MEDICINE

MEDICINE is the art of preventing, curing, or alleviating, those diseases to which the human species are subjected.

Origin of medicine among the Jews; THE fabulous history of the ancients derives this art immediately from their gods; and, even among the moderns, some are of opinion that it may justly be considered as of divine revelation.

But without adopting any supposition of which no probable evidence can be given, we may conclude that mankind were naturally led to it from casual observation on the diseases to which they found themselves subjected; and that therefore, to a certain degree at least, it is as ancient as the human race. But at what period it began to be practised as an art, by particular individuals following it as a profession, is not known. The most ancient physicians we read of were those who embalmed the patriarch Jacob by order of his son Joseph. The sacred writer styles these physicians servants to Joseph: whence we may be assured that they were not præstis, as the first physicians are generally supposed to have been; for in that age we know the Egyptian priests were in such high favour, that they retained their liberty, when, through a public calamity, all the rest of the people were made slaves to the prince.

It is not probable, therefore, that among the Egyptians religion and medicine were originally conjoined; and if we suppose the Jews not to have invented the art, but received it from some other nation, it is as little probable that the priests of that nation were their physicians as those of Egypt.

That the Jewish physicians were absolutely distinct from their priests, is very certain. Yet as the Jews resided for such a long time in Egypt, it is probable they would retain many of the Egyptian customs, from which it would be very difficult to free them. We read, however, that when King Afa was diseased in his feet, "he fought not to the Lord, but to the physicians." Hence we may conclude, that among the Jews the medical art was looked upon as a mere human invention; and it was thought that the Deity never cured diseases by making people acquainted with the virtues of this or that herb, but only by his miraculous power. That the same opinion prevailed among the nations who were neighbours to the Jews, is also probable from what we read of Ahabiah king of Judah, who having sent messengers to inquire of Baalzebub god of Ekron concerning his disease, he did not desire any remedy from him or his priests, but simply to know whether he should recover or not.

What seems most probable on this subject therefore is, that religion and medicine came to be mixed together only in consequence of that degeneracy into ignorance and superstition which took place among all nations. The Egyptians, we know, came at last to be sunk in the most ridiculous and absurd superstition; and then, indeed, it is not wonderful that we should

find their priests commencing physicians, and mingling charms, incantations, &c. with their remedies. That this was the case, long after the days of Joseph, we are very certain; and indeed it seems as natural for ignorance and barbarism to combine religion with physic, as it is for a civilized and enlightened people to keep them separate. Hence we see, that among all modern barbarians their priests or conjurors are their only physicians.

Origin of Medicine. We are so little acquainted with the state of physic among the Egyptians, that it is needless to say much concerning them. They attributed the invention of medicine, as they did also that of many other arts, to Thoth, the HERMES or MERCURY of the Greeks. He is said to have written many things in hieroglyphic characters upon certain pillars, in order to perpetuate his knowledge, and render it useful to others. These were transcribed by Agathodemon, or the second Mercury, the father of Tat, who is said to have composed books of them, that were kept in the most sacred places of the Egyptian temples. The existence of such a person, however, is very doubtful, and many of the books ascribed to him were accounted forgeries as long ago as the days of Galen; there is also great reason to suspect that those books were written many ages after Hermes, and when physic had made considerable advances. Many of the books attributed to him are trifling and ridiculous; and though sometimes he is allowed to have all the honour of inventing the art, he is on other occasions obliged to share it with Osiris, Isis, and Apis or Serapis.

After all, the Egyptian physic appears to have been little else than a collection of absurd superstitions. Origin informs us, that they believed there were 36 demons, or gods of the air, who divided the human body among them; that they had names for each of them; and that by invoking them according to the part affected, the patient was cured. Of natural medicines we hear none recommended by the father of Egyptian physic; except the herb maly, which he gave to Ulysses in order to secure him from the enchantments of Circe; and the herb mercury, of which he first discovered the use. His successors made use of venesection, cathartics, emetics, and clysters. There is no proof, however, that this practice was established by Hermes; on the contrary, the Egyptians themselves pretended that the first hint of those remedies was taken from some observations on brute animals. Venesection was taught them by the hippopotamus, which is said to perform this operation upon itself. On certain occasions, he comes out of the river, and strikes his leg against a sharp-pointed reed. As he takes care to direct the stroke against a vein, the consequence must be a considerable effusion of blood; and this being suffered to run as long as the creature thinks proper, he at last stops up the orifice with mud. The hint of clysters was taken from the Ibis, a bird which is said to give itself clysters with its bill, &c. They used venesection, however, but very little, probably on account of the

warmth of the climate; and the exhibition of the remedies above mentioned, joined with abstinence, formed the most of their practice.

The Greeks too had several persons to whom they attributed the invention of physic, particularly Prometheus, Apollo or Pan, and Asclepius; which last was the most celebrated of any. But here we must observe, that as the Greeks were a very warlike people, their physic seems to have been little else than what is now called surgery, or the cure of wounds, fractures, &c. Hence Asclepius, and his pupils Chiron, Machaon, and Podalirius, are celebrated by Homer only for their skill in curing these, without any mention of their attempting the cures of internal diseases. We are not, however, to suppose that they confined themselves entirely to surgery. They no doubt would occasionally prescribe for internal disorders; but as they were most frequently conversant with wounds, we may naturally suppose the greatest part of their skill to have consisted in knowing how to cure these. If we may believe the poets, indeed, the knowledge of medicine seems to have been very generally diffused. Almost all the heroes of antiquity are reported to have been physicians as well as warriors. Most of them were taught physic by the centaur Chiron. From him Hercules received instructions in the medicinal art, in which he is said to have been no less expert than in feats of arms. Several plants were called by his name; from which some think it probable that he found out their virtues, though others are of opinion that they bore the name of this renowned hero on account of their great efficacy in removing diseases. Aristeus king of Arcadia was also one of Chiron's scholars; and is supposed to have discovered the use of the drug called filiphium, by some thought to be a fastidia. Theseus, Telamon, Jason, Peleus, and his son Achilles, were all renowned for their knowledge in the art of physic. The last is said to have discovered the use of verdegriese in cleansing foul ulcers. All of them, however, seem to have been inferior in knowledge to Palamedes, who hindered the plague from coming into the Grecian camp after it had ravaged most of the cities of Hellepont, and even Troy itself. His method was to confine his soldiers to a spare diet, and to oblige them to use much exercise.

The practice of these ancient Greek physicians, notwithstanding the praises bestowed on them by their poets, seems to have been very limited, and in some cases even pernicious. All the external remedies applied to Homer's wounded heroes were fomentations; while inwardly their physicians gave them wine, sometimes mingled with cheese scraped down. A great deal of their physic also consisted in charms, incantations, amulets, &c. of which, as they are common to all superstitious and ignorant nations, it is superfluous to take any farther notice.

In this way the art of medicine continued among the Greeks for many ages. As its first professors knew nothing of the animal economy, and as little of the theory of diseases, it is plain, that whatever they did must have been in consequence of mere random trials, or empiricism, in the strict and proper sense of the word. Indeed, it is evidently impossible that this or almost any other art could originate from another source than trials of this kind. Accordingly, we find,

that some ancient nations were accustomed to expose their sick in temples, and by the sides of highways, that they might receive the advice of every one who passed. Among the Greeks, however, Asclepius was reckoned the most eminent practitioner of his time, and his name continued to be revered after his death. He was ranked amongst the gods; and the principal knowledge of the medical art remained with his family to the time of Hippocrates, who reckoned himself the seventeenth in a lineal descent from Asclepius, and who was truly the first who treated of medicine in a regular and rational manner.

Hippocrates, who is supposed to have lived 400 years before the birth of Christ, is the most ancient author whose writings expressly on the subject of the medical art are preserved; and he is therefore justly considered as the father of physic. All the accounts which we have prior to this time, if not evidently fabulous, are at the utmost highly conjectural. Even the medical knowledge of Pythagoras, so much celebrated as a philosopher, can hardly be considered as resting on any other foundation. But from the time of Hippocrates, medicine, separated from philosophy and religion, seems to have assumed the form of a science, and to have been practised as a profession. It may not, therefore, be improper to give a particular account of the state of medical science as transmitted to us in his writings. The writings of Hippocrates, however, it may be remarked, are even more than preserved. Many things have been represented as written by Hippocrates which are probably spurious. Nor is it wonderful that attempts should have been made to increase the value of manuscripts, by attributing them to a name of such eminence. But although what are transmitted to us under the title of his works may have been written by different hands, yet the presumption is, that most, if not all of them, are of nearly as early a date, and contain the prevailing opinions of those times.

According to the most authentic accounts, Hippocrates was a native of the island of Cos, and born in the beginning of the 88th Olympiad. In the writings transmitted to us as his, we find a general principle adopted, to which he gives the name of Nature. To this principle he ascribes a mighty power. "Nature (says he) is of itself sufficient to every animal. She performs every thing that is necessary to them, without needing the least instruction from any one how to do it." Upon this footing, as if Nature had been a principle endowed with knowledge, he gives her the title of just; and ascribes virtues or powers to her, which are her servants, and by means of which she performs all her operations in the bodies of animals; and distributes the blood, spirits, and heat, through all parts of the body, which by these means receive life and sensation. And in other places he tells us, that it is this faculty which gives nourishment, preservation, and growth, to all things.

The manner in which nature acts, or commands her subservient power to act, is by attracting what is good and agreeable to each species, and by retaining, preparing, and changing it; and on the other side in rejecting whatever is superfluous or hurtful, after she has separated it from the good. This is the foundation of the doctrine of depuration, concoction, and crises in fevers.

fevers, so much insisted upon by Hippocrates and many other physicians. He supposes also, that every thing has an inclination to be joined to what agrees with it, and to remove from every thing contrary to it; and likewise that there is an affinity between the several parts of the body, by which they mutually sympathize with each other. When he comes to explain what this principle called nature is, he is obliged to resolve it into heat, which, he says, appears to have something immortal in it.

As far as he attempts to explain the causes of disease, he refers much to the humours of the body, particularly to the blood and the bile. He treats also of the effects of sleep, watchings, exercise, and rest, and all the benefit or mischief we may receive from them. Of all the causes of diseases, however, mentioned by Hippocrates, the most general are diet and air. On the subject of diet he has composed several books, and in the choice of this he was exactly careful; and the more so, as his practice turned almost wholly upon it. He also considered the air very much; he examined what winds blew ordinarily or extraordinarily; he considered the irregularity of the seasons, the rising and setting of stars, or the time of certain constellations; also the time of the solstices, and of the equinoxes; those days, in his opinion, producing great alterations in certain distempers.

He does not, however, pretend to explain how, from these causes, that variety of distempers arises which is daily to be observed. All that can be gathered from him with regard to this is, that the different causes above mentioned, when applied to the different parts of the body, produce a great variety of distempers. Some of these distempers he accounted mortal, others dangerous, and the rest easily curable, according to the cause from whence they spring, and the parts on which they fall. In several places also he distinguishes diseases, from the time of their duration, into acute or short, and chronical or long. He likewise distinguishes diseases by the particular places where they prevail, whether ordinary or extraordinary. The first, that is, those that are frequent and familiar to certain places, he called endemic diseases; and the latter, which ravaged extraordinarily sometimes in one place, sometimes in another, which seized great numbers at certain times, he called epidemic, that is, popular diseases; and of this kind the most terrible is the plague. He likewise mentions a third kind, the opposite of the former; and these he calls sporadic, or straggling diseases: these last include all the different sorts of distempers which invade at any one season, which are sometimes of one sort, and sometimes of another. He distinguished between those diseases which are hereditary, or born with us, and those which are contracted afterwards; and likewise between those of a kindly and those of a malignant nature, the former of which are easily and frequently cured, but the latter give the physicians a great deal of trouble, and are seldom overcome by all their care.

Hippocrates remarked four stages in distempers; viz. the beginning of the disease, its augmentation, its state or height, and its declination. In such diseases as terminate fatally, death comes in place of the declination. In the third stage, therefore, the change is most considerable, as it determines the fate of the sick

person; and this is most commonly done by means of a crisis. By this word he understood any sudden change in sickness, whether for the better or for the worse, whether health or death succeed immediately. Such a change, he says, is made at that time by nature, either absolving or condemning the patient. Hence we may conclude, that Hippocrates imagined diseases to be only a disturbance of the animal economy, with which Nature was perpetually at variance, and using her utmost endeavours to expel the offending cause. Her manner of acting on these occasions is to reduce to their natural state those humours whose discord occasions the disturbance of the whole body, whether in relation to their quantity, quality, mixture, motion, or any other way in which they become offensive. The principal means employed by nature for this end is what Hippocrates calls concoction. By this he understood the

bringing the morbid matter lodged in the humours to such a state, as to be easily fitted for expulsion by whatever means nature might think most proper. When matters are brought to this pass, whatever is superfluous or hurtful immediately empties itself, or nature points out to physicians the way by which such an evacuation is to be accomplished. The crisis takes place either by bleeding, stool, vomit, sweat, urine, tumors or abscesses, scabs, pimples, spots, &c. But these evacuations are not to be looked upon as the effects of a true crisis, unless they are in considerable quantity; small discharges not being sufficient to make a crisis. On the contrary, small discharges are a sign that nature is depressed by the load of humours, and that she lets them go through weakness and continual irritation. What comes forth in this manner is crude, because the distemper is yet too strong; and while matters remain in this state, nothing but a bad or imperfect crisis is to be expected. This shows that the distemper triumphs, or at least is equal in strength to nature, which prognosticates death, or a prolongation of the disease. In this last case, however, nature often has an opportunity of attempting a new crisis more happy than the former, after having made fresh efforts to advance the concoction of the humours.—It must here be observed, however, that, according to Hippocrates, concoction cannot be made but in a certain time, as every fruit has a limited time to ripen; for he compares the humours which nature has digested to fruits come to maturity.

The time required for concoction depends on the differences among distempers mentioned above. In those which Hippocrates calls very acute, the digestion or crisis happens by the fourth day; in those which are only acute, it happens on the 7th, 11th, or 14th day; which last is the longest period generally allowed by Hippocrates in distempers that are truly acute: though in some places he stretches it to the 20th or 21st, nay, sometimes to the 40th or 60th day. All diseases that exceed this last term are called chronical. And while in those diseases that exceed 14 days, he considers every fourth day as critical, or at least remarkable, by which we may judge whether the crisis on the following fourth day will be favourable or not; so in those which run from 20 to 40 he reckons only the sevenths, and in those that exceed 40 he begins to reckon by 20. Beyond the 120th he thinks that the number of days has no power over the crisis. They are.

are then referred to the general changes of the seasons; some terminating about the equinoxes; others about the solstices; others about the rising or setting of the stars of certain constellations; or if numbers have yet any place, he reckons by months, or even whole years. Thus (he says), certain diseases in children have their crisis in the seventh month after their birth, and others in their seventh or even their 14th year.

Though Hippocrates mentions the 21st as one of the critical days in acute disempers, as already noticed; yet, in other places of his works, he mentions also the 20th. The reason he gives for this in one of those places of his work is, that the days of sickness were not quite entire. In general, however, he is much attached to the odd days: inasmuch that in one of his aphorisms he tells us, "The sweats that come out upon the 3d, 5th, 7th, 9th, 11th, 14th, 17th, 21st, 27th, 31st, or 34th days, are beneficial; but those that come out upon other days signify that the sick shall be brought low, that his disease shall be very tedious, and that he shall be subject to relapses." He further says, "That the fever which leaves the sick upon any but an odd day is usually apt to relapse." Sometimes, however, he confesses that it is otherwise; and he gives an instance of a salutary crisis happening on the sixth day. But these are very rare instances, and therefore cannot, in his opinion, overthrow the general rule.

Besides the crisis, however, or the change which determines the fate of the patient, Hippocrates often speaks of another, which only changes the species of the disemper, without restoring the patient to health; as when a vertigo is turned to an epilepsy, a tertian fever to a quartan, or to a continued, &c.

But what has chiefly contributed to procure the great respect generally paid to Hippocrates, is his industry in observing the most minute circumstances of diseases, and his exactness in nicely describing every thing that happened before, and every accident that appeared at the same time with them; and likewise what appeared to give ease, and what to increase the malady: which is what we call writing the history of a disease.—Thus he not only distinguished one disease from another by the signs which properly belonged to each; but by comparing the same sort of disemper which happened to several persons, and the accidents which usually appeared before and after, he could often foretell a disease before it began, and afterwards give a right judgement of the event of it. By this way of prognosticating, he came to be exceedingly admired: and this he carried to such a height, that it may justly be said to be his master-piece; and Celsus, who lived after him, remarks, that succeeding physicians, though they found out several new things relating to the management of diseases, yet were obliged to the writings of Hippocrates for all that they knew of signs.

The first thing Hippocrates considered, when called to a patient, was his looks.—It was a good sign with him to have a visage resembling that of a person in health, and the same with what the sick man had before he was attacked by the disease. As it varied from this, so much the greater danger was apprehended. The following is the description which he gives of the looks of a dying man.—"When a patient (says he) has his nose sharp, his eyes sunk, his

temples hollow, his ears cold and contracted, the skin of his forehead tense and dry, and the colour of his face tending to a pale-green, or lead colour, one may pronounce for certain that death is very near at hand; unless the strength of the patient has been exhausted all at once by long watchings, or by a looseness, or being a long time without eating." This observation has been confirmed by succeeding physicians, who have, from him, denominated it the Hippocratic face. The lips hanging relaxed and cold, are likewise looked upon by Hippocrates as a confirmation of the foregoing prognostic. He took also his signs from the disposition of the eyes in particular. When a patient cannot bear the light; when he sheds tears involuntarily; when, in sleeping, some part of the white of the eye is seen, unless he usually sleeps after that manner, or has a looseness upon him: these signs, as well as the foregoing ones, prognosticate danger. The eyes deadened, as it were with a mist spread over them, or their brightness lost, likewise presages death, or great weakness. The eyes sparkling, fierce, and fixed, denote the patient to be delirious, or that he soon will be seized with a frenzy. When the patient sees any thing red, and like sparks of fire and lightning pass before his eyes, you may expect an hemorrhage; and this often happens before those crises which are to be attended by a loss of blood.

The condition of the patient is also shown by his posture in bed. If you find him lying on one side, his body, neck, legs, and arms, a little contracted, which is the posture of a man in health, it is a good sign: on the contrary, if he lies on his back, his arms stretched out, and his legs hanging down, it is a sign of great weakness; and particularly when the patient slides or lets himself fall down towards the feet, it denotes the approach of death. When a patient in a burning fever is continually feeling about with his hands and fingers, and moves them up before his face and eyes as if he was going to take away something that passed before them; or on his bed-covering, as if he was picking or searching for little straws, or taking away some silk, or drawing out little flocks of wool; all this is a sign that he is delirious, and that he will die. Amongst the other signs of a present or approaching delirium he also adds this: When a patient who naturally speaks little begins to talk more than he used to do, or when one that talks much becomes silent, this change is to be reckoned a sort of delirium, or is a sign that the patient will soon fall into one. The frequent trembling or starting of the tendons of the wrist, presage likewise a delirium. As to the different sorts of delirium, Hippocrates is much more afraid of those that run upon mournful subjects, than such as are accompanied with mirth.

When a patient breathes fast, and is oppressed, it is a sign that he is in pain, and that the parts above the spiration; diaphragm are inflamed. Breathing long, or when the patient is a great while in taking his breath, shows him to be delirious; but easy and natural respiration is always a good sign in acute diseases. Hippocrates depended much on respiration in making his prognostics; and therefore has taken care in several places to describe the different manner of a patient's breathing. Continuous watchings in acute diseases, are signs of present pain, or a delirium near at hand.

Hippocrates also drew signs from all excrements, whatever they are, that are separated from the body of man. His most remarkable prognostics, however, were from the urine. The patient's urine, in his opinion, is best when the sediment is white, soft to the touch, and of an equal consistence. If it continue so during the course of the distemper, and till the time of the crisis, the patient is in no danger, and will soon be well. This is what Hippocrates called concocted urine, or what denotes the concoction of the humours; and he observed, that this concoction of the urine seldom appeared thoroughly, but on the days of the crisis which happily put an end to the distemper. "We ought (said Hippocrates) to compare the urine with the purulent matter which runs from ulcers. As the pus, which is white, and of the same quality with the sediment of the urine we are now speaking of, is a sign that the ulcer is on the point of closing; so that which is clear, and of another colour than white, and of an ill smell, is a sign that the ulcer is virulent, and in the same manner difficult to be cured: the urines that are like this we have described are only those which may be named good; all the rest are ill, and differ from one another only in the degrees of more and less. The first never appear but when nature has overcome the disease; and are a sign of the concoction of humours, without which you cannot hope for a certain cure. On the contrary, the last are made as long as the crudity remains, and the humours continue unconcocted. Among the urines of this last sort, the best are reddish, with a sediment that is soft and of an equal consistence; which denotes, that the disease will be somewhat tedious, but without danger. The worst are those which are very red, and at the same time clear and without sediment; or that are muddy and troubled in the making. In urine there is often a sort of cloud hanging in the vessel in which it is received; the higher this rises, or the farther distant it is from the bottom, or the more different from the colour of the laudable sediment abovementioned, the more there is of crudity. That which is yellow, or of a sandy colour, denotes abundance of bile; that which is black is the worst, especially if it has an ill smell, and is either altogether muddy or altogether clear. That whose sediment is like large ground wheat, or little flakes or scales spread one upon another, or bran, presages ill, especially the last. The fat or oil that sometimes swims upon the top of the urine, and appears in a form something like a spider's web, is a sign of a consumption of the flesh and solid parts. The marking of a great quantity of urine is the sign of a crisis, and sometimes the quality of it shows how the bladder is affected. We must also observe, that Hippocrates compared the state of the tongue with the urine; that is to say, when the tongue was yellow, and charged with bile, the urine he knew must of course be of the same colour; and when the tongue was red and moist, the urine was of its natural colour.

Among his prognostics from the excretions by stool are the following. Those that are soft, yellowish, of some consistence, and not of an extraordinary ill smell, that answer to the quantity of what is taken inwardly, and that are voided at the usual hours, are the best of all. They ought also to be of a thicker consistence when the distemper is near the crisis; and it ought to

be taken for a good prognostic, when some worms, particularly the round and long, are evacuated at the same time with them. The prognosis, however, may still be favourable, though the matter excreted be thin and liquid, provided it make not too much noise in coming out, and the evacuation be not in a small quantity nor too often; nor in so great abundance, nor so often, as to make the patient faint. All matter that is watery, white, or of a pale green or red colour, or frothy and viscous, is bad. That which is blackish, or of a livid hue, is the most pernicious. That which is pure black, and nothing else but a discharge of black bile, always prognosticates very ill; this humour, from what part soever it comes, showing the ill disposition of the intestines. The matter that is of several different colours, denotes the length of the distemper; and, at the same time, that it may be of dangerous consequence. Hippocrates places in the same class the matter that is bilious or yellow, and mixed with blood, or green and black, or like the dregs or scrapings of the guts. The stools that consist of pure bile, or entirely of phlegm, he also looks upon to be very bad.

Matter ejected by vomiting ought to be mixed with bile and phlegm; where one of these humours only is observed, it is worse. That which is black, livid, green, or of the colour of a leek, indicates alarming consequences. The same is to be said of that which smells very ill; and if at the same time it be livid, death is not far off. The vomiting of blood is very often a mortal symptom.

The spittings which give ease in diseases of the lungs Expectoratio and in pleurisy, are those that come up readily and without difficulty; and it is good if they be mixed at the beginning with much yellow: but if they appear of the same colour, or are red, a great while after the beginning of the distemper, if they are salt and acrimonious, and cause violent coughings, they are not good. Spittings purely yellow are bad; and those that are white, viscous, and frothy, give no ease. Whiteness is a good sign of concoction in regard to spittings; but they ought not at all to be viscous, nor too thick, nor too clear. We may make the same judgment of the excretions of the nose according to their concoction and crudity. Spittings that are black, green, and red, are of very bad consequence. In inflammations of the lungs, those that are mixed with bile and blood presage well if they appear at the beginning, but are bad if they arise not about the seventh day. But the worst sign in these distempers is, when there is no expectoration at all, and the too great quantity of matter that is ready to be discharged this way makes a rattling in the breast. After spitting of blood, the discharge of purulent matter often follows, which brings on a consumption, and at last death.

A kind good sweat is that which arises on the day Sweatus of the crisis, and is discharged in abundance all over the body, and at the same time from all parts of the body, and thus carries off the fever: A cold sweat is alarming, especially in acute fevers, for in others it is only a sign of long continuance. When the patient sweats no where but on the head and neck, it is a sign that the disease will be long and dangerous. A gentle sweat in some particular part, of the head and breast, for instance, gives no relief, but denotes the seat of the distemper, or the weakness of the part. This

This kind of sweat was called by Hippocrates ephidrosis.

The hypochondria, or the abdomen in general, ought always to be soft and even, as well on the right side as on the left. When there is any hardness or unevenness in those parts, or heat and swellings, or when the patient cannot endure to have it touched, it is a sign the intestines are indisposed.

Hippocrates also inquired into the state of the pulse, or the beating of the arteries. The most ancient physicians, however, and even Hippocrates himself, for a long time, by this word understood the violent pulsation that is felt in an inflamed part, without putting the fingers to it. It is observed by Galen, and other physicians, that Hippocrates touches on the subject of the pulse more slightly than any other on which he treats. But that our celebrated physician understood something even on this subject, is easily gathered from several passages in his writings; as when he observes, that in acute fevers the pulse is very quick and very great; and when he makes mention, in the same place, of trembling pulses, and those that beat slowly. He likewise observes, that in some diseases incident to women, when the pulse strikes the finger faintly, and in a languishing manner, it is a sign of approaching death. He remarks also, in the Coac Præstationes, that he whose vein, that is to say, whole artery of the elbow, beats, is just going to run mad, or else that the person is at that time very much under the influence of anger.

From this account of Hippocrates, it will appear, that he was not near so much taken up with reasoning on the phenomena of diseases, as with reporting them. He was content to observe these phenomena accurately, to distinguish diseases by them, and judged of the event by comparing them exactly together. For his skill in prognostics he was indeed very remarkable, as we have already mentioned, inasmuch that he and his pupils were looked upon by the vulgar as prophets. What adds very much to his reputation is, that he lived in an age when physic was altogether buried in superstition, and yet he did not suffer himself to be carried away by it; on the contrary, on many occasions, he expresses his abhorrence of it.

Having thus seen in what Hippocrates makes the difference between health and sickness to consist, and likewise the most remarkable signs from whence he drew his prognostics, we must now consider the means he prescribed for the preservation of health, and the cure of diseases. One of his principal maxims was this, That, to preserve health, we ought not to overcharge ourselves with too much eating, nor neglect the use of exercise and labour. In the next place, That we ought by no means to accustom ourselves to too nice and exact a method of living; because those who have once begun to act by this rule, if they vary in the least from it, find themselves very ill; which does not happen to those who take a little more liberty, and live somewhat more irregularly. Notwithstanding this he does not neglect to inquire diligently into the articles which those who were in health used for food in his time. Here we cannot help taking notice of the prodigious disparity between the delicacy of the people in our days and in those of Hippocrates: for he takes great pains to tell the difference between the flesh of a dog,

a fox, a horse, and an ass; which he would not have done if at that time they had not been used for victuals, at least by the common people. Besides these, however, Hippocrates speaks of all other kinds of provision that are now in use; for example, salads, milk, whey, cheese, flesh as well of birds as of four-footed beasts, fresh and salt fish, eggs, all kinds of pulse, and the different kinds of grain we feed on, as well as the different sorts of bread that are made of it. He also speaks very often of a sort of liquid food, or broth, made of barley-meal, or some other grain, which they steeped for some time, and then boiled in water. With regard to drink, he takes a great deal of pains to distinguish the good waters from the bad. The best, in his opinion, ought to be clear, light, without smell or taste, and taken out of the fountains that turn towards the east. The salt waters, those that he calls hard, and those that rise out of fenny ground, are the worst of all; he condemns also those that come from melted snow. But though Hippocrates makes all those distinctions, he advises those who are in health to drink of the first water that comes in their way. He speaks also of alum waters, and those that are hot; but does not enlarge upon their qualities. He advises to mix wine with an equal quantity of water: and this (he says) is the just proportion; by using which the wine will expel what is hurtful to the body, and the water will serve to temper the acrimony of the humours.

For those that are in health, and likewise for such Exercise. as are sick, Hippocrates advises exercise. The books, however, which treat on this subject, M. Le Clerc conjectures to have been written by Herodotus, who first introduced gymnastic exercise into medicine, and who is said by Hippocrates himself to have killed several people by forcing them to walk while they were afflicted with fevers and other inflammatory disorders. The advices given in them consist chiefly in directions for the times in which we ought to walk, and the condition we ought to be in before it; when we ought to walk slowly, and when to run, &c. &c. and all this with design to bring the body down, or dissipate the humours. Wrestling, although a violent exercise, is numbered with the rest. In the same place also mention is made of a play of the hands and fingers, which was thought good for health, and called chironomie; and of another diversion which was performed round a sort of ball hung up, which they called corycus, and which they struck forward with both their hands.

With regard to those things which ought to be se- Excretions. parated from, or retained in the human body, Hippocrates observes, that people ought to take great care not to load themselves with excrements, or keep them in too long; and besides the exercise above-mentioned, which carries off one part of them, and which he prescribes chiefly on this account, he advises people to excite and rouse up nature when she flagged, and did not endeavour to expel the rest, or take care of the impediments by which she was resisted. For this reason he prescribed meats proper for loosening the belly; and when these were not sufficient, he directed the use of clysters and suppositories. For thin and emaciated persons he directed clysters composed only of milk and oily unctuous substances, which they mixed with a de- coction

coction of chick-pease; but for such as were plethoric, they only made use of salt or sea-water.

As a preservative against distempers, Hippocrates also advised the use of vomits, which he directed to be taken once or twice a month during the time of winter and spring. The most simple of these were made of a decoction of hyssop, with an addition of a little vinegar and salt. He made those that were of a strong and vigorous constitution take this liquor in a morning fasting; but such as were thin and weakly took it after supper.—Venery, in his opinion, is wholesome, provided people consult their strength, and do not pursue it to excess; which he finds fault with on all occasions, and would have excess avoided also in relation to sleep and watching. In his writings are likewise to be found several remarks concerning good and bad air; and he makes it appear that the good or bad disposition of this element does not depend solely on the difference of the climate, but on the situation of every place in particular. He speaks also of the good and bad effects of the passions, and recommends moderation in regard to them.

From what we have already related concerning the opinions of Hippocrates, it may naturally be concluded, that for the most part he would be contented with observing what the strength of nature is able to accomplish without being assisted by the physician. That this was really the case, may be easily perceived from a perusal of his books entitled, "Of epidemical distempers;" which are, as it were, journals of the practice of Hippocrates: for there we find him often doing nothing more than describing the symptoms of a distemper, and informing us what has happened to the patient day after day, even to his death or recovery, without speaking a word of any kind of remedy. Sometimes, however, he did indeed make use of remedies; but these were exceedingly simple and few, in comparison of what have been given by succeeding practitioners. These remedies we shall presently consider, after we have given an abridgement of the principal maxims on which his practice was founded.

Hippocrates asserted in the first place, That contraries, or opposites, are the remedies for each other; and this maxim he explains by an aphorism; in which he says, that evacuations cure those distempers which come from repletion, and repletion those that are caused by evacuation. So heat is destroyed by cold, and cold by heat, &c. In the second place, he asserted that physic is an addition of what is wanting, and a subtraction or retrenchment of what is superfluous: an axiom which is thus explained, that there are some juices or humours, which in particular cases ought to be evacuated, or driven out of the body, or dried up; and some others which ought to be restored to the body, or caused to be produced there again. As to the method to be taken for this addition or retrenchment, he gives this general caution, That you ought to be careful how you fill up, or evacuate, all at once, or too quickly, or too much; and that it is equally dangerous to heat or cool again on a sudden; or rather, you ought not to do it: every thing that runs to an excess being an enemy to nature. In the fourth place, Hippocrates allowed that we ought sometimes to dilate, and sometimes to lock up: to dilate, or open the passages by which the humours are voided naturally, when they are not sufficiently opened, or when

they are closed; and, on the contrary, to lock up or straiten the passages that are relaxed, when the juices that pass there ought not to pass, or when they pass in too great quantity. He adds, that we ought sometimes to smooth, and sometimes to make rough; sometimes to harden, and sometimes to soften again; sometimes to make more fine or supple; sometimes to thicken; sometimes to rouse up, and at other times to flupify or take away the sense; all in relation to the solid parts of the body, or to the humours. He gives also this farther lesson, That we ought to have regard to the course the humours take, from whence they come, and whither they go; and in consequence of that, when they go where they ought not, that we make them take a turn about, or carry them another way, almost like the turning the course of a river: or, upon other occasions, that we endeavour if possible to recall, or make the same humours return back again; drawing upward such as have a tendency downward, and drawing downward such as tend upward. We ought also to carry off, by convenient ways, that which is necessary to be carried off; and not let the humours once evacuated enter into the vessels again. Hippocrates gives also the following instruction, That when we do any thing according to reason, though the success be not answerable, we ought not easily, or too hastily, to alter the manner of acting, as long as the reasons for it are yet good. But as this maxim might sometimes prove deceitful, he gives the following as a corrector to it: "We ought (says he) to mind with a great deal of attention what gives ease, and what creates pain; what is easily supported, and what cannot be endured." We ought not to do any thing rashly; but ought often to pause, or wait, without doing any thing: by this way, if you do the patient no good, you will at least do him no hurt.

These are the principal and most general maxims of the practice of Hippocrates, and which proceed upon the supposition laid down at the beginning, viz. that nature cures diseases. We next proceed to consider particularly the remedies employed by him, which will serve to give us further instructions concerning his practice.

Diet was the first, the principal, and often the only remedy made use of by this great physician to answer most of the intentions above mentioned: by means of it he opposed the moist to dry, hot to cold, &c.; and what he looked upon to be the most considerable point was, that thus he supported nature, and assisted her to overcome the malady. The dietetic part of medicine was so much the invention of Hippocrates himself, that he was very desirous to be accounted the author of it; and the better to make it appear that it was a new remedy in his days, he says expressly, that the ancients had wrote almost nothing concerning the diet of the sick, having omitted this point, though it was one of the most essential parts of the art.

The diet prescribed by Hippocrates for patients labouring under acute distempers, differed from that which he ordered for those afflicted with chronic ones. In the former, which require a more particular exactness in relation to diet, he preferred liquid food to that which was solid, especially in fevers. For these he used a sort of broth made of cleansed barley; and to this he gave the name of piſan. The manner in which the ancients prepared a piſan was as follows:

They first steamed the barley in water till it was plumped up; and afterwards they dried it in the sun, and beat it to take off the husk. They next ground it; and having let the flour boil a long time in the water, they put it out into the sun, and when it was dry they pressed it close. It is properly this flour so prepared that is called ptisan. They did almost the same thing with wheat, rice, lentils, and other grain: but they gave these ptisans the name of the grain from whence they were extracted, as ptisan of lentils, rice, &c. while the ptisan of barley was called simply ptisan, on account of the excellency of it. When they wanted to use it, they boiled one part of it in 10 or 15 of water; and when it began to grow plump in boiling, they added a little vinegar, and a very small quantity of anise or leek, to keep it from clogging or filling the stomach with wind. Hippocrates prescribed this broth for women that have pains in their belly after delivery. "Boil some of this ptisan (says he), with some leek, and the fat of a goat, and give it to the woman in bed." This will not be thought very singular, if we reflect on what has been hinted above concerning the indelicate manner of living in those times. He preferred the ptisan to all other food in fevers, because it softened and moistened much, and was besides of easy digestion. If he was concerned in a continual fever, he would have the patient begin with a ptisan of a pretty thick consistence, and go on by little and little, lessening the quantity of barley-flour as the height of the distemper approached; so that he did not feed the patient but with what he called the juice of the ptisan; that is, the ptisan strained, where there was but very little of the flour remaining, in order that nature being discharged in part from the care of digesting the aliments, she might the more easily hold out to the end, and overcome the distemper, or the cause of it. With regard to the quantity, he caused the ptisan to be taken twice a-day by such patients as in health used to take two meals a-day, not thinking it convenient that those who were sick should eat oftener than when they were well. He also would not allow eating twice a-day to those who ate but once in that time when in health. In the paroxysm of a fever he gave nothing at all; and in all distempers where there are exacerbations, he forbade nourishment while the exacerbations continued. He let children eat more; but those who were grown up to man's estate, or were of an advanced age, less; making allowance, however, for the custom of each particular person, or for that of the country.

But though he was of opinion that too much food ought not to be allowed to the sick, he did not agree with some physicians who prescribed long abstinence, especially in the beginning of fevers. The reason he gave for this was, that the contrary practice weakened the patients too much during the first days of the distemper, by which means their physicians were obliged to allow them more food when the illness was at its height, which in his opinion was improper. Besides, in acute distempers, and particularly in fevers, Hippocrates made choice of refreshing and moistening nourishment; and amongst other things prescribed orange, melon, spinach, gourd, &c. This sort of food he gave to those that were in a condition to eat, or could take something more than a ptisan.

The drink he commonly gave to his patients was made of eight parts of water and one of honey. In some distempers he added a little vinegar; but besides these, they had another sort named oxoxos, or mixture. One prescription of this sort we find intended for a consumptive person; it consisted of rue, anise, celery, coriander, juice of pomegranate, the roughest red wine, water, flour of wheat and barley, with old cheese made of goats milk. Hippocrates did not approve of giving plain water to the sick; but though he generally prescribed the drinks above mentioned, he did not absolutely forbid the use of wine, even in acute distempers and fevers, provided the patients were not delirious nor had pains in their head. Besides, he took care to distinguish the wines proper in these cases: preferring to all other sorts white-wine that was clear and had a great deal of water, with neither sweetness nor flavour.

These are the most remarkable particulars concerning the diet prescribed by Hippocrates in acute distempers; in chronic ones he made very much use of milk and whey; though we are not certain whether this was done on account of the nourishment expected from them, or that he accounted them medicines.

There were many diseases for which he judged the bath was a proper remedy; and he takes notice of all the circumstances that are necessary in order to cause the patient receive benefit from it, among which the following are the principal. The patient that bathes himself must remain still and quiet in his place without speaking while the assistants throw water over his head or are wiping him dry; for which last purpose he desired them to keep sponges, instead of that instrument called by the ancients strigil, which served to rub off from the skin the dirt and nastiness left upon it by the unguents and oils with which they anointed themselves. He must also take care not to catch cold; and must not bathe immediately after eating and drinking, nor eat or drink immediately after coming out of the bath. Regard must also be had whether the patient has been accustomed to bathe while in health, and whether he has been benefited or hurt by it. Lastly, he must abstain from the bath when the body is too open, or too colicky, or when he is too weak; or if he has an inclination to vomit, a great loss of appetite, or bleeds at the nose. The advantage of the bath, according to Hippocrates, consists in moistening and refreshing, taking away weariness, making the skin soft and the joints pliant; in provoking urine, and opening the other excretories. He allows two baths in a day to those who have been accustomed to it in health.

In chronic distempers Hippocrates approved very much of exercise, though he did not allow it in acute ones: but even in these he did not think that a patient ought always to lie in bed; but tells us, that "we must sometimes push the timorous out of bed, and rouse up the lazy."

When he found that diet and exercise were not sufficient to ease nature of a burden of corrupted humors, he was obliged to make use of other means, of which purgation was one. By this word he understood all the contrivances that are made use of to discharge the stomach and bowels; though it commonly signifies only

only the evacuation by stool. This evacuation he imagined to be occasioned by the purgative medicines attracting the humours to themselves. When first taken into the body, he thought they attracted that humour which was most similar to them, and then the others, one after another.—Most of the purgatives used in his time were emetics also, or at least were very violent in their operation downwards. These were the white and black hellebore; the first of which is now reckoned among the poisons. He used also the Cnidian berries, encorum pepilum, thapsia; the juice of hippophae, a sort of rhamnus; elaterium, or juice of the wild cucumber; flowers of brass, colocynthis, scammony, the magnesian stone, &c.

As these purgatives were all very strong, Hippocrates was extremely cautious in their exhibition. He did not prescribe them in the dog-days; nor did he ever purge women with child, and very seldom children or old people. He principally used purgatives in chronical distempers; but was much more wary in acute ones. In his books entitled "Of Epidemical Distempers," there are very few patients mentioned to whom he gave purgative medicines. He also takes notice expressly, that these medicines having been given in cases of the distempers of which he was treating, had produced very bad effects. We are not, however, from this to conclude, that Hippocrates absolutely condemned purging in acute distempers; for in some places he expressly mentions his having given them with success. He was of opinion, for instance, that purging was good in a pleurisy when the pain was seated below the diaphragm; and in this case he gave black hellebore, or some pepilum mixed with the juice of sa-sserpitium.

The principal rule Hippocrates gives with relation to purging is, that we ought only to purge off the humours that are concocted, and not those that are yet crude, taking particular care not to do it at the beginning of the distemper, lest the humours should be disturbed or stirred up, which happens pretty often. He was not, however, the first who remarked that it would be of ill consequence to stir the humours in the beginning of an acute distemper. The Egyptian physicians had before observed the same thing. By the beginning of a distemper, Hippocrates understood all the time from the first day to the fourth complete.

Hippocrates imagined that each purgative medicine was adapted to the carrying off some particular humour; and hence the distinction of purgatives into hydragogue, chologogue, &c. which is now justly exploded. In consequence of this notion, he contended that we knew if a purgative had drawn from the body what was fit to be evacuated according as the patient was found well or ill upon it. If we found ourselves well, it was a sign that the medicine had effectually expelled the offending humour. On the contrary, if we were ill, he imagined, whatever quantity of humour came away, that the humour which caused the illness still remained; not judging of the goodness or badness of a purge by the quantity of matters that were voided by it, but by their quality and the effect that followed after it.

Vomits were also pretty much used as medicines by Hippocrates. We have already seen what those were

which he preferred to people in health by way of preventives. With regard to the sick, he sometimes advised them to the same, when his intentions were only to cleanse the stomach. But when he had a mind to recall the humours, as he termed it, from the inmost recesses of the body, he made use of brisker remedies. Among these was white hellebore; and this indeed he most frequently used to excite vomiting. He gave this root particularly to melancholy and mad people; and from the great use made of it in these cases by Hippocrates and other ancient physicians, the phrase to have need of hellebore, became a proverbial expression for being out of one's senses. He gave it also in desluxions, which come, according to him, from the brain, and throw themselves on the nostrils or ears, or fill the mouth with saliva, or that cause stubborn pains in the head, and a weariness or an extraordinary heaviness, or a weakness of the knees, or a swelling all over the body. He gave it to consumptive persons in broth of lentils, to such as were afflicted with the droopy called leucophlegmata, and in other chronical disorders. But we do not find that he made use of it in acute distempers, except in the cholera morbus, where he says he preferred it with benefit. Some took this medicine fasting; but most took it after supper, as was commonly practised with regard to vomits taken by way of prevention. The reason why he gave this medicine most commonly after eating was, that by mixing with the aliments, its acrimony might be somewhat abated, and it might operate with less violence on the membranes of the stomach. With the same intention also he sometimes gave a plant called sesamoides, and sometimes mixed it with hellebore. Lastly, in certain cases he gave what he called foet or suave hellebore. This term had some relation to the quality of the hellebore, or perhaps the quantity he gave.

When Hippocrates intended only to keep the body open, or evacuate the contents of the intestines, he made use of simples; as for example, the herb mercury, or cabbage; the juice or decoction of which he ordered to be drunk. For the same purpose he used whey, and also cows and asses milk; adding a little salt to it, and sometimes letting it boil a little. If he gave asses milk alone, he caused a great quantity of it to be taken, so that it must of necessity loosen the body. In one place he prescribes no less than nine pounds of it to be taken as a laxative, but does not specify the time in which it was to be taken. With the same intention he made use of suppositories and clysters. The former were compounded of honey, the juice of the herb mercury, of nitre, powder of colocynth, and other sharp ingredients, to irritate the anus. These they formed into a ball, or into a long cylindrical mass like a finger. The clysters he made use of for sick people were sometimes the same with those already mentioned as preventives for people in health. At other times he mixed the decoction of herbs with nitre, honey, and oil, or other ingredients, according as he imagined he could by that means attract, wash, irritate, or soften. The quantity of liquor he ordered was about 36 ounces; from which it is probable he did not intend that it should all be used at one time.

On some occasions Hippocrates proposed to purge the head alone. This practice he employed, after purging the rest of the body, in an apoplexy, inveterate pains

pains of the head, a certain sort of jaundice, a consumption, and the greatest part of chronic distempers. For that purpose he made use of the juices of several plants, as celery; to which he sometimes added aromatic drugs, making the patients snuff up this mixture into their nostrils. He used also powders compounded of myrrh, the flowers of brats, and white hellebore, which he caused them put up into the nose, to make them freeze, and to draw the phlegm from the brain. For the same purpose also he used what he calls tetragonos, that is, "something having four angles;" but what this was, is now altogether unknown, and was so even in the days of Galen. The latter physician, however, conjectures it to be antimony, or certain flakes found in it.

In the distemper called empyema (or a collection of matter in the breast), he made use of a very rough medicine. He commanded the patient to draw in his tongue as much as he was able; and when that was done, he endeavoured to put into the hollow of the lungs a liquor that irritated the part, which raising a violent cough, forced the lungs to discharge the purulent matter contained in them. The materials that he used for this purpose were of different sorts; sometimes he took the root of arum, which he ordered to be boiled with a little salt, in a sufficient quantity of water and oil; dissolving a little honey in it. At other times, when he intended to purge more strongly, he took the flowers of copper and hellebore; after that he shook the patient violently by the shoulders, the better to loosen the pus. This remedy, according to Galen, he received from the Cnidian physicians; and it has never been used by the succeeding ones, probably because the patients could not suffer it.

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His maxims respecting blood-letting. Blood-letting was another method of evacuation pretty much used by Hippocrates. Another aim he had in this, besides the mere evacuation, was to divert or recall the course of the blood when he imagined it was going where it ought not. A third end of bleeding was to procure a free motion of the blood and spirits.

