Divison I. Class III. Diaphoretics.

Diaphoretics are a class of remedial agents which augment cutaneous transudation; if they produce copious perspiration, they are called sudorifics; if they but increase the insensible transpiration, they are called diaphoretics; the action of the two classes are the same, the degree of influence upon the cutaneous exhalants constituting the only difference.

The function of cutaneous transpiration is one of great importance to the welfare of the animal economy, so much so, indeed, that when it has been entirely arrested death ensues.

To appreciate the importance of this secretion, we have only to consider the extent of the excretory apparatus of the skin, and the amount and character of the matters excreted. In regard to the extent of this apparatus, Erasmus Wilson says: "I counted the perspiratory pores in the palm of the hand, and found 3,528 in a square inch; now each of these pores being the aperture of a little tube, about a quarter of an inch long, it follows that in a square inch of skin on the palm of the hand, there exists a length of tube equal to 882 inches, or 73.5 feet. Surely such an amount of drainage as 73 feet in every square inch of skin, assuming this to be the average of the whole body, is something wonderful, and the thought naturally intrudes itself,—'What if this drainage were obstructed?' The number of square inches of surface in a man of ordinary hight and bulk, is about 2,500; the number of pores therefore, is 700,000, and the number of inches of perspiratory tube, 1,750,000, that is, 145,833 feet, or 48,600 yards, or nearly 28 miles."

It has been estimated by Seguin, from careful observations, that eleven grains of matter are excreted from the skin per minute, being equal to thirty-three ounces in twenty-four hours. This consists of—

The maintenance of the normal condition of this very extensive and highly sensitive tissue, is of primary importance in the preservation of health. This is satisfactorily proven by the morbid conditions so frequently and so speedily induced by the suppression of perspiration, or by derangement of its normal function. When we take into consideration the extent of the cutaneous tissue, the innumerable sudoriferous glands, the ducts of which penetrate it and empty upon its surface, through which much of the effete matters of the system should escape, and through which they do escape, in a state of health, we can not be insensible to the important office which it performs. We can also readily understand the extensive influence which it is capable of exerting upon the whole system if its normal functions are destroyed, and also to the very salutary and extensive influence which may be exerted upon it, and through it upon the entire system, in subverting morbid action in disease.

There are four great emunctories through which all the decayed or decaying materials generated in the system by the processes of disintegration, and which can be no longer subservient to the purposes of the animal economy,—but which if retained, must act as sources of disease, causing fever, irritation, inflammation, etc.,—are excreted. Through these emunctories, the bowels, kidneys, lungs and skin, these obnoxious materials must pass off. Now if any of these excretory organs fail to perform their function, and elimination does not take place, the retained excrementitious materials must become irritants, and if long retained, they will not only vitiate the blood by their presence, but they will communicate the same process of decay to the blood, and hence some variety of fever or inflammation will be the result.

From these remarks relative to the excretions in general, and from the important functions which the skin is destined to perform, the following deductions may be drawn: First, we infer from the great amount of effete material thrown off in this way by this extensive extreting surface, that any cause that may arrest or diminish its normal action, and cause a retention of them, will be a cause of general disease, showing itself in some of the numerous forms of fever; or if some particular organ or tissue be predisposed to take on a diseased action, we may witness a local disease, or one in which the intensity of the excitement is concentrated upon a certain part, while other parts are but sympathetically affected.

"Health," says Dr. Eberle, "is very intimately connected with the regular performance of the perspiratory functions. Whenever the transpiration by the skin is suddenly checked, more or less derangement of the system is invariably the consequence." He further observes, "That portion of the circulating fluid which nature designs to be cast off by the cutaneous emunctories, as no longer fit for the purposes of the animal economy, is retained, and becomes a source of morbific irritation to the heart and other organs." We may also infer from its functions, and from the sympathetic relations which it bears to the glandular, lymphatic, mucous, serous and nervous systems, exalting, modifying or arresting their functions according to its own normal or abnormal condition, that it is an important tissue to act upon, and through which to counteract diseased action, whether excessive or diminished.

Experience has fully convinced us that suppression of the perspiration is a very fruitful source of disease. It is true that this suppression is often counterbalanced by some other emunctory taking upon itself a vicarious action, thus supplying the place of the one whose functions are impaired. We are also quite as well convinced that the restoration of this function is of infinite importance, and that those agents which restore it, whether they act directly or indirectly, are therapeutic agents of the first importance.

