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By yours of the 14th. you do me a great deal
of honour and you may depend upon my utmost attention
to a Case in which you take so great a part not only
as a Physican but as a friend.

I am not disposed to be positive in any Case
and in this I find it difficult to be so and you
must consider what follows to be rather a Consulta¬
tion held with you than as anything to determine
positively either your opinion or practice.

In the first place I cannot perceive that either
his former Vegetable or his present Animal Diet
have been or are not the causes of his complaint.

2. I think it is pretty certain from several con¬
siderations that his pains have never been of the
Inflammatory kind.

3. I cannot find that his disease of whatever
nature it is, is seated in the Stomach as his entire
Appetite and Digestion, his feeling no disorder from

any kind of food and the absence of the Dyspeptic
symptoms he was formerly affected with are all to me
proofs that his stomach is perfectly sound. Vomitings
did not attend to his fits and Vomitings may arise
from a disorder in any part of the Alimentary Canal
and Vomitings violent or repeated will always emulge
the Biliary ducts and draw Bile into the stomach
to be rejected by Vomiting.

4. By rejecting the supposition of inflammation
and finding no room to suspect the application of acrid
matter I am necessarily led to suppose the disease
of the Spasmodic kind. This will be readily admitted
with respect to the paroxysms induced by cold and
relieved by Opiates & Laxatives. But I must at the
same time suppose some permanent topical affection
which Some How acccidentally irritated occasion[ing?]
both more violent spasm and spasms more extensively
affecting the Alimentary Canal.

5. Of what nature the topical affection may be

I am at a loss to determine. It is attended with a sense
of stricture and it may be chiefly of that nature but I
suspect something more perhaps some thickening of the
Coats in one part of the Intestines.

6. This leads me to consider more particularly the seat
of this affection. I have said it is not in the stomach but
from the pain felt on pressing the Epigastric region
and upon a full inspiration it must be near to the stomach
and therefore either in the Duodenum or Colon.

7 The general state of the System and particularly
the weakened tone of it may favour the coming on of such
diseases but I think there must always be also some
causes determining to a particular part. Such causes
indeed cannot be commonly perceived but they undoubtedly
take place and a great part of the Human Race have
from original conformation or particular accidents
have some frailty or fault in particular parts of their
body.

I have now given you from a careful study my
opinion of your patients Case and the grounds of that opinion

more fully than I can afford to do in many of the Cases I
am Consulted for. I am heartily sorry I cannot give in the
case of a particular friend of yours a more favourable opinion
and one that might lead to a certain Cure which indeed
I cannot promise with any confidence.

You have already employed many judicious and
proper↑mising↑ remedies but both from your want of success
and from the nature of the Case more topical than
general mak I must think that tonic remedies
will be of little service in preventing the returns of
the disease. For such prevention you must especially
trust to a very exact attention in guarding against
cold and moisture and for that purpose his using
always warm Cloathing, flannel next his skin and
particular care to keep his feet and legs always
warm and dry. It is not uncommon for such Colics
to come on with a spontaneous coldness of the feet and
by taking notice of the first feelings of this ↑and↑ by taking
pains to restore the heat of these parts the advance

of the fits have been often prevented. You have not
taken notice of his being liable to any Costiveness or of any
degree of that immediately preceeding his fits though
the pill you have employed looks something like it
and a particular attention to the state of the Bowels in
this respect must be of great consequence. With re¬
spect to his Diet the quantity of his Animal food
may perhaps be too much but I am certain that
much of the Vegetable would be still more dangerous
I would not therefore advise any change in his present
general plan but can advise moderation both in
the quality and quantity ↑of his Animal food↑ and though the same
rule is more necessary still with regard to his Vege¬
table food I would allow him or advise him to take
so much of this particularly of farinacea as he
knows from experience he can easily digest. Though
his disease is not of an inflammatory kind I know
that a very full Animal diet may prove a hurtful
irritation in every case of infirmity and especially

of every topical affection. In all cases also the bland
and mild state of the fluids is of consequence and therefore
a milk diet has often been useful. I dont think it
probable that Mr. Yates could bear this ↑entirely↑ but you
have not given me any data upon which I can find
any particular advice. On the subject of Prevention
I have not touched the article of Exercise which how¬
ever I think of great importance. Although you say
he has used Exercise on Horseback without evident
advantage I am persuaded it is always of great use
to the System in general and will always give
a good chance for Nature relieving topical affections.
I therefore recommend the continuance of his exercise
on horseback or in a Carriage as far as the weather
and his strength will allow his motion indeed should
always be gentle but it should be employed as often
and as long at one time as his circumstances mentioned
will allow.

I have now said as much as I can on the subject
of prevention and with respect to the management

of paroxysms when they come on your conduct has
been so perfectly judicious that I can offer no improve¬
ment upon it. I shall only say that upon the appearance
of an Attack if there is no ground to suspect any retention
of fæces which would indeed always engage your first
care I would otherwise be early in the employment
of Opiates and in very full doses. But as the Costive¬
ness induced by by opiates may be hurtful in its turn the
use of Oleum Ricini as the best medicine that
could be thought of will still be proper.

After writing thus far and again reading
your letter I find nothing omitted but
my not taking notice of the many symptoms of debility
which attend the paroxysms and subsist for some time
after them. With respect to these I have only to say
that they are marks of a spasmodic and Nervous
affection which in any part of the Alimentary Canal
is ready to affect the whole System with a great degree
of debility and for relieving which I know no other
remedy but the Opiate which may remove this spasm
that is the cause of it. For the languor that generally

succeeds the fits a light nourishing diet with what wine he
can easily bear may certainly be useful and I suppose you
have employed it and your experience will direct you better
in the management of it than I could do without mroe data
on this subject than you have given me and which I
presume were not necessary.

Before I quit the subject I must again say that though
I would not reserve anything from you I am by no means
positive in my opinion of a topical affection and on the contrary
hope very confidently that the means of prevention proposed
may even in time relieve the uneasy sense of stricture and
every other feeling that can mark a permanent affection and
therefore I am very doubtful in proposing any other means
of Curing it. I have thought both of Mercury & Cicuta but I
need not tell you what difficulties or doubts might be proposed
with respect to them and I will say no more of them till
I have your opinion of both your patients Constitution
and an account of the continuance of his symptoms. In
the case of any friend of yours I would wish to give you all
the assistance I can and the Fee I have received entitles
you to what further Consultation you can desire. I beg
therefore to hear from you whenever you think I can be of any
use.