Hippocrates had also a fourth intention for bleeding, and this was refreshment. So in the iliac passion, he orders bleeding in the arm and in the head; to the end, says he, that the superior venter, or the breast, may cease to be overheated. With regard to this evacuation, his conduct was much the same as to purging, in respect of time and persons. We ought, says he, to let blood in acute diseases, when they are violent, if the party be lusty and in the flower of his age. We ought also to have regard to the time, both in respect to the disease and to the season in which we let blood. He also informs us, that blood ought to be let in great pains, and particularly in inflammations. Among these he reckons such as fall upon the principal viscera, as the liver, lungs, and spleen, as also the quinsy and pleurisy, if the pain of the latter be above the diaphragm. In these cases he would have the patients bled till they faint, especially if the pain be very acute; or rather he advises that the orifice should not be closed till the colour of the blood alters, so that from livid it turn red, or from red livid. In a quinsy he bled in both arms at once. Difficulty of breathing he also reckons among the distempers that require bleeding; and he mentions another sort of inflamma-

tion of the lungs, which he calls a swelling or tumor of the lungs arising from heat; in which case he advises to bleed in all parts of the body; and directs it particularly by the arms, tongue, and nostrils. To make bleeding the more useful in all pains, he directed to open the vein nearest the part affected; in a pleurisy he directs to take blood from the arm of the side affected; and for the same reason, in pains of the head, he directs the veins of the nose and forehead to be opened. When the pain was not urgent, and bleeding was advised by way of prevention, he directed the blood to be taken from the parts farthest off, with a design to divert the blood insensibly from the seat of pain. The highest burning fevers, which show neither signs of inflammation nor pain, he does not rank among those distempers which require bleeding. On the contrary, he maintains that a fever itself is in some cases a reason against bleeding. If any one, says he, has an ulcer in the head, he must bleed, unless he has a fever. He says further, those that lose their speech of a sudden must be bled, unless they have a fever. Perhaps he was afraid of bleeding in fevers, because he supposed that they were produced by the bile and pituita, which grew hot, and afterwards heated the whole body, which is, says he, what we call fever, and which, in his opinion, cannot well be evacuated by bleeding. In other places also he looks upon the presence or abundance of bile to be an objection to bleeding; and he orders to forbear venesection even in a pleurisy, if there be bile. To this we must add, that Hippocrates distinguished very particularly between a fever which followed no other distemper, but was itself the original malady, and a fever which came upon inflammation. In the early ages of physic, the first only were properly called fevers: the others took their names from the parts affected; as pleurisy, peripneumony, hepatitis, nephritis, &c. which names signify that the pleura, the lungs, the liver, or the kidneys, are diseased, but do not intimate the fever which accompanies the disease. In this latter sort of fever Hippocrates constantly ordered bleeding, but not in the former. Hence, in his books on Epidemic Distempers, we find but few directions for bleeding in the acute distempers, and particularly in the great number of continual and burning fevers there treated of. In the first and third book we find but one single instance of bleeding, and that in a pleurisy; in which, too, he staid till the eighth day of the distemper. Galen, however, and most other commentators on Hippocrates, are of opinion that he generally bled his patients plentifully in the beginning of acute disorders, though he takes no notice of it in his writings. But had this been the case, he would not perhaps have had the opportunity of seeing so many fevers terminate by crises, or natural evacuations, which happen of themselves on certain days. Hippocrates, in fact, laid so much weight upon the assistance of nature and the method of diet, which was his favourite medicine, that he thought if they took care to diet the patients according to rule, they might leave the rest to nature. These are his principles, from which he never deviates; so that his writings on Epidemic Diseases seem to have been composed only with an intention to leave to posterity an exact model of management in pursuance of these principles.

With regard to the rules laid down by Hippocrates for bleeding, we must farther take notice, that in all diseases which had their seat above the liver, he bled in the arm, or in some of the upper parts of the body; but for those that were situated below it he opened the veins of the foot, ankle, or ham. If the belly was too loose, and bleeding was at the same time thought necessary, he ordered the looseness to be stopped before bleeding.

Almost all these instances, however, regard scarce any thing but acute distempers; but we find several concerning chronic diseases. "A young man complained of great pain in his belly, with a rumbling while he was fasting, which ceased after eating: this pain and rumbling continuing, his meat did him no good; but, on the contrary, he daily wasted and grew lean. Several medicines, as well purges as vomits, were given him in vain. At length it was resolved to bleed him by intervals, first in one arm and then in the other, till he had scarcely any blood left, and by this method he was perfectly cured."

Hippocrates let blood also in a dropsy, even in a tympany; and in both cases he prescribes bleeding in the arm. In a disease occasioned by an overgrown spleen, he proposes bleeding several times repeated at a vein of the arm which he calls the splenetic; and in one species of jaundice, he proposes bleeding under the tongue. On some occasions he took away great quantities of blood, as appears from what we have already observed. Sometimes he continued the bleeding till the patient fainted: at other times he would bleed in both arms at once; at others, he did it in several places of the body, and at several times. The veins he opened were those of the arm, the hands, the anckles on both sides, the hams, the forehead, behind the head, the tongue, the nose, behind the ears, under the breasts, and those of the arms; besides which, he burnt others, and opened several arteries. He likewise used cupping-vessels, with intent to recel or withdraw the humours which fell upon any part. Sometimes he contented himself with the bare attraction made by the cupping-vessels, but sometimes also he made scarifications.

When bleeding and purging, which were the principal and most general means used by Hippocrates for taking off a plethora, proved insufficient for that purpose, he had recourse to diuretics and sudorifics. The former were of different sorts, according to the constitution of the persons: sometimes baths, and sometimes sweet wine, were employed to provoke urine; sometimes the nourishment which we take contributes to it: and amongst those herbs which are commonly eaten, Hippocrates recommends garlic, leeks, onions, cucumbers, melons, gourds, fennel, and all other things which have a biting taste and a strong smell. With these he numbers honey, mixed with water or vinegar, and all salt meats. But, on some occasions, he took four cantharides, and, pulling off their wings and feet, gave them in wine and honey. These remedies were given in a great number of chronic distempers after purging, when he thought the blood was overcharged with a sort of moisture which he calls sceler; or in suppressions of urine, and when it was made in less quantity than it ought. There were also some cases in which he would force sweat as well as

urine; but he neither mentions the diseases in which sudorifics are proper, nor lets us know what medicines are to be used for this purpose, except in one single passage, where he mentions sweating, by pouring upon the head a great quantity of water till the feet sweat; that is, till the sweat diffuses itself over the whole body, running from head to foot. After this he would have them eat boiled meat, and drink pure wine, and being well covered with clothes, lay themselves down to rest. The disease for which he proposes the above mentioned remedy is a fever; which is not, according to him, produced by bile or pituita, but by mere lassitude, or some other similar cause; from whence we may conclude that he did not approve of sweating in any other kind of fever.

Other remedies which Hippocrates tells us he made use of were those that purged neither bile nor phlegm, but act by cooling, drying, heating, moistening, or by closing and thickening, resolving and dissipating. These medicines, however, he does not particularly mention; and it is probable they were only some particular kinds of food. To these he joined hypnotics, or such things as procure sleep; but these last were used very seldom, and, it is most probable, were only different preparations of poppies.

Lastly, besides the medicines already mentioned, which acted in a sensible manner, Hippocrates made use of others called specifics; whose action he did not understand, and for the use of which he could give no reason but his own experience, or that of other physicians. These he had learned from his predecessors the descendants of Asclepius, who, being empirics, did not trouble themselves about inquiring into the operation of remedies, provided their patients were cured.

Of the external remedies prescribed by Hippocrates, fomentations were the chief. These were of two kinds. The one was a sort of bath, in which the patient sat in a vessel full of a decoction of simples appropriated to his malady; so that the part affected was soaked in the decoction. This was chiefly used in distempers of the womb, of the arms, the bladder, the reins, and generally all the parts below the diaphragm. The second way of fomenting was, to take warm water and put it into a skin or bladder, or even into a copper or earthen vessel, and to apply it to the part affected; as, for example, in a pcurisy. They used likewise a large sponge, which they dipped in the water or other hot liquor, and squeezed out part of the liquor before they applied it. The same use they made of barley, vetches, or bran, which were boiled in some proper liquor, and applied in a linen bag. These are called moist fomentations. The dry ones were made of salt or millet, heated considerably, and applied to the part. Another kind of fomentation was the vapour of some hot liquor; an instance of which we find in his first book of the Distempers of Women. He cast, at several times, bits of red-hot iron into urine, and, covering up the patient close, caused her to receive the steam below. His design in these kinds of fomentations was to warm the part, to resolve or dissipate, and draw out the peccant matter, to mollify and allay pain, to open the passages, or even to shut them, according as the fomentations were emollient or astringent.

Hippo-
crates.
25
Fumiga-
tions.

Fumigations were likewise very often used by Hippocrates. In the quinquy, he burned hyssop with sulphur and pitch, and caused the smoke to be drawn into the throat by a funnel; and by this means he brought away abundance of phlegm through the mouth and through the nose. For this purpose he took nitre, marjoram, and cress-seeds, which he boiled in water, vinegar, and oil, and, while it was on the fire, caused the patient to draw in the steam by a pipe. In his works we find a great number of fumigants for the distempers of women, to promote the menstrual flux, to check it, to help conception, and to ease pains in the matrix, or the suffocation of it. On these occasions he used such aromatics as were then known, viz. cinnamon, cassia, myrrh, and several odoriferous plants; likewise some minerals, such as nitre, sulphur, and pitch, and caused the patient to receive the vapours through a funnel into the uterus.

26
Gargles.

Gargles, a kind of fomentations for the mouth, were also known to Hippocrates. In the quinquy he used a gargle made of marjoram, savory, celery, mint, and nitre, boiled with water and a little vinegar. When this was strained, they added honey to it, and washed their mouths frequently with it.

27
Oils and
ointments.

Oils and ointments were likewise much used by Hippocrates, with a view to mollify and abate pain, to ripen boils, resolve tumours, refresh after weariness, make the body supple, &c. For this purpose, sometimes pure oil of olives was used; sometimes certain simples were infused in it, as the leaves of myrtle and roses; and the latter kind of oil was in much request among the ancients. There were other sorts of oils sometimes in use, however, which were much more compounded. Hippocrates speaks of one named Susinum, which was made of the flowers of the iris, of some aromatics, and of an ointment of narcissus made with the flowers of narcissus and aromatics infused in oil. But the most compounded of all his ointments was that called nesopon, which he made particularly for women; and consisted of a great number of ingredients. Another ointment, to which he gave the name of ceratum, was composed of oil and wax. An ointment which he recommends for the softening a tumor, and the cleansing a wound, was made by the following receipt: "Take the quantity of a nut of the marrow or fat of a sheep, of mastic or turpentine the quantity of a bean, and as much wax; melt these over a fire, with oil of roses, for a ceratum." Sometimes he added pitch and wax, and, with a sufficient quantity of oil, made a composition somewhat more consistent than the former, which he called ceropissus.

28
Cataplasms.

Cataplasms were a sort of remedies less consistent than the two former. They were made of powders or herbs steeped or boiled in water or some other liquor, to which sometimes oil was added. They were used with a view to soften or resolve tumors, ripen abscesses, &c. though they had also cooling cataplasms made of the leaves of beets or oak, fig or olive-trees, boiled in water.

29
Collyria.

Lastly, To complete the catalogue of the external remedies used by Hippocrates, we shall mention a sort of medicine called collyrium. It was compounded of powders, to which was added a small quantity of some ointment, or juice of a plant, to make a solid or dry mass; the form of which was long and round,

which was kept for use. Another composition of much the same nature was a sort of lozenge of the bigness of a small piece of money, which was burnt upon coals for a perfume, and powdered for particular uses. In his works we find likewise descriptions of powders for several uses, to take off fungous flesh, and to blow into the eyes in ophthalmies, &c.

These were almost all the medicines used by Hippocrates for external purposes. The compound medicines given inwardly were either liquid, solid, or lambative. The liquid ones were prepared either by decoction or infusion in a proper liquor, which, when strained, were kept for use; or by macerating certain powders in such liquors, and so taking them together, or by mixing different kinds of liquors together. The solid medicines consisted of juices inspissated; of gums, resins, or powders, made up with them or with honey, or something proper to give the necessary consistence to the medicine. These were made up in a form and quantity fit to be swallowed with ease. The lambative was of a consistence between solid and fluid; and the patients were obliged to keep it for some time to dissolve in the mouth, that they might swallow it leisurely. This remedy was used to take off the acrimony of those humours which sometimes fall upon this part, and provoke coughing and other inconveniences. The basis of this last composition was honey. It is worth our observation, that the compound medicines of Hippocrates were but very few, and composed only of four or five ingredients at most; and that he not only understood pharmacy, or the art of compounding medicines, but prepared such as he used himself, or caused his servants prepare them in his house by his directions.

We have thus given some account of the state of medicine as practised and taught by Hippocrates, who, as we have already observed, has for many ages been justly considered as the father of physic. For when we attend to the state in which he found medicine, and the condition in which he left it, we can hardly bestow sufficient admiration on the judgement and accuracy of his observations. After a life spent in unwearied industry, he is said to have died at Larissa, a city in Thessaly, in the 101st year of his age, 361 years before the birth of Christ.

After the days of Hippocrates, medicine in ancient Greece gradually derived improvement from the labour of other physicians of eminence. And we may particularly mention three to whom its future progress seems to have been not a little indebted, viz. Praxagoras, Erasistratus, and Herophilus.

The first physician of eminence who differed considerably in his practice from Hippocrates was Praxagoras. Celsus Aurelianus acquaints us, that he made great use of vomits in his practice, inasmuch as to exhibit them in the iliac passion till the excrements were discharged by the mouth. In this distemper he also advised, when all other means failed, to open the belly, cut the intestine, take out the indurated faeces, and then to sew up all again; but this practice has not probably been followed by any subsequent physician.

Erasistratus was a physician of great eminence, and flourished in the time of Seleucus, one of the successors of Alexander the Great. According to Galen,

Eraſistratus. Galen, he entirely banished venesection from medicine; though some affirm that he did not totally discard it, but only used it less frequently than other physicians. His reasons for disapproving of venesection are as follow: It is difficult to succeed in venesection, because we cannot always see the vein we intend to open, and because we are not sure but we may open an artery instead of a vein. We cannot ascertain the true quantity to be taken. If we take too little, the intention is by no means answered: if we take too much, we run a risk of destroying the patient. The evacuation of the venous blood also is succeeded by that of the spirits, which on that occasion he supposes to pass from the arteries into the veins. It must likewise, he contends, be observed, that as the inflammation is formed in the arteries by the blood coagulated in their orifices, venesection must of course be useless and of no effect.

As Eraſistratus did not approve of venesection, so neither did he of purgatives, excepting very rarely, but exhibited clysters and vomits; as did also his master Chrysippus. He was of opinion, however, that the clysters should be mild; and condemned the large quantity and acrid quality of those used by preceding practitioners. The reason why purgatives were not much used by him was, that he imagined purging and venesection could answer no other purpose than diminishing the fulness of the vessels; and for this purpose he asserted that there were more effectual means than either phlebotomy or purging. He asserted that the humours discharged by cathartics were not the same in the body that they appeared after the discharge; but that the medicines changed their nature, and produced a kind of corruption in them. This opinion has since been embraced by a great number of physicians. He did not believe that purgatives acted by attraction; but substituted in the place of this principle what Mr Le Clerc imagines to be the same with Aristotle's saga racui. The principal remedy substituted by him in place of purging and venesection was abstinence. When this, in conjunction with clysters and vomits, was not sufficient to eradicate the disease, he then had recourse to exercise. All this was done with a view to diminish plenitude, which, according to him, was the most frequent cause of all diseases. Galen also informs us, that Eraſistratus had so great an opinion of the virtues of succory in diseases of the viscera and lower belly, and especially in those of the liver, that he took particular pains to describe the method of boiling it, which was, to boil it in water till it was tender; then to put it into boiling water a second time, in order to destroy its bitterness; afterwards to take it out of the water, and preserve it in a vessel with oil; and lastly, when it is to be used, add a little weak vinegar to it. Nay, so minute and circumstantial was Eraſistratus with regard to the preparation of his favourite succory, that he gave orders to the several of the plants together, because that was the more commodious method of boiling them. The rest of Eraſistratus's practice consisted almost entirely of regimen; to which he added some topical remedies, such as cataplasms, fomentations, and unctions. In short, as he could neither endure compounded medicines, nor superstitious and fine-spun reasonings, he reduced medicine to a very simple and compendious art.

With regard to surgery, Eraſistratus appears to have been very bold; and as an anatomist he is said to have been exceedingly cruel, inasmuch that he is represented by some as having dissected criminals while yet alive*. In a scirrhous liver, or in tumors of that organ, Celius Aurelianus observes, that Eraſistratus made an incision through the skin and integuments, and having opened the abdomen he applied medicines immediately to the part affected. But though he was thus bold in performing operations on the liver, yet he did not approve of the paracentesis or tapping in the dropsy; because (said he) the waters being evacuated, the liver, which is inflamed and become hard like a stone, is more pressed by the adjacent parts which the waters kept at a distance from it, so that by this means the patient dies. He declared also against drawing teeth which were not loose; and used to tell those who talked with him on this operation, That in the temple of Apollo there was to be seen an instrument of lead for drawing teeth; in order to insinuate that we must not attempt the extirpation of any but such as are loose, and call for no greater force for their extirpation than what may be supposed in an instrument of lead.

Herophilus, the disciple of Praxagoras, and contemporary of Eraſistratus, followed a less simple practice: he made so great use of medicines both simple and compound, that neither he nor his disciples would undertake the cure of any disorder without them. He seems also to have been the first who treated accurately of the doctrine of pulses, of which Hippocrates had but a superficial knowledge. Galen, however, affirms, that on this subject he involved himself in difficulties and advanced absurdities; which indeed we are not greatly to wonder at, considering the time in which he lived. He took notice of a disease at that time pretty rare, and to which he ascribes certain sudden deaths. He calls it a palsy of the heart; and perhaps it may be the same disease with what is now termed the angina pectoris.

According to Celsus, it was about this time that medicine was first divided into three branches, viz. the dietetic, the pharmaceutical, and the churgical medicine. The first of these employed a proper regimen in the cure of diseases; the second, medicines; and the third, the operation of the hands. The same author informs us, that these three branches became now the business of as many distinct classes of men; so that from this time we may date the origin of the three professions of physicians, apothecaries, and surgeons.—Before this division, those called physicians discharged all the several offices belonging to the three professions; and there were only two kinds of them, viz. one called apponemones, who only gave their advice to the patients, and directions to those of an inferior class, who were called deinometes, and worked with their hands either in the performing operations, or in the composition and application of remedies.

The first grand revolution which happened in the medicinal art after the days of Herophilus and Eraſistratus was occasioned by the founding of the empire by Serapion of Alexandria about 287 years before Christ. The division into dogmatists and empirics had indeed subsisted before; but about this time the latter party began to grow strong, and to have champions.

* See Anatomy, Hist.

32
Herophilus.

33
The Empirics.

34
Serapion.

Scrapion. nions publicly asserting its cause. Galen informs us, that Scrapion used Hippocrates very ill in his writings, in which he discovered an excess of pride, self-sufficiency, and contempt for all the physicians that went before him. We have some sketches of his practice in Coelius Aurelianus, from which we may infer that he retained the medicines of Hippocrates and the other physicians who went before him, though he rejected their reasoning. We know not what arguments he advanced for the support of his sentiments, since his works are lost, as well as those of the other empirics; and we should know nothing at all of any of them, if their adversaries had not quoted them in order to confute them.

The empirics admitted only one general method of obtaining skill in the medical art, which was by experience, called by the Greeks ἐμπειρία. From this word they took their name, and refused to be called after the founder or any champion of their sect. They defined experience a knowledge derived from the evidence of sense. It was either fortuitous, or acquired by design. For acquiring practical skill they recommended what they called τέχνη, or one's own observation, and the reading of histories or cases faithfully related by others. Hence they thought that we might be enabled to know a disease by its resemblance to others; and, when new diseases occurred, to conclude what was proper to be done from the symptoms they had in common with others that were before known. They asserted, that observation ought principally to be employed in two different ways; first in discovering what things are salutary, and what are of an indifferent nature; and, secondly, what particular disease is produced by a certain concurrence of symptoms; for they did not call every symptom a disease, but only such a combination of them as from long experience they found to accompany each other, and produced such disorders as began and terminated in the same manner.

On the other hand, the dogmatist affirmed, that there was a necessity for knowing the latent as well as the evident causes of diseases, and that the physician ought to understand the natural actions and functions of the human body, which necessarily presupposes a knowledge of the internal parts. By secret or latent causes they meant such as related to the elements or principles of which our bodies are composed, and which are the origin of a good or bad state of health. They asserted that it was impossible to know how to cure a disease without knowing the cause whence it proceeded; because undoubtedly it behaved diseases to vary prodigiously in themselves according to the different causes by which they were produced.

The next remarkable person in the history of physic is Asclepiades, who flourished in the century immediately preceding the birth of Christ. He introduced the philosophy of Democritus and Epicurus into medicine, and ridiculed the doctrines of Hippocrates. He asserted, that matter considered in itself was of an unchangeable nature; and that all perceptible bodies were composed of a number of smaller ones, between which there were interspersed an infinity of small spaces totally void of all matter. He thought that the soul itself was composed of these small bodies. He laughed at the principle called Nature by Hippocrates, and

also at the imaginary faculties said by him to be subservient to her; and still more at what he called Attraction. This last principle Asclepiades denied in every instance, even in that of the loadstone and steel, imagining that this phenomenon proceeded from a concourse of corpulesces, and a particular disposition or modification of their pores. He also maintained, that nothing happened or was produced without some cause; and that what was called nature was in reality no more than matter and motion. From this last principle he inferred that Hippocrates knew not what he said when he spoke of Nature as an intelligent being, and ascribed qualities of different kinds to her. For the same reason he ridiculed the doctrine of Hippocrates with regard to crises; and asserted that the termination of diseases might be as well accounted for from mere matter and motion. He maintained, that we were deceived if we imagined that nature always did good; since it was evident that she often did a great deal of harm. As for the days particularly fixed upon by Hippocrates for crises, or those on which we usually observe a change either for the better or the worse, Asclepiades denied that such alterations happened on those days rather than on others. Nay, he asserted that the crises did not happen at any time of its own accord, or by the particular determination of nature for the cure of the disorder, but that it depended rather on the address and dexterity of the physician; that we ought never to wait till a distemper terminates of its own accord, but that the physician by his care and medicines must hasten on and advance the cure.—According to him, Hippocrates and other ancient physicians attended their patients rather with a view to observe in what manner they died than in order to cure them; and this under pretence that Nature ought to do all herself, without any assistance.

According to Asclepiades, the particular assemblage of the various corpulesces above mentioned, and represented as of different figures, is the reason why there are several pores or interstices within the common mass, formed by these corpulesces; and why these pores are of a different size. This being taken for granted, as these pores are in all the bodies we observe, it must of course follow that the human body has some peculiar to itself, which, as well as those of all other bodies, contain certain minute bodies, which pass and re-pass through those pores that communicate with each other; and as these pores or interstices are larger or smaller, so the corpulesces which pass through them differ proportionably as to largeness and minuteness. The blood consists of the largest of these corpulesces, and the spirits, or the heat, of the smallest.

From these principles he infers, that as long as the corpulesces are freely received by the pores, the body remains in its natural state; and on the contrary, it begins to recede from that state, when the corpulesces find any obstacle to their passage. Health therefore depends on the just proportion between the pores and the corpulesces they are destined to receive and transmit; as diseases, on the contrary, proceed from a disproportion between these pores and the corpulesces. The most usual obstacle on this occasion proceeds from the corpulesces embracing each other, and being retained in some of their ordinary passages, whether these corpulesces

Asclepiades. cles arrive in too large a number, are of irregular figures, move too fast or too slow, &c.

Among the diseases produced by the corpuscles stopping of their own accord, Asclepiades reckoned phrenesies, lethargies, pleurises, and burning fevers. Pains, in particular, are classed among the accidents which derive their origin from a stagnation of the largest of all the corpuscles of which the blood consists. Among the disorders produced by the bad state and disposition of the pores, he placed deliquiums, languors, extenuations, leanness, and dropsies. These last disorders he thought proceeded from the pores being too much relaxed and opened: the dropy in particular, he thinks, proceeds from the flesh being perforated with various small holes, which convert the nourishment received into them into water. Hunger, and especially that species of it called fames canina, proceeds from an opening of the large pores of the stomach and belly; and thirst from an opening of their small ones. Upon the same principles he accounted for intermittent fevers. According to him, quotidian fevers are caused by a retention of the largest corpuscles, those of the tertian kind by a retention of corpuscles somewhat smaller, and quartan fevers are produced by a retention of the smallest corpuscles of all.

The practice of Asclepiades was suited to remove these imaginary causes of disorders. He composed a book concerning common remedies, which he principally reduced to three, viz. gestation, friction, and the use of wine. By various exercises he proposed to render the pores more open, and to make the juices and small bodies, which cause diseases by their retention, pass more freely; and while the former physicians had not recourse to gestation till towards the end of long-continued disorders, and when the patients, though entirely free from fever, were yet too weak to take sufficient exercise by walking, Asclepiades used gestation from the very beginning of the most burning fevers. He laid it down as a maxim, that one fever was to be cured by another; that the strength of the patient was to be exhausted by making him watch and endure thirst to such a degree, that, for the two first days of the disorder, he would not allow them to cool their mouths with a drop of water. Celsus also observes, that though Asclepiades treated his patients like a butcher during the first days of the disorder, he indulged them so far afterwards as even to give directions for making their beds in the softest manner. On several occasions Asclepiades used frictions to open the pores. The dropy was one of the distempers in which this remedy was used; but the most singular attempt was, by this means, to lull phrenetic patients asleep. But though he enjoined exercise so much to the sick, he denied it to those in health; a conduct not a little surprising and extraordinary. He allowed wine freely to patients in fevers, provided the violence of the distemper was somewhat abated. Nor did he forbid it to those who were afflicted with a phrensy: nay, he ordered them to drink it till they were intoxicated, pretending by that means to make them sleep; because, he said, wine had a narcotic quality and procured sleep, which he thought absolutely necessary for those who laboured under that disorder. To lethargic patients he used it on purpose to excite them, and rouse their sen-

ses: he also made them smell strong-scented substances, such as vinegar, castor, and rue, in order to make them freeze; and applied to their heads cataplasms of mustard made up with vinegar.

Besides these remedies, Asclepiades enjoined his patients abstinence to an extreme degree. For the first three days, according to Celsus, he allowed them no aliment whatever; but on the fourth began to give them victuals. According to Celsus Aurelianus, however, he began to nourish his patients as soon as the accession of the disease was diminished, not waiting till an entire remission; giving to some aliments on the first, to some on the second, to some on the third, and so on to the seventh day. It seems almost incredible to us, that people should be able to fast till this last mentioned term; but Celsus assures us, that abstinence till the seventh day was enjoined even by the predecessors of Asclepiades.

The next great revolution which happened in the medicinal art, was brought about by Themison, the disciple of Asclepiades, who lived not long before the time of Celsus, during the end of the reign of Augustus, or beginning of that of Tiberius. The sect founded by him was called methodic, because he endeavoured to find a method of rendering medicine more easy than formerly.

Themison maintained, that a knowledge of the causes of diseases was not necessary, provided we have a due regard to what diseases have in common and analogous to one another. In consequence of this principle, he divided all diseases into two, or at most three, kinds. The first included diseases arising from stricture; the second, those arising from relaxation; and the third, those of a mixed nature, or such as partook both of stricture and relaxation.

Themison also asserted, that diseases are sometimes acute, and sometimes chronic; that for a certain time they increase; that at a certain time they are at their height; and that at last they were observed to diminish. Acute diseases, therefore, according to him, must be treated in one way, and chronic diseases in another; one method must be followed with such as are in their augmentation, another with such as are at their height, and a third with such as are in their declension. He asserted, that the whole of medicine consisted in the observation of that small number of rules which are founded upon things altogether evident. He said, that all disorders, whatever their nature was, if included under any of the kinds above mentioned, ought to be treated precisely in the same way, in whatever country and with whatever symptoms they happen to arise. Upon these principles, he defined medicine to be a method of conducting to the knowledge of what diseases have in common with each other.

Themison was old when he laid the foundation of the methodic sect; and it was only brought to perfection by Theffalus, who lived under the emperor Nero. Galen and Pliny accuse this physician of intolerable insolence and vanity, and report that he gave himself the air of despising all other physicians; and so intolerable was his vanity, that he assumed the title of the conqueror of physicians, which he caused to be put upon his tomb in the Appian way. Never was mountebank (says Pliny) attended by a greater number of spectators

Theissalus, spectators than Theissalus had generally about him; and this circumstance is the less to be wondered at, if we consider that he promised to teach the whole art of medicine in less than six months. In reality, the art might be learned much sooner if it comprehended no more than what the methodics thought necessary: for they cut off the examination of the causes of diseases followed by the dogmatics; and substituted in the room of the laborious observations of the empirics, indications drawn from the analogy of diseases, and the mutual resemblance they bear to each other. The most skilful of all the methodic sects, and he who put the last hand to it, was Soranus. He lived under the emperors Trajan and Adrian, and was a native of Ephesus.

One of the most celebrated medical writers of antiquity was Celsus, whom we have already had occasion to mention. Most writers agree that he lived in the time of Tiberius, but his country is uncertain. It is even disputed whether or not he was a professed physician. Certain it is, however, that his books on medicine are the most valuable of all the ancients next to those of Hippocrates. From the latter, indeed, he has taken so much, as to acquire the name of the Latin Hippocrates; but he has not attached himself to him so closely as to reject the assistance of other authors. In many particulars he has preferred Asclepiades. With him he laughs at the critical days of Hippocrates, and ascribes the invention of them to a foolish and superstitious attachment to the Pythagorean doctrine of numbers. He also rejected the doctrine of Hippocrates with regard to venesection, of which he made a much more general use; but did not take away so much blood at a time, thinking it much better to repeat the operation than weaken the patient by too great an evacuation at once. He used cupping also much more frequently, and differed from him with regard to purgatives. In the beginning of disorders, he said, the patients ought to endure hunger and thirst: but afterwards they were to be nourished with good aliments; of which, however, they were not to take too much, nor fill themselves suddenly, after having fasted long. He does not specify how long the patient ought to practise abstinence; but affirms, that in this particular it is necessary to have a regard to the disease, the patient, the season, the climate, and other circumstances of a like nature. The signs drawn from the pulse he looked upon to be very precarious and uncertain. "Some (says he) lay great stress upon the beating of the veins or the arteries; which is a deceitful circumstance, since that beating is slow or quick, and varies very much, according to the age, sex, and constitution of the patient. It even sometimes happens that the pulse is weak and languid when the stomach is disordered, or in the beginning of a fever. On the contrary, the pulse is often high, and in a violent commotion, when one has been exposed to the sun, or comes out of a bath, or from using exercise; or when one is under the influence of anger, fear, or any other passion. Besides, the pulse is easily changed by the arrival of the physician, in consequence of the patient's anxiety to know what judgement he will pass upon his case. To prevent this, the physician must not feel the patient's pulse on his first arrival: he must first sit down by him, assume a cheerful air, inform himself of his con-

dition; and if he is under any dread, endeavour to remove it by encouraging discourse; after which he may examine the beating of the artery. This nevertheless does not hinder us from concluding, that if the light of the physician alone can produce so remarkable a change in the pulse, a thousand other causes may produce the same effect." But although Celsus thought for himself, and in not a few particulars differed from his predecessors, yet in his writings, which are not only still preserved, but have gone through almost innumerable editions, we have a compendious view of the practice of almost all his predecessors: and he treats of the healing art in all its branches, whether performed manu, vultu, vel medicamentis. His writings, therefore, will naturally be consulted by every one who wishes either to become acquainted with the practice of the ancients prior to the fall of the Roman empire, or to read medical Latin in its greatest purity.

About the 131st year after Christ, in the reign of Galen, the emperor Adrian, lived the celebrated Galen, a native of Pergamus, whose name makes such a conspicuous figure in the history of physic. At this time the dogmatic, empiric, methodic, and other sects, had each their abettors. The methodics were held in great esteem, and looked upon to be superior to the dogmatics, who were strangely divided among themselves, some of them following Hippocrates, others Erasistratus, and others Asclepiades. The empirics made the least considerable figure of any. Galen undertook the reformation of medicine, and restored dogmatism. He seems to have been of that sect which was called eclectic, from their choosing out of different authors what they esteemed good in them, without being particularly attached to any one more than the rest. This declaration he indeed sets out with; but, notwithstanding this, he follows Hippocrates much more than any other, or rather follows nobody else but him. Though before his time several physicians had commented on the works of Hippocrates, yet Galen pretends that none of them had understood his meaning. His first attempt therefore was to explain the works of Hippocrates; with which view he wrote a great deal, and after this set about composing a system of his own. In one of his books entitled, "Of the establishment of medicine," he defines the art to be one which teaches to preserve health and cure diseases. In another book, however, he proposes the following definition: "Medicine (says he) is a science which teaches what is found, and what is not so; and what is of an indifferent nature, or holds a medium between what is found and what is the reverse." He affirmed, that there are three things which constitute the object of medicine, and which the physician ought to consider as found, as not found, or of a neutral and indifferent nature. These are the body itself, the signs, and the causes. He esteems the human body found, when it is in a good state or habit with regard to the simple parts of which it is composed, and when besides there is a just proportion between the organs formed of these simple parts. On the contrary, the body is reckoned to be unfound, when it recedes from this state, and the just proportion above mentioned. It is in a state of neutrality or indifference, when it is in a medium between soundness and its opposite state. The salutary

signs.

Galen. signs are such as indicate present health, and prognosticate that the man may remain in that state for some time to come. The infalubrious signs, on the contrary, indicate a present disorder, or lay a foundation for suspending the approach of one. The neutral signs, or such as are of an indifferent nature, denote neither health nor indisposition, either for the present, or for the time to come. In like manner he speaks of causes salutary, unsalutary, and indifferent.

These three dispositions of the human body, that is, soundness, its reverse, and a neutral state, comprehend all the differences between health and disorder or indisposition: and each of these three states or dispositions has a certain extent peculiar to itself. A sound habit of body, according to the definition of it already given, is very rare, and perhaps never to be met with; but this does not hinder us to suppose such a model for regulating our judgement with respect to different constitutions. On this principle Galen establishes eight other principal constitutions, all of which differ more or less from the perfect model above mentioned. The four first are such as have one of the four qualities of hot, cold, moist, or dry, prevailing in too great a degree; and accordingly receive their denomination from that quality which prevails over the rest. The four other species of constitutions receive their denominations from a combination of the above mentioned; so that, according to his definition, there may be a hot and dry, a hot and moist, a cold and moist, and a cold and dry, constitution. Besides these differences, there are certain others which result from occult and latent causes, and which, by Galen, are said to arise from an idiosyncrasy of constitution. It is owing to this idiosyncrasy that some have an aversion to one kind of aliment and some to another; that some cannot endure particular smells, &c. But though these eight last-mentioned constitutions fall short of the perfection of the first, it does not thence follow, that those to whom they belong are to be classed among the valetudinarian and diseased. A disease only begins when the deviation becomes so great as to hinder the due action of some parts.

Galen describes at great length the signs of a good or bad constitution, as well as those of what he calls a neutral habit. These signs are drawn from the original qualities of cold, hot, moist, and dry, and from their just proportion or disproportion with respect to the bulk, figure, and situation, of the organical parts. With Hippocrates he establishes three principles of an animal body; the parts, the humours, and the spirits. By the parts he properly meant no more than the solid parts; and these he divided into similar and organical. Like Hippocrates, he also acknowledged four humours; the blood, the phlegm, the yellow bile and black bile. He established three different kinds of spirits; the natural, the vital, and the animal. The first of these are, according to him, nothing else but a subtle vapour arising from the blood, which draws its origin from the liver, the organ or instrument of sanguification. After these spirits are conveyed to the heart, they, in conjunction with the air we draw into the lungs, become the matter of the second species, that is, of the vital spirits, which are again changed into those of the animal kind in the brain. He supposed that these three species of spirits served as instru-

ments to three kinds of faculties, which reside in the respective parts where these faculties are formed. The natural faculty is the first of these, which he placed in the liver, and imagined to preside over the nutrition, growth, and generation, of the animal. The vital faculty he lodged in the heart, and supposed that by means of the arteries it communicated warmth and life to all the body. The animal faculty, the noblest of all the three, and with which the reasoning or governing faculty was joined, according to him, has its seat in the brain; and, by means of the nerves, distributes a power of motion and sensation to all the parts, and presides over all the other faculties. The original source or principle of motion in all these faculties, Galen, as well as Hippocrates, defines to be Nature.

Upon these principles Galen defined a disease to be "such a preternatural disposition or affection of the parts of the body, as primarily, and of itself, hinders their natural and proper action." He established three principal kinds of diseases: the first relates to the similar parts; the second, to the organical; and the third is common to both these parts. The first kind of diseases consists in the intemperance of the similar parts; and this is divided into an intemperance without matter, and an intemperance with matter. The first discovers itself when a part has more or less heat or cold than it ought to have without that change of quality in the part being supported and maintained by any matter. Thus, for instance, a person's head may be overheated and indisposed by being exposed to the heat of the sun, without that heat being maintained by the continuance or congection of any hot humour in the part. The second sort of intemperance is when any part is not only rendered hot or cold, but also filled with a hot or cold humour, which are the causes of the heat or cold felt in the part. Galen also acknowledged a simple intemperance: that is, when one of the original qualities, such as heat or cold, exceeds the natural standard alone and separately; and a compound intemperance, when two qualities are joined together, such as heat and dryness, or coldness and humidity. He also established an equal and unequal temperature. The former is that which is equally in all the body, or in any particular part of it, and which creates no pain, because it is become habitual, such as dryness in the hectic constitution. The latter is distinguished from the former, in that it does not equally subsist in the whole of the body, or in the whole of a part. Of this kind of intemperance we have examples in certain fevers, where heat and cold, equally, and almost at the same time, attack the same part; or in other fevers, which render the surface of the body cold as ice, while the internal parts burn with heat; or lastly, in cases where the stomach is cold and the liver hot.

The second kind of disorders, relating to the organical parts, results from irregularities of these parts, with respect to the number, bulk, figure, situation, &c.; as when one has six fingers, or only four; when one has any part larger or smaller than it ought to be, &c. The third kind, which is common both to the similar and the organical parts, is a solution of continuity, which happens when any similar or compound part is cut, bruised, or corroded.

Like Hippocrates, Galen distinguished diseases into acute and chronic; and, with respect to their nature and genus, into benign and malignant; also into epidemic, endemic, and sporadic.

After having distinguished the kinds of diseases, Galen comes to explain their causes; which he divides into external and internal. The external causes of diseases, according to him, are six things, which contribute to the preservation of health when they are well disposed and properly used, but produce a contrary effect when they are imprudently used or ill disposed. These six things are, the air, aliments and drink, motion and rest, sleeping and watching, retention and excretion, and lastly the passions. All these are called the propter or beginning causes, because they put in motion the internal causes; which are of two kinds, the antecedent and the consequent. The former is discovered only by reasoning; and consists for the most part in a peccancy of the humours, either by plentitude or cacochymy, i. e. a bad state of them. When the humours are in too large a quantity, it is called a plethora; but we must observe, that this word equally denotes too large a quantity of all the humours together, or a redundancy of one particular humour which prevails over the rest. According to these principles, there may be a sanguine, a bilious, a pituitous, or a melancholy plentitude: but there is this difference between the sanguine and the three other plentitudes, that the blood, which is the matter of the former, may far surpass the rest: whereas, if any of the three last mentioned ones do so, the case is no longer called plentitude, but cacochymia; because these humours, abounding more than they ought, corrupt the blood. The causes he also divides into such as are manifest and evident, and such as are latent and obscure. The first are such as spontaneously come under the cognizance of our senses when they act or produce their effects: the second are not of themselves perceptible, but may be discovered by reasoning: the third sort, i. e. such as he calls occult or concealed, cannot be discovered at all. Among this last he places the cause of the hydrophobia.

He next proceeds to consider the symptoms of diseases. A symptom he defines to be "a preternatural affection depending upon a disease, or which follows it as a shadow does a body." He acknowledged three kinds of symptoms: the first and most considerable of these consisted in the action of the parts being injured or hindered; the second in a change of the quality of the parts, their actions in the mean time remaining entire: the third related to defects in point of excretion and retention.

After having treated of symptoms, Galen treats of the signs of diseases. These are divided into diagnostic and prognostic. The first are so called because they enable us to know diseases, and distinguish them from each other. They are of two sorts, pathognomonic or adjunct. The first are peculiar to every disease, make known its precise species, and always accompany it, so that they begin and end with it. The second are common to several diseases, and only serve to point out the difference between diseases of the same species. In a pleurisy, for instance, the pathognomonic signs are a cough, a difficulty of breathing, a pain of the side, and a continued fever; the adjunct

signs are the various sorts of matter expectorated, which is sometimes bloody, sometimes bilious, &c. The diagnostic signs were drawn from the defective or disordered disposition of the parts, or from the diseases themselves; secondly, from the causes of diseases; thirdly, from their symptoms; and lastly, from the particular dispositions of each body, from things which prove prejudicial and those that do service, and from epidemical diseases. The prognostic signs he gathered from the species, virulence, and peculiar genus of the disease: but as we have already spoken so largely concerning the prognostics of Hippocrates, it is superfluous to be particular on those of Galen. His method of cure differed little from that of Hippocrates: but from the specimen already given of Galen's method of teaching the medical art, it is evident that his system was little else than a collection of speculations, distinctions, and reasonings; whereas that of Hippocrates was founded immediately upon facts, which he had either observed himself, or had learned from the observation of others.

The system of Galen, however, notwithstanding its defects and absurdities, remained almost uncontradicted for a very long period. Indeed it may be considered as having been the prevailing system till the inundation of the Goths and Vandals put an almost entire stop to the cultivation of letters in Europe. But during the general prevalence of the system of Galen, there appeared some writers to whom medicine was indebted for improvements, at least in certain particulars. Among the most distinguished of these we may mention Oribasius, Aëtius, Alexander, and Paulus.

Oribasius flourished about the year 360, and was physician to the emperor Julian. He speaks very fully of the effects of bleeding by way of scarification, a thing little taken notice of by former writers; from his own experience he assures us that he had found it successful in a suppression of the menses, defluxions of the eyes, headache, and straitness of breathing even when the person was extremely old. He tells his own case particularly, when the plague raged in Asia and he himself was taken ill. On the second day he scarified his leg, and took away two pounds of blood; by which means he entirely recovered, as did several others who used it. In this author also we find the first description of a surprising and terrible distemper, which he termed λοχαϊμία, a species of melancholy and madness, which he describes thus. "The persons affected get out of their houses in the night-time, and in every thing imitate wolves, and wander among the sepulchres of the dead till day-break. You may know them by these symptoms: Their looks are pale; their eyes heavy, hollow, dry, without the least moisture of a tear; their tongue exceedingly parched and dry, no spittle in their mouth, extreme thirst; their legs, from the falls and the bruises they receive, full of incurable sores and ulcers."

Aëtius lived very near the end of the fifth, or in the beginning of the sixth century. Many passages in his writings serve to show us how much the actual and potential cautery were used by the physicians of that age. In a palsy, he says, that he should not at all hesitate to make an eschar either way, and this in several places; one in the nape, where the spinal marrow takes its rise, two on each side of it; three or four

Alexander. four on the top of the head, one just in the middle, and three others round it. He adds, that in this case, if the ulcers continue running a considerable time, he should not doubt of a perfect recovery. He is still more particular when he comes to order this application for an inveterate asthma, after all other remedies have been tried in vain. One, he says, should be made on each side near the middle of the joining of the clavicle, taking care not to touch the wind-pipe: two other little ones are then to be made near the carotids under the chin, one on each side, so that the caustic may penetrate no further than the skin; two others under the breasts, between the third and fourth ribs; and again, two more backwards towards the fifth and sixth ribs. Besides these there ought to be one in the middle of the thorax, near the beginning of the xiphoid cartilage, over the orifice of the stomach; one on each side between the eighth and ninth ribs; and three others in the back, one in the middle, and the two others just below it, on each side of the vertebrae. Those below the neck ought to be pretty large, not very superficial, not very deep: and all these ulcers should be kept open for a very long time.

Ætius takes notice of the worms bred in different parts of the body called draecunculi, which were unknown to Galen. He seems also to be the first Greek writer among the Christians, who gives us any specimens of medicinal spells and charms; such as that of a finger of St. Blasius for removing a bone which sticks in the throat, and another in relation to a fistula. He gives a remedy for the gout, which he calls the grand drier; the patient is to use it for a whole year, and observe the following diet each month. "In September, he must eat and drink milk; in October, he must eat garlic; in November, abstain from bathing; in December, he must eat no cabbage; in January, he is to take a glass of pure wine in the morning; in February, to eat no beet; in March, to mix sweet things both in eatables and drinkables; in April, not to eat horse-radish, nor in May the fish called polypus; in June, he is to drink cold water in a morning; in July, to avoid venery; and lastly, in August, to eat no mallows." This may sufficiently show the quackery of those times, and how superstition was beginning to mix itself with the art.

Alexander. Alexander, who flourished in the reign of Justinian, is a more original author than either of the two former. He confines himself directly to the describing the signs of diseases, and the methods of cure, without meddling with anatomy, the materia medica, or surgery, as all the rest did. He employs a whole book in treating of the gout. One method he takes of relieving this disease is by purging; and in most of the purges he recommends hermodactyls, of which he has a great opinion. In a caesus, or burning fever, where the bile is predominant, the matter fit for evacuation, and the fever not violent, he prefers purging to bleeding, and says that he has often ordered purging in acute fevers with surprising success. In the caesus also, if a syncope happens from crude and redundant humours, he recommends bleeding. In a syncope succeeding the suppression of any usual evacuation, he recommends bleeding, with frictions. The diagnostics upon which he founds this practice are the following: viz. a face paler and more swelled than usual, a bloated

habit of body, with a small sluggish pulse, having long intervals between the strokes. In tertian, and much more in quartan fevers, he recommends vomits above all other remedies, and affirms that by this remedy alone he has cured the most inveterate quartans. On the bulimus, or canine appetite, he makes a new observation, viz. that it is sometimes caused by worms. He mentions the case of a woman who laboured under this ravenous appetite, and had a perpetual gnawing at her stomach and pain in her head: after taking hiera, she voided a worm above a dozen of cubits long, and was entirely cured of her complaints.—He is also the first author who takes notice of rhubarb; which he recommends in a weakness of the liver and in dysentery.—Alexander is recommended by Dr Freind as one of the best practical writers among the ancients, and well worthy the perusal of any modern.

Paulus was born in the island Ægina, and lived in the 7th century. He transcribes a great deal from Alexander and other physicians. His descriptions are short and accurate. He treats particularly of women's disorders; and seems to be the first instance upon record of a professed man-midwife, for so he was called by the Arabians: and accordingly he begins his book with the disorders incident to pregnant women. He treats also very fully of surgery; and gives some directions, according to Dr Freind, not to be found in the more ancient writers.