The views that we have above expressed relative to the utility of this class of remedies, and the importance of restoring this secretion in numerous diseases, are corroborated by many of our most distinguished authors, as Drs. Wood, Eberle, Thompson, Paris, etc.

In opposition to these views, we present those of Dr. Dunglison. He says: "It may admit, however, of well-founded doubt, whether disease be ever induced by suppression of the cutaneous exhalation." He supposes that cold, operating upon a limited part of the surface of our bodies, morbidly impresses the cutaneoue capillaries of that part, and that the local or general disease is sympathetic, or that the internal capillary system sympathizes with the morbid condition of the external capillaries. He says: "This irregular action of the capillaries of the part is the first link in the chain of phenomena, not the obstruction of perspiration." We readily admit that the first morbid impression from cold thus applied, is made upon the superficial capillaries; but this impression consists in a spasm of the minute vessels; the sudoriferous glands do not receive a supply of blood, and their excretory ducts are closed. There is a general cutaneous paralysis, and thus the excrementitious materials thrown into the capillaries to be eliminated, are retained; they accumulate, render the blood irritating, and produce fever, inflammations, etc. If, as Dr. Dunglison contends, the irregular action of the capillaries constitutes the first link in the chain of morbid phenomena, the superior efficacy of diaphoretics would be none the less important in breaking that "link"; for no influence which can be brought to bear upon the system when it is in a state of disease, so effectually subverts capillary excitement as diaphoretics. Yet, strange as it may seem, Dr. Dunglison still further remarks that, "In any mode, consequently, of viewing the subject, it does not appear that we can ascribe any extensive series of morbid phenomena to simple suppression of perspiration. Such being the fact, the indication of restoring suppressed perspiration—if it be admitted at all—must exist much less frequently than has been imagined." He further observes that but few classes are more frequently used, "and probably none which are more uncertain in their operation, and on which less reliance ought to be placed." Again he remarks "Perhaps we have no class of remedies more uncertain in their operation than anatomical diaphoretics, as ordinarily administered. It might indeed be said that there are no agents so devoid of any beneficial action." He finally sums up the matter in such a way that we can not fail to see the little importance which he attaches to this class of remedial agents. He says: "On the whole, then, even in febrile and inflammatory affections, the use of the ordinary internal diaphoretics is uncertain, and generally of no avail."

These views of this distinguished compiler we conceive to be eminently erroneous; instead of diaphoretics being "of no avail" in febrile and inflammatory diseases, and instead of the indication of restoring suppressed or diminished perspiration rarely existing, their employment in the cases referred to should constitute one of the cardinal measures in the treatment of such cases, and the restoration of the cutaneous transpiration is to be regarded as an indication of paramount importance. It is true many of the diaphoretic agents act indirectly upon the cutaneous capillaries, removing the spasm, and augmenting the secretions; yet their importance as curative agents, and the necessity of restoring or promoting that secretion is none the less imperative.

Action of Diaphoretics.—Diaphoretics may be divided into two classes, according to their mode of action: the first of these classes act directly upon the glands of the skin, and hence we name them specific diaphoretics; the second class produce diaphoresis indirectly, and on account of some other property possessed by them: these may be named indirect diaphoretics.

Specific diaphoretics stimulate the sudoriferous glands to increased action, and thus increase the secretion. We suppose that they act in the same manner as specific diuretics or cathartics; they have an affinity for this secreting structure, pass to it, and are eliminated by it; and in this manner stimulate it to increased action. Volatile diaphoretics belong to this class, as also ammonia and its various salts, and some acrid agents, as guiacum, senega, etc. The best example of this class is probably the asclepias tuberosa, or its active principle, asclepin. These agents are not always certain in their action, owing to the peculiar state of the system, or the different hygrometric states of the surrounding air. But as they act directly from the blood upon the secreting apparatus, if this is in a condition to be impressed by stimulus, these agents act as direct diaphoretics.

