. 
 
( 43 ) 
 
 Whether the patient is of fhlethdrh habit or not, 
 blood fhould be drawn at certain intervals, until 
 fymptoms of relief appear, or death enfues-, for 
 the extravafation can only be removed by abforption •, 
 and as this is a tedious operation, the patient may 
 die from the fubduction of ftimulus.* Further, as 
 the vital is in fome meafure under the influence of 
 the animal funoiions, and thefe are in a ftate of fuf- 
 penfion, venefeflion, independent of relieving the 
 patient from the danger of fubduction of ftimulus, 
 by the fame operations, is calculated to promote ab- 
 forption. 
 
 In performing this operation, the following cir- 
 cumftances mould be ftrictly obferved : — The blood 
 mould flow from a fmall orifice, fo that the ftream 
 may not exceed the diameter of a hair : this mould 
 be interrupted on the difcharge of an ounce, by 
 clofing the orifice, and repeated every ten minutes 
 until one of the effects I have mentioned appear, 
 
 The fituation of the patient fhould be horizontal, 
 becaufe this will counteract the tendency to a ddi- 
 quium animi. 
 
 During the intervals of bleeding, the energy of 
 the fyftcm fhould be fupported by the diffufible fti- 
 
 muli •, 
 
 * Browne'i Elementi of McJicine, 
 
( 44 ) 
 
 muii j the exhibition of which muft be directed by 
 the judgment of the Practitioner.* 
 
 I am fenfible of the inconveniences which will 
 refult from any increafe of debility, and I have ac- 
 cordingly directed the evacuation to be made in a 
 manner, which, I conceive, will effect: the removal 
 of phlethora', without the acceflion of debility in 
 proportion to the quantity loft : For two pounds dis- 
 charged in the way I have prefcribed, will not be 
 equal to three ounces from a large orifice, without 
 interruption, and favoured by an erect pofture. 
 
 I truly lament the neceffity of an ambiguous re- 
 medy, but as We are in pofleffion of none fo proba- 
 bly judicious, the difficulties attending its ufe mufi; 
 be difpenfed with : The objections, though fpecious, 
 will in a great degree yield to a Scrupulous exami- 
 nation. 
 
 I have obferved, that the vital are in fome degree 
 influenced by the animal functions : Now, as the lat- 
 ter are in a ftate of fufpenfion, the abforbents will 
 be diminifhed in proportion to their dependence on 
 the fame. 
 
 Again, 
 
 * Thefe will counteract the enervating tendency of venefedrion, and 
 thus preferve, under the evacuation, the rigour of the fyftem. 
 
( 45 ) 
 
 Again, as .the cavity of the cranium is always the 
 fame, and the bulk of the brain in proportion to the 
 ftate of its veffels, I fay, it is obvious from thefe 
 considerations, that, as the extravafation neceflary 
 to effect compreflion is very inconfiderable,* vene- 
 feclion, by contracting the fenforium, will take off 
 compreflion •, confequently, fo far as the energy of 
 the abforbents was impaired by this caufe, it will be 
 renewed •, and the recovered (uCpznded fun ff ions will 
 afford feveral fources of ftimulus; therefore, the 
 evacuation, fo far from enervating, invigorates the 
 fyftem. 
 
 The ftate of the intejlines fhould be early attended 
 to-, for by difcharging the contents of thefe, the 
 phlethora of the head will be relieved by deriving to 
 the inferior parts : This intention will be bell effect- 
 ed by ftimulating cathartics, thebeft of which is the 
 mercurius dulcis ; for it not only is attended with this 
 laft effect, but, by zftimulus given to the abforbents 
 of the intejlines, communicated by confent to the 
 
 remainder 
 
 • I wai prefent at an operation of the trepan, performed by thatju- 
 diciom Phjfician I>oc"i;r William Moore, of this city : inthi* inftance, 
 the patient laboured under a complete compreffion of the brain, and the 
 eitravafitei! matter Hid not exceed five graim ; on the removal of which he 
 inftantij recovered hi.fcufe.. 
 
( 46 ) 
 
 remainder of the fame fyftem of vefTels, promotes 
 abforption,* 
 
 When the animal functions are in fome meafure 
 reftored, all further evacuation mould be prohibited, 
 and the cure fubmitted to mercury : But as a reco- 
 very of phlethora previous to the removal of extra- 
 vafated matter would occafion a return of the difeafe, 
 this mould be avoided by due attention in preferving 
 a favourable balance between the ingefia and excreta. 
 
 The fecondary fymptoms fo frequently occurring 
 and generally fatal, are attributed to a variety of 
 eaufes. Mr. Bell has fuggefted, that matter extrava- 
 fated or effufed between the cranium and pericranium^ 
 by ftagnating becomes acrid, ftimulates and increafes 
 the action of the veffels, and thus produces inflam- 
 mation, which, by the communication of veffels, 
 fpreads to the brain, and in this way proves fatal : I 
 conceive that the fame extravafation, efFufion, ftag- 
 nation and inflammation, may equally, and fre- 
 quently does take place in the cavity of the cranium y 
 and is attended with all the inconveniencies men- 
 tioned of the former. From this confideration, I 
 
 recommend 
 
 # On this principle I explain the effects of cathartics in the cure 
 jf dropsiis, 2nd not by the evacuation giving occafion to abforption. 
 
C 47 ) 
 
 recommend the continuance of mercury for a con- 
 siderable time, even when all fymptoms of the difeafe 
 have entirely difappeared ; and if this be ftriclly en- 
 joined, that train of fymptoms fo much feared, 
 often occurring, and in nineteen cafes of twenty ter- 
 minating in death, will be avoided. 
 
 FINIS. 
 
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