After the downfall of the Roman empire, and when the inundation of Goths and Vandals had almost completely exterminated literature of every kind in Europe, medicine, though a practical art, shared the same fate with more abstract sciences. Learning in general, banished from the seat of arms, took refuge among the eastern nations, where the arts of peace still continued to be cultivated. To the Arabian physicians, as they have been called, we are indebted both for the preservation of medical science, as it subsisted among the Greeks and Romans, and likewise for the description of some new diseases, particularly the smallpox. Among the most eminent of the Arabians, we may mention Rhazes, Avicenna, Albucais, and Aven-Rhazes. But of their writings it would be tedious, and is unnecessary, to give any particular account.—They were for the most part, indeed, only copiers of the Greeks. We are, however, indebted to them for some improvements. They were the first who introduced chemical remedies, though of these they used but few, nor did they make any considerable progress in the chemical art. Anatomy was not in the least improved by them, nor did surgery receive any advancement till the time of Albucais, who lived probably in the 12th century. They added a great deal to botany and the materia medica, by the introduction of new drugs, of the aromatic kind especially, from the east, many of which are of considerable use. They also found out the way of making sugar; and by help of that, syrups; which two new materials are of great use in mixing up compound medicines.

With regard to their practice, in some few particulars they deviated from the Greeks. Their purging medicines were much milder than those formerly in use; and even when they did prescribe the old ones, they gave them in a much less dose than the Greek and Roman physicians. The same reflection may be made concerning

concerning their manner of bleeding, which was never to that excessive degree practised by the Greeks. They deviated from Hippocrates, however, in one very trivial circumstance, which produced a violent controversy. The question was, Whether blood in a pleurisy ought to be drawn from the arm of the affected side or the opposite? Hippocrates had directed it to be drawn from the arm of the affected side; but the Arabians, following some other ancient physicians, ordered it to be drawn from the opposite one. Such was the ignorance of those ages, that the university of Salamanca in Spain made a decree, that no one should dare to let blood but in the contrary arm; and endeavoured to procure an edict from the emperor Charles V. to second it; alleging that the other method was of no less pernicious consequence to medicine, than Luther's hereby had been to religion.

In consequence of the general decay of learning in the western parts of the world, the Greek writers were entirely neglected, because nobody could read the language; and the Arabians, though principally copies from them, enjoyed all the reputation that was due to the others. The Arabian physic was introduced into Europe very early, with the most extravagant applause: and not only this, but other branches of their learning, came into repute in the west; insomuch that in the 11th century, the studies of natural philosophy and the liberal arts were called the studies of the Saracens. This was owing partly to the crusades undertaken against them by the European princes; and partly to the settlement of the Moors in Spain, and the intercourse they and other Arabians had with the Italians. For, long before the time of the crusades, probably in the middle of the 7th century, there were Hebrew, Arabic, and Latin professors of physic settled at Salernum: which place soon grew into such credit, that Charles the Great thought proper to found a college there in the year 802; the only one at that time in Europe. Constantine the African flourished there towards the latter end of the 11th century. He was a native of Carthage; but travelled into the east, and spent 30 years in Babylon and Bagdad, by which means he became master of the oriental languages and learning. He returned to Carthage; but being informed of an attempt against his life, made his escape into Apulia, where he was recommended to Robert Guiscard, created in 1060 duke of that country, who made him his secretary. He was reputed to be very well versed in the Greek, as well as in the eastern tongues; and seems to have been the first who introduced either the Greek or Arabian physic into Italy. His works, however, contain nothing that is new, or material; though he was then accounted a very learned man.

From this time to the end of the 15th and beginning of the 16th century, the history of physic furnishes us with no interesting particulars. This period, however, is famous for the introduction of chemistry into medicine, and the description of three new distempers, the sweating sickness, the venereal disease, and the scurvy. The sweating sickness began in 1485 in the army of Henry VII. upon his landing at Milford-haven, and spread itself at London from the 21st of September to the end of October. It returned there five times, and always in summer; first in 1495, then

in 1506, afterwards in 1517, when it was so violent that it killed many in the space of three hours, so that numbers of the nobility died, and of the commonality in several towns often the one-half perished. It appeared the fourth time in 1528, and then proved mortal in six hours; many of the courtiers died of it, and Henry VIII. himself was in danger. In 1529, and only then, it infected the Netherlands and Germany, in which last country it did much mischief. The last return of it was in 1551, and in Westminster it carried off 120 in a day. Dr Cais describes it as a pestilent contagious fever, of the duration of one natural day; the sweat he reckoned to be only a natural symptom, or crisis of the distemper. It first affected some particular part, attended with inward heat and burning, unquenchable thirst, restlessness, sickness at stomach, but seldom vomiting, headache, delirium, then faintness, and excessive drowsiness. The pulse was quick and vehement, and the breath short and laborious. Children, poor and old people, were rarely subject to it. Of others, scarce any escaped the attack, and most of them died. Even by travelling into France or Flanders they did not escape; and what is still more strange, the Scots were said not to be affected; abroad the English only were seized, and foreigners in England were free. At first the physicians were much puzzled how to treat this disease. The only cure they ever found, however, was to carry on the sweat for a long time; for, if stopped, it was dangerous or fatal. The way, therefore, was for the patient to lie still, and not expose himself to cold. If nature was not strong enough to force out the sweat, it was necessary to assist her by art, with clothes, wine, &c. The violence of the distemper was over in 15 hours; but there was no security for the patient till 24 were passed. In some strong constitutions there was a necessity to repeat the sweating, even to 12 times. The removing out of bed was attended with great danger; some who had not sweated enough fell into very bad fevers. No flesh meat was to be allowed in all the time of the distemper; nor drink for the first five hours. In the seventh, the distemper increased; in the ninth the delirium came on, and sleep was by all means to be avoided. However terrible this distemper appeared at first, it seldom proved obstinate, if treated in the above-mentioned manner.

In the beginning of the 16th century, the famous Paracelsus, chemist Paracelsus introduced a new system into medicine, founded on the principles of chemistry. The Galenic system had prevailed till his time; but the practice had greatly degenerated, and was become quite trivial and frivolous. The physicians in general rejected the use of opium, mercury, and other efficacious remedies. Paracelsus, who made use of these, had therefore greatly the advantage over them; and now all things relating to medicine were explained on imaginary chemical principles. It will easily be conceived that a practice founded in this manner could be no other than the most dangerous quackery. At this time, however, it was necessary; for now a new disease overran the world, and threatened greater destruction than almost all the old ones put together, both by the violence of its symptoms, and its baffling the most powerful remedies at that time known. This was the venereal disease, which is supposed to have been imported

Modern. imported from the West Indies by the companions of Christopher Columbus. Its first remarkable appearance was at the siege of Naples in 1494, from whence it was soon after propagated through Europe, Asia, and Africa. The symptoms with which it made the attack at that time were exceedingly violent, much more so than they are at present; and consequently were utterly unconquerable by the Galenists. The quacks and chemists, who boldly ventured on mercury, though they no doubt destroyed numbers by their excessive use of it, yet showed that a remedy for this terrible distemper was at last found out, and that a proper method of treating it might soon be fallen upon. Shortly after, the West Indian specific, guaiacum, was discovered: the materia medica was enriched with that and many other valuable medicines, both from the East and West Indies: which contributed considerably to the improvement of the practice of physic. At this period, as sea voyages of considerable duration were more frequent, the scurvy became a more common distemper, and was of course more accurately described. But probably, from supposed analogy to the contagious which at that time were new in Europe, very erroneous ideas were entertained with regard to its being of an infectious nature: And it is not impossible, that from its being attended also with ulcers, it was on some occasions confounded with syphilitic complaints.

54. Progress of medicine in the 17th and 18th centuries.

The revival of learning, which now took place throughout Europe, the appearance of these new distempers, and the natural fondness of mankind for novelty, contributed greatly to promote the advancement of medicine as well as other sciences. While at the same time, the introduction of the art of printing rendered the communication of new opinions as well as new practices so easy a matter, that to enumerate even the names of those who have been justly rendered eminent for medical knowledge would be a very tedious task. It was not, however, till 1628 that Dr. William Harvey of London demonstrated and communicated to the public one of the most important discoveries respecting the animal economy, the circulation of the blood. This discovery, more effectually than any reasoning, overturned all the systems which had subsisted prior to that time. It may justly be reckoned the most important discovery that has hitherto been made in the healing art: for there can be no doubt that it puts the explanation of the phenomena of the animal body, both in a state of health and disease, on a more solid and rational footing than formerly. It has not, however, prevented the rise of numerous fanciful and absurd systems. These, though fashionable for a short time, and strenuously supported by blind adherents, have yet in no long period fallen into deserved contempt. And notwithstanding the abilities and industry of Stahl, Hoffman, Boerhaave,

and Cullen, we may confidently venture to assert that no general system has yet been proposed which is not liable to innumerable and unsurmountable objections. Very great progress has indeed been made in explaining the philosophy of the human body, from ascertaining by decisive experiment the influence of the circulating, the nervous, and the lymphatic systems in the animal economy. But every attempt hitherto made to establish any general theory in medicine, that is to conduct the cure of every disease on a few general principles, has equally deviated from truth with those of Hippocrates and Galen; and has equally tended to mislead those who have adopted it. Many systems of our own days, such for example as that of Brown, though adopted with enthusiasm by the young and inexperienced, have evidently been attended with the most pernicious consequences in practice. Indeed we may with confidence venture to assert, that from the very nature of the subject itself, medicine does not admit of such simplicity. No one can deny that the human body consists of a very great number of different parts, both solids and fluids. It is, however, equally certain, that each of these is from many different causes liable to deviations from the sound state. And although some slight changes may take place without what can be called a morbid affection, yet we well know, that every change taking place to a certain degree in any one part will necessarily and unavoidably produce an affection of the whole. Hence we may without hesitation venture to affirm, that every general theory which can be proposed, attempting to explain the phenomena, and conduct the cure of all diseases on a few general principles, though for some time it may have strenuous advocates, will yet in the end be found to be both ill-grounded and pernicious.

The art of medicine has been much more usefully improved by careful attention to the history, theory, and practice of particular diseases, and by endeavouring to ascertain from cautious observation the symptoms by which they are to be distinguished, the causes by which they are induced, and the means by which they are to be prevented, alleviated, or cured. On this footing, therefore, we shall endeavour to give a brief account of at least the most important affections to which the human body is subjected, delivering what appear to us to be the best established facts and observations respecting each.

But before entering on the consideration of particular diseases, or what has commonly been styled the practice of medicine, it is necessary to give a general view of the most important functions of the animal body, and of the chief morbid affections to which they are subjected; a branch which has usually been named the Theory or Institutions of Medicine.

THEORY OF MEDICINE; or an Account of the principal Functions of the Animal Body.

WHILE the functions of living animals, but particularly of the human species, are very numerous, the accounts given of these both in a state of health and di-

fese are very various. Without, therefore, pretending to enumerate the contradictory opinions of different authors, we shall here present the reader with a view of this subject,

Functions of the Body. Theoreticae of Dr James Gregory, who has collected from other writers the opinions at present most generally adopted.

⁵⁶ Division of the functions into animal, vital, and natural. In this work, which was first published in 1780, and afterwards reprinted under an enlarged form in 1782, Dr Gregory introduces his subject by observing, that some functions of the human body relate to itself only, and others to external things. To the latter class belong those which by physicians are called the animal functions; to which are to be referred all our senses, as well as the power of voluntary motion, by which we become acquainted with the universe, and enjoy this earth. Among the functions which relate to the body, some have been named vital, such as the circulation of the blood and respiration; because, without the constant continuance of these life cannot subsist; others, intended for repairing the waste of the system, have been termed the natural functions: for by the constant attrition of the solids and the evaporation of the fluid parts of the body, we stand in need of nourishment to supply this waste; after which the putrid and excrementitious parts must be thrown out by the proper passages. The digestion of the food, secretion of the humours, and excretion of the putrid parts of the food, are referred to this class; which, though necessary to life, may yet be interrupted for a considerable time without danger. This division of the functions into animal, vital, and natural, is of very ancient date, and is perhaps one of the best that has yet been proposed.

⁵⁷ Distinction of diseases into simple and compound. A disease takes place, when the body has so far declined from a sound state, that its functions are either quite impeded, or performed with difficulty. A disease therefore may happen to any part of the body either solid or fluid, or to any one of the functions: and those may occur either singly, or several of them may be diseased at the same time; whence the distinction of diseases into simple and compound.

We have examples of the most simple kinds of diseases, in the rupture or other injury of any of the corporeal organs, by which means they become less fit for performing their offices; or, though the organs themselves should remain sound, if the solids or fluids have degenerated from a healthy state; or if, having lost their proper qualities, they have acquired others of a different, perhaps of a noxious nature; or lastly, if the moving powers shall become too weak or too strong, or direct their force in a way contrary to what nature requires.

⁵⁸ Symptoms. The most simple diseases are either productive of others, or of symptoms, by which alone they become known to us. Every thing in which a sick person is observed to differ from one in health is called a symptom; and the most remarkable of these symptoms, which most constantly appear, define and constitute the disease.

⁵⁹ Predisposing cause. The causes of diseases are various; often obscure, and sometimes totally unknown. The most full and perfect proximate cause is that which, when present, produces a disease, when taken away removes it, and when changed, changes it.—There are also remote causes, which physicians have been accustomed to divide into the predisposing and exciting ones. The

former are those which only render the body fit for a disease, or which put it into such a state that it will readily receive one. The exciting cause is that which immediately produces the disease in a body already disposed to receive it.

⁶⁰ Exciting cause. The predisposing cause is always inherent in the body itself, though perhaps it originally came from cause without; thus heat or cold, a very sparing or a very luxurious diet, and many other particulars, may operate as causes of predisposition, inducing plethora, inanition, or the like. But the exciting cause may either come from within or without.

From the combined action of the predisposing and exciting causes comes the proximate cause, which neither of the two taken singly is often able to produce.—⁶¹ A body predisposed to disease therefore has already declined somewhat from a state of perfect health, although none of its functions are impeded in such a manner that we can truly say the person is diseased. Yet sometimes the predisposing cause, by continuing long, may arrive at such a height, that it alone, without the addition of any exciting cause, may produce a real disease.—The exciting cause also, though it should not be able immediately to bring on a disease; yet if it continues long, will by degrees destroy the strongest constitution, and render it liable to various diseases; because it either produces a predisposing cause, or is converted into it, so that the same thing may sometimes be an exciting cause, sometimes a predisposing one, or rather a cause of predisposition; of which the inclemencies of the weather, sloth, luxury, &c. are examples.

⁶² Hereditary diseases. Diseases, however, seem to have their origin from the very constitution of the animal machine; and hence many diseases are common to every body when a proper exciting cause occurs, though some people are much more liable to certain diseases than others. Some are hereditary; for as healthy parents naturally produce healthy children, so diseased parents as naturally produce a diseased offspring. Some of these diseases appear in the earliest infancy; others occur equally at all ages; nor are there wanting some which lurk unsuspected even to the latest old age, at last breaking out with the utmost violence. Some diseases are born with us, even though they have no proper foundation in our constitution, as when a fetus receives some hurt by an injury done to the mother; while others, neither born with us nor having any foundation in the constitution, are sucked in with the nurse's milk. Many diseases accompany the different stages of life; and hence some are proper to infancy, youth, and old age. Some also are proper to each of the sexes: and especially the female sex, proceeding, no doubt, from the general constitution of the body, but particularly from the state of the parts subservient to generation. Hence the diseases peculiar to virgins, to menstruating women, to women with child, to lying-in women, to nurses, and to old women. The climate itself, under which people live, produces some diseases; and every climate has a tendency to produce particular diseases, either from its excess of heat or cold, or from the mutability of the weather. An immense number of diseases also may be produced by impure air, or such as is loaded with putrid, marshy, and other noxious vapours. The

same thing may happen likewise from corrupted aliment, whether meat or drink; though even the best and most nutritious aliment will hurt if taken in too great quantity; not to mention poisons, which are endowed with such pernicious qualities, that even when taken in a very small quantity they produce the most grievous diseases, or perhaps even death itself. Lastly, from innumerable accidents and dangers to which mankind are exposed, they frequently come off with broken limbs, wounds, and contusions, sometimes quite incurable; and these misfortunes, though proceeding from an external cause at first, often terminate in internal diseases.

Hitherto we have mentioned only the dangers which come from without; but those are not less, nor fewer in number, which come from within. At every breath, man pours forth a deadly poison both to himself and others. Neither are the effluvia of the lungs alone hurtful: there flows out from every pore of the body a most subtle and poisonous matter, perhaps of a putrefactive nature, which being long accumulated, and not allowed to diffuse itself through the air, infects the body with most grievous diseases; nor does it stop here, but produces a contagion which spreads devastation far and wide among mankind. From too much or too little exercise of our animal powers also no small danger ensues. By inactivity either of body or mind, the vigour of both is impaired; nor is the danger much less from too great employment. By moderate use, all the faculties of the mind, as well as all the parts of the body, are improved and strengthened; and here nature has appointed certain limits, so that exercise can neither be too much neglected, nor too much increased, with impunity. Hence those who use violent exercise, as well as those who spend their time in sloth and idleness, are equally liable to diseases; but each to diseases of a different kind: and hence also the bad effects of too great or too little employment of the mental powers.

Besides the dangers arising from those actions of the body and mind which are in our own power, there are others arising from those which are quite involuntary. Thus, passions of the mind, either when carried to too great excess, or when long continued, equally destroy the health; nay, will even sometimes bring on sudden death. Sleep also, which is of the greatest service in restoring the exhausted strength of the body, proves noxious either from its too great or too little quantity. In the most healthy body, also, many things always require to be evacuated. The retention of these is hurtful, as well as too profuse an evacuation, or the excretion of those things either spontaneously or artificially which nature directs to be retained. As the solid parts sometimes become flabby, soft, almost dissolved, and unfit for their proper offices; so the fluids are sometimes inspissated, and formed even into the hardest solid matter. Hence impeded actions of the organs, vehement pain, various and grievous diseases. Lastly, some animals are to be reckoned among the causes of diseases: such particularly, as support their life at the expence of others: and these either invade us from without, or take up their residence within the body, gnawing the bowels while the person is yet alive, not only with great danger and distress

to the patient, but sometimes even producing death itself.

Man, however, is not left without defence against so many and so great dangers. The human body is possessed of a most wonderful power, by which it preserves itself from diseases, keeps off many, and in a very short time cures some already begun, while others are by the same means more slowly brought to a happy conclusion. This power, called the autoeratica, or vis medicatrix naturae, is well known both to physicians and philosophers. This alone is often sufficient for curing many diseases, and is of service in all. Nay, even the best medicines operate only by exciting and properly directing this force; for no medicine will act on a dead carcass. But though physicians justly put confidence in this power, and though it generally cures diseases of a lighter nature, it is not to be thought that those of the more grievous kind are to be left to the unassisted efforts of the vis medicatrix. Physicians therefore have a twofold error to avoid, either despising the powers of nature too much, or putting too great confidence in them; because in many diseases these efforts are either too feeble or too violent, insomuch that sometimes they are more to be dreaded than even the disease itself. So far therefore is it from being the duty of a physician always to follow the footsteps of nature, that it is often necessary for him to take a directly contrary course, and oppose her efforts with all his might.

After a general view of the functions of the animal body, of the nature and causes of disease, and of the powers by which these are to be combated, Dr. Gregory proceeds to treat of the solid materials of which the body is formed. He tells us, that the animal solid, when chemically examined, yields earth, oil, salt, water, phlogiston or inflammable air, and a great quantity of mephitic air. These elements are found in various proportions in the different parts of the body; and hence these parts are endowed with very different mechanical powers, from the hardest and most solid bone to the soft and almost fluid retina. Nay, it is principally in this difference of proportion between the quantities of the different elements, that the difference between the solid and fluid parts of the animal consist, the former having much more earth and less water in their composition than the latter. The cohesion, he thinks, is owing to something like a chemical attraction of the elements for one another; and its cause is neither to be sought for in the gluten, fixed air, nor earth. This attraction, however, is not so strong but that even during life the body tends to dissolution; and immediately after death putrefaction commences, provided only there be as much moisture in it as will allow an intestine motion to go on. The greater the heat, the sooner does putrefaction take place, and with the greater rapidity does it proceed; the mephitic air flies off, and together with it certain saline particles; after which, the cohesion of the body being totally destroyed, the whole falls into a putrid colluvies, of which at length all the volatile parts being dissipated, nothing but the earth is left behind.

This analysis, he owns, is far from being perfect, and is by no means in the language of modern chemistry.

try. But no modern chemist has ever been able, by combining the chemical principles of flesh, to reproduce a compound any thing like what the flesh originally was: yet, however imperfect the analysis may be, it still has the advantage of showing in some measure the nature and causes of certain diseases, and thus leads physicians to the knowledge of proper remedies.

The solid parts are fitted for the purposes of life in three several ways; namely, by their cohesion, their flexibility, and their elasticity, all of which are various in the various parts of the body. Most of the functions of life consist in various motions. In some the most violent and powerful motions are required; and therefore such a degree of cohesion is necessary in these parts as will be sufficient for allowing them to perform their offices without any danger of laceration. It is therefore necessary that some of the solid parts should be more flexible than others; and it is likewise necessary that these parts, along with their flexibility, should have a power of recovering their former shape and situation, after the removal of the force by which they were altered.

These variations in flexibility, within certain limits, seldom produce any material consequence with regard to the health: though sometimes, by exceeding the proper bounds, they may bring on real and very dangerous diseases; and this either by an excess or diminution of their cohesion, flexibility, or elasticity. By augmenting the cohesion, the elasticity is also for the most part augmented, but the flexibility diminished; by diminishing the cohesion, the flexibility becomes greater, but the elasticity is diminished.

The cause of these affections, though various, may be reduced to the following heads. Either the chemical composition of the matter itself is changed; or, the composition remaining the same, the particles of the solid may be so disposed, that they shall more or less strongly attract one another. As to the composition, almost all the elements may exist in the body in an undue proportion, and thus each contribute its share to the general disorder. But of many of these things we know very little; only it is apparent, that the fluid parts, which consist chiefly of water, and the solid, which are made up of various elements, are often in very different proportions: the more water, the less is the cohesion or elasticity, but the greater the flexibility; and the reverse happens, if the solid or earthy part predominates.

The remote causes of these different states, whether predisposing or exciting, are very various. In the first place, idiosyncrasy itself, or the innate constitution of the body, contributes very much to produce the above-mentioned effects. Some have naturally a much harder and drier temperament of the body than others; men, for instance, more than women; which can with the utmost difficulty, indeed scarce by any means whatever, admit of an alteration. The same thing takes place at different periods of life; for, from first to last, the human body becomes always drier and more rigid. Much also depends on the diet made use of, which always produces a corresponding state of the solids in proportion to its being more or less watery. Neither are there wanting strong reasons for believing, that not only the habit of the body, but even the disposition

of the mind, depends very much on the diet we make use of. The good or bad concoction of the aliment also, the application of the nourishment prepared from it, and likewise the state of the air with regard to moisture or dryness, affect the temperament of the body not a little; and hence those who inhabit mountains or dry countries, are very different from the inhabitants of low marshy places. Lastly, the manner of living contributes somewhat to this effect: Exercise presses out and exhales the moisture of the body, if in too great quantity; on the contrary, sloth and laziness produce an effect directly opposite, and cause a redundancy of fluid.

But, putting the chemical composition of the solid parts out of the question altogether, they may be affected by many other causes. The condensation, for instance, or compression of the particles, whether by mechanical causes or by means of cold or heat, makes a considerable alteration in the strength and elasticity of every solid body. How much mechanical pressure contributes to this may be understood from the experiments of Sir Clifton Wintringham: and hence also are we to deduce the reason of many facts of the highest importance in the animal economy; namely, the growth, state, decrease of the body; its rigidity daily increasing; and at last the unavoidable death incident to old age from a continuance of the same causes.

Perhaps the different density of the solids is in some measure owing to Nature herself; but it seems to depend more on the powers of exercise or inactivity in changing the state of the solids, the effects of which on the body whether good or bad, may hence be easily understood.

Heat relaxes and expands all bodies, but cold renders them more dense and hard; the effects of which on the human body are well known to most people. Though the body is found to preserve a certain degree of heat almost in every situation, yet its surface must unavoidably be affected by the temperature of the circumambient atmosphere; and we have not the least reason to doubt that every part of the body may thus feel the effects of that temperature. What a difference is there between one who, exposed to the south wind, becomes lazy and languid, scarce able to drag along his limbs; and one who feels the force of the cold north wind, which renders the whole body alert, strong, and fit for action?

That these various causes, each of which is capable of affecting the constitution of the body when taken singly, will produce much greater effects when combined, is sufficiently evident. The experiments of Bryan Robinson, the effects of the warm bath, and indeed daily experience, show it fully.

It is not yet certainly known what is the ultimate structure of the minutest parts of the animal-solid; whether it consists of straight fibres or threads, whose length is very considerable in proportion to their breadth, variously interwoven with one another, as Boerhaave supposes; or of spiral ones, admirably convoluted and interwoven with one another, as some microscopical experiments seem to show; or whether the cellular texture be formed of fibres or lamina, and from thence the greatest part of the body, as the celebrated Haller hath endeavoured to prove.

The cellular texture is observed throughout the whole body: it surrounds and connects the fibres themselves, which are sufficiently apparent in many of the organs; and slightly joins the different parts which ought to have any kind of motion upon the neighbouring ones. By a condensation of this substance also, the strongest, and what seem the thinnest, membranes are formed; the most simple of which being accurately examined, discover the cellular structure. This cellular substance sometimes increases to a surprising degree, and all parts formed of it, membranes, vessels, &c. especially by a gentle distension; for a sudden and violent distension either breaks it altogether, or renders it thinner. Sometimes also it grows between neighbouring parts, and joins those which nature has left free. Preternatural concretions of this kind are often observed after an inflammation of the lungs or of the abdominal viscera; and these new membranes are found to be truly cellular. This substance, when cut, or by any other means divided, grows together of its own accord; but if, by reason of very great inflammation and suppuration, a large portion of the cellular texture has been destroyed, it is never again completely renewed, and an ugly scar is left. It is even said, that this substance, in certain cases, is capable of joining the parts either of the same body with one another, or of a foreign body with them; and upon this, if on any foundation, rests the art of Taliscotius and that of transplanting teeth, lately so much talked of.

The cellular texture is in some places merely a kind of net-work, in others filled with fat. Wherever too great bulk or compression would have been inconvenient or dangerous, as in the head, lungs, eyes, eyebrows, penis, scrotum, &c. there it collects no fat, but is lax, and purely reticulated; but between the muscles of the body and limbs below the skin, in the abdomen, especially in the omentum and about the kidneys, very much fat is secreted and collected.

The fat is principally a pure animal oil, not very different from the expressed and mild vegetable ones; during life it is fluid, but of different degrees of thickness in different parts of the body. It is secreted from the blood, and is often suddenly reabsorbed into it, though pure oil is very rarely observed in the blood. It is indeed very probable, that oil, by digestion, partly in the primæ viæ, and partly in the lungs, is converted into gluten, and this again into oil by means of secretion; though no glandular organs secreting the fat can be shown by anatomists. It is however, probable, that there are such organs; and that the cellular texture has some peculiar structure in those parts which are destined to contain the fat already secreted, without suffering it to pass into other places; for it never passes into those parts which are purely reticulated, although the cellular texture is easily permeable by air or water over the whole body from head to foot.

The fat is augmented by the use of much animal-food, or of any other that is oily and nourishing, provided the digestion be good; by the use of strong drink, especially malt-liquor; by much rest of body and mind, much sleep and inactivity, castration, cold, repeated bloodletting, and in general by whatever diminishes the vital and animal powers. Much, however, depends on the constitution of the body itself;

nor is it possible to fatten a human creature at pleasure like an ox. A certain degree of fatness, according to the age of the person, is a sign and effect of good health; but when too great, it becomes a disease of itself, and the cause of other diseases. It may always be very certainly removed by strong exercise, little sleep, and a spare diet. The fat commonly makes up a considerable part of the bulk of the body, and sometimes by far the greatest part. Its use seems to be to make the motion of the body more easy and free, by lessening the friction of the moving parts, and thus preventing the abrasion of the solids, which would otherwise happen. It is also of use to hinder the parts from growing together, which sometimes happens, when by an ulcer or any other accident a part of the cellular texture containing the fat is destroyed. Besides all this, the fat contributes not a little to the beauty of the body, by filling up the large interstices between the muscles, which would otherwise give the person a deformed and shocking appearance. It is thought to be nutritious, when absorbed from its cells into the blood; but of this we have no certain proof. It seems to have some power of defending from the cold; at least, nature has bestowed it in very great quantity on those animals which inhabit the colder regions, as whales, bears, &c.

Those parts of the body which enjoy sense and mobility, are called living or vital solids. They are the brain, cerebellum, medulla oblongata, spinal marrow, the nerves arising from these and diffused throughout the whole body, and which are distributed through the various organs of sense and through the muscles, and lastly the muscles themselves. Sensation is much more general than mobility, as being common to all the parts already mentioned. Mobility is proper to the muscular fibres alone: wherever there is sensation, therefore, we may believe that there are nerves; and wherever there is mobility, we may believe that muscular fibres exist. Nay, even mobility itself seems to originate from the connection which the muscles have with the nerves; for soon after the nerves are compressed, or tied, or cut, the muscles to which they are distributed lose their faculties; which happens, too, when the brain itself, or the origin of the nerves, is affected. Some reckon that the muscles are produced from the nerves, and consist of the same kind of matter. Both indeed have a similar structure, as being fibrous and of a white colour: for the muscles when well freed from the blood, of which they contain a great abundance, are of this colour as well as the nerves; neither can the nervous fibres by any means be distinguished from the muscular fibres themselves. Both have also sensation; and both stimulants and sedatives act in the same manner, whether they be applied to the muscles themselves or to the nerves. These circumstances have led Dr Cullen and many others to consider the muscular fibre as being merely a continuation of nerve. But to this opinion there are many strong objections; though there can be no doubt that the contraction of the muscular fibre is intimately connected with nervous influence.

It is difficult for us to discover the origin of many parts of the body, or to ascertain whether they are produced all at the same time or one after another: yet it must be owned, that many of the muscular parts are observed to have attained a remarkable degree of

strength, while the brain is still soft and almost fluid; and that the action of these muscular parts is required for the action and growth of the brain. The muscles are also of a much firmer texture than the nerves; and enjoy a power of their own, namely, that of irritability, of which the nerves never participate. Of necessity, therefore, either the muscles must be constructed of some kind of matter different from that of the nerves; or if both are made of the same materials, their organization must be exceedingly different. But if the substance of the muscles and nerves be totally different, we may easily be convinced that much of the one is always mixed with the other; for it is impossible to prick a muscle, even with the smallest needle, without wounding or lacerating many nervous fibres at the same time. Since, therefore, there is such a close connection between the muscles and nerves both as to their functions and structure, they are deservedly reckoned by physiologists to be parts of the same genus, called the genus nervosum, or nervous system.

After treating of sense in general, Dr Gregory proceeds to consider particularly each of the senses both external and internal. He begins with the sense of feeling, as being the most simple, and at the same time in common to every part of the nervous system. In some places, however, it is much more acute than in others; in the skin, for instance, and especially in the points of the fingers. These are reckoned to have nervous papillae, which by the influx of the blood are somewhat erected in the action of contact, in order to give a more acute sensation; though indeed this opinion seems rather to be founded on a conjecture derived from the structure of the tongue, which is not only the organ of taste, but also a most delicate organ of touch, than upon any certain observations.

From the sense of feeling, as well as all the other senses, either pain or pleasure may arise; nay, to this sense we commonly refer both pain and almost all other troublesome sensations, though in truth pain may arise from every vehement sensation. It is brought on by any great force applied to the sentient part; whether this force comes from within or from without. Whatever, therefore, pricks, cuts, lacerates, distends, compresses, bruises, strikes, gnaws, burns, or in any manner of way stimulates, may create pain. Hence it is so frequently conjoined with so many diseases, and is often more intolerable than even the disease itself. A moderate degree of pain stimulates the affected part, and by degrees the whole body; produces a greater flux of blood to the part affected, by increasing the action of its vessels; and it seems also to increase the sensibility of the part affected to future impressions. It often stimulates to such motions as are both necessary and healthful. Hence, pain is sometimes to be reckoned among those things which guard our life. When very violent, however, it produces too great irritation, inflammation and its consequences, fever, and all those evils which flow from too great force of the circulation; it disorders the whole nervous system, and produces spasms, watching, convulsions, delirium, debility, and fainting. Neither the mind nor body can long bear very vehement pain; and indeed Nature has appointed certain limits, beyond which she will not permit pain to be carried, without bringing on delirium, convulsions, syncope, or

even death, to rescue the miserable sufferer from his torments.

Long-continued pain, even though in a more gentle degree, often brings on debility, torpor, palsy, and rigidity of the affected part. But if not too violent, nor accompanied with fever, sickness, or anxiety, it sometimes seems to contribute to the clearness and acuteness of the judgement, as some people testify who have been afflicted with the gout.

Anxiety is another disagreeable sensation, quite different from pain, as being more obtuse and less capable of being referred to any particular part, though frequently more intolerable than any pain. But we must take care to distinguish between this anxiety of which we treat in a medical sense, and that which is spoken of in common discourse. The latter does not at all depend on the state of the body, but belongs entirely to the mind; and arises from a sense of danger, or a foresight of any misfortune. The former is truly corporeal; and derives, no less than pain, its origin from a certain state of the body. Notwithstanding this difference, however, it is very possible for both these kinds of anxiety to be present at the same time, or for the one to be the cause of the other. A very great bodily anxiety will strike fear and despondency into the most resolute mind; and mental anxiety, on the contrary, if very violent and long-continued, may induce the former, by destroying the powers of the body, especially those which promote the circulation of the blood.

Anxiety, in the medical sense of the word, arises in the first place from every cause disturbing or impeding the motion of the blood through the heart and large vessels near it. Anxiety, therefore, may arise from many diseases of the heart and its vessels, such as its enlargement, too great constriction, ossification, polypus, palpitation, syncope, inflammation, debility, and also some affections of the mind. It is likewise produced by every difficulty of breathing, from whatever cause it may arise; because then the blood passes less freely through the lungs: anxiety of this kind is felt deep in the breast. It is said also to arise from the difficult passage of the blood through the liver or other abdominal viscera.

A certain kind of anxiety is very common and troublesome to hypochondriacal people; and arises from the stomach and intestines being either loaded with indigested and corrupted food, or distended with air produced by fermentation and extricated from the aliments. By such a load, or distention, the stomach, which is a very delicate organ, becomes greatly affected. Besides, the free descent of the diaphragm is thus hindered, and respiration obstructed. Anxiety of this kind is usually very much and suddenly relieved by the expulsion of the air; by which, as well as by other signs of a bad digestion, it is easily known. In these cases the anxiety is usually, though with little accuracy, referred to the stomach.

Anxiety also frequently accompanies fevers of every kind, sometimes in a greater and sometimes in a lesser degree. In this case it arises as well from the general debility as from the blood being driven from the surface of the body and accumulated in the large vessels; as in the beginning of an intermittent fever. Or it may arise from an affection of the stomach, when

when overloaded with crude, corrupted aliment; or distended and nauseated with too much drink, especially medicated drink. As the fever increases, the anxiety of the patient becomes greater and greater; remarkably so, according to the testimony of physicians, either immediately before the crisis or on the night preceding it; as before the breaking out of exanthemata, hemorrhagies, sweat, or diarrhoea, which sometimes remove fevers. The patient feels likewise an anxiety from the striking in of any eruption or critical metastasis. This sensation also accompanies fevers and most other diseases, when the vital power is exhausted, and death approaches, of which it is the forerunner and the sign. It happens at that time, because the vital powers, unable to perform their functions, cannot make the blood circulate. But what kind of anxiety this is, the other signs of approaching death show very evidently. Moreover, even in the time of sleep, anxiety may arise from the same causes: hence frightful dreams, which frequently disturb our repose with surprise and terror.

Itching, an uneasy sensation, with a desire of scratching the place affected, is often very troublesome, although it seems to be more akin to pleasure than to pain. As pain proceeds from too great an irritation, either chemical or mechanical, so does itching proceed from a slight one. Titillation, or friction, of a woollen shirt, for instance, upon the skin of a person unaccustomed to it, and of a delicate constitution, excites itching; as do also many acrid fossils, vegetables, and animals. Hence an itching is the first sensation after the application of cantharides, although the same, when augmented becomes painful. The same effect is produced by any thing acrid thrown out upon the skin; as in exanthematic fevers, the disease called the itch, &c. Lice, worms, especially ascarides, irritating either the skin or the intestines, excite a troublesome itching.

Too acute a sensation over the whole body is very rarely if ever observed. In a particular part the sense of feeling is often more acute than it ought to be, either from the cuticle itself being too thin and soft, or being removed; or from the part itself being inflamed, or exposed to too great heat. It becomes obtuse, or is even quite destroyed over the whole body, or in great part of it, from various affections of the brain and nerves; as when they are wounded, compressed, or defective in vital power. This is called anæsthesia, and sometimes accompanies palsy.

This sense may be deficient in a particular part, either from the nerve being diseased, or from its being compressed or wounded, or from the part itself being exposed to too great a degree of cold;—or from the scarf-skin which covers it being vitiated, either becoming too thick or hard, by the handling of rough, or hard, or hot bodies, as is the case with glass-makers and smiths; or from the elevation of the cuticle from the subjacent cutis, or true skin itself, by the interposition of blood, serum, or pus; or from the cutis being macerated, relaxed, or become torpid, which sometimes happens to hydropic persons; or lastly, from the whole organ being corrupted by gangrene, burning, cold, or contusion. This sense is very rarely depraved, unless perhaps in the case of delirium, when all the functions of the brain are disturbed in a surprising manner.

The sense next to be considered is that of taste, the principal organ of which is the tongue; the nearer the tip of it, the more acute is the sense, and the nearer the glottis so much the more obtuse. It must be owned, however, that some kind of acrid substances, the taste of which is scarcely perceived upon the tip of the tongue, excite a most vehement sensation about its roots, or even in the throat itself. The tongue is endowed with many large and beautiful nervous papillae, which seem to be the chief seat of this sense, and in the act of tasting are elevated and erected, in order to give the more acute sensation.

Nothing can be tasted which is not soluble in the saliva, that, being applied in a fluid form, it may pervade the involucra of the tongue, and affect its nervous pulp; and hence insoluble earths are quite insipid. Neither is it sufficient for a body to be soluble that it may be tasted: it must also have something in it saline, or at least acrid, in order to stimulate the nervous substance; and hence, whatever has less salt than the saliva is totally insipid.

The taste is rarely found to be too acute, unless through a fault in the epidermis which covers the tongue. If this be removed or wounded, or covered with ulcers, aphthæ, &c. then the taste, becoming too acute, is painful: or sometimes no other sensation than that of pain is felt. It may be impaired, as well as the sense of feeling, from various diseases of the brain and nerves; of which, however, the instances are but rare. In some people it is much more dull than in others; and in such the sense of smelling is usually deficient also. The taste is most commonly deficient on account of the want of saliva; for a dry tongue cannot perceive any taste: hence this sense is very dull in many diseases, especially in fevers, catarrhs, &c. as well on account of the defect of saliva as of appetite, which is of so much service in a state of health; or by reason of the tongue being covered with a viscid mucus.

The taste is frequently depraved; when, for example, we have a perception of taste without the application of any thing to the tongue; or if any thing be applied to it, when we perceive a taste different from what it ought to be. This happens for the most part from a vitiated condition of the saliva, which is itself tasted in the mouth. Hence we may perceive a sweet, saline, bitter, putrid, or rancid taste, according to the state of the saliva: which may be corrupted either from the general vitiated condition of the mass of humours, or the glands which secrete it; or of the mouth itself; or even of the stomach, the vapours and eruptions of which rise into the mouth, especially when the stomach is diseased.

Besides the faults of the saliva, however, the taste may be vitiated from other causes; as, for instance, the condition of the nervous papillae. This, however, is as yet but little known to us; for the taste is sometimes plainly vitiated when at the same time the saliva appears quite insipid when tasted by other people.

Physicians, in almost every disease, but especially in fevers, inquire into the state of the tongue; not, indeed, without the greatest reason: for from this they can judge of the condition of the stomach; of the thirst, or rather the occasion the patient has for drink, when, on account of his delirium or stupor, he neither feels his

thirst, nor is able to call for drink. And, lastly, from an inspection of the tongue, physicians endeavour to form some judgement concerning the nature, increase, and remission of the fever.

After the sense of taste, we shall next treat of that of smell. Its seat is in that very soft and delicate membrane, filled with nerves and blood-vessels, which covers the internal parts of the nose, and the various sinuses and cavities proceeding from thence. This sense is more acute about the middle of the septum, and the ossa spongioza, where the membrane is thicker and softer, than in the deeper cavities, where the membrane is thinner, less nervous, and less filled with blood-vessels; although even these do not seem to be altogether destitute of the sense of smelling.

As by our taste we judge of the soluble parts of bodies, so by our smell we judge of those very volatile and subtile parts which fly off into the air; and like the organ of taste, that of smell is kept moist, that it may have the more exquisite sensation, partly by its proper mucus, and partly by the tears which descend from the eyes.

Some kinds of odours greatly affect the nervous system, and produce the most surprising effects. Some gratefully excite it, and immediately recruit the spirits when almost sinking; while some produce fainting, nay, as it is alleged, even sudden death. To this head also are we to refer those antipathies, which, though truly ridiculous, are often not to be subdued by any force of mind.

This sense is sometimes too acute, as well from some disease in the organ itself, which happens more rarely, as from the too great sensibility of the nervous system in general, as is sometimes observed in nervous fevers, phrenitis, and hysteria. It is more frequently, however, too dull, either from diseases of the brain and nerves, as from some violence done to the head, or from some internal cause; or it may proceed from a dryness of the organ itself, either on account of the customary humours being suppressed or turned another way, or from the membranes being oppressed with too great a quantity of mucus or of tears. Of both these cases we have instances in the catarrh, where at first the nostrils are dry, but afterwards are deluged with a thin humour, or stopped up with a thick one. But in these, and many other examples, the membrane of the nose itself is affected with inflammation, relaxation, or too great tension, by which the nerves, which constitute a great part of it, must be vitiated. It is evident also, that whatever obstructs the free entrance of the air into the nostrils, or impedes its passage through them, must prove detrimental to the sense of smelling.

The sense of hearing is more frequently vitiated than almost any of the rest, as having a most delicate organ, and one composed of many and very small parts, of which an account is given under the article ANATOMY.—It frequently becomes too acute; either from the general habit of the body being too irritable, such as often happens to hysterical and lying-in-women; or from too great a sensibility of the brain itself, which is not unfrequently observed in fevers, as well as in phrenitis, and sometimes in the true mania; or it may be from a disease of the ear itself, as when it is affected with inflammation, pain, or too great tension.—It may

be rendered dull, or even be altogether destroyed, so that the person shall become totally deaf, from the same causes acting with different degrees of force. This happens especially from the want of the external ear; or from the meatus auditorius being stopped up with mucus, wax, or other matters; or from the sides of the canal growing together, as sometimes happens after suppuration or the small-pox; or by the membrane of the tympanum becoming rigid or relaxed, or being eroded or ruptured; or the tympanum itself, or the Eustachian tube, may from certain causes be obstructed; or some of the little bones or membranes, or some of the muscles of the labyrinth, may be affected with concretion, spasm, palsy, or torpor; or lastly, it may happen from diseases of the brain and nerves, all the organs of hearing remaining sound. Hence deafness is often a nervous disease, coming suddenly on, and going off spontaneously. Hence also it is common in old people, all of whose solid parts are too rigid, while their nervous parts have too little sensibility.

Persons labouring under fevers, especially of the typhous kind, often become deaf. When this comes on along with other signs of an oppressed brain, and a great prostration of strength, it may be a very bad symptom; but for the most part it is a very good one, even though accompanied with some degree of torpor or sleepiness.

A very common disease in the sense of hearing is when certain sounds, like those of a drum, a bell, the falling of water, &c. are heard without any tremor in the air, or without a sound person's hearing any thing. This disease is called tinnitus aurium, of which various kinds have been observed. For the most part it is a very slight transient disorder; but sometimes it is most obstinate, long-continued, and troublesome. It often arises from the slightest cause, such as any thing partially stopping up the meatus auditorius or Eustachian tube itself, so that access is in part denied to the air; whence it happens that the latter strikes the membrane of the tympanum, or perhaps the interior parts, unequally, and with too much force. Hence bombs, a kind of tinnitus, are heard even by the most healthy when they yawn.

A much more frequent and troublesome species of tinnitus accompanies many diseases both of the febrile and nervous kind. This is occasioned partly by the increased impetus of the blood towards the head, with an increase of sensibility in the nervous system itself, so that the very beatings of the arteries are heard; and partly from the increased sensation and mobility of the nerves and muscles of the labyrinth; whence it happens, that the parts which ought to be at rest until excited by the tremor of the air, begin to move of their own accord, and impart their motion to other parts which are already in a morbid state of too great sensibility.

A tinnitus sometimes arises from any vehement affection of the mind; sometimes from a disorder in the stomach; sometimes from a rheumatic disorder affecting the ears and head; or from a catarrh, which commonly affects the Eustachian tube. Sometimes, however, the tinnitus alone affects the patient; and even this is a disease of no small consequence. These various causes, however, bath of this and other disorders of the hearing,

External Senses. hearing, are often very difficult to be distinguished, as well on account of the inaccessible situation of the organ, as on account of the little knowledge we have of its action. But from whatever cause it arises, both this and the other affections of the hearing can neither be cured certainly nor easily, but by the removal of the cause, whatever it may be.

81 Sight. Concerning the nature of the sense of sight, the reader may consult the articles ANATOMY and OPTICS. Of this sense some slight disorders, or rather varieties, are often observed. Those persons are called short-sighted who cannot see distinctly unless the object be very near them. This disorder arises from too great a refraction of the rays by reason of their being too soon collected into a focus by the crystalline lens, and diverging again before they fall upon the retina, by which means they make an indistinct picture upon it. The most common cause is too great a convexity of the eye or some of its humours, as too prominent a cornea. It is a disorder common to young people, which is sometimes removed when they grow older. As soon as the first approaches of short-sightedness are observed, it is supposed it may be obviated by the person's accustoming himself to view remote objects, and keeping his eyes off very small and near ones; as, on the contrary, it may be brought on by the opposite custom; because the eye accommodates itself somewhat to the distances of those objects which it is accustomed to view. But a concave glass, which causes the rays of light to diverge more than naturally they would before falling upon the cornea, is the most simple and certain remedy.

Long-sighted people are those who cannot see an object distinctly unless it be at a considerable distance from them. This arises from causes contrary to the former; namely, the eye being too flat, so that there is no room for refracting the rays and bringing them into a focus. Hence this defect is common in old people, and remedied by the use of convex glasses.