Indirect diaphoretics may act by relaxing the cutaneous tissues, or by determining the circulation to it. The effect of remedies which relax the system, in the production of diaphoresis, may be accounted for by the relaxed state of the capillary vessels of the skin, and the readiness with which the watery portions of the blood will pass through their coats in this condition, and also by the relaxation of the tissues surrounding the sudoriferous glands and ducts, whereby they are enabled to freely receive and throw their secretion upon the surface. This condition of the cutaneous surface is produced by emetics and nauseants; we also notice it in the relaxation which follows fever, and in the night-sweats of debilitating or exhausting diseases.

Determination of blood to the skin is an important part of diaphoresis; anything that will determine to the surface will increase the secretion, providing the cutaneous tissue is relaxed. Thus, in fever we have an increased circulation and determination to the surface, but the skin is constricted, hot and dry, and the walls of the capillaries tense and rigid; hence it is impossible for transudation to take place. But if the temperature and pulse are reduced by sedatives, we then have all the conditions present (if the body is kept warm) for the production of indirect diaphoresis.

The action of all diaphoretics is promoted by cleansing the skin, keeping the body warm, and by the free exhibition of warm diluents. Diaphoresis may he produced, simply by bathing the feet in warm water and keeping the body warm. The warm water relaxes the skin, and the heat determines to the surface.

The wet-sheet pack acts in a similar manner. Its first effects are indeed the opposite of diaphoresis; but when reaction takes place, the circulation is determined to the surface, which is relaxed by being in contact with the water.

Lastly, if the skin is kept cool, diaphoresis is prevented; that which would have been eliminated by the skin passes off by the kidneys. Thus, if we wish to produce diaphoresis, the skin should be kept warm, and the fluids taken should also be warm; while, if we wish to produce diuresis, we administer the remedy or diluents cool, and also keep the skin cool.

Therapeutic Indications.

Very different diaphoretics are demanded in different states of the system. If obstructed perspiration depends upon an exalted vital action, as in fever, nauseants, refrigerants, sedatives, ablutions (either tepid or cold), aided by any of the warm diaphoretic infusions, or even cold acidulated drinks, as iced water, lemonade, etc., will diminish the momentum of the circulation, lessen the vascular tonicity, and favor not only the restoration of the cutaneous transpiration, but other organs may be excited to resume their functions also. These agents act as sedatives, and indirectly as diaphoretics; they diminish morbid excitement throughout the vascular system, and particularly in the capillaries, and promote the secretions. A combination of properties as sedative, refrigerant, anodyne, nauseant, expectorant, diuretic, diaphoretic, etc., frequently adds much to their medicinal virtues; a combination of diaphoretics is always better than single articles.

Obstructed perspiration may depend upon a slow and languid circulation, in which case the skin will be shriveled and cold, indicating the cutaneous torpor and internal congestion; in this case a very different class of diaphoretics will be demanded. In these cases copious draughts of warm, stimulating diaphoretic infusions, as the aristolochia, eupatorium, monarda, asclepias, etc., aided by stimulating ablutions and brisk frictions to the surface, will prove most beneficial. These measures tend to relieve the internal congestions or visceral engorgements, by inviting the blood back to the surface, and by the determination to, and excitement of the sudoriferous apparatus, diaphoresis is the result.

In the advanced periods of life, when diaphoretics are demanded, a very different class should be selected to meet the indications. In the diseases of old persons the reaction is feeble; instead of that vigorons constitution and corresponding reaction of youth, their diseases, both febrile and inflammatory, are not attended with a high grade of vascular excitement, and consequently our remedies, both internal and external, to produce diaphoresis, should be of a stimulant character. Nor is it necessary or proper to carry diaphoresis to the same extent, even in the same diseases in aged persons, that we should in the young and vigorous. In such cases we frequently find it necessary, as well as advantageous, to add spirits to even the exciting diaphoretic infusions, and to the warm ablutions.

In the various forms of pneumonia we avoid stimulating diaphoretics, except in the advanced stages of the disease, unless they are combined with nauseants and expectorants. In these cases cold or acidulated drinks, or even stimulating or exciting diaphoretics, unless modified by nauseants and sedatives, are improper. A similar modification in our external applications should be observed. In high grades of fever we admit cold air to the surface, cold ablutions, etc., the whole course being refrigerant during the excitement; but in pneumonia we keep the surface warm, apply warm ablutions, or warm and emollient fomentations to the surface, to invite the blood to the superficial capillaries, in order to relieve the hyperemia of the lungs, and maintain constant diaphoresis. We resort to diaphoretics devoid of stimulating properties, as the asclepias tuberose, etc., and we continue them with nauseants.