Those are called myelopes who see better with a very weak than with a strong light. It is a defect very seldom to be met with in the human race, though every person is sensible of it who hath been long kept in the dark and is then suddenly brought into the light. The disease arises from too great a sensibility of the retina, and the pupil being too open.

The sight is liable to many and grievous disorders. It is sharpened beyond measure, so that the person either perceives nothing distinctly, or with great pain, from the same causes that induce a similar disorder in the other senses; namely, excessive sensibility in the general habit of body; or a particular state of the brain common in phrenitis, or even in those afflicted with fevers arising from inflammation or too great excitement; though more frequently from the condition of the eye itself, one becomes unable to bear the light. The inflammation of the tunica adnata, and the fore-part of the sclerotica, is communicated to the back parts of it, and from thence to the choroides and retina itself. Hence the light becomes intolerable, and vision is attended with pain and great irritation, sometimes inducing or augmenting a delirium.

The sense of seeing is made dull, or even totally abolished, by age; the aqueous humour not being supplied in sufficient quantity, and the cornea and

External Senses. lens, or the vitreous humour, becoming shrivelled or decayed. It may likewise happen from the cornea becoming dry and opaque; which is to be imputed to the languid motion of the blood, and to great numbers of the small vessels being obstructed or having their sides concreted;—or from the crystalline lens becoming yellow like amber, and the retina itself less sensible, for old age diminishes every sensation. It is totally abolished by injuries of the brain, the optic nerve, or the retina, even though the structure of the organ should remain sound. This disease is called an amaurosis; and is easily known by the dilatation and immobility of the pupil, the humours of the eye remaining clear. It is commonly owing to congestion of blood; and sometimes, where no congestion of blood can be discovered, to mere torpor of the nerves. If it be only a torpor of part of the retina, we see black spots in those things at which we look; or flies seem to pass before our eyes, a very bad sign in fevers, and almost always mortal. The sight is abolished also by the obscurity or opacity of any of the parts through which the rays ought to pass and be refracted; as if the cornea lose its transparency by being covered with spots; or the aqueous humours become corrupted with blood, serum, or pus; or the lens (which often happens and which is called a cataract) becomes of a gray or brown colour, or the vitreous humour be in like manner corrupted; or lastly, when all the humours being dissolved, confused, and mixed together, by inflammation and suppuration, either do not suffer the light to pass at all, or to pass imperfectly and unequally; whence either no image is formed on the retina, or it appears obscure, distorted, imperfect, and ill-coloured.

The sight is also depraved, when things appear to it of a colour different from their own, or even in another situation and of another shape than they ought to have. This happens from the humours being tinctured with any unusual colour, as is said to happen in some instances of jaundice; or from an extravasation and mixture of the blood with the aqueous humour. A surprising deprivation also, or constant and perpetual defect of vision, is not unfrequently observed in men otherwise very healthy, and who see quite clearly; namely, that they cannot distinguish certain colours, green, for example, from red. Another deprivation is, when, without any light being admitted to the eyes, sparks, small drops of a flame or gold colour, and various other colours, are observed to float before us. This is generally a very slight and transient disorder, common to those whose constitutions are very irritable; and arises from the slight impulse, as it would seem, on the retina, by the vessels beating more vehemently than usual. A fiery circle is observed by pressing the eye with the finger after the eye lids are shut. The same reason, perhaps, may be given for those sparks which are seen by persons labouring under the falling-sickness, and increasing to the size of an immense and luminous beam before they fall down in convulsions. A similar beam those who have recovered from hanging or drowning testify that they have observed: for by reason of the respiration being suppressed, the vessels of the head swell and compress the whole brain and nervous parts of the head. Sparks of the same kind, and these too of no good omen,

omen, are observed in patients labouring under a fever, where a phrenitis or fierce delirium is at hand; and likewise in those who are threatened with palsy, apoplexy or epilepsy.—A distinct but false perception, namely of visible things which do not exist, is to be imputed to some injury of the brain, to madness or a delirium, not to any disease of the eye.

A very frequent defect of vision remains to be mentioned; namely, squinting. A person is said to squint who has the axes of the eyes more oblique than usual, and directed to different points. Hence a great deformity, and often an imperfect and confused vision by which the objects are sometimes seen double. It is an evil for the most part born with the person, and often corrected by those attempts which an infant makes to see more pleasantly and distinctly; and this even without being conscious of its own defects. It is also easily learned, especially in infants, even without their own knowledge, by that kind of imitation which has a great influence over the human race, especially in their tender years.—It is by no means, however, so easily unlearned.

Squinting is frequently occasioned by a spasm, palsy, rigidity, &c. of the muscles which manage the eye; by epilepsy; by certain diseases of the head, the hydrocephalus especially; or by any great injury done to the head. Sometimes, though very rarely, it comes on suddenly without any known cause. It is very probable, however, that squinting often arises from a fault of the retinae, when their central points, for instance, and those similarly placed with respect to the centre, do not agree. In this case there must be a contortion of the eye, that the object may not be seen double. This seems also to be the reason why squinting is much increased when the person brings the object near his eye in order to view it more perfectly. Or if the central point of either, or both, of the retinae be insensible or nearly so, it is necessary for the person to distort his eyes that he may have any distinct vision of objects. If the optic nerve had not entered the retina obliquely, but passed directly through its centre, we would all either have squinted or seen double.

Physicians have referred to the sense of vision that most troublesome sensation which we call a vertigo; though it seems rather to belong to that of feeling, or of consciousness; for in many instances the disorder is not removed either in the dark or by shutting the eyelids. The vertigo takes place when external objects really at rest seem to reel, to whirl round, to tremble, or to move in any manner of way. If the disorder be very violent, the person is neither able to see, on account of a dimness of sight; nor can he stand, as the powers fail which ought to govern the limbs. A nausea also usually accompanies the vertigo, and the one generally produces the other.

This disorder is observed to be both the symptom and forerunner of some dangerous diseases; such as apoplexy, epilepsy, hysteria; hemorrhages from the nose and other parts; suppressions of the menses; plethora; fevers, as well such as are accompanied with debility as those in which there is an increased impetus of the blood towards the head. An injury done to the head also, but rarely one done to the eyes, unless as it affects the whole head, brings on a ver-

tigo. A vertigo may be likewise produced by a very great and sudden loss of blood or other fluid; by debility; syncope; various diseases of the alimentary canal, of the stomach especially; poisons admitted into the body, particularly of the narcotic kind, as opium, stramonium, wine, &c. and hence vertigo is a symptom of every kind of drunkenness. Various motions also, either of the head or the whole body, being tossed in a ship, especially if the vessel be small and the sea runs high, produce a vertigo. In these and similar examples, the unusual and inordinate motions of the blood are communicated to the nervous parts which are in the head; or these being affected by sympathy from the neighbouring parts, produce a confused sensation as if of a rotatory motion. Nay, it is often produced from an affection of the mind itself, as from beholding any thing turned swiftly round, or a great cataract, or looking down a precipice, or even by intense thought without looking at any thing.

Though a vertigo be for the most part a symptom and concomitant of other diseases, yet it is sometimes a primary disease, returning at intervals, increasing gradually, and equally impeding and destroying the functions of the body and mind.

After having treated of the external senses, we shall next proceed to consider those properly called internal; which are, the memory, the imagination, and the judgement. The first is lessened, disturbed, or even totally destroyed, in many diseases, especially those which affect the brain; as in apoplexy, palsy, internal tumours of the head, external violence applied, fevers, especially those in which there is an increased motion of the blood towards the head, or where the brain is any other way very much affected. It is very rarely, however, depraved in such a manner that ideas are not represented to the mind in their proper order; or if at any time such a disorder occurs, it is considered rather as a disorder of the imagination, or as a delirium, than a failure of the memory. The mind is said to be disordered when the perceptions of memory or imagination are confounded with those of sense, and of consequence those things believed to be now present which are really past or which never existed; or when the sense of the person concerning ordinary things is different from that of other people. The general name for such disorders is vesania: if from fever, it is called delirium. A general fury without a fever, is called mania or madness; but a partial madness, on one or two points, the judgement remaining sound in all other respects, is called melancholia. There is, however, no exact and accurate limits between a sound mind and madness. All immoderate vivacity borders upon madness; and, on the other hand, a sorrowful and gloomy disposition approaches to melancholy.

Delirium accompanies fevers of many different kinds. Sometimes it is slight, easily removed, and scarce to be accounted a bad sign. Often, however, it is very violent, and one of the very worst of signs, requiring the utmost care and attention.

A delirium is either fierce or mild. The fierce delirium is preceded and accompanied by a redness of the countenance, a pain of the head, a great beating of the arteries, and noise in the ears; the eyes in the mean time looking red, inflamed, fierce, shining, and unable to bear the light; there is either no sleep at all,

Delirium. all; or sleep troubled with horrid dreams; the wonted manners are changed; an unusual peevishness and ill-nature prevail. The depravation of judgement is first observed between sleep and waking, and by the person's crediting his imagination, while the perceptions of sense are neglected, and the ideas of memory occur in an irregular manner. Fury at last takes place, and sometimes an unusual and incredible degree of bodily strength, so that several attendants can scarcely keep a single patient in his bed.

The mild delirium, on the contrary, is often accompanied with a weak pulse, a pale collapsed countenance, and a vertigo when the patient sits in an erect posture; he is seldom angry, but often stupid, and sometimes remarkably grieved and fearful. The loss of judgement, as in the former kind, is first perceived when the patient is half awake; but a temporary recovery ensues upon the admission of the light and the conversation of his friends. The patient mutters much to himself, and attends little to the things around him; at last, becoming quite stupid, he neither feels the sensations of hunger or thirst, nor any of the other propensities of nature, by which means the urine and excrements are voided involuntarily. As the disorder increases, it terminates in subfultus tendinum, tremors, convulsions, torpor, and death. The other species of delirium also frequently terminates in death, when the spirits and strength of the patient begin to fail.

The symptoms accompanying either of these kinds of delirium show an unusual, inordinate, and unequal motion of the blood through the brain, and a great change in that state of it which is necessary to the exercise of the mental powers. It is very probable, that an inflammation of the brain, more or less violent and general, sometimes takes place, although the signs of universal inflammation are frequently slight. This we learn from the dissection of dead bodies, which often show an unusual redness of the brain or of some of its parts, or sometimes an effusion or suppuration.

The state of the brain, however, may be much affected, and delirium induced, by many other causes besides the motion of the blood. In many fevers, typhus, for instance, the nervous system itself is much sooner and more affected than the blood's motion; and though the morbid affections of the nervous system are as invisible to the senses as the healthy state of it, the symptoms of its injuries plainly show that its action, or excitement, as some call it, is unequal and inordinate. In this way, too, delirium is produced by several poisons.

The pathology of melancholy and mania is much more obscure; as coming on without any fever, or disturbance in the blood's motion. Often also they are hereditary, depending on the original structure of the body, especially of the brain; the fault of which, however, cannot be detected by the nicest anatomist. But it is well known, that various diseases of the brain, obstructions, tumors, either of the brain itself, or of the cranium pressing upon it, any injury done to the head, and, as some physicians relate, the hardness and dryness of the brain, and some peculiar irritations affecting the nervous system, are capable of bringing on this malady. And indeed so great are the irritations affecting the nervous system in mad people, that they often sleep little or none for a long time.—Yet even this so defective and imperfect knowledge of the dis-

cases of the brain and nerves, is by no means free from difficulties. For though we know that the brain, or a certain part of it, is hurt, or that it is irritated by a swelling, or a pointed bone growing into it, nobody can foretell how great, or what may be the nature of the malady from such a hurt: for examples are not wanting of people who, after losing a large part of the brain, have recovered and lived a long time; there are many instances also of persons who have perceived no inconvenience from a large portion of that viscous being corrupted, until at length they have fallen suddenly down and died in convulsions.

Another disease of the internal senses, quite different from these, is fatuity or idiotism. Those are called idiots who are destitute either of judgement or memory, or else have these faculties unequal to the common offices of life. A weak memory, however, is by no means essential to idiotism. For there are some instances of idiots who have had very correct and very extensive memories. A kind of idiotism is natural and common to all infants; neither is it to be accounted a disease; but if it last beyond the state of infancy, it is a real disease, and for the most part incurable. It has the same causes with the other diseases of the internal senses; although these can scarcely be detected by the eye or by the knife of the anatomist. It frequently accompanies, or is the effect of, epilepsy. Hence, if the epilepsy derives its origin from causes not seated in the head, as from worms lodging in the intestines, the fatuity may be cured by dislodging these, and removing the epilepsy. It is not unlikely that the fatuity of children, and the dotage of old men, may arise from the brain being in the former too soft, and in the latter too hard; or perhaps in the one case not evolved, and in the other somewhat decayed.

The muscular power may be diseased in a great number of ways. The mobility itself may be too great; but this must be carefully distinguished from vigour. By mobility is meant the ease with which the muscular fibres are excited into contraction. The vigour, on the other hand, is that power with which the contraction is performed. They are sometimes joined, but more frequently separate, and for the most part the excesses of each are owing to contrary causes.

Too great mobility is when motions are excited by a very slight stimulus, or when very violent motions are produced by the customary stimulus. A certain habit of body, sometimes hereditary, renders people liable to this disease. Women have a greater share of mobility than men. Infants have a great deal of mobility, often too great; youth has less than infancy, but more than man's estate; though old age has commonly too little. A lazy, sedentary life, full diet, a suppression of the usual evacuations, fulness of the blood-vessels, and sometimes their being suddenly emptied, laxity, flaccidity of the solids in general, but sometimes too great a tension of the moving fibres, the use of diluents, especially when warm, or heat applied in any manner, produce too great mobility. And this may be either general or particular, according as the causes have been applied to the whole body, or only to a part of it.

Vigour in general is rarely morbid; although sometimes certain muscular parts appear to have too great strength. In maniacs and phrenetics, an immense strength

Disorders in strength is observed in all the muscles, especially in those the Muscular Power. which serve for voluntary motion; this is not unjustly reckoned morbid. The reason of this excess is very obscure; however, it is plainly to be referred to a diseased state of the brain.

A more frequent and more important excess of vigour is observed in those muscular fibres that do not obey the will, such as those which move the blood. Its circulation is thus often increased, not without great inconvenience and danger to the patient. But a lighter excess of this kind, pervading the whole body, renders people apt to receive inflammatory diseases, and is usually called a phlogistic diathesis. But this is better observed when local, as in inflammation itself.

Too great vigour of the muscular fibres may arise from the nervous power increased beyond measure, as in mania, phrenitis, or violent affections of the mind; from too great a tension of the fibres, by which they more easily and vehemently conceive motions, as of the arteries when filled with too much blood; from catching cold, by being exposed either to cold or heat, as usually happens in the spring; or lastly, though the nervous power and tension of the fibres should not at all be changed, their action may become too great, from a stimulus more violent than usual being applied, or from the usual stimulus, if the fibres themselves have already acquired too great a share of mobility.

⁹⁰
Torpor.
The opposite to too great mobility is torpor, and to too great vigour is debility. Torpor is such a diminution of mobility as renders the parts unequal to their functions. It arises from causes directly opposite to mobility; such as, a harder and more rigid texture of the parts themselves, or even sometimes from one too lax and flaccid; from old age; from some peculiar temperament of body, such as one phlegmatic, frigid, or insensible; too great and incessant labour, cold, spare diet, and an exhausted body. This evil is the more to be dreaded, because, the powers of the body being deficient, nature is neither able to make any effort of herself, nor are the remedies, in other cases the most efficacious, capable of affording her any assistance.

⁹¹
Debility.
Debility takes place, when the motion of the muscles, either voluntary or involuntary, is not performed with sufficient strength. A greater or lesser share of debility, either general or of some particular part, accompanies almost all diseases, and is indeed no small part of them: for it is hardly possible that a disease can subsist for any length of time without inducing some degree of debility. When a state of debility is induced, it renders a man obnoxious to innumerable disorders, and throws him as it were defenceless in their way. It often depends on the original structure of the body, so that it can be corrected neither by regimen nor medicines of any kind. A different degree of strength also accompanies the different ages of mankind; and thus, in some cases, debility cannot be reckoned morbid. But a truly morbid and unusual debility arises from the nervous energy being diminished; from diseases of the brain and nerves, or of the muscles through which they are distributed; from a decay of the nerves themselves; from a want of the due tension of the fibres, or the fibres themselves becoming torpid; from the body exhausted

by spare diet, want, evacuations; or lastly, from disorders in the Muscular Power. cases affecting the whole body, or some particular parts of it.

The highest degree of debility, namely, when the strength of the muscles is altogether or nearly destroyed, is called paralysis or palsy; and is either universal, or belonging only to some particular muscles. An universal palsy arises from diseases of the brain and nerves, sometimes very obscure, and not to be discovered by the anatomist; for the nervous power itself is often deficient, even when the structure of the nerves remains unhurt; yet often a compression, obstruction, or injury of the vessels, extravasation of blood, or serum, collections of pus, swellings, &c. are discovered. It frequently arises from certain poisons acting on the nerves; from the fumes of metals; from the diseases of parts, and affections of the muscles, very remote from the brain, as in the colic of Poictou. A palsy of single muscles, but less perfect, often arises without any defect of the brain or nerves, from any violent and continued pain, inflammation, too great tension, relaxation, rest, or destruction of the texture of the parts, such as commonly happens after the rheumatism, gout, luxations, fractures of the bones, and ischuria.

An universal palsy, however, as it is called, seldom affects the whole body, even though it should originate from a disease of the brain. We most commonly see those who are paralytic affected only on one side, which is called an hemiplegia. It is said that the side of the body opposite to the diseased side of the brain is most commonly affected. If all the parts below the head become paralytic, it is called a paraplegia. In these diseases the senses for the most part remain; though sometimes they are abolished, and at others rendered dull. Sometimes, though rarely, and which is an exceeding bad symptom, the motion, sensation, pulse, and heat of the paralytic limbs are lost; in which case the arteries themselves become paralytic. A palsy of the whole body, as far as regards the voluntary motions, with anaesthesia and sleep, is called an apoplexy. This proceeds from some injury of the brain: though a state very similar to it is induced by narcotics, opium, wine itself, or any generous liquor taken to excess; and lastly, by breathing in air corrupted by noxious impregnations, such as a large proportion of carbonic acid, hydrogenous gas, or similar active aeriform fluids.

Another disease to which muscular motion is liable, ⁹² and that neither slight nor unfrequent, is called spasm. This is a violent and irregular motion of the muscles. Of spasms there are two kinds, the tonic and clonic. The latter is frequently called a convulsion; in order to distinguish it from the other, which is more peculiarly called spasm.

Spasm therefore is a violent, constant, and preternatural contraction of the muscular fibres; but a convulsion is an unusual and violent contraction alternated with relaxation. People are rendered liable to spasm by too sensible a habit of body, or too great mobility; and hence it is a disease common in women, in infants, and in weak, luxurious, lazy, and plethoric people. It is brought on those already predisposed to it, by any kind of stimulus applied to the brain, or to any nerve, muscle, or nervous part connected with it: of

of which we have examples in dentition; worms lodged in the intestines, and irritating them; any acrid matter infecting the blood, or much affecting the stomach and intestines; the irritation of any nerve, or of the brain itself, by an exostosis, swelling, too great fulness of the vessels, pain, vehement affections of the mind, sudden evacuation, or poisons admitted into the body. Frequently, however, the malady originates from slight causes, little known, and not easily observed.

Spasm is both the cause and effect, and frequently constitutes the greatest part, of many diseases. It is often very difficult either to be known or cured; because it is so multiform, and produces as many different symptoms as there are organs affected; of which it surprisingly disturbs, impedes, or increases the functions. It is a disease seated in the original lamina of the constitution; and neither to be removed by slight remedies, nor in a short time.

With regard to sleep, its use is sufficiently apparent from the effects which it produces in the body. It restores the powers both of mind and body when exhausted by exercise, giving vigour to the one, and restoring its wonted alacrity to the other. It renders the muscles again active and moveable, after they have become wearied, rigid, painful, and trembling by hard labour. It moderates the quickness of the pulse, which usually increases at night, and brings it back to its morning standard. It seems also to assist the digestion of the aliment; lessens both the secretions and excretions; and renders the fluids thicker than otherwise they would be, especially in a body endowed with much sensibility or mobility. Hence sleep is not only useful, but absolutely necessary for preserving life and health; and is a most excellent remedy both for alleviating, and totally removing, many diseases.

Want of sleep is hurtful in many different ways, especially to the nervous system. It renders the organs of sense both external and internal, as well as those of every kind of motion, unfit for performing their offices. Hence the sensations are either abolished, or become imperfect or depraved; and hence imbecility of mind, defect of memory, a kind of delirium, mania itself, pain of the head, weakness of the joints, an imperfect or inordinate action of the vital organs, quickness of pulse, heat, fever, depraved digestion, atrophy, leanness, and an increase or perturbation of the secretions and excretions.

Sleep may be prevented both in healthy and sick people from various causes; such as strong light, noise, pain, anger, joy, grief, fear, anxiety, hunger, thirst, vehement desire, motion of the body, memory, imagination, intense thought, &c. On the other hand, sleep is brought on by a slight impression on the organs of sense, or none at all; by the humming of bees, the noise of falling water, cold and insipid discourse; or lastly, by such an exercise of the memory as is neither too laborious nor disturbing to the mind.—Too great an impulse of the blood towards the head, such as often happens in fevers, prevents sleep; but a free and equal distribution of the blood through the whole body, especially the extreme parts, frequently brings it on. Whatever weakens the body also favours sleep; and hence various kinds of evacuations, the warm bath, fomentations, sometimes heat itself, are useful for promoting it. It also comes on easily after

taking food, or indulging venery; the violent sensation being then quieted, and the body itself somewhat weakened. Cold produces a deep sleep of long continuance, not easily disturbed, and often terminating in death. Lastly, There are certain substances which, when applied to the body, not only do not excite the nervous system, but plainly lay us asleep, and render us unfit for sensation; of this kind are those called narcotics, as opium and the like, among which also we may reckon wine taken in too great quantity. Lastly, Watching itself is often the cause of sleep; because while a man is awake he always more or less exercises the organs of his body, by which the nervous influence is diminished, and thus the more violently the body is exercised, in the same proportion is the person under a necessity of sleeping.

Sleep is deficient in many diseases; for there are few which do not excite pain, anxiety, or uneasiness, sufficient to prevent the approach of sleep, or to disturb it. Fevers generally cause those who labour under them to sleep ill; as well on account of the uneasiness which accompanies this kind of disease, as by reason of the impetus of the blood towards the head being frequently increased; and likewise from the stomach being disordered, loaded with meat, or distended with drink. Hence also we may see the reason why many hypochondriac and hysterick patients sleep so ill; because they have a bad digestion, and their stomach is disposed to receive many things frequently slight disorders; the slightest of which, however, is sufficient to deprive the patient of rest, provided the body be already irritable, and endowed with too great a share of mobility.

Want of sleep will hurt in diseases as well as in health; and for the same reason; but in a greater degree, and more quickly, in the former than in the latter; and is therefore not only a very troublesome symptom of itself, but often produces other very dangerous ones.

Too much sleep, on the other hand, produces many mischiefs, rendering the whole body languid, torpid, and lazy; and it even almost takes away the judgement. It also disturbs the circulation, and diminishes most of the secretions and excretions. Hence plethora, fatness, flaccidity, and an inability for the common offices of life.—The causes of this excess are, either the usual causes of sleep above mentioned increased beyond measure, or some fault in the brain, or a compression of it by an extravasation of the humours; or sometimes, as it would seem, from great debility produced by an unusual cause, as in those who are recovering from typhous fevers and other diseases. In these examples, however, this excess of sleep is by no means hurtful; nor even, perhaps, in those cases where an excess of grief continued for a long time, or a great fright, have produced a surprising and unexpected somnolency. Lastly, Many people have accustomed themselves, and that not without a great deal of hurt to their constitutions, to sleep too much. Nor are there examples wanting of some who have passed whole days, and even months, in sleep almost uninterrupted.

With regard to the manner in which the circulation of the blood is performed, and the various principles of which it is composed, see the articles BLOOD, and ANATOMY. As for the disorders to which the blood and its circulation are subject, it has been observed, that

Disorders that in our younger years the veins are much more dense, firm, and strong, than the arteries; but the latter, by reason of the continual pressure upon them, and the strength which they exert, become daily more firm, hard, and strong, until at last they equal or exceed the veins themselves in strength; and it is not uncommon in old men to find some part of the arteries converted into an horny substance, or even into a solid bone. Hence in the state of infancy the greatest part of the blood is contained in the arteries, and in old age in the veins; an affair indeed of no small moment, as it shows the reason, in some measure, of the state of increase and decrease of the body. Besides, if any disease happens from too great a quantity of blood, it thence appears that it must show itself in young subjects in the arteries, and in old ones in the veins; and this is the reason of many diseases which accompany certain periods of life.

In most, if not in all species of animals, the arteries of the females are much more lax and capacious when compared with the veins, and the veins much less, than in the males of the same genus. The design of nature in this conformation, is probably that they may be the better able to nourish the fetus in their womb. The same likewise seems to be the reason why women are more inclined to plethora than men; and to this greater capacity of the arteries and smallness of the veins are we to ascribe that beauty and elegant shape of the arms in women, not disfigured or livid with veins as in men.

The blood is also distributed in various proportions to the different parts of the body, and that proportion too differs at different periods of our lives. At first a great quantity is sent to the head, because that part of the body is first to be evolved and fitted for its offices: but as soon as the parts begin to make a considerable resistance to the efforts of the blood, and the vessels cannot easily be further dilated, it is necessarily sent off to other parts; by which means the rest of the body increases in bulk, and becomes fitted for performing its proper functions. The effect of this change is also very soon observed, namely, when none of the blood passes through the navel, and of consequence a greater quantity is sent by the iliac arteries to the inferior extremities. These, though so small and slender in the fetus, increase very suddenly; so that often in not many months the child can not only stand on its feet, but even walk tolerably well. And during the earliest periods of infancy, the inferior extremities grow more rapidly than any other part of the body.

Physicians are wont to judge of the state of the circulation by the pulse, which indeed is very various, as well with regard to its frequency, as to the strength and equality of its strokes and intervals.—Its common quickness in a healthy adult is about 70 strokes in a minute. In a fetus, perhaps, it is more than double; and in an infant a few months old, hardly less than 120. As we grow up, this quickness gradually diminishes; so that in extreme old age it sometimes does not exceed 50, or is even slower. This rule, however, is not without exceptions: for many, especially those of an irritable habit, have the pulse much quicker; while others, even in the vigour of their age, have their pulse remarkably slow. It is for the most part somewhat quicker in women than in men.

The pulse is also rendered quicker, both in a healthy and diseased body, by the application of stimuli of many different kinds. Exercise especially, by accelerating the return of the blood through the veins, increases the quickness of the pulse to a surprising degree. Various kinds of irritations affecting the nervous system, as intense thinking, passions of the mind, pain, heat, stimulating medicines, wine, spices, &c. likewise produce the same effect. The acrimony of the blood itself also is thought to quicken the pulse.

When a person first awakes in the morning, the pulse is slow, but becomes quicker by degrees on account of the many irritating matters applied to the body. Its quickness is increased after taking food, especially of the animal kind, or such as is hot or seasoned with spices. In the evening a slight fever comes on, for which rest and sleep are the remedy. These things, however, are scarcely to be observed in a healthy person, but are very evident in one that is feverish, especially when the fever is a hectic.—Again, even debility itself often renders the pulse quicker than usual; because the ventricle of the heart not being quite emptied, it is the sooner dilated again, and of consequence contracts the sooner. For this reason a physician can never judge of the strength of the circulation from the frequency of the pulse.

Lastly, In all fevers, however different from one another, the pulse is found to be too quick, partly perhaps from debility, partly from the acrimony of the fluids, and partly from the repulsion of the blood from the surface of the body, and the accumulation of it in the large vessels where it acts as a stimulus; though it must be owned, that a great deal of this is obscure, if not totally unknown; nor in truth are we able to understand in what manner the aucerateia acts with regard to the frequency of the pulse.

The pulse is seldom observed too slow, unless when the mobility of the body is much diminished, as in decrepid old age, or from a compression or disease of the brain, as is exemplified in the second stage of hydrocephalus; but a greater compression of the brain usually produces a still more remarkable slowness of the pulse, as in the third stage of hydrocephalus.—Sometimes also the pulse is too slow in those who are recovering from tedious fevers. But this is a matter of little moment, and seems to be owing to some kind of torpor. Indeed it has generally been considered as a mark of a thorough and complete solution of the fever; for it is commonly observed, that when this state of the pulse takes place, the patient seldom suffers a relapse.

While the frequency of the pulse continues the same, its strokes may be either full, great, strong, and hard; or soft, small, and weak. A full, great, and strong pulse takes place when the ventricle strongly and completely empties itself; throwing out a great quantity of blood into the arteries, which fully distends them and stimulates them to a strong contraction. A pulse of this kind is common in strong healthy men, and is seldom to be accounted a symptom of disease. But if it be too strong, and strike the finger of the person who feels it violently and sharply, it is called a hard pulse. This hardness is produced by a sudden and violent contraction of the heart and arteries, which distends even the remote branches, as those of the wrist, too suddenly and

Disorders and smartly, and excites them also to sudden and violent contractions.

A hard pulse therefore denotes too great an action of the heart and arteries. It may arise from various causes: in the first place, from too great a tension of the vessels; for instance, from their being too full, and by that means more prone to motion, and the more fit for receiving violent motions. It may arise also from too great a density and firmness of the solids; and hence it is most frequent in cold countries, among strong robust people, and such as are accustomed to hard labour. It may likewise arise from various causes irritating the whole nervous system, or only the heart and arteries. Lastly, it accompanies many fevers, as well as most inflammatory disorders, whether the inflammation arises from a general stimulus applied to the whole body, or from the irritation of particular parts, by degrees extended over the whole body. In such a state of the circulation, the patient frequently stands in need of blood-letting, and almost always bears it well.

A small, weak, and soft pulse is generally owing to causes opposite to the former, and indicates a contrary state of the circulation and nervous system. It frequently requires stimulants; nor does it generally require blood-letting, or easily bear it. Sometimes, however, a pulse of this kind is observed even in the case of a dangerous inflammation, of the stomach for instance, or intestines. But in these and the like examples we ought to attend to the nature of the malady, much more than to the state of the pulse.

The pulse is said to intermit, when the stroke does not return after the usual interval, and perhaps not till after twice, thrice, or four times the usual space. A pulse of this kind seems to be almost natural and constant in some animals, and is common to some men even in the most perfect health; and if these happen to be seized with a fever, the pulse sometimes becomes regular, nor can the disease be removed before the intermission has returned.

Moreover, in some people, though their pulse beats equally while in health, yet the slightest illness makes it intermit; and in others, especially those who have a great deal of mobility in their constitution, such as hypochondriac and hysterical people, the intermission of the pulse is felt, without applying the finger to the artery, merely by the uneasiness which they perceive in their breasts during those intervals in which the pulse is deficient. An intermittent pulse likewise occurs in many diseases of the breast, especially when water is collected in it; and the like happens in the end of all diseases, especially fevers, when the strength is nearly exhausted, and death approaches, of which it is frequently the forerunner.

An intermittent pulse therefore seems to arise from an unequal influx of the nervous power into the heart, or from the decay and exhaustion of the nervous power, by which means the heart is not able to contract till it has been distended beyond its due pitch. Or lastly, it may arise from diseases of the organ itself, or the neighbouring parts; from swellings, water, &c. pressing upon them, and impeding the action of the heart: which indeed is a very dangerous disorder, and almost always mortal.

Many other variations of the pulse are enumerated by physicians, but most of them are uncertain, and not confirmed by experience. We shall therefore now consider the motion of the blood, which may be either too great, too small, or irregular.

A quick pulse, ceteris paribus, produces a more rapid circulation, because the sooner that the ventricle of the heart is emptied, the more quickly is the blood thrown into the arteries; and their actions must answer to this stronger stimulus. Hence exercise, heat, stimulants, plethora, every kind of irritation, passions of the mind, and fever, increase the circulation. The effect of this increase is a distention of the vessels, a stimulus applied to the whole body, an increase of heat, and often a debility. The secretion of sweat is increased while the other secretions are diminished, and the various functions of the body impeded; thirst comes on, the appetite is lost, the fat consumed, and a disposition to putrescency introduced. Sometimes the smaller vessels are burst; whence effusions of blood and haemorrhages. But we are by no means to forget, that this violent motion of the blood, however hurtful it may seem, is among the best remedies made use of by nature in curing many diseases.

The motion of the blood is diminished, especially by debility, torpor, the want of irritation or of exercise: the same thing happens to all the fluids, if there be any obstruction in the vessels, or any cause by which their return is hindered or rendered more difficult. Thus, from the very weight of the blood itself, if a person has stood long on his feet, the humours return more slowly from the inferior extremities. Any disease of the heart and arteries also, as an aneurysm, contraction, ossification, must necessarily obstruct the circulation. The same thing happens from obstructions of the veins, or interrupted respiration, by which the passage of the blood through the lungs to the left side of the heart is impeded.

But, from whatever causes this diminution of the circulation takes place, the bad consequences are perceived chiefly in the veins, because in them the blood always moves more slowly than in the arteries. Hence varices, and congestions of blood, especially in those parts of the body where the veins are destitute of valves, and of consequence where the motion of the muscles cannot assist the circulation. Hence also arise dropsies from an impeded or languid motion of the blood; because the resistance of the veins being increased, the blood is received into them with the greater difficulty, and more of the thin humour is driven into the exhalant vessels, and by them deposited in such quantities as cannot be reabsorbed by the lymphatics. These diseases, as well as all others proceeding from defects of the circulation, are also more difficult of cure than others, because all the vital powers are weakened at the same time.

Another disorder of the circulation is where the blood is carried to one part of the body in too great quantity, by which means the other parts are deprived of their due proportion. This irregular distribution of the vital fluid frequently arises from a stimulus applied to the part itself, or to the brain, or at length acting on the mind, which, according to the laws of sympathy, produces a certain definite distribution of the

Disorders of Circulation. the blood. It arises also not unfrequently from a spasm taking place in some other parts, which drives the blood out of its ordinary course.

In proportion to this irregularity of the circulation are the consequences; heat, swelling, redness, inflammation, rupture of vessels, haemorrhages, effusions, destruction, corruption, and suppuration of the cellular texture and adjoining parts, &c. Even this evil, however, nature often converts into an excellent remedy; and physicians, following her steps, frequently attempt to direct the distribution of the blood in particular diseases, well knowing that a change in the distribution of the blood is frequently efficacious either for radically curing some diseases, or relieving their most urgent symptoms.

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Palpitation. Lastly, Some disorders in the motion of the heart itself, and those of no small consequence, remain yet to be taken notice of, namely, palpitation and syncope. A palpitation is a violent and irregular action of the heart, such as for the most part is perceived by the patient himself, and that not without a great deal of uneasiness and oppression at his breast; and it is also manifest to the by-standers, if they apply their hands, or look at his naked breast; the pulse of the arteries in the mean time being weak, unequal, and intermittent. This is a spasmodic disorder; and is induced by various causes affecting either the nervous system in general, or the heart in particular. Every disease of the organ itself, such as a constriction of its valves and blood-vessels, an ossification, enlargement, or polypus, hindering the free action of the heart, and evacuation of blood from it, are capable of exciting it to violent and unusual contractions. The same effect will also follow plethora, or too violent an impulse of the blood. The heart will likewise frequently palpitate from a violent excitement of the nervous system, especially where the constitution is endowed with a great deal of mobility. Hence palpitations arise from any affection of the mind, and in hysterical women. Palpitation may likewise arise from an affection of the stomach, occasioned by worms, a surfeit, status, or stimulation by various acrid substances. It frequently also accompanies the gout when repelled, or even when a fit is coming on. Sometimes it arises from debility, whatever may be the cause; frequently from any difficulty in breathing; and many of these causes may be joined at the same time, or some of them produce others.

Hence we may see why the evil is sometimes slight and of short continuance; at other times altogether incurable, and certainly mortal in a longer or shorter time; why it sometimes returns at intervals, often coming on and being increased by every kind of irritation and exercise, and sometimes relieved or totally removed by stimulants or exercise.

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Syncope. A syncope takes place when the action of the heart, and along with it that of the arteries, is suddenly and very much lessened; whence the animal powers, the senses, and voluntary motions, immediately cease. This may be produced by almost all the causes of palpitation; because whatever can disturb and disorder the motion of the heart, may also weaken or suspend it. The vitiated structure of the heart itself therefore, violent passions of the mind, whether of the depressing kind, or those which suddenly and vehemently excite, various kinds of nervous diseases, those of the stomach,

every kind of debility and evacuation, especially a great loss of blood, excessive and unremitting labour, long watching, heat, pain, many kinds of poisons, &c. produce fainting.

Hence we see, that whatever weakens the motion of the blood through the brain tends to produce fainting; and, on the contrary, whatever tends to augment that motion, also tends to refresh, and to prevent the person from fainting. Hence also we see how the mere posture of the body may either bring on or keep off fainting, or remove it after it has already come on. We likewise see how this disorder may sometimes be of little consequence and easily removed; at others very dangerous, not only as a symptom, but even of itself, as sometimes terminating in death; and lastly, how it may be used as a remedy by a skilful physician, and artificially induced, either to free the patient from violent pain, or to stop an immoderate effusion of blood scarce to be restrained by any other method.

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With regard to the disorders of the blood itself, the glutinous part of it, or, more properly, its fibrine separated from the red particles, produces that buff-coloured appearance often seen upon blood drawn from people afflicted with inflammatory disorders, and even sometimes when no such diseases are present. This crust indeed is nothing else than the fibrine of the blood taking longer time than usual to coagulate, by which means the red particles have an opportunity of falling to the bottom. This indicates no lentor, density, thickness, or tenacity of the blood, as was formerly thought; but rather its thinness, or at least a less tendency in it to coagulate. It arises for the most part from a violent agitation and conflagration of the blood within the body; and hence it accompanies many fevers, all inflammations, sometimes haemorrhages, exanthemata, plethora, pain, and many irritations. It must, however, be allowed, that in several of these diseases it is rendered highly probable at least, from experiments apparently accurate, that the quantity of the fibrine of the blood is really increased in the proportion which it bears to the other parts. This crust, however, is not always to be accounted morbid, as it often happens to the most healthy; and may even be produced or destroyed by the slightest causes while the blood is running from the vein, so that frequently we shall see a very thick and tenacious crust on the blood flowing into one cup, while that which runs into another has little or none at all. In general, however, the appearance of this crust shows, that the patient will bear blood-letting well, though those have been in a great mistake who have directed this operation to be repeated till no more crust appeared on the blood.

The coagulable part of the blood also frequently produces those masses called polypi, which sometimes take place during life, but more frequently after death, in the large vessels near the heart, or even in the cavities of that organ. Similar masses also are frequently formed in the uterus, and are called moles.

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The quantity of blood contained in a healthy body is very various, and difficult to be ascertained. Many diseases, however, may arise from its being either too scanty or too abundant. Too great a quantity of blood is produced by the use of rich, nourishing diet, strong drink, accompanied with a good digestion; from a lazy, sedentary life, or much sleep, especially in

in those who have been formerly accustomed to much exercise; with many other causes of the same kind. It renders the person dull and languid, and sometimes almost totally oppresses him; nor are those organs destined for moving the blood sufficient for driving forward such a load. The pulse sinks; and sometimes a syncope, vertigo, or palpitation takes place. More frequently, however, the vessels are too much distended, and ready to be thrown into violent and irregular motions. Hence a disposition to fevers, inflammations, an unequal distribution of the blood, unusual congestions, rupture of the vessels, and hemorrhages. Besides this, in consequence of the close connection between the sanguiferous and the nervous system, a fulness of blood produces a disposition to spasm and other diseases of that kind.

Hence we may understand why a plethora is sometimes accompanied with a weak and sometimes with a strong and hard pulse, why it is the cause as well as a part of so many distempers, why it is the effect of a high state of health, &c.

The want of a due quantity of blood is no less pernicious than too great an abundance of it. It debilitates the person, and renders him unable to perform the proper duties of life; produces a languid circulation, syncope, spasms, and at last death itself. In a lighter degree of the disease the body is emaciated through want of nourishment, and its functions are vitiated in various ways. It may arise from want, bad food, or such as affords little nourishment: from bad digestion, or the chyle being hindered from passing into the blood: from fevers, or other diseases which exhaust the body and hinder nutrition: or lastly, from various evacuations, particularly of blood; and that the more especially if they are sudden, for in slow evacuations the vessels accommodate themselves surprisingly to the quantity left in them. Besides, if the body be slowly exhausted, the excretions are lessened by reason of the deficiency of the vital power; so that the unusual expence is easily compensated by the unusual retention. But if the evacuation happens to be very sudden and great, it may either prove mortal in a short time, or break the constitution to a degree beyond recovery.

By a great and long-continued deficiency of blood the quality of it also is impaired; because the thin part of it is easily and soon made up; but the glutinous, and red part, not so easily. Hence the blood becomes thin, pale, scarcely capable of coagulation, or of affording a proper support to the body. Too great thinness of the blood also proceeds from using much drink, especially of the aqueous kind, slender and unnutritious diet, a bad digestion in the stomach; from diseases of the lungs and those organs which elaborate the red part; or from suppression of the usual evacuations of thin humours, as sweat or urine, induced by cold, a fault of the secreting organs, or from putrefaction. But along with this, other disorders of the blood concur.

A too thin and watery blood makes the face pale, the body weak and languid. The solid parts become flaccid from want of nourishment, and having too great a quantity of water in their composition. It brings on hydropic effusions of water in all parts of the body, by reason of the increased exhalation of that thin fluid which moistens all the inward parts; partly by reason

of the vessels being relaxed beyond their usual pitch, and not making a proper resistance. Besides, in this case, the lymphatics are so far from absorbing more than usual, that, partaking likewise of the general debility, they are scarcely fitted for performing their proper offices.

Nature, however, has taken care, by the most simple means, to provide against so many and so great evils; for neither does the blood so easily become thin as some have imagined, nor when this quality takes place does it want a proper remedy. For almost instantly, if the person be otherwise in health, the excretions of watery matters are greatly augmented, and the whole mass of blood in a short time becomes as thick as formerly.

The opposite to this, namely, too great a thickness of the blood, though often spoken of by physicians, is very rarely if ever observed; and those fevers and inflammations which have been thought to arise from thence, are now found to originate from other causes. The following would seem to be the law of the human constitution. As soon as the blood has attained the due degree of thickness, or gone in the least beyond it, the excretions are either suppressed or diminished, the body attracts more moisture from the air, the person is thirsty, and drinks as much as is necessary for diluting the blood. But if water be wanting, and the person cannot satisfy his thirst, then the blood is so far from being thickened, that by reason of a putrefaction begun or augmented, it is much dissolved, becomes acrid, and is with difficulty contained in the vessels.

The acrimony of the fluids has afforded a large field for declamation to speculative physicians, and upon this slender foundation many perplexed and intricate theories have been built. It is certain indeed, that the blood in a state of health has some small share of acrimony; and this acrimony, from certain causes, may be a little increased so as to produce various diseases of a dangerous nature. This we are assured of from the increase of motion in the heart and arteries, and the similar augmentation of the action of the secretory organs, when certain acrid substances are taken inwardly. The same thing also appears from the unusual acrimony of the secreted fluids in such cases, by which the vessels are sometimes greatly stimulated, and sometimes even quite eroded. Very many acrid substances, however, are daily taken into the stomach; so that these must either be corrected in the prima via, or changed by digestion before they pass into the blood; or at least by dilution with much water, or being blunted by an admixture with gluten, oil, or different gases, they must deposit much of their acrimony, and at last be thrown out of the body as noxious substances. Thus a vast quantity of salts, acid, alkaline, and neutral, may pass through the body, without in the least affecting the health; though these salts, if taken in very large quantity, undiluted, or not thrown out of the body, will do much hurt.

Moreover, even while life continues, putrefaction is going on, and produces much of that substance called animal salt; for into this a great part of our food is converted, and passes off by the urine. But if this putrescent disposition be too great, it will produce too large a quantity of animal salt; especially if much of any saline substance is otherwise thrown into the body without.

without proper dilution: and this kind of disease is well known to sailors who have been long at sea without having an opportunity of getting fresh provisions.

For this spontaneous putrescency, nature has suggested a proper remedy, namely, fresh meat, especially of the vegetable and acescent kind, and such as is much impregnated with acid, which it may impart to the body. But where this kind of food is wanting, the putrefaction goes on apace, and a very great thinness and acrimony of the juices take place; especially if there be also a scarcity of urine, or the excretions which ought to carry the putrid matters out of the body languish, either from cold, sloth, torpor, depressing passions of the mind, or from the constitution being broken by diseases; or lastly, from too great heat, which always favours putrefaction.

Besides, it would seem, that sometimes a disposition to putrefaction is much increased by the reception of a putrid ferment into the body; of which we have examples in some infectious fevers, where the contagion is very much assisted by heat, animal diet, certain kinds of salts, debility and nastiness.

Lastly, Any single part of the body may putrefy from various causes, as from inflammation, cold, &c. and thus may the whole body be infected; although for the most part the disease proves fatal before the corruption has spread over the whole body.

But when the mass of blood begins to putrefy greatly, it not only becomes very acrid, but thin also, so that it either will not coagulate at all, or shows only a slight and very loose crassamentum. Nay, even the red globules are broken down and destroyed; in which case it necessarily follows, that the blood must become very acrid, as well on account of the evolution of the salt, as by reason of the rancid and putrid gluten, which stimulates, and frequently even erodes, the vessels; producing spots, first red, then livid and black, tumors, and ulcers scarce possible to be cured, without first removing the putrescent disposition of the humours. From the same causes proceed haemorrhages from every part of the body, hardly to be restrained; a most intolerable fetor of the breath and all the excrements; the highest debility and laxity of the solids; the putrefaction acting as a poison to the nervous system, and at length bringing on death.

An acrimony of the acid kind never takes place in the human blood, nor in any of the humours secreted from it; though one of them, namely the milk, turns acid spontaneously in a very short time after it is drawn from the breast. Neither does an alkaline acrimony seem ever to take place in the blood. Putrescency indeed tends this way, and at last terminates in it; but scarcely while the person lives, though the nature of the urine, even while recent, seems to be but little distant from that of an alkali.

Many kinds of acrimony may exist in the blood from too liberal an use of spices, wine, spirits, &c. but of these we know nothing certain. We well know, however, that the body is often infected with various kinds of morbid acrimony, which bring on many and dangerous diseases, as the small-pox, measles, cancers, lues venerea, &c. of which the origin and manner of acting are very little understood, though the effects are abundantly evident. In most cases, nature has taken

no less care to provide against the acrimony than against the too great viscosity of the blood. Sometimes an antidote is afforded, either by the excitement of thirst, that the acrid substance may be diluted with plenty of drink; or by increasing the evacuations, that it may be thrown out of the body; or lastly, by exciting various motions and actions of the vital powers, by which it may be either subdued, changed, rendered innocuous, or expelled from the body by new and unwonted passages.

With regard to respiration, it may be obstructed from various causes seated either in the lungs themselves or the surrounding parts. But from whatever cause this obstruction may arise, it undoubtedly produces all those diseases which proceed from an interrupted circulation. The lungs themselves also being at length compressed, and not suffered to dilate sufficiently, cannot throw off the vapour which arises from them; and hence they are frequently oppressed with moisture. At the same time they are irritated, so that a greater quantity of mucus, and that of a thicker kind than usual, is secreted; by which means the passages through which the air enters them are stopped up, till a violent cough at length throws off the load.

The respiration is also subjected to some other disorders, as a cough and sneezing; which, though at first sight they may seem very dangerous, are not destitute of use, and may even be reckoned among the most salutary attempts of nature to relieve the patient. Often, however, they are attended with danger, or very great uneasiness; namely, when they are either too violent or exerted in vain. At any rate, it is necessary for a physician to know the nature, causes, and effects of these, that he may be enabled to promote them when necessary, to moderate them when too violent, and to stop them when noxious or of no use.

A cough is a violent, frequently involuntary, and sonorous expiration, suddenly expelling the air with great force through the glottis somewhat contracted. The convulsion of the muscles serving for expiration, gives a great force to the air, while the contraction of the glottis produces the sound. It is often long continued, being repeated at certain intervals, during each of which the inspiration is imperfect and obstructed by reason of the contraction of the glottis. It is excited by any kind of acrid substance, either chemically or mechanically applied to those passages through which the air enters. These are lined with a membrane so exceedingly delicate and impatient of stimulus, that it cannot even bear the touch of the mildest substance, such as a small drop of water, without throwing the muscles serving for expiration into a violent convulsion; the glottis at the same time contracting by means of the sympathy between it and the neighbouring parts. Thus the air is thrown out with such violence, that it drives the irritating substance along with it; and thus a cough becomes not only useful, but absolutely necessary for the preservation of life, as being able to free the lungs from every kind of irritating substance or foulness, which might soon bring on a suffocation. Hence a cough is almost an inseparable companion of every inflammation of the lungs, as well as every difficulty in respiration; and even frequently accompanies the entrance of the purest air when the

trachea

Disorders of Respiration. trachea and bronchiae are excoriated, or become too sensible. Examples also are not wanting, where a violent and troublesome cough has arisen from an irritability of the nervous system, or even of some particular part, of the ear, for instance, the stomach and intestines, the liver by inflammation, &c.

Coughing may also be voluntarily excited, and may then be managed at pleasure. Even when involuntary, it may be moderated, or suppressed, by a contrary effort: though a violent fit of coughing cannot by any means be resisted. When it is once excited, the cough goes on till the irritating substance be expelled, or the sense of irritation abolished, or perhaps overcome by a more uneasy sensation than even the cough itself; after which, the irritation again returning at a certain interval, the cough also returns. Hence we are taught a method of allaying and quieting this most troublesome malady, though frequently it is not in our power to remove the cause of it altogether.

A very violent cough is often dangerous: For by the retention of the breath, and the strong efforts made in coughing, a great quantity of blood is collected in the lungs, of which the vessels are distended, and frequently broken; and hence there sometimes happens a violent and even fatal haemorrhage. More frequently, however, it is the cause of a flower, though equally fatal, disease. Nay, a frequent and troublesome cough, without any great haemorrhage, or even without any haemorrhage at all, may injure the lungs to such a degree, especially if they be of a more tender structure than usual, as to lay the foundation of a phthisis almost always incurable.

Again, by a long-continued and violent cough, the passage of the blood through the lungs being impeded, it must necessarily flow through the veins towards the head: hence redness and lividness in the countenance, haemorrhages, palsies, apoplexies, and sometimes fatal convulsions. Lastly, by a violent cough the abdominal viscera are compressed with remarkable violence; and if any part happens to be weaker than usual, a hernia, prolapsus uteri, abortion, or similar accidents, may happen.

Even when the cough is more gentle, if it happens to be importunate and frequent, although we have nothing of this kind to fear, yet the patient is by no means free from danger; as he is thereby agitated, fatigued, has his constitution broken, is deprived of rest, has a fever brought upon him, his lungs are shaken and irritated, digestion and all the other functions are impeded, till at last he sinks under a complication of maladies.

Sneezing is somewhat similar to cough, as consisting of a very full inspiration, to which succeeds a most violent expiration, by which the air is driven out through the nostrils with immense violence, and sweeps the passage through them as it goes out. It is a convulsion much more violent than a cough, and is besides very difficult to be stopped when once a propensity to it has taken place. As a cough proceeds from an irritation of the glottis, trachea, bronchia, and lungs, so sneezing arises from an irritation of the membrane of the nostrils, but rarely from sympathy with any distant part. It is sometimes of service, as well as a cough; though it is also sometimes prejudicial, for the reasons which have been already assigned.

VOL. XIII. Part I.

The last affections of which we shall here speak, are those arising from a bad digestion, disordered motion of the intestines, and some of the principal secretions. The first of these are sometimes very troublesome, though seldom dangerous. The principal symptoms are oppression, anxiety, pain at the stomach; eructations, by reason of air extricated from the fermenting aliment, and irritating the stomach; nausea and vomiting, from the irritation and distention of the same organ; the belly sometimes too costive, and sometimes too loose; a defect of nourishment; a general debility; relaxation of the solid parts; too great thinness of the fluids; all the functions impeded; pain of the head; vertigo, syncope, asthma, palpitation; great sinking of the spirits, especially if the patient has been of a peculiar constitution; sometimes the gout, sometimes a dropy, or a slow fever which may prove fatal.

The motion of the intestines may be either too great or too little; and hence proceeds either costiveness or looseness. The former is frequently not to be accounted morbid; but, when it is, it may arise from the structure of the intestines being injured, or from their being shut up or obstructed by spasm or otherwise, or from a deficiency of those humours which moisten the intestines; or it may arise from mere debility, from a palsy of the fibres, perhaps, or from a deficiency of the usual stimulus, of the bile, for instance, or from too dry or slender a diet.

The consequences of long-continued costiveness, are, first, an affection of the alimentary canal, and then of the whole body. The stomach is diseased, and does not digest the aliments properly; the whole body is left destitute of its usual stimulus; the blood is corrupted, perhaps from the resorption of the putrid matter into it. The circulation through the abdominal viscera is impeded; hence frequent and irregular congestions, varices of the veins, haemorrhoids, &c. Nay, the intestines themselves being overloaded, distended and irritated by an heavy, acrid, and putrid load of aliment or other matters, are excited to new and unusual contractions, which, if they do not get the better of the obstruction, bring on tormina, colic, or an iliac passion, inflammation and gangrene, fatal in a very short time.

Looseness, or diarrhoea, is a malady extremely common; being sometimes a primary disease, and sometimes only a symptom or an effect of others. Sometimes it is a salutary effort of nature, such as the physician ought to imitate and bring on by art. It is also familiar to infants, and to people of a certain constitution; and to them costiveness is very prejudicial. It may arise, in the first place, from something taken into the body, or generated in the intestines; from a fermentation and corruption of the mass of aliment; from the bile being too abundant and acrid, or from blood or pus poured into the intestines; from the intestines themselves being eroded, or deprived of their natural mucus; from the humours being driven from the surface of the body towards the inward parts, as by cold, especially when applied to the feet; or from a general corruption of the whole body, as in the phthisis, hectic, or putrid fever, especially towards the end of these disorders. In fevers it is sometimes salutary, or even puts an end to the disease altogether, or

F f

at

Disorders of the Alimentary Canal. at least renders it milder: more frequently, however, deriving its origin from putrescency, it is of no service, but rather exhausts the strength of the patient. A diarrhoea likewise, almost incurable, and often fatal in a short time, frequently arises after the operation for the fistula in ano. Some have their intestines so extremely weak and moveable, that from the slightest cause, such as catching cold, any violent commotion of the mind, &c. they are subject to a violent diarrhoea. Lastly, whatever be its origin, if it has continued for a long time, the viscera are rendered so weak and irritable, that the disease, though often removed, still returns from the slightest causes, and even such as are not easily discovered.

A diarrhoea proves very pernicious, by hindering digestion and the nourishment of the body; for the stomach is commonly affected, and the aliments pass through the intestines so quickly, that they can neither be properly digested, nor are the lacteals able to absorb the chyle from them as they go along. Such a violent evacuation is also hurtful by exhausting the body, and carrying off a great quantity of the nutritious matter from the blood. Neither indeed, is it only the alimentary mass which is thrown out sooner than it ought to be; but at the same time, a great quantity of the fluids secreted in the intestines, so that the whole body quickly partakes of the debility.

Sometimes a violent and long-continued diarrhoea rises to such a height, that the aliment is discharged with little or no alteration. Sometimes also, though rarely, from a similar cause, or from the obstruction of the mesenteric glands, and its other passages into the blood, the chyle itself is thrown out like milk along with the excrements; and this disease is called the fluxus cœliacus.

A dysentery is attended with very severe gripes in the belly, a frequent desire of going to stool, and vain efforts, when nothing is excreted besides the mucus of the intestines mixed with a little blood; it is also accompanied with excessive debility, and frequently with putrescency and fever. It is thought to arise from the constriction of some part of the intestines, of the colon especially: by which means the bowels, though ever so much irritated, can pass nothing; neither can the disease be removed, until the belly has been well purged by proper medicines.

A tenesmus is a frequent and insatiable propensity to stool, without being able to pass any thing, notwithstanding the most violent efforts. It may be occasioned by any kind of irritation, either of the rectum itself or of the neighbouring parts, by acrid substances taken into the body; by some of the stronger purges, especially aloes, a substance very difficult of solution, which will pass even to the rectum with very little alteration; by a violent and obstinate diarrhoea, dysentery, haemorrhoids, worms, fistula, calculus, ulcer in the bladder, urethra, &c. It is often very pernicious, both from the excessive uneasiness it occasions to the patient, and from its exhausting his strength, by the frequent and vain efforts bringing on a prolapsus ani, and communicating the violent irritation to the neighbouring parts, as the bladder, &c.

A nausea and vomiting are disorders very common, and owing to almost innumerable causes; not only to affections of the stomach itself, but also to affections and

irritations of the remotest parts of the body which may act upon the stomach by sympathy. Every irritation and distention of that viscus therefore, a load of crude aliment, an obstruction about the pylorus, all acrid substances taken into it, diseases of the liver, intestines, kidneys, uterus, the head, the feet, the skin, or indeed the whole body, inflammation, the stone, king's evil, scirrhous, apoplexy, compression of the brain, fracture of the skull, vertigo, syncope, violent pain, the gout, especially when repelled, fevers, passions of the mind, disagreeable imaginations or discourses, frequently induce nausea and vomiting.

These affections are often serviceable by freeing the stomach from something with which it was overloaded; promoting spitting in some cases where the lungs are overcharged with mucus, blood, pus, or water; producing sweat, and a free and proper distribution of blood to the surface of the body; partly, perhaps, by the great straining which accompanies vomiting, but rather by that wonderful sympathy which takes place between the stomach and skin: and hence, in many diseases, vomiting is a most excellent remedy. It is however in some cases hurtful, if too violent or too frequently repeated, partly by debilitating and making the stomach more easily moved; and partly by fatiguing the patient with violent strainings, which occasion hernias, abortions, &c.

Sometimes we find the motion of the intestines totally inverted, from the anus to the mouth; a most dangerous distemper, which hath obtained the name of the iliac passion. It most frequently arises from some obstruction in the alimentary canal hindering the descent of the excrements, as scirrhous, spasms, inflammation, &c.: though the most perfect iliac passion takes place without any obstruction, so that clysters will be vomited; and even after this has continued for several days, the patients have at length recovered.

A lighter degree of the iliac passion, namely the inversion of the peristaltic motion of the duodenum, always takes place in long-continued and violent vomiting, as in sea-sickness, or when a person has taken too large a dose of an emetic; by which means a vast quantity of bile frequently ascends into the stomach, and is discharged by vomiting.

An excessive vomiting with looseness is called a cholera, when the matter discharged has a bilious appearance. It arises from a very great irritation of the alimentary canal without any obstruction; and is for the most part occasioned by too great a quantity, or from an acrimony of the bile, from whence it takes its name. It may originate from several causes, as too strong a dose of an emetic and cathartic medicine, eating too great a quantity of summer fruits, &c. and is a very violent malady, often killing the patient in a few hours, unless proper remedies be applied in time.

From a suppression of any of the secretions, or a disorder of any of the secretory organs, many misperceptions may arise. A diminution of perspiration produces plethora, lassitude, languor, depression of mind, bad digestion, loss of appetite, and even a general corruption of the humours from the retention of such a quantity of putrescent matter.—The more suddenly the diminution or suppression of the perspiration takes place,

place, the sooner the mischief is produced, and the greater it is; not only by retaining the matter which ought to be thrown out, but by repelling the humours from the surface of the body, and directing them to other parts; whence fevers, inflammations, congestions of the blood, &c. frequently take place.

Thus suppression of perspiration may arise from many different causes; as from cold suddenly applied to the body when very hot; sometimes from very violent passions of the mind; or from spasmodic diseases, as the hysterics, &c. It may be suppressed also by that kind of constriction of the vessels of the skin which is produced by various kinds of fevers, the nature of which has hitherto been but little known.

Excessive perspiration or sweating is injurious by debilitating the body, relaxing the skin, and exposing the patient to all the evils which arise from catching cold. It may even be carried to such a height as to produce fainting and death; though it must be owned that we cannot easily bring examples of people having, from this cause, their blood inspissated, corrupted, or being thence made liable to inflammations and fevers.

A suppression of urine is still more dangerous than that of perspiration, and unless relieved in a short time will certainly prove fatal. This disorder, which is called ischuria, may arise from various diseases of the kidneys, ureters, bladder, urethra, &c. Thus any obstruction or irritation of one or other of the kidneys or ureters, by a stone, gravel, mucus, blood, inflammations, spasm, suppuration, scirrhous swellings of the neighbouring parts, &c. may either prevent the urine from being secreted, or may give rise to a scanty or depraved secretion, or, finally, may obstruct its passage into the bladder after it is secreted.

The urine also, after it has entered the bladder, is there frequently suppressed, by reason of various disorders to which that organ is liable, as an irritation or inflammation, spasm, acrid substances injected, or sympathy with the neighbouring parts; or by reason of the texture of the bladder itself being destroyed, or from a palsy, scirrhous, ulcer, &c. in the bladder. Or, lastly, the urine may be retained in the bladder from a general stupor, as from a disease of the brain, which happens in some fevers, when the patient is neither sensible of the usual stimulus, nor even of one much greater, so that the fibres can scarcely be excited to contraction by any means whatever. This, in fevers, is always a bad sign, and sometimes even proves fatal.

A suppression of urine for any length of time produces an immense distention of the bladder, oppression, uneasiness, and pain, not only of the part itself, but of the surrounding ones, and even of the whole body; a spasm, or insuperable constriction of the sphincter; an inflammation, gangrene, or laceration of the bladder itself; a violent irritation of the whole habit; then a nausea, vomiting, vertigo, general stupor, and an impregnation of the whole mass of blood with a humour of an urinous nature, which at last being poured out into various cavities of the body, especially of the head, soon brings on a deep sleep, convulsions, and death.

From the same causes, but acting with less force, proceeds that disease called a dysuria, when the urine passes with difficulty and pain, and is frequently

red, black, bloody, purulent, mucous, and sandy; the reason of all which appearances is very much unknown.—The most frequent complaint, however, in making water, is where the patient has a continual and violent desire of passing his urine, while at the same time only two or three drops can be passed at once, and that not without some pain. This may be occasioned even in healthy people, by some acrid substance taken into the stomach; and is very common to old people, who are generally subject to disorders of the kidneys and bladder. It arises also frequently from a stone irritating the bladder, or from an inflammation of it, or its being deprived of its mucus, or this last being somehow or other corrupted; or lastly, from certain diseases, or some particular state of the neighbouring parts, as of the uterus, vagina, urethra, prostate gland, &c.

Akin to the strangury is an incontinence of urine, when the patient's water either comes away against his will, or altogether without his knowledge. This disorder may arise from debility, palsy, an ulcer or wound, or any long-continued and violent irritation of the bladder, especially of its sphincter, as from a stone, a general palsy, or in females difficult labour, injuring the neighbouring parts.—This symptom occurs in a great number of diseases, especially in the hydrocephalus.—Sometimes the urine is expelled with violence, either by reason of universal spasms, or by violent contractions of the muscles of respiration, as in sneezing, laughter, &c.

Among the disorders incident to the urine we may reckon the production of calculi, which frequently bring on the most excruciating and dangerous diseases.—The urine, besides the water and salts, contains no small share of the glutinous part of the blood already somewhat corrupted, and still inclined to farther corruption. Hence the urine even of the most healthy people deposits a sediment after it has stood for some time; and though none of this sediment be formed in a healthy body, yet if the smallest particle of foreign matter be introduced into the bladder, a crust soon gathers round it, and it is sure to become the basis of a concretion, which by degrees grows to a very great size. It is not unlikely, also, that some unknown fault of the fluids may contribute to the production of those calculi, as the stone is well known to be an hereditary disease, and to be born with the patient. Calculous persons also are commonly subject to complaints of the stomach, especially to an acidity of it; and many have received no little relief from alkaliescent or alkaline medicines.—From the same causes may calculi be formed in the kidneys; from which proceed a horrid train of symptoms described in the subsequent part of this treatise.

It is now found, by accurate experiments of the most able chemists, that urinary calculi do not, as was once supposed, consist almost entirely of an earthy matter. Their principal constituent is a peculiar acid approaching more nearly to the phosphoric found in the bones than to any other. But the acid of calculus being in some respects peculiar in its nature, has among modern chemists obtained a peculiar name, and been distinguished by the appellation of the lithic or uric acid. It is highly probable that this acid present in the circulating mass, is precipitated and disengaged by the introduction

introduction of other acids, and thus thrown off in greater quantities by the kidneys. Thus, then, we can understand the influence of acids as tending to the generation of calculus, and of alkalies as tending to prevent it.

The last disorder here to be taken notice of is a disorder of the glands themselves, owing to some kind of obstruction, and is one of the most dreadful diseases incident to human nature. Hence happens a great swelling and surprising hardness, not only without pain, but sometimes even with a diminution of sensation in the part affected; and when the gland is thus affected, it is called a schirrus. Sometimes it remains in this state for a long time; but sooner or later produces the most excruciating torment. By degrees it is infected with a slow and malignant suppuration, degenerating into an horrid ulcer, consuming not only the part itself,

but eating away the neighbouring ones, and corrupting the whole body with the most acrid and incurable poison. This disease is called a cancer, of which the causes are very little known.

Of the organs in both sexes concerned in the function of generation, and of that function as far as we yet know any thing respecting it, an account has already been given in ANATOMY; and after what has been said of the different functions, and of the morbid affections, to which these are subjected, we may conclude our remarks on the theory of medicine, with mentioning the remarkable versatility of the human constitution; which, more than that of any other animal, is capable of accommodating itself to every climate and to all kinds of diet. Hence we may conclude, that a large proportion of the diseases to which we are subjected are produced by ourselves.

PRACTICE OF MEDICINE, or an Account of the principal Diseases to which the Human Body is subjected.

WE have already defined medicine to be the art of preventing, curing, and alleviating, those diseases to which mankind are subjected. While these affections, however, are in number almost infinite, each in its progress is subjected to almost endless varieties from differences in climate, constitution, treatment, and a variety of other particulars. Hence we may readily explain both the difficulty of distinguishing morbid affections from each other in actual practice, and the diversity of names which have been affixed to them in the writings of ancient physicians. It may readily be supposed, that in this, as well as other subjects, there has been a gradual improvement from the progressive labours of industrious and ingenious men. And although much yet remains to be done in the proper arrangement and distinction of diseases, or what has been called methodical nosology, yet there cannot be a doubt, that during the course of the 18th century, this subject has received very great improvements. For these, we are, in the first place, highly indebted to the labours of Franciscus Boissier de Sauvages, an eminent professor of medicine at Montpellier, who, following out an idea suggested by the sagacious Dr Sydenham of England, first successfully attempted to arrange diseases, as botanists had done plants, into classes, orders, genera, and species. Since the publication of the Nosologia Methodica of Sauvages, this subject has been successfully cultivated by several ingenious men, particularly by Sir Charles Linnæus of Upsal, to whose genius for arrangement every branch of natural history, but botany in particular, has been so highly indebted; by Rudolphus Augustus Vogel, an eminent professor at Gottingen; and by John Baptist Sagar, a distinguished physician at Iglaw in Moravia: But of all the systems of arrangement yet presented to the medical world, that published by the late illustrious Dr William Cullen of Edinburgh, may justly be considered as the best. In treating, therefore, of the principal diseases to which the human body is subjected, we shall follow his plan, endeavouring to deliver the best established observations respecting the history, theory, and practice of each. In treating of particular genera of disease, although we

follow the arrangement of Dr Cullen, yet for the satisfaction of the reader, we shall often point out the classes to which the same affection is referred by the other eminent writers whom we have mentioned. And on this account, it may not be improper briefly to enumerate the general classes to which each of them have referred the affections of the human body.

The Classes of Sauvages are,

The Classes of Linnæus are,

The Classes of Vogel are,

The Classes of Sagar are,

Besides

Besides these, two other systems have been presented to the public, which may be considered as deserving attention; those, viz. of the late learned Dr M'Bride of Dublin, and of the ingenious Dr Darwin of Derby.

The Classes and Orders of M'Bride.

Class I. Universal Diseases.

Or. 1. Fevers.
2. Inflammations.
3. Fluxes.
4. Painful diseases.
5. Spasmodic diseases.
6. Weaknesses or privations.
7. Asthmatic disorders.
8. Mental disorders.

Class II. Local Diseases.

Or. 1. Of the internal senses.
2. Of the external senses.
3. Of the appetites.
4. Of the secretions and excretions.
5. Impeding different actions.
6. Of the external habit.
7. Dislocations.
8. Solutions of continuity.

Class III. Sexual Diseases.

Or. 1. General proper to men.
2. Local proper to men.
3. General proper to women.
4. Local proper to women.

Class IV. Infantile Diseases.

Or. 1. General.
2. Local.

The Classes and Orders of Darwin.

Class I. Diseases of Irritation.

Or. 1. Increased irritation.
2. Decreased irritation.
3. Retrograde irritative motions.

Class II. Diseases of Sensation.

Or. 1. Increased sensation.
2. Decreased sensation.
3. Retrograde sensitive motions.

Class III. Diseases of Volition.

Or. 1. Increased volition.
2. Decreased volition.

Class IV. Diseases of Association.

Or. 1. Increased associated motions.
2. Decreased associated motions.
3. Retrograde associated motions.

After this short view of different classifications, we shall next present to our readers a more particular account of the arrangement of Dr Cullen; which, although it can by no means be represented as free from errors or imperfections, is yet in many respects the best that has hitherto been published.

CULLEN'S Arrangement.

CLASS I. ERYXIS. A frequent pulse coming on after a horror; considerable heat; many of the functions injured; the strength of the limbs especially diminished.

Order I. FERRES. Pyrexia without any primary local affection, following languor, lassitude, and other symptoms of debility.

Section I. Intermittentes. Fevers arising from the mis-
alma of marthes; with an apyrexia, or at least a very
evident remission; but the disease returns regularly, and
for the most part with a horror or trembling.

Genus I. Tertiana. Similar paroxysms after an in-
terval of about 48 hours, coming on most commonly at
mid-day. A tertian hath either;

I. An apyrexia interposed.

1. Varying the duration of the paroxysms.

A, The tertian whose paroxysms are not extended
beyond 12 hours.

B, The tertian with paroxysms extended beyond 12
hours.

2. Varying in the return of paroxysms.

C, The tertian returning every day with unequal
paroxysms alternately similar to one another.

D, The tertian returning every third day with two
paroxysms on the same day.

E, The tertian returning every day, with two pa-
roxysms on every third day, and only one on the inter-
mediate ones.

F, The tertian returning every day, with an evident
remission interposed between the odd and the even days,
but a less remarkable one between the even and the odd
days.

3. Varying in its symptoms.

G, The tertian accompanied with a disposition to
sleep.

H, Accompanied with spasms and convulsive mo-
tions.

I, Accompanied with an efflorescence on the skin.

K, with phlegmasia.

4. Varying in being complicated with other diseases.

5. Varying as to its origin.

II. With the interposition only of a remission between
the paroxysms.

Genus II. Quartana. Similar paroxysms, with an
interval of about 72 hours, coming on in the afternoon.

I. With the interposition of an apyrexia.

1. Varying in the type.

A, The quartan with single paroxysms, returnin-
every fourth day, none on the other days.

B, With two paroxysms every fourth day, and none
on the other days.

C, With three paroxysms every fourth day, and
none on the intermediate days.

D, Of the four days having only the third free from
fever, with similar paroxysms every fourth day.

E, The quartan coming on every day, with similar
paroxysms every fourth day.

2. Varying in its symptoms.

3. Varying in being complicated with other diseases.

II. With a remission only between the paroxysms.

Genus III. Quotidiana. Similar paroxysms with

an interval of about 24 hours, coming on commonly in the morning.

I. With the interposition of an apyrexia.

1. Varies in being solitary.

A. Universal.

B. Partial.

2. Complicated with other diseases.

II. With a remission only between the paroxysms.

Sec. II. Continuar. Fevers without evident intermission, and not occasioned by marshy miasmata; but attended with exacerbations and remissions, though not always very remarkable.

Genus IV. Synocha. Great heat; a frequent, strong, and hard pulse; high-coloured urine; the functions of the sensorium a little disturbed.

Genus V. Typhus. A contagious disease; the heat not much above the natural; the pulse small, weak, and for the most part frequent; the urine little changed; the functions of the sensorium very much disturbed, and the strength greatly diminished.

The species are,

I. Typhus petechialis. Typhus for the most part with petechiae.

Varying in degree. 1. Mild typhus. 2. Malignant typhus.

II. Typhus icteroder. Typhus with a yellowness of the skin.

Genus VI. Synochus. A contagious disease. A fever compounded of synocha and typhus; in the beginning a synocha, but towards the end a typhus.

Order II. PHLEGMASIE. A synocha fever, with inflammation or topical pain, the internal function of the parts being at the same time injured; the blood drawn and concreted exhibiting a white coriaceous surface.

Genus VII. Phlogosis. Pyrexia; redness, heat, and painful tension, of some external part.

The species are,

I. Phlogosis (phlegmone) of a vivid red colour; a swelling well defined, for the most part elevated to a point, and frequently degenerating into an abscess, with a beating or throbbing pain.

The variations are, 1. In the form. 2. In the situation.

II. Phlogosis (erythema) of a reddish colour, vanishing by pressure; of an unequal and creeping circumference, with scarce any swelling; ending in the scaling off of the cuticle, in pustules, or blisters.

The variations are, 1. In the degree of violence. 2. In the remote cause. 3. In being complicated with other diseases.

The consequences of a phlogosis are, an imposthume, gangrene, sphacelus.

Genus VIII. Ophthalmia. A redness and pain of the eye, with an inability to bear the light; for the most part with an effusion of tears.

The species and varieties of the ophthalmia are,

I. Idiopathic.

1. Ophthalmia (membranarum), in the tunica adnata, and the membranes lying under it, or the coats of the eye.

A. Varying in the degree of the external inflammation.

B. In the internal coats affected.

2. Ophthalmia (tarfi) of the eye-lids, with swelling, erosion, and glutinous exudation.

II. Symptomatic.

1. From a disease of the eye itself.

2. From diseases of other parts, or of the whole body.

Genus IX. Phrenitis. Violent pyrexia; pain of the head; redness of the face and eyes; inability to endure the light or any noise; watchfulness; a furious delirium, or typhomania.

I. Idiopathic.

II. Symptomatic.

Genus X. Cynanche. Pyrexia sometimes inclining to a typhus; difficulty of swallowing and breathing; with a sensation of narrowness in the fauces.

The species are,

I. Cynanche (tonsillaris) affecting the mucous membrane of the fauces, but especially the tonsils, with redness and swelling, accompanied with a synocha.

II. Cynanche (maligna) affecting the tonsils and mucous membrane of the fauces with swelling, redness, and mucous crusts of a whitish or ash-colour, creeping, and covering ulcers; with a typhous fever and exanthemata.

III. Cynanche (trachealis) attended with difficult respiration, noisy and hoarse inspiration, loud cough, without any apparent tumor in the fauces, somewhat difficult deglutition, and a synocha.

IV. Cynanche (pharyngea) attended with redness in the bottom of the fauces, very difficult and painful deglutition, respiration sufficiently free, and a synocha.

V. Cynanche (parotidæ) with great swelling in the parotids and maxillary glands appearing on the outside: the respiration and deglutition but little injured; a synocha, for the most part mild.

Diseases of this genus are symptomatic, either from external or internal causes.

Genus XI. Pneumonia. Pyrexia, with a pain in some part of the thorax, difficult respiration, and cough. The species are,

I. Peripneumony, with a pulse not always hard, but sometimes soft; an obtuse pain of the breast; the respiration always difficult; sometimes the patient cannot breathe unless in an upright posture; the face swelled, and of a livid colour; the cough for the most part moist, frequently bloody.

1. Simple idiopathic peripneumonies.

Varying in degree.

2. Idiopathic peripneumonies complicated with fever.

3. Symptomatic peripneumonies.

II. Pleurisy, with a hard pulse; for the most part attended with a pungent pain of one side, augmented chiefly during the time of inspiration; an uneasiness when lying on the side; a most painful cough, dry in the beginning of the disease, afterwards moist, and frequently bloody.

1. Simple idiopathic pleurises.

2. Pleurises, complicated, (1.) With fever. (2.) With catarrh.

3. Symptomatic pleurises.

4. False pleurises.

The consequences of pleurisy are a vomica or empyema.

Genus XII. Carditis. Pyrexia; pain about the heart; anxiety; difficulty of breathing; cough; unequal pulse; palpitation of the heart, and fainting.

I. Idiopathic.

II. Symptomatic.

Genus XIII. Peritonitis. Pyrexia; pain of the belly, exasperated by an upright posture, without the proper signs of other abdominal phlegmasie.

I. Peritonitis (propria), situated in the peritoneum, properly so called, surrounding the inside of the abdomen.

II. Peritonitis (omentalis), in the peritoneum extended through the omentum.

III. Peritonitis (mesenterica), in the peritoneum spread through the mesentery.

Genus XIV. Galritis. Pyrexia inclining to a typhus; anxiety; pain and heat of the epigastrium, augmented when any thing is taken into the stomach; an inclination to vomit, and an immediate rejection of every thing swallowed; an hiccough.

I. Idiopathic.

1. From internal causes.

A. Galritis (phlegmonodæa), attended with acute pain and violent pyrexia.

2. From external causes.

B. Galritis (erysipelatoſa), with a less violent fever and pain: an erysipelatus redness appearing on the fauces.

II. Symptomatic.

Genus XV. Enteritis. Pyrexia of a typhous nature; pungent pain of the belly, stretching and twisting about the navel; vomiting; the belly obstinately bound.

I. Idiopathic.

1. Enteritis (phlegmonodæa), with acute pain, violent fever, vomiting, and constipation of the belly.

2. Enteritis (erysipelatoſa), with less acute fever and pain, without vomiting; but accompanied with a diarrhoea.

II. Symptomatic.

Genus XVI. Hepatitis. Pyrexia; tension and pain of the right hypochondrium; sometimes pungent like that of a pleurisy, but more frequently obtuse; a pain reaching to the clavicle and top of the right shoulder; a difficulty of lying on the left side; dyspnoea; dry cough, vomiting, and hiccough.

Genus XVII. Splenitis. Pyrexia; tension, heat, and swelling of the left hypochondrium, the pain increasing by pressure; without the signs of nephritis.

Genus XVIII. Nephritis. Pyrexia; pain in the region of the kidney, often following the course of the ureter: frequent discharge of urine, either thin and colourless, or very red; vomiting; fluvor of the thigh; with a retraction or pain of the testicle of the same side. The species are,

I. Idiopathic. Spontaneous.

II. Symptomatic.

Genus XIX. Cystitis. Pyrexia; pain and swelling of the hypogastrium: frequent and painful discharge of urine, or ischuria; and tenesmus. The species are,

I. Those arising from internal causes.

II. Those from external causes.

Genus XX. Hysteritis. Pyrexia; heat, tension, swelling, and pain of the hypogastrium; the os uteri painful when touched; vomiting.

Genus XXI. Rheumatismus. A disease arising from an external and frequently very evident cause; pyrexia; pain about the joints, frequently following the course of the muscles; infesting the knees and other large joints rather than those of the feet or hands; increased by external heat.

The species are either idiopathic or symptomatic. The former varies in situation.

A. In the muscles of the loins.

B. In the muscles of the coxendix.

C. In the muscles of the breast.

Genus XXII. Odontalgia; a rheumatism of the jaws from a caries of the teeth.

Genus XXIII. Podagra. An hereditary disease, arising without any evident external cause, but for the most part preceded by an unusual affection of the stomach; pyrexia; pain of a joint for the most part of the great toe of the foot, at least infesting chiefly the wrists and ankles; returning by intervals; and often alternated with affections of the stomach and other internal parts.

I. Podagra (regularis), with a pretty violent inflammation of the joints remaining for some days, and by degrees going off with swelling, itching, and desquamation of the affected part.

II. Podagra (atonica), with an atony of the stomach, or some other internal part; and either without the usual inflammation of the joints, or only with slight and wandering pains; and frequently alternated with dyspepsia, or other symptoms of atony.

III. Podagra (retrograda), with the inflammation of the joints suddenly disappearing, and an atony of the stomach and other parts immediately following.

IV. Podagra (aberrans), with the inflammation of an internal part either preceding or not, and suddenly disappearing.

Genus XXIV. Arthropoſis. Deep, obtuse, and long-continued pains of the joints or muscular parts, frequently following contusions; with either no swelling, or a moderate and diffused one; no phlogosis; pyrexia, at first gentle, afterwards hectic, and at length an impothume.

Order III. EXANTHEMATA. Contagious diseases; affecting a person only once in his life; beginning with fever; after a certain time appear phlogoses, for the most part small and in considerable number, and dispersed over the skin.

Genus XXV. Erysipelas. A synocha of two or three days, for the most part attended with drowsiness, often with a delirium. In some parts of the skin, most frequently the face, appears a phlogosis. The species are,

I. Erysipelas (vesiculosum), with erythema, redness creeping, occupying a large space, and in some parts ending in large blisters.

II. Erysipelas (phlyctanodes), with an erythema formed of a number of papule, chiefly occupying the trunk of the body, ending in phlyctene or small blisters.

The disease is also symptomatic.

Genus XXVI. Peltis. An exceedingly contagious typhus, with the highest debility. On an uncertain day of the disease buboes and carbuncles break forth. It is various in degree, but the species are uncertain.

Genus

Genus XXVII. Variola; a contagious synocha, with vomiting, and pain on pressing the epigastrium. On the third day begins, and on the fifth is finished, the eruption of inflammatory pustules, which suppurate in the space of eight days, and at last go off in crusts; frequently leaving depressed cicatrices or pockpits in the skin. The species are,

I. Variola (discreta), with few, distinct, turpid, pustules, having circular bases; the fever ceasing immediately after the eruption.

II. Variola (confluent), with numerous, confluent, irregularly shaped pustules, flaccid, and little elevated; the fever remaining after the eruption.

Genus XXVIII. Varicella. Synocha; papulae breaking out after a short fever, similar to those of the small-pox, but hardly ever coming to suppuration; after a few days going off in small scales, without leaving any mark.

Genus XXIX. Rubeola. A contagious synocha, with sneezing, epiphora, and dry hoarse cough. On the fourth day, or a little later, break forth small, clustered, and scarcely elevated papulae; after three days going off in very small branny scales.

I. Rubeola (ulgaris), with very small confluent co-rumble papulae, scarcely rising above the skin.

Varying,

1. In the symptoms being more severe, and the course of the disease less regular.

2. In being accompanied with a cynanche.

3. With a putrid diathesis.

II. Rubeola (variolodes), with distinct papulae, raised above the skin.

Genus XXX. Miliaria. Synochus with anxiety, frequent sighing, unrelieved sweat, and a sense of pricking as of pin points in the skin. On an uncertain day of the disease, break out red, small, distinct papulae, spread over the whole body as well as the face; the apices of which, after one or two days, become very small white pustules, remaining for a short time.

Genus XXXI. Scarlatina. A contagious synocha. On the fourth day of the disease the face swells a little; at the same time an universal redness occupies the skin in large spots, at length running together; after three days going off in branny scales; frequently succeeded by an anasarca. The species are,

I. Scarlatina (simplex), not accompanied with cynanche.

II. Scarlatina (cynanchica), with an ulcerous cynanche.

Genus XXXII. Urticaria. A quotidian fever. On the second day of the disease, red spots resembling the stinging of nettles, almost vanishing during the day, but returning in the evening with the fever, and after a few days going off altogether in very small scales.

Genus XXXIII. Pemphigus. A contagious typhus. On the first, second, or third day of the disease, blisters break out in several parts of the body, of the bigness of a bean, remaining for many days, and at last pouring out a thin ichor.

Genus XXXIV. Aphtha. Synochus; the tongue somewhat swelled and of a livid colour, as well as the fauces; eschars first appearing in the fauces, but at length occupying the whole internal parts of the mouth, of a white colour, sometimes distinct, often running to-

gether; quickly growing again when taken off; and remaining for an uncertain time.

The species are, 1. Idiopathic. 2. Symptomatic.

Order IV. HEMORRHAGIE. Pyrexia; with a discharge of blood, without any external violence: the blood drawn from a vein hath the same appearance as in phlegmasiae.

Genus XXXV. Epistaxis. Pain or weight of the head, redness of the face; a discharge of blood from the nose.

I. Idiopathic.

Varying according to the time of life.

1. Epistaxis of young people, with symptoms of an arterial plethora.

2. Epistaxis of old people, with symptoms of a venous plethora.

II. Symptomatic.

1. From internal causes.

2. From external causes.

Genus XXXVI. Haemoptysis. Redness of the cheeks; a sensation of uneasiness, or pain, and sometimes of heat in the breast; difficulty of breathing; tickling of the fauces; either a severe or less violent cough, bringing up florid and frequently frothy blood.

The idiopathic species are,

1. Haemoptysis (plethorica), without any external violence, and without being preceded by any cough or suppression of any customary evacuation.

2. Haemoptysis (violenta), from external violence applied.

3. Haemoptysis (phthisica), after a long-continued cough, with a leanness and debility.

4. Haemoptysis (calculosa), in which some calculous molecules, for the most part of a calcareous nature, are thrown up.

5. Haemoptysis (vicaria), after the suppression of a customary evacuation.

Besides these, there are a number of symptomatic species mentioned by different authors. The consequence of an haemoptysis is, a

Phthisis. A wasting and debility of the body, with a cough, hectic fever, and for the most part a purulent expectoration. The species are,

I. An incipient phthisis, without any expectoration of pus.

II. A confirmed phthisis, with an expectoration of pus.

Both species vary, 1. As to their remote cause. 2. As to the origin of the purulent matter.

Genus XXXVII. Haemorrhoids. Weight and pain of the head; vertigo; pain of the loins; pain of the anus; livid painful tubercles, from which for the most part blood flows out; which sometimes also drops out of the anus, without any apparent tumor. The species are,

1. Haemorrhoids (tumens), external from mariscae.

Varying,

A. Bloody.

B. Mucous.

2. Haemorrhoids (procidens), external from a procidentia ani.

3. Haemorrhoids (fluens), internal, without any swelling, or procidentia ani.

4. Haemorrhoids

4. Hæmorrhoidis (circa), with pain and swelling of the anus, without any profusion of blood.

Genus XXXVIII. Menorrhagia. Pains of the back, belly, and loins, like those of child-birth; an unusually copious flux of the menses or blood from the vagina. The species are,

1. Menorrhagia (rubra), bloody in women neither with child nor in child-birth.

2. Menorrhagia (abortus), bloody in women with child.

3. Menorrhagia (lochialis), bloody in women after delivery.

4. Menorrhagia (vitiorum), bloody from some local disease.

5. Menorrhagia (alba), serous, without any local disease, in women not pregnant.

6. Menorrhagia (Nabothi), serous in women with child.

Order V. PROFLUVIA. Pyrexia, with an increased excretion, naturally not bloody.

Genus XXXIX. Catarrhus. Pyrexia frequently contagious; an increased excretion of mucus, at least efforts to excrete it.

The species are,

1. From cold.

2. From contagion.

Genus XL. Dysenteria. Contagious pyrexia; frequent mucous or bloody stools, while the alvine faeces are for the most part retained; gripes; tenesmus.

Varying,

1. Accompanied with worms.

2. With the excretion of small fleshy or sebaceous bodies.

3. With an intermittent fever.

4. Without blood.

5. With a military fever.

CLASS II. NEUROSES. A preternatural affection of sense and motion, without an idiopathic pyrexia or any local affection.

Order I. COMATA. A diminution of voluntary motion, with sleep, or a deprivation of the senses.

Genus XLI. Apoplexia. Almost all voluntary motion abolished, with sleep more or less profound; the motion of the heart and arteries remaining.

The idiopathic species are,

1. Apoplexia (sanguinea), with symptoms of universal plethora, especially of the head.

2. Apoplexia (serosa), with a leucophlegmatica over the whole body, especially in old people.

3. Apoplexia (hydrocephalica), coming on by degrees; affecting infants, or those below the age of puberty, first with lassitude, a slight fever and pain of the head, then slowness of the pulse, dilatation of the pupil of the eye, and drowsiness.

4. Apoplexia (arrabiliaria), taking place in those of a melancholic constitution.

5. Apoplexia (traumatica), from some external injury mechanically applied to the head.

6. Apoplexia (venenata), from powerful sedatives taken internally or applied externally.

7. Apoplexia (mentalis), from an affection or emotion of the mind.

VOL. XIII. Part I.

8. Apoplexia (cataleptica), the muscles remaining contracted, by external motion of the limbs.

9. Apoplexia (suffocata), from some external suffocating power.

The apoplexy is frequently symptomatic.

1. Of an intermittent fever. 2. Continued fever.

3. Phlegmasia. 4. Exanthema. 5. Hysteria. 6. Epilepsia.

7. Podagra. 8. Worms. 9. Ichuria. 10. Scurvy.

Genus XLII. Paralysis. Only some of the voluntary motions impaired, frequently with sleep.

The idiopathic species are,

1. Paralysis (partialis) of some particular muscles only.

2. Paralysis (hemiplegica) of one side of the body.

Varying according to the constitution of the body.

a. Hemiplegia in a plethoric habit.

b. In a leucophlegmatic habit.

3. Paralysis (paraplegica) of one half of the body taken transversely.

4. Paralysis (venenata) from sedative powers applied either internally or externally.

A symptom either of an Asthenia or Palsy is,

Tremor; an alternate motion of a limb by frequent strokes and intervals.

The species are, 1. Asthenic. 2. Paralytic. 3. Convulsive.

Order II. ADYNAMIA. A diminution of the involuntary motions, whether vital or natural.

Genus XLIII. Syncope; a diminution, or even a total stoppage, of the motion of the heart for a short time.

I. Idiopathic.

1. Syncope (cardiaca), returning frequently without any manifest cause, with violent palpitations of the heart during the intervals.—From a fault of the heart or neighbouring vessels.

2. Syncope (occasionalis) arising from some evident cause.—From an affection of the whole system.

II. Symptomatic; of diseases either of the whole system, or of other parts besides the heart.

Genus XLIV. Dyspepsia. Anorexia, nausea, vomiting, inflation, eructation, rumination, cardialgia, gastrodynia, more or fewer of those symptoms at least concurring; for the most part with a constipation of the belly, and without any other disease either of the stomach itself or of other parts.

I. Idiopathic.

II. Symptomatic.

1. From a disease of the stomach itself.

2. From a disease of other parts, or of the whole body.

Genus XLV. Hypochondriasis. Dyspepsia, with languor, sadness and fear, without any adequate causes, in a melancholy temperament.

Genus XLVI. Chlorosis. Dyspepsia, or a desire of something not used as food; a pale or discoloured complexion; the veins not well filled: a soft tumor of the whole body; asthenia; palpitation; suppression of the menses.

Order III. SPASMI. Irregular motions of the muscles or muscular fibres.

SECT. I. In the animal functions.

Genus XLVII. Tetanus. A spastic rigidity of almost the whole body.

Varying according to the remote cause, as it rises either from something internal, from cold, or from a wound. It varies likewise, from whatever cause it may arise, according to the part of the body affected.

Genus XLVIII. Trismus. A spastic rigidity of the lower jaw.—The species are,

1. Trismus (nascentium), attacking infants under two months old.

2. Trismus (traumaticus), attacking people of all ages either from a wound or cold.

Genus XLIX. Convulsio.—An irregular clonic contraction of the muscles without sleep.

I. Idiopathic.

II. Symptomatic.

Genus L. Chorea, attacking those who have not yet arrived at puberty, most commonly within the 10th or 14th year, with convulsive motions for the most part of one side in attempting the voluntary motion of the hands and arms, resembling the gesticulations of mountebanks; in walking, rather dragging one of their feet than lifting it.

Genus LI. Raphania. A spastic contraction of the joints, with a convulsive agitation, and most violent periodical pain.

Genus LII. Epilepsia. A convulsion of the muscles, with sleep.

The idiopathic species are.

1. Epilepsia (cerebralis), suddenly attacking without any manifest cause, without any sense of uneasiness preceding, excepting perhaps a slight vertigo or dimness of sight.

2. Epilepsia (sympathica), without any manifest cause, but preceded by the sensation of a kind of air rising from a certain part of the body towards the head.

3. Epilepsia (occasionalis), arising from a manifest irritation, and ceasing on the removal of that irritation.

Varying according to the difference of the irritating matter. And thus it may arise,

From injuries of the head; pain; worms; poison; from the repulsion of the itch, or an effusion of any other acrid humour; from crudities in the stomach; from passions of the mind; from an immoderate haemorrhagy; or from debility.

SECT. II. In the vital functions.

In the action of the heart.

Genus LIII. Palpitatio. A violent and irregular motion of the heart.

In the action of the lungs.

Genus LIV. Asthma. A difficulty of breathing returning by intervals, with a sense of straitness in the breast, and a noisy respiration with hissing. In the beginning of the paroxysm there is either no cough at all, or coughing is difficult; but towards the end the cough becomes free, frequently with a copious spitting of mucus.—The idiopathic species are,

1. Asthma (spontaneum), without any manifest cause or other concomitant disease.

2. Asthma (exanthematicum), from the repulsion of the itch or other acrid effusion.

3. Asthma (plethoricum), from the suppression of

some customary sanguineous evacuation, or from a spontaneous plethora.