Diaphoretics are a very important class of remedial agents in all those diseases that arise from atmospherical vicissitudes. In these diseases, torpor of the sudoriferous apparatus constitutes the first link in the chain of morbid phenomena which follow, and diaphoretics constitute our most valuable therapeutic agents to restore that secretion, and thus remove the cause of the diseased action.

I. Action in Fever.—Diaphoretics are of primary importance in the treatment of all febrile affections; the class of diaphoretics, and the extent to which they should be carried in particular cases, can only be determined by the stage of the disease, the grade of excitement, the age and vigor of the patient, its congestive, sthenic or asthenic tendencies, etc. All of these circumstances must be taken into consideration in determining the extent to which diaphoresis should be carried, and the proper diaphoretics to be selected and used.

In the early stages of most fevers, if the patient is young and vigorous, copious and protracted perspiration should be secured and maintained by cold or tepid baths, by nauseants, refrigerant and sedative diaphoretics, or they may be combined with those possessing stimulating properties. It is proper here to remark, that their employment should be preceded by the free use of cathartics, or emetics if indicated. In similar attacks of old persons, the stimulating diaphoretics and tepid ablutions should be employed, but in this case gentle diaphoretics alone are indicated. In the advanced stage of fevers, especially those of a typhoid type, free perspiration is too debilitating to be tolerated by the system, and should be avoided; but gentle diaphoresis or simple moisture of the surface is beneficial. If the fever is of an adynamic character, gentle and excitant diaphoretics, aided by tepid stimulating ablutions to the surface with brisk friction is very important.

Their sanative powers seem to depend upon a variety of influences which they exert upon the system. First, they remove the constriction of the cutaneous capillaries, and act as depletives by increasing the perspiratory function, and may therefore be regarded as antiphlogistic. Secondly, the evaporation which attends perspiration carries off the caloric, and thus lessens the abnormal heat of the system; in this sense they may be regarded as refrigerants. Thirdly, they equalize the circulation, by determining the blood to the surface; they remove congestion of internal organs. Fourth, they promote the elimination of morbid material from the blood, which if retained would prove a source of irritation, often producing fever, or if it already exists, it would tend to perpetuate it and render its type lower. They modify the condition of the skin, they soften and relax it, they lessen the heat and tension of it, and by an intimate sympathy existing between this extensive surface and every other organ or tissue of the body, a like salutary influence is exerted upon all.

II. Action in Inflammation.—The remarks which have been made relative to their utility in febrile disease, and to their therapeutic action, apply with equal force to their employment in inflammatory diseases. It will be recollected, that atmospheric vicissitudes play a very important part in the production of the phlegmasia, as well as fevers. When one organ or tissue is more disposed to take on morbid excitement than another, we meet with a local instead of a general disease; thus a number of persons exposed to the same morbific influences, may be the subject of as many different diseases; or but a small part of the number may contract disease, owing to the predisposition of some systems, or some organs to take on diseased action. Those who do not contract a disease are indebted for their escape to the sound and vigorous constitutions which they possess, for warding off the morbid influences, and securing them against its effects.

In inflammatory, as well as in febrile diseases, they are important as depletives, or antiphlogistics. They remove cutaneous spasms, lessen the morbid heat, abate the fever, produce sedation, invite the circulation to the surface, and thus act as revulsives, equalize the circulation, relieve pain, overcome the tension of the tissues implicated, and thus act as emollients, etc. They thus do as much, if not more, to effect a resolution of the disease than any other class of agents with which we are acquainted, providing proper perseverance and energy of action characterize their mode of employment,

The intimate sympathy existing between the cutaneous surface and the lungs, or between the functions of each, points to the employment of diaphoretics in pulmonic inflammation, as a class of remedial agents of singular efficacy. When perspiration is copious, the skin moist and relaxed, respiration is less painful and less laborious, and the distress or oppression in the chest is mostly, if not entirely relieved. The functions of the skin and lungs, it will be recollected, are analogous in several respects, and a very close sympathy exists between the two. We would therefore suppose that any agent which would relax the skin, and increase its secretion, would prove beneficial in arresting inflammation of the lungs — and experience has proved this to be true.