Genus LV. Dyspnoea. A continual difficulty of breathing, without any sense of straitness, but rather of fullness and infarction in the breast; a frequent cough throughout the whole course of the disease.

The idiopathic species are,

1. Dyspnoea (catarrhalis), with a frequent cough, bringing up plenty of viscid mucus.

2. Dyspnoea (secca), with a cough for the most part dry.

3. Dyspnoea (aërea), increased by the least change of weather.

4. Dyspnoea (terrea), bringing up with the cough an earthy or calculeous matter.

5. Dyspnoea (aquosa), with scanty urine and cede-matous feet; without any fluctuation in the breast, or other signs of an hydrothorax.

6. Dyspnoea (pinguedinosa), in very fat people.

7. Dyspnoea (thoracica), from an injury done to the parts surrounding the thorax, or from some malconformation of them.

8. Dyspnoea (extrinseca), from evident external causes.

The symptomatic species of dyspnoea are consequences,

1. Of diseases of the heart or large vessels.

2. Of a swelling in the abdomen.

3. Of various other diseases.

Genus LVI. Pertussis. A contagious disease; convulsive strangling cough reiterated with noisy inspiration; frequent vomiting.

SECT. III. In the natural functions.

Genus LVII. Pyrosis. A burning pain in the epigastrium, with plenty of aqueous humour, for the most part insipid, but sometimes acrid, belched up.

Genus LVIII. Colica. Pain of the belly, especially twisting round the navel; vomiting; and a constipation.

The idiopathic species are,

1. Colica (spasmodica), with retraction of the navel, and spasms of the abdominal muscles.

Varying, by reason of some symptoms superadded. Hence,

a. Colica, with vomiting of excrements, or of matters injected by the anus.

b. Colica, with inflammation supervening.

2. Colica (piëtonum), preceded by a sense of weight or uneasiness in the belly, especially about the navel; then comes on the colic pain, at first slight and interrupted, chiefly augmented after meals: at length more severe and almost continual, with pains of the arms and back, at last ending in a palsy.

Varying according to the nature of the remote cause; and hence,

a. From metallic poison.

b. From acids taken inwardly.

c. From cold.

d. From a contusion of the back.

3. Colica (stercorea), in people subject to costiveness.

4. Colica (accidentalis), from acrid matter taken inwardly.

5. Colica (meconialis), in new-born children from a retention of the meconium.

6. Colica.

6. Colica (callosa), with a sensation of stricture in some part of the intestines, and frequently of a collection of flatus with some pain; which flatus also passing through the part where the stricture is felt, gradually vanishes; the belly flow, and at last passing only a few liquid faeces.

7. Colica (calculosa), with a fixed hardness in some part of the abdomen, and calculi sometimes passed by the anus.

Genus LIX. Cholera. A vomiting of bilious matter, and likewise a frequent excretion of the same by stool; anxiety; gripes; spasms in the calves of the legs.

1. Cholera (spontanea), arising in a warm season, without any manifest cause.

2. Cholera (accidentalis), from acrid matters taken inwardly.

Genus LX. Diarrhoea. Frequent stools; the disease not infectious; no primary pyrexia.

1. Diarrhoea (eripulosa), in which the excrements are voided in greater quantity than naturally.

2. Diarrhoea (biliosa), in which yellow faeces are voided in great quantity.

3. Diarrhoea (mucosa) in which either from acrid substances taken inwardly, or from cold, especially applied to the feet, a great quantity of mucus is voided.

4. Diarrhoea (calicosa), in which a milky humour of the nature of chyle is discharged by stool.

5. Diarrhoea (lenteria), in which the aliments are discharged with little alteration soon after eating.

6. Diarrhoea (hepatirrhæa), in which a bloody ferrous matter is discharged without pain.

Genus LXI. Diabetes. A chronic profusion of urine, for the most part preternatural, and in immoderate quantity.

1. Diabetes (mellitus), with urine of the smell, colour, and taste of honey.

2. Diabetes (insipidus), with limpid, but not sweet, urine.

Genus LXII. Hysteria. Rumbling of the bowels; a sensation as of a globe turning itself in the belly, ascending to the stomach and fauces, and there threatening suffocation; sleep; convulsions; a great quantity of limpid urine; the mind involuntarily fickle and mutable.

The following are by Sauvages reckoned distinct idiopathic species; but, by Dr Cullen, only varieties of the same species.

A. From a retention of the menses.

B. From a menorrhagia cruenta.

C. From a menorrhagia serosa, or fluor albus.

D. From an obstruction of the viscera.

E. From a fault of the stomach.

F. From too great salacity.

Genus LXIII. Hydrophobia. A dislike and horror at any kind of drink, as occasioning a convulsion of the pharynx; induced, for the most part, by the bite of a mad animal. The species are,

1. Hydrophobia (rabiosa), with a desire of biting the bystanders, occasioned by the bite of a rabid animal.

II. Hydrophobia (simplex), without madness, or any desire of biting.

Order IV. VESANIE. Disorders of the judgement, without any pyrexia or coma.

Genus LXIV. Amentia; an imbecility of judgement, by which people either do not perceive, or do not remember, the relations of things. The species are,

I. Amentia (congenita), continuing from birth.

II. Amentia (senilis), from the diminution of the perceptions and memory through extreme old age.

III. Amentia (acquisita), occurring in people formerly of a sound mind, from evident external causes.

Genus LXV. Melancholia; a partial madness, without dyspepsia.

Varying according to the different subjects concerning which the person raves; and thus it is,

1. With an imagination in the patient concerning his body being in a dangerous condition, from slight causes; or his affairs in a desperate state.

2. With an imagination concerning a prosperous state of affairs.

3. With violent love, without satyrasis or nymphomania.

4. With a superstitious fear of a future state.

5. With an aversion from motion and all the offices of life.

6. With restlessness, and an impatience of any situation whatever.

7. With a weariness of life.

8. With a deception concerning the nature of the patient's species.

Dr Cullen thinks that there is no such disease as that called dæmonomania, and that the diseases mentioned by Sauvages under that title are either,

1. Species of melancholy or mania; or

2. Of some disease by the spectators falsely ascribed to the influence of an evil spirit; or

3. Of a disease entirely feigned; or

4. Of a disease partly true and partly feigned.

Genus LXVI. Mania; universal madness.

1. Mania (mentalis), arising entirely from passions of the mind.

2. Mania (corporea), from an evident disease of the body.

Varying according to the different disease of the body.

3. Mania (obscura), without any passion of mind or evident disease of the body preceding.

The symptomatic species of mania are,

1. Paraphrosyne from poisons.

2. Paraphrosyne from passion.

3. Paraphrosyne febrilis.

Genus LXVII. Oneirodynia. A violent and troublesome imagination in time of sleep.

1. Oneirodynia (activa), exciting to walking and various motions.

2. Oneirodynia (grava), from a sense of some weight incumbent, and pressing on the breast especially.

CLASS III. CACHEXIÆ; a depraved habit of the whole or greatest part of the body, without primary pyrexia or neurosis.

Order I. MARCORES; emaciation of the whole body.

Genus LXVIII. Tabes. Leanness, asthenia, hectic fever. The species are,

1. Tabes (parulenta), from an external or internal ulcer, or from a vomica.

Varying in its situation: hence,

2. Tabes (scrophulosa), in scrofulous constitutions.

3. Tabes (venenata), from poison taken inwardly.

Genus LXIX. Atrophia. Leanness and asthenia, without hectic fever. The species are,

1. Atrophia (inanitorum), from too great evacuation.

2. Atrophia (famelicorum), from a want of nourishment.

3. Atrophia (cacochymica), from corrupted nourishment.

4. Atrophia (debilitum), from the function of nutrition being depraved, without any extraordinary evacuation or cacochymia having preceded.

Order II. INTUMESCENTIÆ. An external swelling of the whole or greatest part of the body.

Secl. I. Adiposæ.

Genus LXX. Polysarcia; a troublesome swelling of the body from fat.

Secl. II. Flatuosæ.

Genus LXXI. Pneumatosis; a tense elastic swelling of the body, crackling under the hand. The species are,

1. Pneumatosis (spontanea), without any manifest cause.

2. Pneumatosis (traumatica), from a wound in the breast.

3. Pneumatosis (venenata), from poison injected or applied.

4. Pneumatosis (hysterica), with hysteria.

Genus LXXII. Tympanites; a tense, elastic, sonorous swelling of the abdomen; costiveness; a decay of the other parts. The species are,

1. Tympanites (intestinalis), with a tumor of the abdomen frequently unequal, and with a frequent evacuation of air relieving the tension and pain.

2. Tympanites (abdominalis), with a more evident noise, a more equable tumor, and a less frequent emission of flatus, which also gives less relief.

Genus LXXIII. Physometra; a light elastic swelling in the epigastrium, having the figure and situation of the uterus.

Secl. III. Aquosæ or Dropsæ.

Genus LXXIV. Anasarca. A soft, inelastic swelling of the whole body, or some part of it. The species are,

1. Anasarca (serosa), from a retention of serum on account of the suppression of the usual evacuations, or from an increase of the serum on account of too great a quantity of water taken inwardly.

2. Anasarca (oppilata), from a compression of the veins.

3. Anasarca (exanthematica), arising after exanthemata, especially succeeding erysipelas.

4. Anasarca (anæmia), from the thinness of the blood produced by hemorrhagy.

5. Anasarca (debilitum), in weak people after long diseases, or from other causes.

Genus LXXV. Hydrocephalus. A soft inelastic swelling of the head, with the sutures of the cranium opened.

Genus LXXVI. Hydrorachitis. A soft, slender tumor above the vertebrae of the loins; the vertebrae gaping from each other.

Genus LXXVII. Hydrothorax. Dyspnoea; paleness of the face; oedematous swellings of the feet; scanty urine; difficult lying in a recumbent posture; a sudden and spontaneous bursting out of sleep, with palpitation; water fluctuating in the breast.

Genus LXXVIII. Ascites. A tense, scarce elastic, but fluctuating swelling of the abdomen. The species are,

1. Ascites (abdominalis), with an equal swelling of the whole abdomen, and with a fluctuation sufficiently evident.

Varying according to the cause.

A. From an obstruction of the viscera.

B. From debility.

C. From a thinness of the blood.

2. Ascites (saecatus), with a swelling of the abdomen, in the beginning at least, partial, and with a less evident fluctuation.

Genus LXXIX. Hydrometra. A swelling of the hypogastrium in women, gradually increasing, keeping the shape of the uterus, yielding to pressure, and fluctuating; without ischuria or pregnancy.

Genus LXXX. Hydrocele. A swelling of the scrotum, not painful; increasing by degrees, soft, fluctuating, and pellucid.

Secl. IV. Solidæ.

Genus LXXXI. Physconia. A swelling chiefly occupying a certain part of the abdomen, gradually increasing, and neither sonorous nor fluctuating. The species are,

Physconia hepatica.

Physconia splenica.

Physconia renalis.

Physconia uterina.

Physconia ab ovario.

Physconia mesenterica.

Physconia intestinalis.

Physconia omentalis.

Physconia polyplachna.

Physconia visceralis.

Physconia externa lumbalis.

Physconia externa schirrhodea.

Physconia externa hydatidosa.

Physconia ab adipi subcutaneo.

Physconia ab excrementis.

Genus LXXXII. Rachitis. A large head, swelling most in the fore part, the ribs depressed; abdomen swelled, with a decay of the other parts.

Varying,

1. Simple, without any other disease.

2. Joined with other diseases.

Order III. IMPETIGINES. Cachexies chiefly deforming the skin and external parts of the body.

Genus

Genus LXXXIII. Serophula. Swellings of the conglobate glands, especially in the neck; swelling of the upper lip and of the nose; the face florid, skin thin, abdomen swelled. The species are,

1. Serophula (vulgaris), simple, external, and permanent.

2. Serophula (mesenterica), simple, internal, with paleness of the face, want of appetite, swelling of the abdomen, and unusual fetor of the excrements.

3. Serophula (fugax), most simple, appearing only about the neck; for the most part proceeding from the resorption of the matter of ulcers in the head.

4. Serophula (Americana), joined with the yaws.

Genus LXXXIV. Syphilis. A contagious disease; ulcers of the tonsils, after impure venery, and a disorder of the genitals; clustered pimples of the skin, especially about the margin of the hair, ending in crusts and crusty ulcers; pains of the bones; exostoses.

Genus LXXXV. Scorbutus; in cold countries, attacking after putrescent diet, especially such as is salt and of the animal kind, where no supply of fresh vegetables is to be had; ashenia; stomacace; spots of different colours on the skin, for the most part livid, and appearing chiefly among the roots of the hair.

Varying in degree.

a. Scorbutus incipiens.

b. Scorbutus crescens.

c. Scorbutus inveteratus.

Varying also in symptoms.

d. Scorbutus lividus.

e. Scorbutus petechialis.

f. Scorbutus pallidus.

g. Scorbutus ruber.

h. Scorbutus calidus.

Genus LXXXVI. Elephantiasis; a contagious disease; thick, wrinkled, rough, unctuous skin, destitute of hairs, anaesthesia in the extremities, the face deformed with pimples, the voice hoarse and nasal.

Genus LXXXVII. Lepre; the skin rough, with white, branny, and chopped eschars, sometimes moist beneath, with itching.

Genus LXXXVIII. Framboesia; swellings resembling fungi, or the fruit of the mulberry or raspberry, growing on various parts of the skin.

Genus LXXXIX. Trichoma; a contagious disease; the hairs thicker than usual, and twisted into inextricable knots and cords.

Genus XC. Icterus; yellowness of the skin and eyes; white feces; urine of a dark red, tinging what is put into it of a yellow colour.

The idiopathic species are,

1. Icterus (calculosus), with acute pain in the epigastric region, increasing after meals; biliary concretions voided by stool.

2. Icterus (spasmodicus), without pain after spasmodic diseases and passions of the mind.

3. Icterus (hepaticus), without pain, after diseases of the liver.

4. Icterus (gravidarum), arising during the time of pregnancy, and going off after delivery.

5. Icterus (infantum), coming on in infants a few days after birth.

CLASS IV. LOCALES. An affection of some part, but not of the whole body.

Order I. DYSESTHESIA. The senses depraved or destroyed, from a disease of the external organs.

Genus XCI. Caligo. The sight impaired or totally destroyed, on account of some opaque substance interposed between the objects and the retina, inherent in the eye itself or the eyelids. The species are,

1. Caligo (lentic), occasioned by an opaque spot behind the pupil.

2. Caligo (cornea), from an opacity of the cornea.

3. Caligo (pupillae), from an obstruction of the pupil.

Varying according to the different causes from which it proceeds.

4. Caligo (humorum), from a disease or defect of the aqueous humour.

Varying according to the different state of the humour.

5. Caligo (palpebrarum) from a disease inherent in the eyelids.

Varying according to the nature of the disease in the eyelids.

Genus XCII. Amaurosis. The sight diminished, or totally abolished, without any evident disease of the eye; the pupil for the most part remaining dilated and immovable. The species are,

1. Amaurosis (compressionis), after the causes and attended with the symptoms of congestion in the brain.

Varying according to the nature of the remote cause.

2. Amaurosis (atonica), after the causes and accompanied with symptoms of debility.

3. Amaurosis (spasmodica), after the causes and with the signs of spasm.

4. Amaurosis (venenata), from poison taken into the body or applied outwardly to it.

Genus XCIII. Dyopia. A depravation of the sight, so that objects cannot be distinctly perceived, except at a certain distance, and in a certain situation.

The species are,

1. Dyopia (tenebrarum), in which objects are not seen unless they be placed in a strong light.

2. Dyopia (luminis), in which objects are not distinctly seen unless by a weak light.

3. Dyopia (distitorum), in which distant objects are not perceived.

4. Dyopia (proximorum), in which the nearest objects are not perceived.

5. Dyopia (lateralis), in which objects are not perceived unless placed in an oblique posture.

Genus XCIV. Pseudoblepsis; when the sight is diseased in such a manner that the person imagines he sees things which really do not exist, or sees things which do exist after some other manner than they really are. The species are,

1. Pseudoblepsis (imaginaria), in which the person imagines he sees things which really do not exist.

Varying according to the nature of the imagination.

2. Pseudoblepsis (mutans), in which objects really existing appear somehow changed.

Varying

Varying according to the change perceived in the objects, and according to the remote cause.

Genus XCV. Dylecœa. A diminution or total abolition of the sense of hearing. The species are,

1. Dylecœa (organica), from a disease in the organs transmitting sounds to the internal ear.

Varying according to the nature of the disease and of the part affected.

2. Dylecœa (atonica), without any evident disease of the organs transmitting the sounds.

Varying according to the nature of the cause.

Genus XCVI. Paracusis; a depravation of the hearing. The species are,

1. Paracusis (imperfecta), in which though sounds coming from external objects are heard, yet it is neither distinctly nor in the usual manner.

Varying,

a, With a dulness of hearing.

b, With a hearing too acute and sensible.

c, When a single external sound is doubled by some internal causes.

d, When the sounds which a person desires to hear are not perceived, unless some other violent sound is raised at the same time.

2. Paracusis (imaginaria), in which sounds not existing externally are excited from internal causes.

Varying according to the nature of the sound perceived, and according to the nature of the remote cause.

Genus XCVII. Anosmia; a diminution or abolition of the sense of smell. The species are,

1. Anosmia (organica), from a disease in the membrane lining the internal parts of the nostrils.

Varying according to the nature of the disease.

2. Anosmia (atonica), without any evident disease of the membrane of the nose.

Genus XCVIII. Agheustia; a diminution or abolition of the sense of taste.

1. Agheustia (organica), from a disease in the membrane of the tongue, keeping off from the nerves those substances which ought to produce taste.

2. Agheustia (atonica), without any evident disease of the tongue.

Genus XCIX. Anæsthesia; a diminution or abolition of the sense of feeling. The species from Sauvages, adopted by Dr Cullen, are,

1. Anæsthesia à spina bifida.

2. Anæsthesia plethorica.

3. Anæsthesia nascentium.

4. Anæsthesia melancholica.

Order II. DYSOREXIE; error or defect of appetite.

Secl. I. Appetitus erronei.

Genus C. Bulimia; a desire for food in greater quantities than can be digested.

The idiopathic species are,

1. Bulimia (helluonum), an unusual appetite for food, without any disease of the stomach.

2. Bulimia (syncopalis), a frequent desire of meat, on account of a sensation of hunger threatening syncope.

3. Bulimia (emetica), an appetite for a great quantity of meat, which is thrown up immediately after it is taken.

Genus CI. Polydipsia; an appetite for an unusual quantity of drink.

The polydipsia is almost always symptomatic, and varies only according to the nature of the disease which accompanies it.

Genus CII. Pica; a desire of swallowing substances not used as food.

Genus CIII. Satyriasis; an unbounded desire of venery in men. The species are,

1. Satyriasis (juvenilis), an unbounded desire of venery, the body at the same time being little disordered.

2. Satyriasis (surens), a vehement desire of venery with a great disorder of the body at the same time.

Genus CIV. Nymphomania; an unbounded desire of venery in women.

Varying in degree.

Genus CV. Noctalgia; a violent desire in those who are absent from their country of revisiting it.

1. Noctalgia (simplex), without any other disease.

2. Noctalgia (complicata), accompanied with other diseases.

Secl. II. Appetitus deficientes.

Genus CVI. Anorexia. Want of appetite for food. Always symptomatic.

1. Anorexia (humoralis), from some humour loading the stomach.

2. Anorexia (atonica), from the tone of the fibres of the stomach being lost.

Genus CVII. Adipsia; a want of desire for drink. Always a symptom of some disease affecting the sensorium commune.

Genus CVIII. Anaphrodisia; want of desire for, or impotence to, venery.

The true species are,

1. Anaphrodisia paralytica.

2. Anaphrodisia gonorrhœica.

The false ones are,

1. Anaphrodisia à mariscis.

2. Anaphrodisia ab urethre vitio.

Order III. DYSGINESIE. An impediment, or depravation of motion from a disorder of the organs.

Genus CIX. Aphonia; a total suppression of voice without coma or syncope. The species are,

1. Aphonia (gutturalis), from the fauces or glottis being swelled.

2. Aphonia (trachealis), from a compression of the trachea.

3. Aphonia (atonica), from the nerves of the larynx being cut.

Genus CX. Mutitas; a want of power to pronounce words. The species are,

1. Mutitas (organica), from the tongue being cut out or destroyed.

2. Mutitas (atonica), from injuries done to the nerves of the tongue.

3. Mutitas (surdorum), from people being born deaf, or the hearing being destroyed during childhood.

Genus CXI. Paraphonia; a depraved sound of the voice. The species are,

1. Paraphonia (puberum) in which, about the time of puberty, the voice from being acute and sweet, becomes more grave and harsh.

2. Paraphonia.

2. Paraphonia (rauca), in which, by reason of the dryness or flaccid tumor of the fauces, the voice becomes rough and hoarse.

3. Paraphonia (resonans), in which, by reason of an obstruction in the nostrils, the voice becomes hoarse, with a sound hissing through the nostrils.

4. Paraphonia (palatina), in which, on account of a defect or division of the uvula, for the most part with an hare-lip, the voice becomes obscure, hoarse, and unpleasant.

5. Paraphonia (elongens), in which the voice is changed to one acute, shrill, and small.

6. Paraphonia (comatosa), in which, from a relaxation of the velum palati and glottis, a sound is produced during inspiration.

Genus CXII. Pselismus; a defect in the articulation of words. The species are,

1. Pselismus (hæstans), in which the words, especially the first ones of a discourse, are not easily pronounced, and not without a frequent repetition of the first syllable.

2. Pselismus (ringens), in which the sound of the letter R is always aspirated, and, as it were, doubled.

3. Pselismus (lallans), in which the sound of the letter L becomes more liquid, or is pronounced instead of R.

4. Pselismus (emolliens), in which the hard letters are changed into the softer ones, and thus the letter S is much used.

5. Pselismus (balbutiens), in which, by reason of the tongue being large, or swelled, the labial letters are better heard, and often pronounced instead of others.

6. Pselismus (acheilos), in which the labial letters cannot be pronounced at all, or with difficulty.

7. Pselismus (lagostomatum), in which, on account of the division of the palate, the guttural letters are less perfectly pronounced.

Genus CXIII. Strabismus; the optic axes of the eyes not converging. The species are,

1. Strabismus (habitualis), from a bad custom of using only one eye.

2. Strabismus (concomitans), from the greater debility or mobility of one eye above the other; so that both eyes cannot be conveniently used.

3. Strabismus (necessarius), from a change in the situation or shape of the parts of the eye.

Genus CXIV. Dysphagia; impeded deglutition, without phlegm or the respiration being affected.

Genus CXV. Contractura; a long-continued and rigid contraction of one or more limbs. The species are,

1. Contractura (primaria), from the muscles becoming contracted and rigid.

a, From the muscles becoming rigid by inflammation.

b, From muscles becoming rigid by spasm.

c, From muscles contracted by reason of their antagonists having become paralytic.

d, From muscles contracted by an irritating acrimony.

2. Contractura (articularis), from stiff joints.

Order IV. APOCENOSIS. A flux either of blood or some other humour flowing more plentifully than usual, without pyrexia, or an increased impulse of fluids.

Genus CXVI. Profusio; a flux of blood.

Genus CXVII. Ehidrosis; a preternatural evacuation of sweat.

Symptomatic ehidroses vary according to the nature of the diseases which they accompany, the different nature of the sweat itself, and sometimes the different parts of the body which sweat most.

Genus CXVIII. Epiphora; a flux of the lachrymal humour.

Genus CXIX. Ptyalismus; a flux of saliva.

Genus CXX. Enuresis; an involuntary flux of urine without pain. The species are,

1. Enuresis (atonica), after diseases injuring the sphincter of the bladder.

2. Enuresis (irritata), from a compression or irritation of the bladder.

Genus CXXI. Gonorrhœa; a preternatural flux of humour from the urethra in men, with or without a desire of venery. The species are,

1. Gonorrhœa (para), in which, without any impure venery having preceded, a fluid resembling pus, without dysuria or propensity to venery, flows from the urethra.

2. Gonorrhœa (impura), in which, after impure venery, a fluid like pus flows from the urethra with dysuria. The consequence of this is,

Gonorrhœa (mucosa), in which after an impure gonorrhœa, a mucous humour flows from the urethra with little or no dysuria.

3. Gonorrhœa (laxorum), in which an humour for the most part pellucid, without any erection of the penis, but with a propensity to venery, flows from the urethra while the person is awake.

4. Gonorrhœa (dormientium), in which the seminal liquor is thrown out, with erection and desire of venery, in those who are asleep and have lascivious dreams.

Order V. ERISCHESSES; suppressions of evacuations.

Genus CXXII. Obliptatio; the stools either suppressed, or slower than usual. The species are,

1. Obliptatio (debilium), in lax, weak, and for the most part dyspeptic persons.

2. Obliptatio (rigidorum), in people whose fibres are rigid, and frequently of an hypochondriac disposition.

3. Obliptatio (obstructorum), with symptoms of the colica 1st, 2d, 4th, and 7th, above-mentioned.

Genus CXXIII. Ischuria; an absolute suppression of urine. The species are,

1. Ischuria (renalis), coming after a disease of the kidneys, with pain, or troublesome sense of weight in the region of the kidneys, and without any swelling of the hypogastrium, or desire of making water.

2. Ischuria (ureterica), coming after a disease of the kidneys, with a sense of pain or uneasiness in some part of the ureter, and without any tumor of the hypogastrium, or desire of making water.

3. Ischuria (vesicalis), with a swelling of the hypogastrium, pain at the neck of the bladder, and a frequent stimulus to make water.

4. Ischuria (urethralis), with a swelling of the hypogastrium, frequent stimulus to make water, and pain in some part of the urethra.

All these species are subdivided into many varieties, according to their different causes.

Genus CXXIV. Dysuria; a painful, and somehow impeded emission of urine. The species are,

1. Dysuria.

1. Dysuria (ardens), with heat of urine, without any manifest disorder of the bladder.
2. Dysuria (spasmodica), from a spasm communicated from the other parts to the bladder.

3. Dysuria (compressiva), from the neighbouring parts pressing upon the bladder.

4. Dysuria (phlogistica), from an inflammation of the neighbouring parts.

5. Dysuria (irritata), with signs of a stone in the bladder.

6. Dysuria (mucosa), with a copious excretion of mucus.

Genus CXXV. Dyspermatismus; a flow, impeded, and insufficient emission of semen in the venereal act. The species are,

1. Dyspermatismus (urethralis), from diseases of the urethra.

2. Dyspermatismus (nodosus), from knots on the corpora cavernosa penis.

3. Dyspermatismus (praeputialis), from too narrow an orifice of the prepuce.

4. Dyspermatismus (mucosus), from mucus infesting the urethra.

5. Dyspermatismus (hypertonicus), from too strong an erection of the penis.

6. Dyspermatismus (epilepticus), from a spasmodic epilepsy happening during the time of coition.

7. Dyspermatismus (apraclodes), from an imbecility of the parts of generation.

8. Dyspermatismus (refusus), in which there is no emission of semen, because it returns from the urethra into the bladder.

Genus CXXVI. Amenorrhoea. The menses either flowing more sparingly than usual, or not at all, at their usual time, without pregnancy. The species are,

1. Amenorrhoea (emanfionis), in those arrived at puberty, in whom, after the usual time, the menses have not yet made their appearance, and many different morbid affections have taken place.

2. Amenorrhoea (suspensionis), in adults, in whom the menses which had already begun to flow are suppressed.

3. Amenorrhoea (difficilis), in which the menses flow sparingly, and with difficulty.

Order VI. TUMORES; an increased magnitude of any part without phlogosis.

Genus CXXVII. Aneurisma; a soft tumor, with pulsation, above an artery.

Genus CXXVIII. Varix; a soft tumor, without pulsation, above a vein.

Genus CXXIX. Ecchymoma; a diffused, little eminent, and livid tumor.

Genus CXXX. Schirrus; a hard tumor of some part, generally of a gland, without pain, and difficultly brought to suppuration.

Genus CXXXI. Cancer; a painful tumor of a schirrous nature, and degenerating into an ill-conditioned ulcer.

Genus CXXXII. Bubo; a suppurating tumor of a conglomerate gland.

Genus CXXXIII. Sarcoma; a soft swelling, without pain.

Genus CXXXIV. Verruca; a harder scabrous swelling.

Genus CXXXV. Clavus; a hard, lamellated thickness of the skin.

Genus CXXXVI. Lupia. A moveable, soft tumor below the skin, without pain.

Genus CXXXVII. Ganglion. A hard moveable swelling, adhering to a tendon.

Genus CXXXVIII. Hydatis; a cuticular vesicle filled with aqueous humour.

Genus CXXXIX. Hydarthrus; a most painful swelling of the joints, chiefly of the knee, at first scarce elevated, of the same colour with the skin, diminishing the mobility.

Genus CXI. Exostosis; a hard tumor adhering to a bone.

Order VII. ECTOPIÆ; tumors occasioned by the removal of some part out of its proper situation.

Genus CXLI. Hernia; an ectopia of a soft part as yet covered with the skin and other integuments.

Genus CXLII. Prolapsus; a bare ectopia of some soft part.

Genus CXLIII. Luxatio; the removal of a bone from its place in the joints.

Order VIII. DIALYSES. A solution of continuity; manifest to the sight or touch.

Genus CXLIV. Vulnus; a recent and bloody solution of the unity of some soft part by the motion of some hard body.

Genus CXLV. Ulcus. A purulent or ichorous solution of a soft part.

Genus CXLVI. Herpes; a great number of phlyctenæ or small ulcers, gathering in clusters, creeping, and obflinate.

Genus CXLVII. Timea; small ulcers among the roots of the hair of the head, pouring out a fluid which changes to a white friable scurf.

Genus CXLVIII. Pfora. Itchy pustules and little ulcers of an infectious nature, chiefly infecting the hands.

Genus CXLIX. Fractura; bones broken into large fragments.

Genus CL. Caries; an ulceration of a bone.

HAVING thus presented to our readers Dr Cullen's general systematic view of all the diseases to which the human body is subjected, we come next to give a more particular account of the more important affections, treating of them in the order which Dr Cullen has arranged them.

CLASS I. PYREXIÆ, or the Febrile Diseases.

ORDER I. FEBRES, Or FEVERS strictly so called.

Sautrag. Clafs II. Vog. Clafs I. Sagar. Clafs XII. Morbi Febriles Critici, Lin. Clafs II.

SECT. I. INTERMITTENTS.

Intermittentes of many authors; Savo. Clafs II. Order III. Lin. Clafs II. Order II. Vog. Clafs I. Order I. Sag. Clafs XII. Order III.

1. Description. This disease, in its most regular form, consists of repeated paroxysms, returning every second day, the patient during the intermediate period enjoying apparently a state of good health. This is the most common form of ague, as it is commonly called in Britain. Each paroxysm consists of three parts, the cold, the hot, and the sweating stages. The paroxysm commonly begins with a remarkable shivering, increasing frequently to a convulsive shaking of the limbs. The extremities are always cold, sometimes remarkably so. The cold for the most part is first perceived about the lumbar regions, from thence ascending along the spine it turns towards the pit of the stomach. Sometimes it begins in the first joint of the fingers and tip of the nose. Sometimes it attacks only a particular part of the body, as one of the arms, the side of the head, &c. This cold is often preceded by a heavy and sleepy torpor, languor, and lassitude, which we are partly to ascribe to real weakness and partly to mere languor. To these symptoms succeed yawning and stretching; after which the cold comes on as above described, not unfrequently with a pain of the back, and a troublesome sensation of tension in the precordia and hypochondria. To this succeed nausea and vomiting: and the more genuine the disease, the more certainly does the vomiting come on; by which a great deal of tough mucous matter, and sometimes bilious stuff or indigested food, is evacuated during the first paroxysm. In some there is only a violent straining to vomit, without bringing up any thing: sometimes, instead of these symptoms, a diarrhoea occurs; and this chiefly in weak, phlegmatic, and aged people, or where an indigested mucous faburra has long remained in the primæ visc.

When these symptoms have continued for an hour or two, the cold begins to go off, and is succeeded by a lassitude, languor, and flaccidity of the whole body, but chiefly in the limbs, with an uneasy soreness as if the parts had been bruised; excepting in those cases where the nausea continues for a longer time. After this languor, a heat comes on, the increase of which is generally slow, but sometimes otherwise, with pain of the head, thirst, and bitterness in the mouth. The pulse is quick and unequal; sometimes beating 130 strokes in a minute. As soon as this heat has abated, a little moisture or sweat is observed to break forth; not always indeed in the first, but always in the succeeding paroxysms, and the urine lets fall a quantity of lateritious sediment. The whole paroxysm is seldom over in less than six hours, more frequently eight, and in violent cases it extends to 12 hours; but that which exceeds 12 hours is to be reckoned a spurious kind, and approaching to the nature of conti-

nued fevers. All these symptoms, however, are repeated every second day, in such a manner that the patient is quite free from fever for at least 24 hours. The paroxysms return much about the same time, though sometimes a little sooner or later.

2. Causes of this disease, and persons subject to it. The genuine tertian attacks men rather than women, young people rather than old: the latter being more subject to anomalous tertians. It likewise seizes the lusty and active, rather than the lazy and indolent. Those, however, who are apt to nauseate their meat fall easily into a tertian fever. The cause, according to Dr Cullen, is the miasma of marshes, and that only. Other physicians have taken in many more causes, almost every thing indeed which debilitates the body: but the Doctor denies that any of these, though they may dispose the body for receiving the disease, or may augment it, can by any means produce it without the concurrence of the marsh miasma; and it cannot be denied, that it is a disease almost peculiar to marshy situations. Thus we find it very frequent in the fenny counties of Britain, although in other parts of this island it may be considered as a very rare disease; nay, in many it may perhaps be said that it never occurs. And it is also well known that intermitments have almost entirely disappeared in many parts of Britain, in which they were very common before the marshes of these places were drained.

3. Prognosis. The genuine simple tertian, unless improper medicines be administered, is generally very easily cured; nay, the vulgar reckon it of such a salutary nature, that after it they imagine a person becomes more strong and healthy than before. Hippocrates has observed, that these fevers terminate of their own accord after seven or nine paroxysms. Juncker tells us, that it frequently terminates before the seventh paroxysm, but rarely before the fourth. He also denies that any thing critical is to be observed in its going off; but in this he differs from Vogel, who tells us, that the urine, for some days after the fever is quite gone off, appears slimy, and lets fall much sediment. The latter also informs us, that besides the common crisis by sweat and urine, the tertian hath one peculiar to itself, namely, dry scabby ulcers breaking out upon the lips. These sometimes appear about the third or fourth paroxysm; and then we may venture to foretell that the disease will go off spontaneously after the seventh. But though the disease be never dangerous, in cold climates at least, when properly treated; yet the improper use of hot and stimulating medicines may change it into a continued fever, more or less dangerous according to the quantity of medicines taken and the constitution of the patient; in which case the prognosis must be regulated by the particular symptoms which occur. In warm climates, however, the tertian fever may be considered as a much more alarming disease; and unless the most powerful remedies be employed, the patient is in danger of falling a victim to every paroxysm.

A variety of theories have been proposed for explaining the phenomena of this affection; but we may assert, that every thing hitherto said upon the subject is highly unsatisfactory. For although it be now almost universally admitted, that this fever does arise from the effluvia of marshes, yet in what manner the

action of those effluvia induces fever, and particularly why this fever returns in regular paroxysms, are questions with regard to which we are still totally in the dark. Dr Cullen, with much ingenuity, attempted to prove, that the remote causes of this, as well as of other fevers, operate by inducing a state of debility; that this debility gives rise to spasms, which induces increased action, from which the phenomena are to be explained. But this theory is liable to no less numerous and unrefutable objections than the exploded hypotheses which had before been proposed by others. For it is an undeniable truth, that debility often exists, even to the highest imaginable degree, without any fever; nay, that when fever has taken place, the debility is often much greater after it is entirely gone than at any period during its course. When spasms and increased action do take place, we have no reason to view them in any other light than merely as symptoms of the disease; and while they are often absent in this affection, they frequently occur in others where the sickness, anxiety, and other characterizing symptoms of fever are entirely absent: and upon the whole, a probable or rational theory of intermittents, as well as of other fevers, still remains to be discovered.

Cure. The treatment of all genuine intermittents, whether tertians, quotidians, or quartans, being almost precisely the same, the general method of cure applicable to all of them may be here given, to which it will be easy to refer when we come to describe the others.

In treating intermittent fevers, physicians have formed indications of cure according to their different theories. The followers of Boerhaave, Stahl, &c. who imagined that the disease proceeded from a lentor or other disorders in the blood, always thought it necessary to correct and evacuate these peccant humours by emetics and purgatives, before they attempted to stop the disease by the Peruvian bark or any other medicine. Cinchona indeed, among some, seems to be held in very little estimation: since Vogel affirms, that this medicine, instead of deserving to have the preference of all other febrifuge medicines, ought rather to be ranked among the lowest of the whole; and for this reason he ascribes the cures, said to be obtained by the use of the Peruvian bark, entirely to nature.

According to Dr Cullen, the indications of cure in intermittent fevers may be reduced to the following:

1. 1. In the time of intermission, to prevent the return of the paroxysm.
2. 2. In the time of paroxysms, to conduct these in such a manner as to obtain a final solution of the disease.
3. 3. To take off certain circumstances which might prevent the fulfilling of the two first indications.

The first indication may be answered in two ways:

1. 1. By increasing the action of the heart and arteries some time before the period of accession, and supporting that increased action till the period of accession be over, and thus preventing the recurrence of that atony and spasm of the extreme vessels, which he thinks give occasion to the recurrence of paroxysms.
2. 2. By supporting the tone of the vessels, and thereby preventing atony and the consequent spasm, without increasing the action of the heart and arteries, the recurrence of paroxysms may be prevented.

The action of the heart and arteries may be increas-

ed, 1. By various stimulant remedies internally given, or externally applied, and that without exciting sweat. 2. By the same remedies, or by others, managed in such a manner as to excite sweating, and to support that sweating till the period of accession be for some time past. 3. By emetics, supporting for the same time the tone and action of the extreme vessels.

The tone of the extreme vessels may be supported without increasing the action of the heart and arteries, by various tonic medicines; as, 1. Astringents alone. 2. Bitters alone. 3. Astringents and bitters conjoined. 4. Astringents and aromatics conjoined. 5. Certain metallic tonics; and, 6. Opiates. A good deal of exercise, and as full a diet as the condition of the patient's appetite and digestion allow, will be proper during the time of intermission, and may be considered as belonging to this head. Although many particulars in this plan of cure are deduced from Dr Cullen's theory, yet there can be no doubt that the object chiefly to be aimed at is to employ such remedies during the intermission as will prevent a recurrence of the paroxysm. Of all the remedies hitherto employed with this intention, the most celebrated, perhaps the most certainly effectual, is the Peruvian bark; or, to speak more properly, the bark of the Cinchona officinalis of Linnaeus. But it must be observed, that good effects are only to be expected from this medicine when employed in substance and in large quantity; and for its use the following rules or observations have been given:

1. The cinchona may with safety be employed at any period of intermitting fevers, providing that at the same time there be neither a phlogistic diathesis prevailing in the system, nor any considerable or fixed congestion present in the abdominal viscera.

2. The proper time for exhibiting the cinchona in intermitting fevers is during the time of intermission, and it is to be abstained from in the time of paroxysms.

3. In the case of genuine intermittents, while a due quantity of cinchona is employed, the exhibition of it ought to be brought as near to the time of accession as the condition of the patient's stomach will allow.

4. In all cases of intermittents, it is not sufficient that the recurrence of paroxysms be stopped for once by the use of the cinchona; a relapse is commonly to be expected, and should be prevented by the exhibition of the cinchona repeated at proper intervals.

The advantage of administering the medicine as early as possible, was fully ascertained by Dr Lind in the years 1765, 1766, and 1767, during an uncommon prevalence of intermittents. When the disease was stopped by the cinchona immediately after the first or second fit, which was the case with 200 of the Doctor's patients as well as himself, neither a jaundice nor dropsy ensued; whereas, when the cinchona could not be administered, on account of the imperfect intermission of the fever, or when the patient had neglected to take it, either a dropsy, jaundice, or constant headache, were the certain consequences, and the violence of the disease was in proportion to the number of the preceding fits, or to the continuance of the fever. By every paroxysm the dropical swellings were visibly increased, and the colour of the skin rendered of a deeper yellow. When the fever continued a few days without intermission, the belly and legs generally swelled; a violent headache, likewise, and vertigo, for the most part distressed the patient;

Fevers. patient; so that some, even after the fever had left them, were not able to walk across their chamber for a fortnight or three weeks. When the returns of the fever were regular and even, but slight, four or five fits of a simple tertian were sometimes followed by the most dangerous symptoms; especially in the year 1765, when these fevers raged with the greatest violence. It, as frequently happened, a dropical patient relapsed into the intermittent, there was an absolute necessity for putting an immediate stop to it by the cinchona; and in upwards of 70 such patients, Dr Lind observed the most beneficial effects to accrue from this practice. Without regard to a cough, or any other chronic indisposition, he ordered it to be given in large doses.

Cinchona has been often observed to fail in removing intermitting, from not continuing the use of it for a sufficient length of time, from administering it in too small a dose, or from giving it in an improper form. It was a prevailing opinion, that an ounce, or an ounce and a half, taken during one intermission, was sufficient to prevent the return of another paroxysm. But this is not always the case; for a severe fit will often attack a patient who has taken such a quantity. When this happens, the patient ought to persevere during the following intermissions, with an increase of the dose, till five or six ounces at least have been taken. The medicine also ought not to be omitted as soon as one fit is stopped, but should be continued in a smaller dose, and after longer intervals, for at least ten days or a fortnight. Even for several months after the disease is entirely removed, it would be advisable to take a little occasionally in damp weather, or during an easterly wind, to prevent a relapse. Where the intervals between the fits are short, as in quotidian and double tertians, from one to two drams of it ought to be taken every two or three hours.

The form in which this medicine is administered is of some consequence. Mucilages and syrups have been recommended to conceal the taste of it; but, from various experiments, Dr Lind found nothing more effectual for this purpose than small beer or milk, especially the latter. A dram of bark mixed with two ounces of milk, and quickly drank, may easily be taken by a person of the most delicate taste, and by washing the mouth afterwards with milk, there will not remain the least flavour of the bark; but if the mixture be not drank immediately, the bark will impart a bitter taste to the milk. This medicine is commonly given in electuaries or boluses; but Dr Lind observes, that in these forms it proves much less efficacious than when administered in juleps or draughts, with the plentiful addition of wine or spirits. He has remarked, that six drams of powdered bark, given in a julep, consisting of one fourth or one third of brandy, is as effectual as an ounce of the powder in the form of an electuary, and proves less disagreeable to the stomach. For patients unaccustomed to wine or spirits, each draught should be warmed with spiritus ammonice, or tinct. myrrh. by both of which the efficacy of the bark is he thinks increased. Dr Lind is also fully convinced that wine or spirits improve the virtues of the bark much more than elixir vitrioli, tinct. rosar. or such other medicines as have been recommended by different physicians.

For those who nauseate cinchona from a weakness

of the stomach or other cause, he advises it to be given in clysters, in which form it is, he tells us, as efficacious as when taken by the mouth. For this purpose the extract is most proper with the addition of a sufficient quantity of the tinctura thebaica, in order to its being longer retained. For children labouring under intermitting fevers, Dr Lind orders the spine of the back to be anointed, at the approach of the fit, with a liniment composed of equal parts of tinctura thebaica and liniment. sapon. which has often prevented it. If this should not produce the desired effect, he informs us that two or three tea-spoonfuls of syrup. de mecon. given in the hot fit, will generally mitigate the symptoms. But for the entire removal of the disease, after purging with magnesia alba, he prescribes a dram of the extract. cinchona with a few drops of tinct. thebaica, in a clyster, to be repeated every three hours for a child of about a year old. When the stomach is oppressed with phlegm, the magnesia frequently occasions vomiting, which should be promoted with warm water. The constant heaviness of the head occasioned by those fevers in such tender constitutions is best relieved by the application of a blister to the back.

Cinchona has also proved effectual for the cure of intermitting in children, even when externally applied, by putting the powder of it into a quilted waistcoat. Of its efficacy in this way several instances are related by Dr Samuel Pye in the second volume of Medical Observations and Inquiries. In short, so effectual was it found in removing these fevers when properly applied, that of between four and five hundred afflicted with them in the year 1765, Dr Lind lost only two, neither of whom had taken this medicine.

In all these cases, a vomit was administered whenever the patient complained of a sickness and retching to vomit, or was seized with a spontaneous vomiting; and cinchona was never given till this sickness was removed, or a purgative taken to clear more perfectly the whole alimentary canal. In those patients who were troubled with a cough, attended with a pain in the side affecting the breathing, when the pain was not relieved by warm fomentations, the balsamum anodynum, or by a blister, Dr Lind generally ordered a few ounces of blood to be taken away, and endeavoured to stop the fever as soon as possible by the administration of cinchona; having found that every return of the fever increased all such pains.—When the headache was very violent, and harassed the patient during the intermissions, the success of cinchona was rendered more complete by the application of a blister to the back.—A giddiness of the head, which is the symptom most commonly remaining after even a slight intermitting fever, was generally relieved by the sal C. C. and cinchona in wine. The former of these was administered in the following manner.

R. Aq. Alex. Simp. $\backslash frac\{3\}\{4\}$ vii.

Sal C. C. $\backslash frac\{3\}\{4\}$ s.

Syr. de Cort. Aurant. $\backslash frac\{3\}\{4\}$ i. M. f. julep. Cap. cochlear. ij. subinde.

If from the continuance of the fever the patient was distressed with a flatulence, a distention of the abdomen, and a swelling of the legs, a spoonful of tinctura facra, with the addition of 30 drops of the spirit. lavend. compos. was ordered to be taken every night.—A

H h 2 continue

continuance of cinchona, a change of air, and the cold bath, were often found requisite to prevent a relapse.

Such is the method of cure recommended by this experienced author, who has also discovered the efficacy and success of opium in intermitting fevers. He informs us, that he has prescribed an opiate to upwards of 300 patients labouring under this disease; and he observed, that, if taken during the intermission, it had not the least effect either in preventing or mitigating the succeeding paroxysm: when given in the cold fit, it once or twice seemed to remove it; but when given half an hour after the commencement of the hot fit, it generally gave immediate relief.— When given in the hot fit, the effects of opium are as follow: 1. It shortens and abates the fit; and this with more certainty than an ounce of cinchona is found to remove the disease. 2. It generally gives a sensible relief to the head, takes off the burning heat of the fever, and occasions a profuse sweat. This sweat is attended with an agreeable softness of the skin, instead of the burning sensation which affects patients sweating in the hot fit, and is always much more copious than in those who have not taken opium. 3. It often produces a soft and refreshing sleep to a patient tortured in the agonies of the fever, from which he awakes bathed in sweat, and in a great measure free from all complaints.

Dr Lind has always observed, that the effects of opium are more uniform and constant in intermitting fevers than in any other disease, and are then more quick and obvious than those of any other medicine. An opiate thus given soon after the commencement of the hot fit, by abating the violence and lessening the duration of the fever, preserves the constitution so entirely uninjured, that, since he used opium in agues, a dropsy or jaundice has seldom attacked any of his patients in those diseases. When opium did not immediately abate the symptoms of the fever, it never increased their violence. On the contrary, most patients reaped some benefit from an opiate given in the hot fit, and many of them bore a larger dose at that time than they could do at any other. He assures us, that even a delirium in the hot fit is not increased by opium, though opium will not remove it. Hence he thinks it probable, that many symptoms attending these fevers are spasmodic; but more especially the headache. However, if the patient be delirious in the fit, the administration of the opiate ought to be delayed until he recovers his senses, when it will be found greatly to relieve the weakness and faintness which commonly succeed the delirium. Dr Lind is of opinion, that opium in this disease is the best preparative for cinchona; as it not only produces a complete intermission, in which case alone that remedy can be safely administered; but occasions such a salutary and copious evacuation by sweat, as generally to render a much less quantity of cinchona requisite. He commonly prescribes the opiate in about two ounces of tinctura sacra, when the patient is cositive, who is to take the cinchona immediately after the fit. By these means the paroxysm is shortened, and the intestines are cleansed, previous to the administration of cinchona; as the opiate does not prevent, but only somewhat retards, the operation of the purgative. When a vomit is given immediately before the paroxysm, the administration of the opiate should be postponed till the hot fit be begun.

In the administration of cinchona, care should be taken that it be of a good quality. And different opinions have been entertained with respect to the choice, even where there is no reason to believe that it has been adulterated by the mixture of other articles. For a long time, the preference was given to small quilled pieces of pale-coloured bark; but of late the red bark, which is generally in larger masses, of an apparently coarser texture, and evidently of a more resinous nature, has been highly celebrated by Dr Saunders and others. And in cases where it does not disagree with the stomach or excite looseness, it is admitted by the most accurate observers to be more powerful in preventing the return of intermitting. Whether the red bark be the product of a different species of the cinchona, or be obtained as well as the pale quilled bark from the cinchona officinalis, is not yet ascertained with sufficient accuracy. Cinchona of a yellow colour has lately been imported into Britain and highly extolled. Its botanical history is not ascertained. It contains more bitter extractive matter, and more tannin and gallic acid, than either the pale or red; but less gum than the pale, and less resin than the red. It seems to produce the same medical effects in smaller doses. And it has sometimes succeeded in the cure of intermitting where the pale and red cinchona have before been employed in vain.

A species of cinchona, distinguished by the title of cinchona Jamaicensis, has been discovered in Jamaica and other islands in the West Indies. A very accurate description of it has been given by Dr Wright of Jamaica in the Philosophical Transactions of London. The bark of this species also has been recommended in the cure of intermitting; but the advantages of it have not hitherto been sufficiently confirmed by experience.

The barks of various trees readily cultivated in Britain, particularly different species of the salix, the prunus, the fraxinus, and the quercus, have by some been represented as no less efficacious than the cinchona. But we may safely venture to assert, that although several of them may possess some power in stopping intermitting, yet that none hitherto tried can be considered as in any degree approaching to the cinchona in point of efficacy.

But although the Peruvian bark be the best cure for intermitting hitherto discovered, yet while it can by no means be represented as the only cure, it is very certain that other remedies have in different cases succeeded after the cinchona has failed. Cures have often been obtained by the use of different aromatics, bitters, and astringents. Many articles from the mineral kingdom also have been employed with advantage. And intermitting have unquestionably been in certain cases stopped by different preparations of iron, zinc, copper, lead, and mercury. But of all the articles of this nature, arsenic has of late been the most celebrated. Arsenic is on good grounds conjectured to be the basis of an article much employed in the cure of intermitting in some of the countries where they are most prevalent, and sold under the title of the toilette's ague drop. The great success attending the use of this article, led Dr Fowler, an ingenious physician of Stafford, to examine it with particular attention. And in a treatise which he has lately published, entitled Medical Reports on the effects of arsenic in the cure of agues, he has given a formula for an arsenical solution,

Petret. solution, which he has found very successful in affections of this kind, and which is probably very nearly the same with the taiteless ague drop. Dr Fowler's mineral solution, as he styles it, is found by dissolving 64 grains of arsenic and as much fixed vegetable alkaline salt in a pound of distilled water. This solution is given in doses from three to 12 drops, varied according to the condition of the patient, and repeated two or three times a-day. And where the cinchona has failed in stopping intermittents, it seems to be one of the most powerful remedies yet discovered. But after all remedies prove ineffectual, intermittents are often stopped by change of season and of situation.

But besides the remedies employed in tertians and other intermittents, with the view of preventing the return of paroxysms, it is often also necessary to employ powerful articles with other intentions, particularly to mitigate and shorten the paroxysm when present; to obviate urgent symptoms, especially those of an inflammatory or putrid nature; and to obtain a complete apyrexia or intermission from fever after the paroxysm has ceased. With these intentions, recourse is not unfrequently had to emetics, laxatives, blood-letting, blisters, opium, diluents, or sudorifics, as the circumstances of the case may require.

Tertiana notha five spuria, Sauv. sp. 2. Sennert.
Cleghorn. Hoffman.

The characteristic marks of this fever are, that its paroxysms last longer than 12 hours, and consequently it inclines more to the quotidian or continued fever than the former. Its paroxysms have no stated hour of attacking. The cure, however, is precisely the same with that above described, observing the proper cautions already mentioned with regard to the use of the cinchona.

Tertiana duplex, Sauv. sp. 13. Vog. G. 12. Sennert.
Cleghorn.

Duplicata, Lin. 18.

The double tertian comes on every day; but differs from the quotidian in this, that its paroxysms do not answer to each other singly, but alternately. The first day, for instance, the fit will come on in the forenoon, in the second in the afternoon, the third in the forenoon, and the fourth in the afternoon.

Of these fevers we shall give the following description from Cleghorn's treatise on the diseases of Miasmata: "They are called double tertians when there are two fits and two intervals within the time of each period. But commonly there is some difference between the two fits, either in respect of the hour they come at, the time of their duration, or the nature and violence of their concomitant symptoms. Some double tertians begin in this manner.—On the evening of Monday, for example, a slight fit comes on, and goes off early next morning; but on Tuesday, towards the middle of the day, a more severe paroxysm begins, and continues till night. Then there is an interval to Wednesday evening, when a slight fit commences a new period of the fever, which proceeds in the same

manner as the first; so that according to the way physicians calculate the days of diseases, by beginning to reckon from the first hour of their invasion, both paroxysms happen on the odd days, while the greatest part of the even days is calm and undisturbed. But in most double tertians the patient has a fit every day of the disease; the severe one commonly appearing at noon upon the odd days, the slight one towards evening on the even days; though sometimes the worth of the two fits happen on the even days.

"There is a tertian fever sometimes to be met with, during each period of which there are three different fits, and as many intervals. For example, towards Monday noon the patient is seized with a paroxysm, which declines about five or six o'clock the same evening; a few hours after, another fit begins, and continues until morning: from which time there is an interval to Tuesday evening, when a third fit comes on, and lasts most part of the night. On Wednesday there are again two paroxysms, as on Monday, and on Thursday like that of Tuesday; and thus the fever goes on with a double fit on each of the odd days, and a single fit on the even days.

"In double tertians, that interval is the most considerable which follows the severe fit; for the slight fit oftener ends in a remission than intermission, and frequently lingers till the other approaches: Hence it is, that the night preceding the vehement fit is much more restless than that which comes after it, as has been observed by Hippocrates. In double tertians, the vehement fit often comes on a little earlier in each period, while the slight fit returns at the same hour, or perhaps later and later every second day: so that the motions of one have no influence on those of the other; from whence it appears, that each of these fits hath its own proper independent causes."

Tertiana duplicata, Sauv. sp. 14. Jones. Rover.

This hath two fits on the same day, with an intermediate day on which there are none. This also does not differ in any remarkable particular from those already described.

Tertiana triplex, Sauv. sp. 15. Cleghorn.

Semitertiana, Hoffman.

Semitertiana primi ordinis, Spig.

This differs from the former in having a single and double fit alternately: thus, for instance, if there be two fits the first day, there is only one the second, two the third, one the fourth, &c. Its cure is the same as before.

Hemiteritus, Celsi.

Semitertiana, Cleghorn.

Semitertiana secundi ordinis, Spig.

Amphimerina hemiteritus, Sauv. sp. 8.

Amphimerina pseudo-hemiteritus, Sauv. sp. 9.

The semitertian is described by Dr Cullen as having only an evident remission between its paroxysms; more remarkable between the odd and even day, but less so between the even and odd one. For this reason, he adds, that possibly some semitertians ought rather

to be classed among the remittents; and owns that it is difficult to settle the boundaries between them. But Cleghorn, whom he quotes, describes it in the following manner. "A fit begins on Monday noon, for example, and goes off the same night. On Tuesday afternoon a second fit comes on, and gradually increases till Wednesday night, when it terminates. On Thursday morning there is such another interval as happened on Tuesday morning: But on Thursday afternoon another long fit like the preceding commences; and returning regularly every second day, leaves only a short interval of ten or twelve hours during the eight and forty.

Concerning the cure of these fevers Dr Cullen observes, that though no entire apyrexia occurs, cinchona may be given during the remissions: and it should be given even though the remissions be inconsiderable; if, from the known nature of the epidemic, intermissions or considerable remissions are not to be expected, and that great danger is apprehended from repeated exacerbations.

The Sleepy TERTIAN. Sp. I. var. 3. G.
Tertiana carotica, Sauv. sp. 10. Werlhof.
Tertiana hemiplegica, Sauv. sp. 20. Werlhof.
Quotidiana soporosa, Sauv. sp. 8. Car. Pis.
Febris caput impetens, Sydenham, ep. ad. R. Brady.

This, according to Vogel, is a most dangerous species, and very commonly fatal; for which reason he ranks it among those intermitments which he calls malignant. Sometimes he tells us the alarming symptom of a sleepiness comes on, not at the beginning of the disease, but will unexpectedly occur during the third, fourth, fifth, or sixth paroxysm. It commonly begins with the cold fit, and continues during the whole time of the paroxysm, and, becoming stronger at every succeeding one, at last terminates in a mortal apoplexy. Sometimes fevers of this kind rage epidemically. Vogel relates, that he saw a simple tertian changed into one of these dangerous fevers. The patient was a woman of a delicate constitution, and the symptom appeared in consequence of her being put in a violent passion: however, it occurred but once, and she recovered. Hoffman mentions a carus in a double tertian occurring seven times without proving mortal; though Vogel says, that the powers of nature are very seldom sufficient to conquer the disease.

In 1678, Dr Sydenham tells us that intermitments raged epidemically at London, where none had appeared before from 1664. Of them "it is to be noted (says he), that though quartans were most frequent formerly, yet now tertians or quotidian were most common, unless the latter be entitled double tertians; and likewise, that though these tertians sometimes began with chillness and shivering, which were succeeded first by heat, and soon after by sweat, and ended at length in a perfect intermission, returning again after a fixed time; yet they did not keep this order after the third or fourth fit, especially if the patient was confined to his bed and used hot cardies, which increase the disease. But afterwards this fever became so unusually violent, that only a remission happened in the place of an intermission; and approaching every day nearer the species of continued fevers,

it seized the head, and proved fatal to abundance of Tertiana persons."

From this description of Sydenham's we may have an idea of the nature of the disease. As to its cure he strongly recommends cinchona; telling us, that, even in the most continued kind of intermitments, "the nearer the intermittent approaches to a continued fever, either spontaneously, or from using too hot a regimen, so much the more necessary is it to exhibit a larger quantity of the bark; and that he took advantage of a remission, though ever so small."

The Spasmodic or Convulsive TERTIAN. Sp. I. var. 3. H.

Tertiana asthmatica, Sauv. sp. 6. Bonnet.
Tertiana hysterica, Sauv. sp. 8. Wedel. A. N. C. Dec. I. A. II. obl. 193.
Hysteria febricosa, Sauv. G. 135. sp. 8. A. N. C. Dec. I. Ann. II.
Tertiana epileptica, Sauv. sp. 16. Calder. Lutter.
Quotidiana epileptica, Sauv. sp. 3. Edinb. Essays, vol. v. art. 49.
Ecclampsia febricosa, Sauv. G. 139. sp. 17.
Epilepsia febricosa, Sauv. G. 134. sp. 9.
Tertiana tetanodes Med. Beobacht I. Band.
Tetanus febricosis, Sauv. G. 122. sp. 10. Stork, Ann. Med. II.

Tertians of this kind occur with very different symptoms from those of the true ones, and sometimes even with those which are very extraordinary. In some they are attended with symptoms of asthma, in others with those of hysterics, in others with convulsions. Where the symptoms of asthma occur, the disease must be treated with diuretics and antispasmodics joined with cinchona. In the hysterical asthma the fit comes on with cold, yawning, cardialgia, terror and dejection of mind. The disease is to be removed by mild aperients and antihysterics joined with cinchona.

Of the convulsive tertian we have a most remarkable instance in the Edinburgh Medical Essays, vol. v. The patient was a farmer's son about 26 years of age, of a strong plethoric habit of body. He had laboured under an ague half-a-year, and had taken a great deal of Peruvian bark. While he was telling his case to the surgeon (Mr Baine of Pembroke), he was suddenly taken with a violent flumping of his feet; and the convulsions gradually ascended from the soles of the feet to his legs, thighs, belly, back, and shoulders. His head was then most violently convulsed, with a total deprivation of speech; but he had a most dismal vociferation, which might have been heard at a considerable distance, his abdomen and thorax working and heaving violently and unusually in the mean time. This fit having lasted half an hour, a profuse sweat broke out over all his body, which relieved him; and he then became capable of answering such questions as were put. These extraordinary fits, he said, had been occasioned by a fright, and his neighbours had concluded that he was bewitched. They returned sometimes twice a-day, and always at the times the ague used to return. During the paroxysm his pulse was very high and quick, his face much inflamed, and his eyes ready to start out of his head. After

Febr. the fit was over, he complained of a most torturing pain of the bowels. His tongue was generally moist, and he had a suppression of urine.—This formidable disease, however, was totally subdued by the use of cinchona, mercurials, antispasmodics, opiates, and saline draughts.

334 The Eruptive TERTIAN. Sp. I. var. 3. I.
Tertiana petechialis, Sauv. sp. 3. Donat. Lauter.
Tertiana scorbutica, Wedel. A. N. C. Dec. I. A.
II. obs. 193.
Tertiana urticata, Sauv. sp. 22. Planchon. Journ. de Med. 1765. Cleghorn.
Tertiana militis, Sauv. sp. 21. Waltheri de Med. Ger.

This species of tertian is accompanied with red or livid blotches on the skin, or an eruption like that occasioned by the stinging of nettles. In the latter case Dr Cleghorn says the disease is very dangerous; and as the former indicates an incipient dissolution and putrefaction of the blood, it must also be reckoned of very dangerous tendency.

335 The Inflammatory TERTIAN. Sp. I. var. 3. K.
Tertiana pleuritica, Sauv. sp. 4. Vales. Laut.
Pleuritis periodica, Sauv. G. 103. sp. 14.
Tertiana arthritis, Sauv. sp. 5. Morton. Laut.

Sauvages informs us, that he has seen a true and genuine pleurisy having all the pathognomic signs of the disease, but assuming the form of an intermittent; that is, the patient is one day affected with the pleurisy, and the next seemingly in perfect health. He also tells us, that in the month of May 1760 a tertian raged epidemically, which after the third fit imitated a pleurisy, the pain of the side and difficulty of breathing coming regularly on, and the fever from an intermittent becoming remittent; the blood had also the same appearance with that of pleuritic persons, and the disemper yielded to bleeding and gentle cathartics.—Morton also informs us, that he has observed similar disorders an hundred times, which were always certainly and safely cured by the Peruvian bark.

336 The TERTIAN complicated with other Disorders.
Sp. I. var. 4.
Tertiana scorbutica, Sauv. sp. 9. Estmuller. Timout.
Tertiana syphilitica, Sauv. sp. 17. Deidier.
Tertiana verminosa, Sauv. sp. 18. Stiffer. in a&g.
Helmsted. Lancif. de noxiis palud. Pringle.
Ramazzini. Van den Bosch. de consil. vermin.

The scorbutic tertian, according to Sauvages, is exceedingly anomalous, its periods being sometimes much anticipated, and sometimes much postponed. It is exceedingly obstinate, and will return if the body be not cleared of its scorbutic taint. The patient is affected with lancinating pains of a wandering nature. The urine lets fall a dusky red sediment, or a thick branny matter is copiously scattered up and down in it, seemingly tinged with blood. The usual symptoms of scurvy, viz. livid spots, and rotten fetid gums, also frequently occur. For this the Peruvian bark is very useful, both as a febrifuge and antiscorbutic.

A tertian accompanied with worms is taken notice

of by Sir John Pringle in his treatise on the diseases of the army. The worms, he tells us, were of the round kind; and though we are by no means to reckon them the cause of the fever, they never failed to make it worse, occasioning obstinate gripings or sickness at stomach. In these cases stitches were frequent; but, being flatulent, were not often relieved by bleeding. The worms were discharged by vomiting as well as by stool. For discharging these worms, he commonly gave half a dram of rhubarb with 12 grains of calomel; without observing any inconvenience from such a large dose of mercury. Anthelmintics, which act slowly, had little chance of doing good; for though worms will sometimes lie long in the bowels without giving much uneasiness to a person otherwise well, yet in a fever, especially one of a putrid kind (to which his intermittees always seemed to incline), the worms being disturbed by the increase of heat, and the corruption of the humours in the prime vie, begin to move about, and struggle to get out. Lancifius, who makes this remark, adds, that upon opening the bodies of some who had died at Rome of fevers of this kind, wounds were found in the intestines made by the biting of the worms; nay, that some of them had even pierced through the coats of the guts, and lay in the cavity of the abdomen. Pringle never had any instance of this; but knew many cases in which the worms escaped by the patient's mouth, though there had been no previous retching to bring them up. One soldier was thrown into violent convulsions, but was cured by the above-mentioned powder.

The TERTIAN varied from its Origin. Sp. I. var. 5. 337
Tertiana accidentalis, Sauv. sp. 12. Sydenham.
Tertiana à scabie, Sauv. sp. 12. Juncer, tab. 80.
Hoffman, II. p. 12.

The existence of fevers of this kind, as we have already observed, is denied by Dr Cullen; the accidental fever of Sauvages was said to arise from any slight error in the non-naturals, and consequently was very easily cured. That which arose from the repulsion of the itch, was cured as soon as the eruption returned.

The TERTIAN with only a remission between the fits. Sp. II. 338
Tritæophya, Sauv. Gen. 85. Sag. p. 695.
Tritæus, Lin. 21.
Hemiriteæ, Lin. 23.
Tertianæ remittentes et continue Auctorum.
Tertianæ subintrantes, proportionatæ, subcontinæ, Torti.
Tertiana subcontinua, Sauv. sp. 19.
Quotidiana deceptiva, Sauv. sp. 2.
Amphimerina semiquintana, Sauv. sp. 24.
Tritæophya deceptiva, Sauv. sp. 10.
Causus Hippocratis.
Tritæophya causus, Sauv. sp. 2.
Febris ardens Boerhaavii, aph. 738.
Tertiana perniciofa, quæ simulata tertiani circuitus
essigie lethalis, et mille accidentibus periculosis.
mis implicata, exilit. Lud. Mercatus.
Tertiana pestilens, P. Sal. Diversus.

Tertiana

Tertiana maligna pestilens, Riverii.
Morbus Hungaricus, Lang. Lemb. Senneri. Jordan.
Languor Pannonicus, Gober.
Amphimerina Hungarica, Sauv. sp. 10.
Hemitriticus pestilens, Schenck. ex Corn. Gamma.
Febrēs pestilentes Ægyptiorum, Alpin.
Febris tertiana epidemica, Bartsholin.
Febrēs epidemicae, autumni 1657 et 1658, Willis.
Febris synoches epidemica, ab anno 1658 ad 1664, et postea ab anno 1673 ad 1691, Morton.
Febrēs autumnales incipientes, Sydenham.
Affectus epidemicus Leidenfis, Fr. Syloui.
Morbus epidemicus Leidenfis, 1669, Fanois.
Tertianae perniciosae et pestilentes, et febrēs castrenses epidemicae, Laneisi.
Febrēs intermittentes anomaliae et mali moris, Hoffman.
Febris cholERICA minus acuta, Hoffman.
Febris epidemica Leidenfis, anno 1719, Koker apud Haller, Disp. tom. v.
Amphimerina paludosa, Sauv. sp. 19.
Febris paludum, Pringle.
Bononiensis constitutio hiemalis 1729, Beccari in A. N. C. vol. iii.
Amphimerina biliosa, Sauv. sp. 22.
Febris castrensis, Pringle.
Febris putrida epidemica, Huxham de aere ad ann. 1729.
Febris biliosa Laufenensis, Tiffot.
Triticophya Wratislaviensis, Sauv. sp. 3. Hahn.
Epidemia verna Wratislav. in App. ad A. N. C. vol. x.
Triticophya Americana, Sauv. sp. 12.
Febris anomala Batava, Grainger.
Morbus Naronianus, Pujati.
Febris continua remittens, Hillary's diseases of Barbadoes.
Febris remittens Indiae Orientalis, Lind. diff. inaug. 1768.
Febris critica et febr. biliosa æstatis, Rouppre.
Febris remittens regionum calidarum, Lind on the diseases of hot climates.
A. Tertiana cholERICA five dyfenterica, Tort. Therap. Special. lib. iii. cap. 1. Lauter. Hist. Med. cas. 6. 16. 17. 20. Morton, App. ad Exerc. II.
B. Tertiana subcrucenta five atrabiliaris, Tort. ibid. Never seen by Cleghorn.
C. Tertiana cardiaca, Tort. ibid. Lauter. Hist. Med. cas. 15. 16. 23.
Amphimerina cardiaca, Sauv. sp. 5.
Triticophya asfodes, Sauv. sp. 6.
Febris continua asfodes, Vog. 27.
D. Tertiana diaphoretica, Tort. ibid.
Triticophya typhodes, Sauv. sp. 4.
Triticophya clodes, Sauv. sp. 5.
Febris continua clodes, Vog. 21.
E. Tertiana syncopalis, Tort. ibid. Lauter. cas. 11. 12. 13. 15. 16.
Triticophya syncopalis, Sauv. sp. 1.
Amphimerina syncopalis, Sauv. sp. 4.
Amphimerina humorosa, Sauv. sp. 6.
Febris continua syncopalis, Vog. 29.
F. Tertiana algida, Tort. ibid. Lauter. cas. 15.
Amphimerina epiala, Sauv. sp. 3.

Amphimerina phricodes, Sauv. sp. 7.
Triticophya leipyrina, Sauv. sp. 9.
Tertiana leipyrina, Sauv. sp. 23. Valcarengli Med. Ration. p. 18.
Febris continua epiala et leipyrina, Vog. 19. et. 24.
G. Tertiana lethargica, Tort. ib.
Triticophya carotica, Sauv. sp. 7. Lauter. 1. 7. 14.
Tertiana apoplectica, Morton. Exerc. 1. cap. ix. hist. 25.
Tertiana soporosa, Werlhof. de febr. p. 6.
Febris epidemica Urbevetana, Laneisi. de noxiis pal. effluv. 1. II. c. 3.

The remittent fevers are much more dangerous than the true intermittents, as being generally attended with much greater debility of the nervous system and tendency to putrescency in the fluids than the latter. Sauvages divides his triticophya, a remittent tertian into the following species:

1. Triticophya syncopalis, or that attended with fainting. It begins like a tertian, with cold succeeded by heat and profuse sweating; but attended with much more dangerous symptoms, such as cardialgia, enormous vomiting, great weakness, small contracted pulse, coldness of the extremities, and, unless timely assistance be given, kills during the second or third paroxysm.

2. The causus, or burning fever of Hippocrates, returns every third day without any new sensation of cold; and is attended with great thirst, heat, but without diarrhoea or sweat, and continues only for one week or two at the utmost. It attacks chiefly young people of a robust and bilious habit of body, who have been accustomed to much exercise, and exposed to the sun during the heats of summer, and have also used a phlogistic regimen. The tongue is dry, sometimes black; the urine of a red or flame colour; together with pain of the head, anxiety, and sometimes other symptoms still more dangerous.

3. Triticophya Wratislaviensis, was a pestilential disease occasioned by famine, during which the people fed on putrid alimēts: the air was infected by the vast numbers of bodies of those slain in battle, and the inhabitants were also dejected by reason of being deprived of their harvest, and other calamities; to all which was added the continuance of a calm in the atmosphere for a long time. It began with an acute fever, leipyrina or coldness of the external parts and a sensation of burning heat inwardly; general weakness; pain of the head and præcordia; ferous, or bilious diarrhoea; a delirium, in some furious, and accompanied with a dread of being exposed to the air; on the second day the thirst was violent, attended with a bilious vomiting, as well as diarrhoea, tough viscid spitting, fainting, burning heat in the bowels, the tongue dry and seeming as if burnt with a hot iron, a suppression of the voice, anxiety, stupor, after which quickly followed convulsions and death. In some fevers leipyrina came on with an exceeding great cold of the extremities, presently followed by an intolerable heat of the viscera, with symptomatic sweats, violent diarrhoea, followed by a very itchy military eruption. On the fourth day came on copious sweats, spasms of the lower jaw, nausea, involuntary passing of urine, slight delirium, a flux of ichorous matter from the nostrils, an exceeding tough spitting, an epilepsy, and death. Professor Hahn, who gives

Feb. gives the history of this disease, was himself attacked by it, and suffered in the following manner: On the first day was a violent febrishy paroxysm without rigor, a sharp pain in the occiput, and immediately an inflammatory pain over the whole head; the feet were extremely cold, and the extremities rigid with spasms. The pain continued to increase daily to such a degree, that the contact of the air itself became at last intolerable; a dejection of mind and incredible weakness followed; he passed restless nights with continual sweating, heavy and pained eyes, and an universal sensation of rheumatism over the whole body. On the third day the pains were assuaged, but he had a very bad night. On the fourth day all the symptoms were worse, the feet quite chilled, the hands very red and agitated with convulsive motions; he was terrified with apprehensions of death, and had a vomiting every now and then: this day sponges dipped in cold water were applied over the whole body, and he used cold water for his drink. On the eighth day the pulse was convulsive; and the pains were so violent that they made him cry out almost continually. On the ninth day he was delirious, and threw up some grumous blood. On the 11th his pulse was more quiet, and he had a sweat; a decoction of cinchona was given: his voice was broken, his speech interrupted, and his teeth chattered upon one another. On the 12th his jaw was convulsed, he had a rhus sardonicus, and deafness; after which the paroxysms returned less frequently, and only towards night. On the 14th he had a chilling cold over the whole body, a cold sweat; frequent lotions were applied, and all the symptoms became milder. On the 18th he had a quick delirium, but fainted as soon as taken out of bed; a sensation of hunger, followed by copious sweats; profound sleep; an aversion from noise; every thing appeared new and extraordinary. On the 36th a cholera; on the 48th a scaling off of the skin, and falling off of the nails. This epidemic carried off above 3000 people at Warfaw. Frequent lotion of the body either cold or tepid, watery glysters, and the copious introduction of watery fluids under the form of drink, were of service. But the most favourable crisis was under the form of some cutaneous eruption.

142 4. Tritophya typhodes. The principal symptom of this fever was a continual sweat with which the patients were almost always wet; with paroxysms returning every third day. Sauvages tells us, that he had twice an opportunity of observing this fever; one was in the teacher of an academy, about 40 years of age, and of a melancholic temperament. He sweated every second night so plentifully, that he was obliged to change his linen nine times; and even on the intermediate days was never perfectly free of fever, and had his skin moistened with sweat. The other was of a woman who went about in man's clothes, and was discovered only after her death. The disease began with a slight sensation of cold, after which she sweated for eight hours. It was attended with the highest debility, anxiety, and at the same time an insatiable hunger.

143 5. Tritophya elodes, was an inflammatory epidemic, but not contagious, terminating about the 14th or 21st day. The disease came on in the night-time, with disturbed rest, universal weakness, watchings, great

heat and sweat, redness of the face and almost of the whole body, sparkling eyes, the tongue dry and white; a hard, tense, and turgid pulse: about the third day a kind of frenzy frequently came on with the febrishy paroxysm, the forerunner of an universal milia erythema; or, what was worse, with purple spots so close together, that they looked like an erysipelas of the whole body. Sometimes blisters of the size of small pearls, filled with acrid serum, appeared on the neck, armpits, and trunk of the body, which were of all the symptoms the most dangerous. There was a variety of the disease, which Sauvages calls the humoralis, and in which the pulse was soft and feeble, with greater weakness over the whole body, and the disposition to sleep more frequent than in the other; the eyes languid; the tongue very white, but not dry; and worms were sometimes discharged.

6. Tritophya affodes. This species arose from a foulness of the prime vie, and the effluvia of waters in which hemp had been steeped. It began with rigor, followed by great heats, restlessness, tossing of the limbs, faintings, immoderate thirst, dryness of tongue, delirium, and at length excessive watchings; these last, however, were less dangerous than vertigo or a comatose disposition, which brought on convulsions or apoplexies.

7. Tritophya carotica. This had exacerbations every other evening; and its distinguishing symptom was an excessive inclination to sleep, preceded by a severe headache, and followed by delirium, and sometimes convulsions; the tongue was black, and the patient insensible of thirst after the delirium came on. In those cases where the disease proved fatal, a subfultus tendinum and other alarming symptoms, came on.

8. Tritophya leiporia is only a variety of the tritophya caesus, already described.

9. Tritophya deceptiva. This species at first assumes the appearance of a continued fever; but afterwards degenerates into a remittent, or even an intermittent. It is described by Sydenham, but attended with no remarkable symptoms.

10. The last of Sauvages's species of Tritophya belonging to the remitting tertian is the Americana. This, according to Sauvages, is the ardent fever with which the Europeans are usually seized on their first arrival in America, and generally carries off one half of them. Of this there are two varieties, the very acute and the acute. The very acute ends before the seventh day. It comes on a few days after the person's arrival, with loss of appetite, with dyspnoea and fighting from weakness, headache, lassitude, and pain of the loins: a pyrexia succeeds, with great thirst, sweat, and heat; the sickness increases, nausea comes on, with vomiting of porraceous bile; the tongue rough, the extremities often cold; watching, furious delirium; and the patient frequently dies on the third day. Copious sweats, and a plentiful hemorrhagy from the nose on the fifth day, but not sooner, are serviceable; but a bilious diarrhoea is the best crisis of all.

The acute kind terminates most frequently on the ninth, but very rarely goes beyond the fifteenth day. Death frequently comes on between the fourth and seventh days. It begins with headache, pain in the loins, and sometimes shivering; great lassitude, dys-

ncea, thirst; burning fever, increasing every third day; inflation of the abdomen, pain at the pit of the stomach, nausea, and bilious vomiting. Such is the state of the disease within twenty-four hours. The eyes are red, and full of tears; the urine pellucid; there is a low delirium, and continual anxiety; the tongue is dry and red, and sometimes, though rarely, black, which is a still worse sign; the pulse, formerly strong and full, sinks about the fourth day, and becomes tense and spasmodic: if a carus then comes on, the patient dies the fifth or sixth day; but if the pulse keeps up, and no carus comes on, a crisis is to be expected by sweat, by a copious hemorrhage from the nose, or, which is still more safe, by a bilious diarrhoea, which is never salutary if it comes on before the fifth day.

To the remitting tertian also belong the following species mentioned by Sauvages, viz.

149 1. Tertiana fuliginosa. This begins like a genuine tertian, and at first hath distinct paroxysms; but these grow gradually more and more obscure, the disease acquiring daily more of the appearance of continued fever, by which it is to be distinguished from the other varieties of this species. It is not unfrequently joined with those symptoms which attend the fatal fever already mentioned; as cardialgia, cholera, syncope, &c. but in a much less degree. The disease commonly begins with little or no sense of cold, but rather a sensation of heat; when the tertian is doubled, it has first a lighter and then a more severe fit; and thus goes on with an exacerbation on the even days: and though it should change from a double into a single tertian, we are still to suspect it, if a weak fit is the forerunner of a very strong one. This change of the tertian into a continued fever is also to be prognosticated if a heat remarkable to the touch is perceived on the day of intermission, together with some disturbance of the pulse, thirst, and dryness of the tongue; all of which show a tendency to inflammation: the same is foretold by the urine being in small quantity, and very red, or of a saffron colour; also an ulcerous or aphthous inflammation of the throat, with difficulty of swallowing, or any very severe symptom coming on in the beginning of the disease, excepting only a delirium, which is easily removed.

150 2. Quotidiana deceptiva. This is a disorder of an inflammatory kind, with a strong tendency to putrefaction, and sometimes assumes the form of a quotidian. In it the patient frequently complains of cold when he really is hot, and the remission is very indistinct. The disease is known by the great languor of the patient and the foulness of his tongue.

151 3. Amphimerina cardiaca is an acute malignant fever, with daily exacerbations, attended with fainting and vomiting of green bile. Afterwards, the weakness increasing, the patient's extremities grow cold, and a profuse sweat comes on, which is frequently succeeded by death on the fourth day. Another species resembling this Sauvages calls the syncopealis; but the cardiaca differs from it in being attended with cardialgia.

152 4. Amphimerina paludosa. This is the fever described by the British physicians under many different names, and appearing under various forms, according to the different constitutions of the patients. This fever in the East Indies, according to Dr Lind of Windsor, generally comes on suddenly, and begins with a sense

of debility and a very great lowness of spirits. These symptoms, are attended with a greater or less degree of chilliness, vertigo, nausea, very acute pains in the head and loins, and a trembling of the hands; the countenance is pale, the skin commonly very dry and corrugated, the eyes dull and heavy, the pulse quick and small, the breath generally difficult, and interrupted with hiccough.

As the paroxysm increases, the chilliness now and then gives way to irregular heats, which soon become violent and permanent; the nausea likewise increases; and in some there comes on a vomiting, in which they throw up a great deal of bile. Sometimes bile is likewise voided by stool. The skin grows red; the eyes appear small, and sometimes not a little inflamed. The pulse becomes fuller, and the breath more difficult, attended with great restlessness and a troublesome thirst; notwithstanding which (so great is the nausea) the patient cannot endure any kind of liquids. The tongue becomes foul, and the pain of the head and loins more violent; a delirium then follows; a slight moisture appears on the face, and from thence spreads to the other parts; whilst the violence of the other symptoms abates, and shows the beginning of a remission, which is completed by plentiful sweats.

On the fever's remitting, the pulse returns almost to its natural state; the pains of the head and loins still continue, though somewhat less violent, as likewise the nausea and want of appetite. When the disease gains strength, the remission is scarcely obvious, and is immediately followed by another paroxysm; which begins, not indeed with so great a shivering, but is attended with a greater pain of the head, the greatest anxiety, a heartburn, nausea, vomiting, and bilious stools. The matter most commonly evacuated by vomit and stool is whitish like chalk and water, or curdled milk which is vomited by sucking children, when the curd is much broke down. A heat, immoderate thirst, and delirium, now come on. The tongue becomes more foul; the teeth and inside of the lips are covered with a black crust; the breath grows hot and fetid: another remission ensues, attended with a sweat; but this remission is both shorter and less obvious than the first.

This second remission is succeeded by a paroxysm, in which the symptoms are far more violent than in the former; that which the patient discharges by vomiting and purging is more fetid; the mouth, teeth and inside of the lips, are not only covered with a black crust, but the tongue becomes so dry and stiff, that the patient's voice can scarcely be heard. Violent delirium, with restlessness and anxiety, come on chiefly during the paroxysm; nor do these symptoms abate till the fever remits, and the patient sweats.

When the fever becomes so violent, during the third fit, as to end in death, which is often the case, some of the sick have a coma; in others the delirium becomes more violent. The discharges now become more fetid, and have a cadaverous smell; the stools are involuntary; the pulse is so quick, small, and irregular, that it is scarce to be counted, or even felt; a cold sweat is diffused over the whole body, especially the head and neck; the face becomes Hippocratic and convulsed; the patient picks the bed-clothes; a subsultus tendinum comes on; the sick lie constantly on their backs, and insensibly

Febres. insensibly slide down to the foot of the bed; their extremities grow cold; they are then seized with convulsions, with which the scene closes.

In this fever, the urine, which at the beginning is pale, becomes of a deeper colour by degrees, but without depositing any sediment. There seldom or never appear any petechie, and the prickly heat which was before on the skin vanishes on the first appearance of the fever. But though these were the general symptoms of this disorder, they varied in the different subjects, and at different seasons of the same year. The pulse, for example, in some, was quick in the beginning of the disorder; in others, it varied with the other symptoms. The skin was generally dry in the beginning of the fit; but in some it was moist, and covered with sweat from the very beginning of the disease. In the month of September, when the disorder raged most, the remissions were very imperfect and obscure; but, on the return of winter and the healthy season, they became more regular, and the disease assumed the appearance of an intermitting fever, to such a degree as at length not to be distinguished from it. In some the remissions could scarce be perceived, and the fever continued for two weeks without any material change for the better or the worse. At this time numbers were seized with it. When the disorder continued for any time without a change, it generally ended in death; while the weather grew better, it sometimes, in the space of a few days, from a common fever became an intermitting one, and the patient recovered, unless his liver, which was sometimes the case, happened to be affected. The cure of an inflammation of the liver proved uncertain and tedious; as it was commonly followed by a colliquative diarrhoea, which generally endangered the patient's life.—Every succeeding paroxysm was observed to be more dangerous than the preceding; the third generally proved fatal; some died during the first. When this happened, the fever, in the language of the country, was called a pucca, that is a strong fever.

This disease, according to Dr Lind of Hassar hospital, is the autumnal fever of all hot countries, the epidemic disease between the tropics, and the disease most fatal to Europeans in all hot and unhealthy climates. All authors agree that intermitting in general, but particularly this dangerous kind of them, are produced by heat and moisture, but particularly the evaporation of moisture from marshes. Dr Lind of Windsor remarks, that the European seamen are very subject to the fever above mentioned when they happen to arrive at Bengal in autumn. They are predisposed to it from the nature of their food, their confinement on board, the very great heats to which they are exposed during the voyage, and their lying for hours together exposed to the night colds.

Most of the meat used by the crews of those ships is salted, and often in a putrid state, without any fresh vegetables, they having only biscuits, and some other farinaceous matters. The quantity of the vinous or spirituous liquors allowed them is, in his opinion, by far too small to subdue the putrescent disposition of their animal-food. Their fluids consequently become, from day to day, more and more putrescent, and of course more apt to breed and contract this disorder. This disposition is likewise induced by their being stowed

very close together, and that for a considerable length of time, and in a foul air, especially when the weather happens to be too stormy to permit the hatches and port-holes to be kept open.

Though the heats they endure in the voyage to India are less considerable than those of the country itself, yet they are too much for an European constitution to bear. The general heat at sea within the tropics is about $84^\{\backslash circ\}$ of Fahrenheit's thermometer, which is sufficient to relax them, and promote a corruption of their humours, especially when it coincides with the above causes. It likewise creates a languor and indolence, which alone are sufficient to increase that putrefaction. These causes are apt to be considerably aggravated by the men's being often exposed, when on duty, for hours together, to rain, damp, and cold air; a circumstance which frequently happens to them when working their ships up the river Ganges in the night-time. Hence the perspiration is checked, and the excrementitious fluid which used to be discharged by the skin being retained in the body, contributes, he thinks, very much towards the predisposition to this disease.

But the most powerful of all the remote causes is justly thought to be the effluvia of marshes replete with putrid animal-substances. We have not, however, been able to determine from what kind of putrid animal-substances these effluvia derive their virus. For that every kind of putrefaction has not such an effect appears from this, that neither practical anatomists, nor those who by their trades are exposed to the putrid effluvia of animals, for instance such tanners and butchers as keep their shops and stalls very dirty, are more subject than others to putrid diseases. Nor are the ship-stewards and their servants, whose business it is to deliver out the provisions to the ships crews, and who spend the most of their time amongst the putrid and rancid effluvia of the places in which those provisions are kept, more subject to putrid fevers than their ship-mates. But whatever be in this, we are well assured that some particular putrid fermentations produce noxious vapours, which, united with those of marshes, render them more pernicious. Hence evidently proceeds the extreme unhealthfulness of a place called Culpi, on the eastern bank of the Ganges. The shores about it are full of mud, and the banks covered with trees. Opposite to the place where the ships lie there is a creek, and about a mile from its entrance stands the town of Culpi: the ships lie about a mile from the shore. None of the sailors on board the ships stationed at this place enjoyed their health. The burying ground also contributed not a little to spread the infection. The ground being marshy, the putrid water flowed from the old graves into the new ones, which infected the grave-diggers and those that attended the funerals; and from this cause many were suddenly seized while they were performing the last duty to their companions. This place has ever been remarkable for the unhealthfulness of its air. It was once customary to send some of the Company's servants here to receive the cargoes of the ships, and send them to Calcutta; but so many of them died on this duty, that the Company was at length obliged to disperse with it.

Hence it plainly appears, how apt putrid animal and vegetable substances are to render the effluvia of

Feb. 25. Fenny places more pernicious than they would otherwise be. The reason why great inundations of the Nile and Ganges are followed by a healthy season is, that by this means the putrid animal and vegetable substances dispersed over the contiguous countries are carried off into the sea.—The noxious vapours arising from fens spread but a little way. Dr Lind has often known ships crews at a very little distance from the shore quite free from this disorder. But although these marsh miasmata first bring on the disease, yet contagion particularly spreads it, and renders it more epidemic. Thus the Drake East Indiaman continued free from the disorder for two weeks together, when she had no communication with the other ships; but as soon as the disorder was brought on board, many were seized with it within a few days in such a manner as to leave no room to entertain the least doubt concerning its contagious nature.

Dr Lind of Hallar hospital has given a very curious and learned account of the appearance of this fever throughout the various parts of the globe. It was very common in England in the years 1765 and 1766, one obvious cause of which was the prevalence of the eastern wind. This wind in England is often said to bring with it a fog from the sea; but the truth of the matter is, that in many places of this island the east-wind frequently raises a copious vapour from water, mud, and all marshy or damp places. To this exhalation quality of the eastern wind Dr Lind has often been an eye-witness. When the wind changes to the east, the mud sometimes sends up a vapour as thick as smoke; and the doctor has observed two fish-ponds in his neighbourhood, one of fresh and the other of salt water, which on the approach of an easterly wind sometimes also emit a dense vapour, as from a pot of boiling water. In order to view this phenomenon distinctly, the person should stand at about 100 yards distance from the mud or ponds. If the sun shines when the wind changes to the east, he will observe a constant stream of vapours arising out of the ponds, from about five to ten yards in height, while the air about him remains serene. As the vapour or fog arising from other bodies glides along the surface of the earth, and is brought by the easterly wind to the ponds, he will still be able, for some time, to distinguish the vapours ascending perpendicularly out of the ponds from those which are carried in an horizontal direction by the wind; especially if the sun continues to shine, though faintly.

This evaporating quality of the east-wind seems to manifest itself also by its effects both on the thermometer and the human body; for a thermometer hung over a damp piece of ground during the fogs or exhalations arising from it, will often indicate a degree of cold below the freezing point. The chilliness of the body, so sensibly perceived when in this situation, seems to proceed from the same cause, and to produce nearly the same sensations, which the damp arising from the wet floor of a chamber communicates to those who happen to be in it.

Winds are not constant in their effects. As we have sometimes warm weather with a north-wind, and sometimes very little heat with one blowing from the south; so the fogs attending an east-wind are not constant, neither is the evaporation above mentioned at all times

to be perceived. It is possible, however, that in all this there may be a deception; and that instead of supposing the quantity of vapours exhaled to be increased by an easterly wind, the coldness of that wind may only condense and render visible the vapours in the air at that time. But even this supposition is liable to great objections, as our coldest north-winds seldom or never produce such an effect, but on the contrary are attended with dry and serene weather.

Be this as it will, however, an east-wind is usually accompanied with a cold, damp, and unwholesome vapour, which is observed to affect the health both of animals and vegetables, and in many places to produce obstinate intermitting fevers, and also to occasion frequent relapses. In particular spots of the low damp island of Portsea, the ague frequently prevails during the autumnal season, and in some years is much more frequent and violent than in others. It is also observable, that this disease always attacks strangers, or those who have formerly lived on a drier soil, and in a more elevated situation, with greater severity than those who are natives of the island.

The year 1765 was remarkable, not only for the long continuance of the easterly winds, but for an excessive degree of heat, which produced a more violent and general appearance of those diseases than had been known for many years before. In the month of August the quicksilver in Fahrenheit's thermometer often rose to 82° in the middle of the day. This considerable addition of heat, together with the want of refreshing rains, greatly spread the fever, increased its violence, and even changed its form in many places. At Portsmouth, and throughout almost the whole island of Portsea, an alarming continual or remitting fever raged, which extended itself as far as Chichester. At the same time, the town of Gosport, though distant only one mile from Portsmouth, enjoyed an almost total exemption from sickness of every kind; whereas in the neighbouring villages and farm-houses, a mild regular tertian ague affected whole families. The violence of the fever, with its appearances in a continued, remitting, or intermitting form, marked in some measure the nature of the soil. In Portsmouth the symptoms were bad, worse at Kingston, and still more dangerous and violent at a place called Half-way House; a street so named, about half a mile from Portsmouth, where scarcely one in a family escaped this fever, which generally made its first attack with a delirium. In the large suburb of Portsmouth called the Common, it seemed to rage with more violence than in the town, some parts excepted; but even whole streets of this suburb, together with the houses in the dock-yard, escaped its attack.

The marines, who were three times a-week exercised early in the morning on South-sea beach, suffered much from the effect of the stagnant water in an adjoining morass. Half a dozen of them were frequently taken ill in their ranks when under arms; some being seized with such a giddiness of their head, that they could scarcely stand; while others fell down speechless, and upon recovering their senses complained of a violent headache. When such patients were received into the hospital, it was observed that some few had a regular ague, but that far the greater number laboured under a remitting fever, in which sometimes indeed there

was no perceptible remission for several days. A constant pain and giddiness of the head were the most inseparable and distressing symptoms of this disease. Some were delirious, and a few vomited up a quantity of bile; but in all the countenance was yellow. A long continuance of the fever produced a droopy or jaundice, or both. Even a slight attack reduced the most robust constitution to a state of extreme debility; and this weakness, together with the giddiness, continued for a long time after the fever. A scabby eruption now and then made its appearance on the lips and the corners of the mouth: but dry itchy spots over the whole body, resembling much the common itch, and seeming to partake of the nature of that disease, were more frequently observed in the patients at Portsmouth, where there was not the least reason to suspect any infection.