The same remarks apply to their employment in dysentery and diarrhea. The most superficial observer has not failed to notice the immediate influence which the obstruction of the cutaneous transpiration often exerts upon the bowels. Here, also, we have the same continuous membrane, and the same continuous sympathy, and the modifications of the function of either membrane influences that of the other; hence the great value of diaphoretics in these diseases. Diaphoretics, possessing anodyne and sedative properties, are of peculiar advantage in these cases. They are revulsives, determining the circulation to the surface, thus relieving internal hyperemia. They are anodyne, and lessen pain and dysenteric tenesmus. By their anodyne and sedative influence they lessen the pain and irritation in the bowels, diminish the mucous and intestinal secretions, and also diminish the augmented peristaltic action upon which the frequent discharges are dependent. They excite the cutaneous emunctories, equalize the circulation, break up morbid sympathies, and throw off the excrementitious matters which if retained can not fail to derange the system, and increase the existing disease.

III. Action in Rheumatism.—Diaphoretics are of much importance in rheumatism, and they probably owe their beneficial influence not only to the effects which have been before alluded to, but also to their eliminative action in removing from the system a morbid material upon which the disease depends. Dr. Williams states that "The perspiratory secretion contains lactic acid and lactates of soda and ammonia, which probably proceed from the transformation or decay of the textures, particularly the muscular, which the recent researches of Liebig have shown to contain a preponderance of this acid. Hence these products abound during great muscular exertion, and when perspiration is checked by external cold, they may be retained in the blood, causing rheumatism, urinary disorders, or various cutaneous diseases. The very serious effects sometimes resulting from sudden cold on the perspiring body may be partly owing to the same cause, as well as to the disorder produced in the circulation. Rheumatism is especially liable to occur as an effect of cold, where the body is fatigued with much muscular exertion; and I have frequently observed that the rheumatism chiefly affects the limbs which have been most exercised. Where the skin fails to excrete, an increased task is thrown on the kidneys, whence may result various diseases of these organs; and if these organs fail in the task, the lactic acid accumulates in the blood, and probably acting as a ferment, causes the formation of more, and of the kindred products, lithic acid and its compounds and products; these, in inflammatory subjects, excite rheumatic fever; in cachetic persons, miliary fever, erysipelas and pemphigus; and in more torpid frames, various local rheumatic or gouty affections. All these cases are frequently remarkable for the acid character of the cutaneous and renal excretions; and in a few instances, the blood has been found to possess acid qualities, or to be deficient in its usual alkaline reaction."

The direct action of diaphoretics in this disease is, then, to stimulate the sudoriferous apparatus to increased elimination, and as lactic acid is a normal constituent of this secretion, it is removed from the system in large quantities; lactic acid being the supposed cause of rheumatism, its removal is followed by a cessation of the disease. Such agents as increase both the secretions from the skin and kidneys, prove most advantageous; and as the materies morbi is an acid, we would suppose that alkaline diaphoretics and diuretics would prove the most valuable agents, and experience fully substantiates this conclusion. As the type of such a diaphoretic, we may mention the compound of asclepias tuberosa (℥j.), eupatorium perfoliatum (℥j.), sanguinaria canadensis (ʒij.), and nitrate of potassa (℥ij.); in this we have active diaphoretic and diuretic agents, with the alkali to neutralize the excess of acid.

Again, by promoting perspiration, we cause relaxation of the system, equalize the circulation, and remove the tension of the inflamed part. To fulfill these indications, we not only administer diaphoretics, but we also resort to emollient fomentations, to the alcoholic vapor-bath, to embrocations, brisk frictions, etc., to relieve the pain, subdue the irritation and inflammation, and assist in producing diaphoresis. Moderate diaphoresis sometimes gives much relief in gout, but the employment of these agents is not as beneficial as it is in rheumatism.

IV. Action in Cutaneous Diseases,—In the acute exanthematous diseases, this class of agents proves very beneficial. Moderate diaphoresis tends to advance the eruption, and moderate the febrile action, and in cases where the eruption is tardy, or where there has been a retrocession of the eruption, stimulating diaphoretics, aided by tepid ablutions of an excitant character, are of decided utility.

In the chronic cutaneous forms of disease, as in herpes, lepra, etc., a moderate moisture of the surface, promoted by the use of the medicated vapor-bath, continued for weeks, or even months, constitutes an important part of our remedial treatment.

V. Action in Dropsy.—In dropsies they are less beneficial than we might be led to suppose. From the large quantity of serous fluid which they evacuate, we should suppose they would be important, but experience does not confirm this view; they occasionally, however, prove important. In dropsy it is difficult to induce sweating; if, however, we succeed, advantage results from their use. The use of the tepid-bath, with brisk frictions to the surface, tends to invite the circulation to the skin, restore the perspiratory function which is always torpid, and promote absorption, which is an indication worthy of our attention in this disease.

VI. Action in Disease of the Kidneys.—The kidneys are closely connected in function with the skin, and when either is diseased the other performs a vicarious function, its secretion being increased to make up for the deficit in the other. Thus in suppression of urine, the perspiration sometimes acquires a marked urinous odor, and when the skin fails to perform its function, the secretion of the kidneys is increased. From these facts we can readily appreciate the importance of diaphoretics in renal diseases. Thus, in nephritis, no measures that can be adopted will produce such speedy relief as the production of free diaphoresis; they not only equalize the circulation, and thus remove the congestion of the kidneys, but they likewise remove much of the material that would have been excreted by the kidney in its normal condition. The same remarks will apply to other acute diseases of these organs.

Suppressed or diminished perspiration is supposed to exert some agency in the production of calculous affections. In some of these conditions of the system they may prove beneficial by removing the irritation of the kidney, and by causing the skin, for the time being, to perform a vicarious function.

We might extend the same remarks to their employment in diabetes. By determining to the surface, we change the organ of depuration, we throw the burden upon the skin and relieve the kidneys; hence the importance of the induction of a constant and free action of the skin. The frequent use of the hand-bath, accompanied with brisk frictions, cleanses the skin and invites the circulation to the surface, and gives the kidneys an opportunity to regain their normal vigor. In connection with this, hydragogue cathartics, stimulating diuretics, tonics and astringents, cooperate in effecting a cure.

Recapitulation.

1st. Diaphoretics are important both as depletives and eliminatives, lessening vascular repletion, and promoting the elimination of effete materials existing in the system.

2d. They overcome the vital tonicity and cohesion of the capillaries of the surface, and thus promote perspiration, equalize the circulation, counteract congestion, and serve to lessen fever and inflammation.

3d. By their excitant action on the sudoriferous follicles and capillaries of the surface, they act as mild, but none the less efficient revulsives, diverting excitement from internal organs, equalizing the circulation, and thus proving very efficient agents in the treatment of inflammation of any of the internal viscera.

4th. The surface is the great refrigerator (as well as one of the great depurating organs of the system), and hence the utility of suitable diaphoretic means and appliances; diaphoresis serving to carry off the morbid heat of the surface, and lessen the excessive generation of caloric. Either cold or warm ablutions, as well as internal agents, may facilitate this result.

5th. Diaphoresis promotes absorption by reducing the serum of the blood; and hence their utility in dropsies, particularly in those of a sthenic character.

6th. Diaphoresis exercises an emollient influence upon the entire surface, according to its degree, by which a soothing and relaxing influence is extended by contiguous and continuous nervous and capillary sympathy, to deep-seated and remote parts, lessening internal excitement and inflammation. By this means they may arrest fever or inflammation, modify or change its type for the better, if they do not effect a radical cure.

7th. They are useful both in acute and chronic diseases; free sweating being indicated as a general rule in the acute forms of disease, and an increase in the insensible transpiration in chronic affections.

8th. The extent of their use in acute disease, must depend upon its duration, they being used freely in the early stages, and before there is much exhaustiou; and less freely, or even sparingly, after the patient has become prostrated by its duration.

9th. In diseases attended with a high degree of excitement, nauseating and sedative diaphoretics, with the free use of ablutions, either tepid or cold are demanded.

10th. In coldness of the surface, with a languid state of the circulation, accompanied with internal congestion, excitant and stimulating diaphoretics, assisted by warm or even hot stimulating baths, are indicated.

11th. In old age, and in the advanced stages of disease, if attended with debility, diaphoretics of a tonic and stimulating character are indicated.

12th. Suitable diaphoretic measures, modifying as they do every organic function of the body, are among our most important curative, as well as auxiliary means in the treatment of nearly all diseases.

The American Eclectic Materia Medica and Therapeutics, 1898, was written by John M. Scudder, M.D.