Such is the appearance of the remitting fever occasioned by marsh miasmata in England. In the Netherlands its symptoms are not much different. Dr Lind informs us, that at Middleburg, the capital of West Zealand, a sickness generally reigns towards the latter end of August, or the beginning of September, which is always most violent after hot summers. It commences after the rains which fall in the end of July; the sooner it begins the longer it continues, and it is only checked by the coldness of the weather. Towards the end of August and beginning of September it is a continual burning fever, attended with a vomiting of bile, which is called the gall-sickness. This fever, after continuing three or four days, intermits, and assumes the form of a double tertian; leaving the patient in a fortnight, or perhaps sooner. Strangers that have been accustomed to breathe a dry pure air do not recover so quickly. Foreigners in indigent circumstances, such as the Scots and German soldiers, who are garrisoned in the adjacent places, are apt after those fevers to have a swelling in their legs and a droopy; of which many die.

These diseases, the doctor observes, are the same with the double tertians common within the tropics. Such as are seized with the gall-sickness have at first some flushes of heat over the body, a loss of appetite, a white foul tongue, a yellow tinct in the eyes, and a pale colour in the lips. Such as live well, drink wine, and have warm clothes and good lodgings, do not suffer so much during the sickly season as the poor people; however, these diseases are not infectious, and seldom prove mortal to the natives.

Sir John Pringle observes, that the prevailing epidemic of autumn in all marshy countries, is a fever of an intermitting nature, commonly of a tertian form, but of a bad kind; which, in the dampest places and worst seasons, appears as a double tertian, a remitting, or even an ardent fever. But however these fevers may vary in their appearance according to the constitution of the patient and other circumstances, they are all of a similar nature. For though, in the beginning of the epidemic, when the heat or rather the putrefaction in the air is the greatest, they assume a continued or a remitting form, yet by the end of autumn they usually terminate in regular intermittents.

In Zealand, where the air is more corrupted than in other parts of the Netherlands, this distemper is called the gall-sickness; and indeed both the redundancy and depravation of the bile is sometimes so great, that it has

been generally ascribed to the corruption and overflowing of that humour. But though it cannot with justice be said to originate from corrupted bile, it is certain that the disease may be continued, and the symptoms aggravated, by an increased secretion and putrefaction of the bile occasioned by the fever. In proportion to the coolness of the season, to the height and dryness of the ground, this distemper is milder, remits or intermits more freely, and removes further from the nature of a continued fever. The higher ranks of people in general are least liable to the diseases of the marshes; for such countries require dry houses, apartments raised above the ground, moderate exercise, without labour in the sun or evening damps, a just quantity of fermented liquors, plenty of vegetables, and fresh meats. Without such helps, not only strangers, but the natives themselves, are sickly, especially after hot and close summers. The hardiest constitutions are very little excepted more than others; and hence the British in the Netherlands have always been liable to fevers.

By this distemper the British troops were harassed throughout the whole of the war from 1743 to 1747. It appeared in the month of August 1743; the paroxysms came on in the evening, with great heat, thirst, a violent headache, and often a delirium. These symptoms lasted most of the night, but abated in the morning, with an imperfect sweat, sometimes with an haemorrhagy from the nose or a looseness. The stomach from the beginning was disordered with a nausea and sense of oppression, frequently with a bilious and offensive vomiting. If evacuations were either neglected, or too sparingly used, the patient fell into a continued fever, and sometimes grew yellow as in a jaundice. When the season was further advanced, this fever was attended with a cough, rheumatic pains, and fizy blood. The officers being better accommodated than the common men, and the cavalry who had cloaks to keep them warm, were not so subject to it; and others who belonged to the army, but lay in quarters, were least of all affected; and the less in proportion to their being little exposed to heats, night-damps, and the other fatigues of the service.

In this manner did the remitting fever infest the army for the remaining years of the war; and that exactly in proportion to their distance from the marshy places, of which we have several notable instances in Pringle's observations. In Hungary the same disease appears with still more violence, and is readily complicated with fevers of a truly pestilential nature, by which means it becomes extremely dangerous. Hungary is acknowledged to be the most sickly climate in Europe, and indeed as bad as any in the world. Here it was where the crusaders in only marching through the country to invade Asia, often lost half their number by sickness; and where the Austrians not long since buried, in a few years, above 40,000 of their best troops, who fell a sacrifice to the malignant disposition of the Hungarian air. The reason of this uncommon malignity is, that Hungary abounds with rivers, which, by often overflowing, leave that low flat country overspread with lakes and ponds of stagnating water, and with large unwholesome marshes. So great is the impurity of these stagnated waters, that by them the rivers, even the Danube, whose course is slow, become in some places corrupted and offensive. The air is

moist, and in summer quite sultry. In the nights of harvest, Kramer tells us, it was so very damp, that the Austrian soldiers could not secure themselves from the moisture even by a triple tent-covering. Here epidemical distempers begin constantly to rage during the hottest months of the year; which are July, August, and September: and these complaints, according to the observations of the physician above mentioned, are the same with those which are epidemic upon the coast of Guinea, and in the sickly climates of the East and West Indies, of which malignant fevers of the remitting and intermitting kind are the most common and dangerous.

The heat of the sun in Hungary is more intense than in any other country of Europe; and in proportion to the heat is the pestifential quality of the marshy exhalations. It is constantly observed, that the nearer any city or fort is to a morass or a large river with foul and oozy banks, the more unhealthy are the inhabitants. At such seasons and places, the air swarms with numberless insects and animalcules, a sure sign of its malignant disposition; and the hotter the summer, the more frequent and mortal are the diseases. In short, this country, on account of its unhealthiness, has been termed the grave of the Germans; and in Italy, the Campania of Rome is almost equally unhealthy. Lanfius, physician to Pope Clement XI. furnishes us with a very striking instance of the malignant quality of the air of Campania. Thirty gentlemen and ladies of the first rank in Rome having made an excursion, upon a party of pleasure, towards the mouth of the Tyber, the wind suddenly shifting, blew from the south over the putrid marshes, when 29 were immediately seized with a tertian fever, only one escaping.

The island of Sardinia is annually visited with an epidemical sickness, which rages from June to September, and is called by the natives the intemperies. In some years there is a want of rain for four or five months; and then it is that this sickness exerts its utmost violence, being always more fatal in some places than in others, and in particular to strangers. Of this the British had a severe proof in 1758.—Admiral Broderick, in the Prince ship of war, anchored in the bay of Oristagni, where 27 of his men, sent ashore on duty, were seized with the epidemical distemper of this island; twelve of them in particular, who had slept on shore, were brought on board delirious. All of them in general laboured under a low fever, attended with great oppression at the breast and at the pit of the stomach, a constant retching, and sometimes a vomiting of bile; upon which a delirium often ensued. These fevers changed into double tertians, and terminated in obstinate quartan agues. It is worthy of remark, that in this ship, which lay only two miles from the land, none were taken ill but such as had been on shore, of whom seven died. The prior of a convent, making a visit to the English officers, informed them, that the intemperies of the island was a remitting or intermitting fever, and that he himself had suffered several attacks of it. Sardinia was formerly so remarkable for its unwholesome air, that the Romans used to banish their criminals thither; and it is at present but thinly peopled, owing to the mortality occasioned by this annual sickness. For although it is about 140 miles long, and in several places 75

miles broad, yet it is computed that the whole number of its inhabitants does not exceed 250,000: an inconsiderable number, when compared with the inhabitants of the lesser, but comparatively more healthful, island of Corsica; though even there the French lost a number of their troops by intermitting and remitting fevers. In the island of Minorca, too, Dr Cleghorn informs us, that fevers of this kind prevail exceedingly; that their types are various, their symptoms violent, the intermissions fallacious, and that they frequently and suddenly prove fatal. It is more than probable, he adds, from the accounts of several physicians and travellers, that epidemical tertians are not wholly confined to the coasts and islands of the Mediterranean, but that they are equally frequent and destructive in many other parts of the globe; and perhaps may be deemed the anniversary autumnal distempers of most hot countries in the world. And though in the mild climate of Britain, a tertian may easily be cured when it is discovered; yet in warm climates, such is the rapid progress of the distemper, that it is necessary to know it in the very beginning, which is very difficult for those who have never seen any but the tertians usually met with in Britain.

From Dr Cleghorn's account of Minorca, however, it doth not appear why that island should be so much infested with fevers of this kind, since it is far from being a marshy country; nay, on the contrary, is very dry. The south wind, he observes, is very unhealthy; and it is the prevalence of this wind which brings on the fever: but still the difficulty is not removed, because the sea air is so far from bringing on such dangerous diseases, that it is one of the greatest preservatives against them. As to the moisture which must necessarily accompany an insular situation, that cannot reasonably be admitted as a cause of this or any other disease. In the London Medical Observations we find a paper on a subject very similar to the present, namely, the mischiefs produced by lying in damp sheets, or being exposed to moist vapour. The author tells us, that he hardly knows a distemper the origin of which has not by some been ascribed to lying in a damp bed, or sitting in a wet room; and yet he does not know any one which will certainly be produced by these causes, and people frequently expose themselves to such causes without suffering any ill effects. "It must be owned indeed, (says he), that the vapours arising from the bilge-water of ships tend to produce a scurvy. The swampy plains also near the mouths of great rivers which are often overflowed, and low grounds which cannot readily be drained, and those tracts of land where the thickness and extent of the woods keep the ground moist and half putrid for want of ventilation, are destructive to the neighbouring inhabitants, by occasioning obstinate intermitting in the colder climates, and pestifential fevers in the hotter regions. But all this mischief arises not merely from moisture, but from an unventilated and putrid moisture; for the inoffensiveness of mere wetness, untainted with putridity, may be reasonably inferred from the following considerations. The air is often fully saturated with moisture; and yet neither is any epidemical distemper produced by it, nor are those remarkably aggravated with which the sick happen at that time to be afflicted. The air from rivers and from the sea is probably more replenish-

Fevers. ed with vapours than inland countries cleared of their woods: yet the most celebrated of the ancient physicians recommended the bank of a running river for the situation of a house, on account of its peculiar healthfulness; and many invalids are sent by the modern physicians to the sea side, only for the benefit of the sea air.

"Where the sailors are cleanly, and not too much crowded, they are often as healthy during long voyages at sea, as they would have been upon any part of the land. Venice is not observed to be less healthy than London or Paris.

"Those who are much disposed to sweat, lie many hours in bedclothes impregnated probably with a less wholesome moisture than would have been left in the sheets half-dried after washing; and there is no reason to think that any remarkable injury was done to the health by the continuance of such sweats almost every night for weeks, and for months, except what arose from the too great copiousness of this evacuation.

"Children, and such as are troubled with the stone, and those who, from other infirmities or age, constantly wet their beds with their urine, do not appear to suffer in their health on this account.

"It is a common practice, in some disorders, to go to bed with the legs or arms wrapped in linen cloths thoroughly soaked in Malvern water, so that the sheets will be in many places as wet as they can be; and I have known these patients and their bedfellows receive no harm from a continuance of this practice for many months. Nor can it be said that the Malvern water is more innocent than any other water might be, on account of any ingredients with which it is impregnated; for the Malvern water is purer than that of any other spring in England which I ever examined.

"The greatest valetudinarians do not scruple to sprinkle lavender-water upon their sheets; and yet, when the spirit is blown off, there is left what is as truly water as if it had been taken from the river.

"Is it observed, that laundresses are peculiarly unhealthy above other women, though they live half their time in the midst of wet linen, in an air fully saturated with vapours? Many other employments might be mentioned, the persons occupied in which are constantly exposed to wet floors or pavements, or to be surrounded with watery vapours, or to have their clothes often wet for many hours together.

"Is it the coldness of wet linen which is to be feared? But shirts and sheets, colder than any unfrozen water can be, are safely worn and lain in by many persons, who, during a hard frost, neither warm their shirts nor their sheets.—Or does the danger lie in the dampness? But then how comes it to pass, that a warm or cold bath, and long-continued fomentations, can be used, without the destruction of those who use them? Or is it from both together? Yet we have long heard of the thickness and continuance of the cold fogs in the seas north-west of England, but have never yet been told of any certain ill effect which they have upon those that live in these countries."

With regard to the causes of fevers, however, Dr Lind is of opinion, that noxious vapours arising from the earth are for the most part to be blamed. Even in countries seemingly dry, and where violent rains are not frequent, he thinks that the air may load itself with putrid exhalations from the ground; and that,

except in the burning deserts of Arabia or Africa, people are nowhere exempt from diseases occasioned by putrid moisture. In most of the hot countries, the pernicious effects of the putrid vapours are by no means equivocal. In Guinea, they seem to be more extraordinary than anywhere else in the world; neither indeed can it be supposed, that a hot and moist atmosphere can be without putrescency. It may in general be remarked, that in saltry climates, or during hot weather, in all places subject to great rains, where the country is not cleared and cultivated, but is overrun with thickets, shrubs, or woods, especially if there are marshes or stagnating waters in the neighbourhood, sickness may be dreaded, and particularly the remitting fever of which we now treat. The fens, even in different counties of England, are known to be very prejudicial to the health of those who live near them, and still more so to strangers; but the woody and marshy lands in hot countries are much more pernicious to the health of Europeans. In all those unhealthy places, particularly during fogs or rains, a raw vapour, disagreeable to the smell, arises from the earth, and especially in the huts or houses. But of all the vapours which infect the torrid zone, the most malignant and fatal are the harmattans: They are said to arise from the conflux of several rivers in the king of Dormeo's dominions at Benin (the most unwholesome part of Guinea), where travellers are obliged to be carried on men's backs for several days journey, through swampy grounds, and over marshes, amidst stinking ooze, and thickets of mangrove trees which are annually overgrown. These vapours come up the coast to a surprising distance, with the south-east and north-east winds: and it has been observed, that in their progress they have often changed both the course of the winds and of the sea-currents. The times of their appearance at Cape Coast are the months of December, January, or February. The north-east and south-east winds are always unhealthy, but particularly so during the harmattan season. In some years this vapour is scarcely perceptible; but in others it is thick, noxious, and destructive to the blacks as well as whites.—The mortality is in proportion to the density and duration of the fog. It has a raw putrid smell; and is sometimes so thick, that a person or house cannot be discerned through it at the distance of 15 or 20 yards: and it continues so for 10 or 14 days; during which it opens the seams of ships, splits or opens the crevices of wood as if shrunk or dried with a great fire, and destroys both man and beast.—In the year 1754 or 1755, the mortality occasioned in Guinea by this stinking fog was so great, that in several negro towns the living were scarce sufficient to bury the dead.—Twenty women brought from Holland by a new governor to the Castle del Mina, perished, together with most of the men in the garrison. The gates of Cape Coast castle were shut up for want of centinels to do duty; the blacks dying at this time as well as the white people. It is lucky that it is only in some years that harmattans are so very thick and noxious, otherwise that part of the country would be depopulated. It is observed that all fogs are extremely unhealthy in those parts, particularly before and after the rainy seasons; but the above account of the harmattans appeared so very extraordinary and incredible to some of Dr Lind's readers, that he thought proper to publish.

publish a further corroboration of the facts above mentioned. "A gentleman (says he), who had long resided at Cape Coast castle, informed me, that during the time of this fog, being in the upper chambers of the fort, the boards of the floor shrunk so much, that he could discern the candles burning in the apartments below him (there are no plaster ceilings used in those hot countries), and that he could then even distinguish what people were doing in the apartments below; the seams of the floor having opened above half an inch while the fog lasted, which afterwards, upon its being dispelled, became close and tight as before."

In Africa the rains and dews seem to be possessed of qualities almost equally pernicious with the fogs. This much is certain, that in Guinea, many of the principal negroes, and especially of the mulatto Portuguese, take the utmost precaution to avoid being wet with those rains, especially such as fall first. At the setting in of the rainy season, they generally shut themselves up in a close well-thatched hut, where they keep a constant fire, smoke tobacco, and drink brandy, as preservatives against the noxious quality of the air at that time. When wet by accident with the rain, they immediately plunge themselves into salt-water, if near it. Those natives generally bathe once a-day, but never in the fresh water rivers when they are overflowed with the rains: at such times they prefer for that purpose the water of springs. The first rains which fall in Guinea are commonly supposed to be the most unhealthy. They have been known, in 48 hours, to render the leather of the shoes quite mouldy and rotten; they stain clothes more than any other rain; and soon after their commencement, even places formerly dry and parched swarm with frogs. At this time skins, part of the traffic of Senegal, quickly generate large worms; and it is remarked, that the fowls, which greedily prey on other insects, refuse to feed on these. It has been further observed, that woollen cloths wet in those rains, and afterwards hung up to dry in the sun, have sometimes become full of maggots in a few hours.—It is also probable, that as in some of those countries the earth, for six or eight months of the year, receives no moisture from the heavens but what falls in dews, which every night renew the vegetation, the surface of the ground in many places becomes hard and incrustated with a dry crust, which pens up the vapours below; until, by the continuance of the rains for some time, this crust is softened, and the long pent up vapours set free. That these dews do not penetrate deep into the earth is evident from the constant dryness and hardness of such spots of ground in those countries as are not covered with grass and other vegetables. Thus the large rivers in the dry season being confined within narrow bounds, leave a great part of their channel uncovered, which having its moisture totally exhaled, becomes a solid hard crust; but no sooner the rains fall, than by degrees this long parched up crust of earth and clay gradually softens, and the ground, which before had not the least smell, begins to emit a stench, which in four or five weeks becomes exceedingly noisome, at which time the sickness is generally most violent.

This sickness, however, is not different from the remitting fever which has been described under so many various forms and names. An inflammatory fever is seldom observed, during the season of sickness,

in this part of the world; and we shall conclude our description of the amphimerina paludosa with some extracts from the surgeon's journal in a ship that sailed up the rivers of Guinea.

"On the 5th of April we sailed up the river of Gambia, and found all the English in the fort in perfect health. The surgeons of the factory informed me, that a relaxation of the stomach, and consequently a weakened digestion, seemed to bring on most of the diseases so fatal to Europeans in the sickly season. They were generally of a bilious nature, attended with a low fever, sometimes of a malignant, at other times of a remitting kind.—On the 12th of April, after sailing 30 miles up the river St Domingo, we came to Catchou, a town belonging to the Portuguese, in Lat. 20° N. In this town were only four white people, the governor, and three friars. The number of whites in the trading ships was 51. One morning, towards the latter end of April, a little rain fell. On the 13th of May there was a second shower, accompanied with a tornado. On the 18th of May it rained the whole day; and the rain continued, with but short intervals, until the beginning of October.

"In the month of June, almost two-thirds of the white people were taken ill. Their sickness could not be well characterized by any denomination commonly applied to fevers: it however approached nearest to what is called a nervous fever, as the pulse was always low, and the brain and nerves seemed principally affected. It had also a tendency to frequent remissions. It began sometimes with a vomiting, but oftener with a delirium. Its attack was commonly in the night; and the patients, being then delirious, were apt to run into the open air. I observed them frequently recover their senses for a short time, by means of the heavy rain which fell upon their naked bodies. But the delirium soon returned: they afterwards became comatose, their pulse sunk, and a train of nervous symptoms followed; their skin often became yellow; bilious vomitings and stools were frequent symptoms. The fever reduced the patient's strength so much, that it was generally six weeks or two months before he was able to walk abroad. A consuming flux, a jaundice, a dropsy, or obstructions in the bowels, were the consequences of it. Of 51 white men, being the companies of four ships which were at Catchou, one third died of the fever, and one-third more of the flux, and other diseases consequent upon it; and of these not one was taken ill till the rains began.

"I believe, on the whole face of the earth, there is hardly to be found a more unhealthy country than this during the rainy season: and the idea I then conceived of our white people was by making a comparison of their breathing such a noxious air, with a number of river-fish put into stagnating water; where, as the water corrupts, the fish grow less lively, they droop, pine away, and many die.

"Thus some persons became dull, inactive, or slightly delirious, at intervals; and, without being so much as confined to their beds, they expired in that delirious and comatose state in less than 48 hours, after being in apparent good health. The white people in general became yellow; their stomach could not receive much food without loathing and retchings. Indeed, it is no wonder that this sickness proved so fatal, that recoveries

ries from it were so tedious, and that they were attended with fluxes, dropsies, the jaundice, ague-cakes, and other dangerous chronical distempers. It seems more wonderful to me that any white people ever recover, while they continue to breathe so pestiferous an air as that at Catchon during the rainy season. We were, as I have already observed, 30 miles from the sea, in a country altogether uncultivated, overflowed with water, surrounded with thick impenetrable woods, and overrun with slime. The air was vitiated, noisome, and thick; insomuch that the lighted torches or candles burnt dim, and seemed ready to be extinguished: even the human voice lost its natural tone. The smell of the ground and of the houses was raw and offensive; but the vapour arising from putrid water in the ditches was much worse. All this, however, seemed tolerable, when compared with the infinite numbers of insects swarming every where, both on the ground and in the air; which, as they seemed to be produced and cherished by the putrefaction of the atmosphere, so they contributed greatly to increase its impurity. The wild bees from the woods, together with millions of ants, overrun and destroyed the furniture of the houses; at the same time, swarms of cockroaches often darkened the air, and extinguished even candles in their flight; but the greatest plague was the mosquitoes and sand-flies, whose incessant buzz and painful stings were more insupportable than any symptom of the fever. Besides all these, an incredible number of frogs on the banks of the river made such a constant and disagreeable croaking, that nothing but being accustomed to such an hideous noise could permit the enjoyment of natural sleep. In the beginning of October, as the rains abated, the weather became very hot; the woods were covered with abundance of dead frogs, and other vermin, left by the retreat of the river; all the mangroves and shrubs were likewise overspread with stinking slime."

After so particular a description of the remitting fever in many different parts of the world, we presume it will be needless to take notice of any little varieties which may occur in the warm parts of America, as both the nature and cure of the distemper are radically the same: neither shall we lengthen out this article with further descriptions of remitting fevers from the works of foreign authors, as, from what we have already said, their nature cannot easily be mistaken.

Cure. The great difficulty in the cure of remitting fevers arises from their not being simple diseases, but a complication of several. Fevers, properly speaking, have but three or four different appearances which they can assume without a complication. One is, when they are attended with a phlogistic diathesis: another is, when they assume the form of genuine intermitents; a third is, when they produce a great debility of the nervous system; and the fourth is, when along with this debility there is also a rapid tendency to putrefaction. If, therefore, all these species happen to make an attack at once, the most dangerous fever we can imagine will be produced; and however contrary it may be to our theories to admit the possibility of such an attack, the truth of the fact is too often confirmed by fatal experience. In the beginning of remittent fevers, for instance, the symptoms indicate a high degree of inflammation; but if the practitioner at-

tempts to remove this inflammation by blood-letting or other evacuations, the pulse sinks irrecoverably, and the person dies with such symptoms as show that the nervous system has been from the beginning greatly affected; at the same time the high stimulants and cordials, or cinchona, which would have conquered the nervous part of the disease, increase the inflammatory part of it to such a degree, that, by a too early exhibition of them, the patient also dies, but after another manner.

In the remitting fever of the East Indies, Dr Lind of Windsor formed the following indications of cure. 1. To allay the violence of the fever. 2. To evacuate the putrid humours, and take great care to prevent the body from inclining to putrefaction. 3. To keep up the strength of the patient as much as possible during the disorder. 4. To lose no time in preventing the return of the paroxysms.

To allay the violence of the fever, every thing that can contribute to increase it ought to be carefully avoided or removed; such as great heat, too strong a light falling on the eyes, noise, and motion. If during the paroxysm the head and loins be affected with violent pains, the pulse be full and hard, and the heat intense, bleeding may be used, but with the greatest caution: for, however useful this operation may be in cold climates, the success of it in warm ones is so far from being certain, that the lives of the patients have been often very much endangered, nay even destroyed by it. Dr Bdenoch, and the surgeon of the Pomborne, endeavoured each of them to relieve two patients by blood-letting; and the consequence was, that each of them lost one patient. Dr Lind bled two patients; one of whom was Mr Richardson, the first mate of the ship, who complained of a most violent pain in his head, with a full hard pulse. About four or five ounces of blood were taken from him, by which he was greatly relieved: nor was the cure retarded by it; nay, the fever afterwards became less irregular. At the time the other patient was bled, the disease was exceedingly frequent and violent. He was so earnest for bleeding, that he fired all the rest with the same desire, swearing, that by refusing them this only remedy, every one of them would be sent to their graves. To quiet them, therefore, and get quit of their importunities, the doctor complied with their request, and took about five or six ounces from him who had been the first to require it. The consequence was, that he immediately lost his strength; and in less than an hour, during which time he made his will, was carried off by the next fit. It is necessary, however, to observe, and indeed the doctor himself makes the observation, with regard to this patient, that he was bled at an improper time, namely, between the fits; whereas, had he been bled in the hot fit, it is possible he might have been relieved.

In support of the advantages to be derived from bleeding under proper circumstances, we have the authority both of Cleghorn and Pringle. As Dr Cleghorn practised in a very hot country, his observations must in the present case have greater weight than those of Pringle, who practised in a colder one. The former acquaints us, that if he was called in early enough, unless there was a strong contra-indication, he always used to take away some blood from people

people of all ages; namely, from robust adults, 10 or 12 ounces; from others a smaller quantity, in proportion to their strength and years. And further, if a violent headache, obstinate delirium, and heat or pains of the bowels, were urgent, the bleeding was repeated within a day or two. By this seasonable evacuation, he found the vehemence of all the paroxysms somewhat diminished; the apyrexia became more complete; the operation of emetics and cathartics rendered safer and more successful; and the terrible symptoms which happened about the height of the distemper, such as raving sonor, difficulty of breathing, inflammations of the abdominal viscera, &c. were either prevented or mitigated. But if the fever had continued for some time before he was called, and the mass of blood appeared to be too much melted down or inclined to a putrid dissolution, he either abstained from bleeding entirely, or took away a very small quantity, though some urgent symptoms might seem to require a larger evacuation. As to the time of performing the operation, he acquaints us, that it is safe enough, except when the cold fit lasts or is soon expected, or while the skin is covered with critical sweats; and that he usually opened a vein in the beginning of the hot fit; by which means the sick were relieved, the immoderate heat of the body, which is often productive of fatal effects, was diminished, and the critical sweats brought on sooner and in greater abundance.

But though Dr Lind found venesection to be of such pernicious tendency in his patients, cooling acidulated liquors were of the utmost service, as they corrected the putrid humours, lessened the heat and thirst, and of course prevented the fever from arriving at so great an height as it would otherwise have done. Those cooling liquors are the best which are made up with some farinaceous substance, as they most easily unite with our fluids. Fossile acids too, and crystals of tartar, especially the latter, are of considerable use, not only in this, but in other fevers. The neutral salts, prepared with the juice of lemons, were likewise given with success during the heat of the fever. They lessen the nausea, the fits become more regular, and the remissions more full; and they are particularly grateful when given in a state of effervescence. The good effects of these draughts we are in a great measure to ascribe to the antiseptic quality of the fixed air extracted from them during the effervescence.

During the remission, it is proper to evacuate the putrid humours by small doses of ipecacuanha, or rather tartar emetic. The tartar emetic indeed appears to be endowed with some kind of febrifuge virtue, which Dr Cullen thinks is owing to its relaxing the febrile spasm taking place in the capillary vessels. But should there appear any symptoms of a topical inflammation in some of the abdominal viscera, a thing which never happens unless the disorder has been of some standing, vomiting is to be avoided, and we are to depend upon purgatives alone for the evacuation of the putrid bile. These are always useful in the cure of this disorder. But all acrid and strong purgatives are to be carefully avoided, and only the mild antiseptic ones made use of, such as crystals of tartar, or tamarinds made up with manna or with Glauber's salt.

Though in these diseases there is a great quantity of putrescent bile collected in the body, yet it seems much more probable that this is the effect than the cause of the disorder; and therefore, though we carry off the quantity collected ever so often, more of the same kind will still be produced by the putrescent disposition of the other fluids, at the same time that the strength of the patient must necessarily be diminished by repeated evacuations, when it ought rather to be kept up by all possible means. We ought well to observe, however, that the mineral acids have not that property of sweetening putrid bile which the vegetable ones have; and therefore the same relief will not be given by them which might reasonably be expected from vinegar or lemon juice.

In order to keep up the strength of the patient, good food is absolutely necessary. Dr Lind allowed the sick small messes of panada made with boiled rice and barley mixed with currants or raisins and prunes, seasoned with sugar and a little wine, especially claret. During the paroxysms, they had gruel made of flour and rice, with sugar and the juice of acid fruit; and when the fit went off, a little wine was added to this mixture.

The shirts and bedding must be very often changed and well aired; their stools, and all filth and nastiness, are to be immediately removed; the places where they are lodged should be well aired and frequently sprinkled with vinegar; and, in the last place, the sick must be exceedingly well nursed. Blisters, according to Dr Lind, should never be used till the fever has been of long continuance, or the spirits and pulse of the patient have begun to flag. But here our author has implicitly followed Dr Huxham, whose theory concerning the use of blisters is now found to be erroneous. According to that celebrated author, blisters are capable of doing considerable hurt in all cases where there is a tendency to inflammation, by increasing the motion of the fluids and the oscillatory power of the vessels, both of which are already too great. They are also improper, according to him, where there is a considerable tendency of the fluids to putrefaction; because he supposes the salts of these flies to operate in the same manner with volatile alkalies, that is, by dissolving and putrefying the blood still farther. But Sir John Pringle has shown, that, in inflammatory fevers as well as those of the putrid kind, both blisters and volatile salts may be of service; the latter, particularly, he hath experimentally proved to be so far from promoting putrefaction, that they are exceedingly strong antiseptics.

In the East Indies, Dr Lind found it absolutely necessary to exhibit the Peruvian bark in large quantities, and as early as possible. By this method he not only secured the patient from the imminent danger of death to which he was exposed at every fit, but likewise conquered those obstructions which were apt to ensue in the abdominal viscera, and which are to be attributed to the continuance of the disorder, and not to the bark employed to cure it. He always gave the cinchona during the second remission, as all his care was during the first to cleanse the primæ viæ. He observes, however, that it is to no purpose to give the bark till the necessary purgations are over; but assures us, that it never fails, unless from the coming on of a vomiting

Fevers. or diarrhoea it cannot be taken in sufficient quantities before the return of a paroxysm. To prevent the medicine from vomiting or purging, he mixed a few drops of liquid laudanum with every dose of it. Half a dram was given every half hour in some convenient vehicle, beginning as soon as the fever had considerably abated, and the pulse was returned nearly to its natural state; both which generally happened before the sweats were over. An ounce of the bark was sometimes found too little to check the fever, but an ounce and a half never failed. It must be continued daily in small doses till the patient has recovered his strength, and then a greater quantity must be given, especially at the season when the rivers overflow the country.

Dr Pringle found the autumnal remittents in the Netherlands complicated with a great many inflammatory symptoms; for which reason it was generally found necessary to open a vein in the beginning. The venal and later autumnal remitting fevers are accompanied with pleuritic and rheumatic pains from the coldness of the weather, and on that account require more bleeding. A physician unacquainted with the nature of the disease, and attending chiefly to the paroxysms and remissions, would be apt to omit this evacuation entirely, and give the cinchona too soon, which would bring on a continued inflammatory fever. In these countries a vein may be safely opened either during the remission or in the height of a paroxysm; and our author also found good effects resulting from bleeding in the hot fits of the marsh fever, even after it had almost come to regular intermissions. After bleeding, a purgative was usually exhibited, of which he gives us the following formula.

R. Infusi senæ commun. 3iij.
Ect. Lentic. 3ss.
Nitr. pur. 3i.
Tinct. sen. 3vi. M.

Of this only one half was taken at once; and if it did not operate twice in four hours, the remainder was then taken. This potion agreed with the stomach, purged plentifully, and therefore was a very useful composition. Next morning, when there was almost always some remission, he gave one grain of emetic tartar rubbed with 12 grains of crabs-eyes, and repeated the dose in two hours, if the first had little or no effect; or at any rate in four hours. This medicine was intended not only to vomit, but also to operate by stool, and excite a sweat. If these evacuations were procured, the fever generally became easier, and was even sometimes cured. This he prefers to the ipecacuanha, and therefore in the latter years of his practice disused that root entirely. The same medicine was repeated next day or the day following; or if not, a laxative clyster was thrown up: and this method was continued till the fever either went off altogether, or intermitted in such a manner as to be cured by the cinchona.

A similar method was followed by Dr Huck in the remitting fevers of the West Indies and North America. In the beginning he let blood; and in the first remission gave four or five grains of ipecacuanha, with from half a grain to two grains of emetic tartar. This powder he repeated in two hours, taking care that the

patient should not drink before the second dose; for then the medicine more readily passed into the bowels after it had operated by vomiting. If, after two hours more, the operation either way was small, he gave a third dose, which commonly had a good effect in opening the first passages; and then the fever either went quite off, or intermitted in such a manner as to yield to the bark. On the continent, he found little difficulty after the intermission; but in the West Indies, unless he gave the cinchona upon the very first intermission, though imperfect, the fever was apt to assume a continued and dangerous form.

In the remitting fevers of hot countries, however, it must be observed, that the lancet must in all cases be much more sparingly used than in similar diseases of the colder regions; and we must also be sparing of venesection in those countries where the marsh effluvia are very strong and prevail much. For this reason Dr Lind of Hatlar greatly condemns the practice of indiscriminate bleeding when people first arrive in hot climates. The first diseases indeed which occur in a voyage to the southward are, for the most part, of an inflammatory nature, and owing to a sudden transition from cold to hot weather. This occasions a fullness and distension of the vessels; whence all Europeans, on their first arrival under the tropic, bear evacuations much better than afterwards. The practice of indiscriminately bleeding, however, a number of the ship's company when they first come into a warm latitude, is by no means found to answer the purpose of a preventive. In such cases, indeed, as plainly indicate a plethoric disposition brought on by the heat, blood-letting is certainly useful. The signs of this are a pain and giddiness in the head; a heaviness and dulness of the eyes, which sometimes appear slightly inflamed: there is also commonly a sense of weight and fulness in the breast, the pulse at the same time being quick and oppressed.

But the case is quite different after a longer continuance of sultry weather, and when the constitution is in some measure habituated to the hot climate. For it is then observed, that the symptoms of inflammations in the bowels, even the most dangerous, are not near so severe in such climates as in cold countries; nor can the patients bear such large evacuations. The physician, however, must take care not to be misled by the apparent mildness of the symptoms: for he will find, notwithstanding such deceitful appearances, that the inflammation makes a more rapid progress in hot countries than in cold, suppurations and mortifications being much more suddenly formed; and that in general all acute distempers come sooner to a crisis in the warm than in colder regions. Hence it is an important rule of practice in those climates, to seize the most early opportunity, in the commencement of all threatening inflammations, to make frequent though not copious evacuations by blood-letting. For by delay the inflammation quickly passes from its first to its last or fatal stage; at least, an imperfect crisis in such inflammatory fevers ensues, which fixes an obstruction in the viscera extremely difficult to remove.

It is indeed a general maxim with some physician in the West Indies, that in most acute distempers bleeding in that country is prejudicial. This is founded upon a supposition that the crassamentum of the blood

is thinned, and the solids greatly weakened, by the heat of the climate. It is therefore objected, that bleeding in such an habit of body weakens the powers of nature, and withdraws the strength which is requisite to support the patient until the crisis of the fever.

This reasoning is partly just; but, like all general maxims, will admit of exceptions. First, with regard to sailors, it is to be remembered, that they are more exposed to quick vicissitudes of heat, cold, damps, and to various changes of the air and weather, than most of the other inhabitants of the Torrid Zone. Add to this, that their intemperance, and the excesses they are apt to fall into whenever it is in their power to commit them, render them more liable to inflammations than any other set of people. Hence their diseases require more plentiful evacuations than the land-inhabitants of those parts of the world, and generally they bear them better. But with regard to the natives of the country, or those who have remained long there, it must be proper to bleed them very sparingly, making allowance for the different seasons of the year, the temperature of the air, and the situation of the places where they reside. Thus, in some parts, even on the island of Jamaica, at particular seasons, the weather is cool; wherefore, in these places, and at such seasons, the inhabitants having their fibres more rigid, and a firmer crasis of their blood, bear venesection much better.

In cold countries the state of the air greatly assists in restoring the impaired spring of the fibres; whereas every thing almost in warm weather, such as heat, moisture, &c. concur to relax and weaken the habit of body. Thus we may daily see persons in Britain, after having suffered a most severe fit of sickness, recover their strength and spirits in a few days, and in a very short time their natural constitution. But the case is very different in the sultry regions of the Torrid Zone, or indeed in any part of the world where the heat of the season causes the mercury to stand for any length of time at the 77th degree and upward of Fahrenheit's thermometer. During such an excess of heat, debility after fevers is apt to remain with European constitutions for several months. In Jamaica, the convalescents are sent to the cool summits of the mountains; but a retreat to a more northern climate is often absolutely necessary to recover their wonted tone and vigour of body. It is a well-established observation, that the negroes and aborigines of the Torrid Zone cannot bear plentiful evacuations by the lancet. They commonly mix the most stimulating poignant spices with their ordinary light food, and this is found by experience suitable to their constitutions.

As proper preventives for the dangerous fevers of which we are treating, Dr Lind on all occasions recommends the avoiding of stagnant water, or putrid marshes; the use of proper food, cleanliness, and sobriety. Of the propriety of removing from the neighbourhood of those places whose pestilential effluvia produce the disorders, we cannot possibly entertain a doubt; and of the efficacy of proper food in preventing putrid disorders he gives a remarkable instance in the Sheerness man of war, bound to the East Indies. As they went out, the men being apprehensive of

sickness in so long a voyage, petitioned the captain not to oblige them to take up their salt provisions, but rather to permit them to live upon the other species of their allowance. It was therefore ordered, that they should be served with salt-meat only once a-week; and the consequence was, that, after a passage of five months and one day, the ship arrived at the Cape of Good Hope without having a single person sick on board. As the use of Sutton's pipes had been then newly introduced into the king's ships, the captain was willing to ascribe part of such an uncommon healthfulness to their beneficial effects; but it was soon discovered, that, by the neglect of the carpenter, the cock of the pipes had all this while been kept shut. This ship remained in India some months, where none of the men, except the boats crew, had the benefit of going on shore; notwithstanding which, the crew continued to enjoy the most perfect state of health; they were, however, well supplied with fresh meat. On leaving India, knowing they were to stop at the Cape of Good Hope, and trudging to a quick passage, and the abundance of refreshments to be had there, they ate their full allowance of salt meats, during a passage of only 10 weeks; and it is to be remarked the air-pipes were now opened. The effects of this was, that when they arrived at the Cape, 20 of them were afflicted in a most miserable manner with scrofulous and other disorders. These, however, were speedily recovered by the refreshments they met with on shore. Being now thoroughly sensible of the beneficial effects of eating, in these southern climates, as little salt meat as possible when at sea, they unanimously agreed, in their voyage home from the Cape, to refrain from their too plentiful allowance of salt flesh. And thus the Sheerness arrived at Spithead, with her full complement of 160 men in perfect health and with unbroken constitutions, having in this voyage of 14 months and 15 days buried but one man, who died in a mercurial salivation.

Thus we see, that a free and pure air is not a sufficient preservative against a putrescent state of the fluids, without proper food; and, on the other hand, we have a very remarkable instance of the inefficacy of the most salutary food to prevent putrid diseases, in a very noxious state of the atmosphere. In the year 1717, at the siege of Belgrade in Hungary, the fever of the country, and the flux, occasioned a most extraordinary mortality among the troops. The dread of these diseases caused every one, as may naturally be supposed, to have recourse to different precautions for self-preservation. Prince Eugene, the commander in chief, had water and the provisions for his table sent him twice a-week from Vienna. The pure stream of the river Kahlenberg was regularly brought to him: he avoided all excesses, and lived regularly, or rather abstemiously; refreshed himself often by eating a cool melon; and mixed his usual wine, which was Burgundy, with water. Yet, notwithstanding his utmost care, he was seized with a dysentery; which would have quickly put an end to his life, had not the speedy conclusion of that campaign permitted him to make a quick retreat.

At this unhealthy season, when hardly one imperial officer, much less their several domestics, escaped those malignant diseases, the renowned Count Bonneval and his

his numerous retinue continued in perfect health, to the surprise, or to use the words, of Dr. Kramer, to the envy, of all who beheld them. The only precaution he used, was to take, two or three times a-day, a small quantity of brandy in which the Peruvian bark was infused; and he obliged all his attendants and domestics to follow his example. It is no less remarkable that the count, placing his certain preservation in the use of this single medicine, lived for many years afterwards in the most unhealthy spots of Hungary, without any attack or apprehension of disease; and continued to enjoy a perfect state of health during the hottest and most sickly seasons. And thus, with an unbroken and sound constitution, which is seldom the case of those who reside long in such climates, he lived to a great age. There is an instance produced by the same author, of a whole regiment in Italy having been preserved by the use of cinchona from the attack of these malignant diseases, viz. the flux, and bilious fever as it is frequently called, when the rest of the Austrian army, not pursuing that method, became greatly annoyed with them.

The intemperance and irregular living of those Europeans who visit the hot climates is frequently accused as the cause of their destruction; but our author thinks, without sufficient reason; for though intemperance will make the body more liable to receive such diseases, it will not bring them on. It must by no means, however, be imagined, that in those climates Europeans may with impunity be guilty of excesses in eating or drinking; for the least error in that way will often prove fatal by debilitating the body, whose utmost strength in time of full health was perhaps scarce sufficient to resist the pestilential miasmata of the atmosphere.

It appears, therefore, from the concurrent testimony of the most eminent physicians, that the most proper medicine to be used, either as a preventive or cure for remitting and intermitting disorders, is the Peruvian bark, administered with proper precautions and after the perine via have been evacuated of the putrid bilious matter collected in them. In those species of tritophya, &c. belonging to this class, enumerated by Sauvages, the same remedies only were useful; but in that pestilential distemper which he calls tritophya Vratissaviensis, he tells us, that washing the body with water sometimes hot, sometimes cold, watery clysters, and plenty of aqueous drink, were likewise of use.

Quartana auctorum, Sauv. Gen. 89. Lin. 17. Vog. 3. Sog. 711. Hoffm. II. p. 23. Junck. tab. 81.

The Genuine QUARTAN, Sp. I. var. 1. A.
Quartana legitima, Sauv. sp. 1. Sydenham de morb. acut. cap. v.

Description. The genuine quartan, according to Juncker, keeps its form more exactly than other intermitments; scarcely coming on at any other time than four or five in the afternoon. The cold is less violent than in the tertian; but is very perceptible, though it doth not proceed to such a height as to make the limbs shake; it continues for about two hours. It is preceded and accompanied by a languor both of body

and mind. There is seldom any vomiting unless when the stomach is manifestly overloaded with aliment; neither is there any diarrhoea, but the belly in general is rather bound, not only on the days on which the paroxysm takes place, but also on the intermediate ones. The heat, which slowly succeeds the cold, is less troublesome to the patient by its violence than by the uneasy dryness of the skin, which is scarcely ever moistened with sweat. This heat rarely continues longer than four or five hours, unless perhaps at the first or second paroxysm. It is accompanied also with a giddiness and dull pain of the head. On the termination of the paroxysm, the patient returns to a middling state of health, and continues in the same for the rest of the intermediate days; only there remains somewhat of a loathing, and a deep-seated pain as if the person was all over bruised or broken, which kind of sensation the physicians are wont to call osteocopus. The fit returns every fourth day, and that precisely at the same hours, being rarely postponed.

Causes of, and persons subject to, this disorder. The same general causes concur in producing this as other intermitments, namely marsh miasmata, and whatever can dispose the body to be easily affected by them. Studious people, and those of a melancholic turn, are said to be particularly subject to quartans; but what are the immediate causes which produce a return of the fits every fourth day, instead of every day, or every third day, must probably lie for ever concealed, as depending upon the secret and inexplicable mechanism of the human body.

Prognosis. A simple quartan, where there is no reason to dread any induration of the viscera, may very certainly admit of a cure; and the prognosis can never be unfavourable, unless in cases of extreme weakness, or where the distemper hath been unskillfully treated.

Cure. This does not in the least differ from that which hath been fully laid down for the simple tertian, and which it is therefore needless to repeat here.

Quartana duplicata, Sauv. sp. 4. Bonet.

This is entirely similar to the duplicated tertian already mentioned; proper allowance being made for the difference between the type of a tertian and quartan.

Quartana triplicata, Sauv. sp. 16.

This hath three paroxysms every fourth day, while the intermediate days are entirely free from fever.

Quartana duplex, Sauv. sp. 3. Vog. sp. 13.

In the double quartan, the fits come on every day except the third; but so that the first paroxysm answers to the third, the second to the fourth, and so on.

Quartana triplex, Sauv. sp. 5. Vog. sp. 14. Bartholin. H. anat. c. 1. 95.

This comes on every day, but the quartan type is still.

still preserved by the times of accession; that is, the time of the fourth paroxysm's coming on answers to that of the first, the fifth to the second, the sixth to the third, &c.

The QUARTAN, accompanied with Symptoms of other diseases. Sp. I. var. 2.

137 Quartana cataleptica, Sauv. sp. 7. Bonet. polyalth. vol. i. p. 805.
Quartana comatosa, Sauv. sp. 15. Werlhof. de febr. C. Pisonis Observ. de morbis à colluvie feros. obs. 166, 167, 168, 169, 171, 172, 173, 174.
Quartana epileptica, Sauv. sp. 8. Scholzii Conf. 379, 380.
Quartana hysterica, Sauv. sp. 10. Morton, Pyret. exerc. i. cap. ix. H. 10, 11.
Quartana nephralgica, Sauv. sp. 9.
Quartana metastatica, Sauv. sp. 17.
Quartana amens, Sauv. sp. 12. Sydenham de morb. acut. cap. v.
Quartana splenetica, Sauv. sp. 2. Etmuller, Coll. consult. cas. 25.

The QUARTAN complicated with other Diseases. Sp. I. var. 3.

138 Quartana syphilitica, Sauv. sp. 6. Plateri, observ. L. III. p. 676. Edin. Ess. art. xvii. obs. 8.
Quartana arthritica, Sauv. sp. 11. Musgr. de Arthr. sympt. cap. ix. H. 4. et 5.
Arthritis febrifeca, Sauv. sp. 10.
Arthritis febricosa, Sauv. sp. 10. Werlhof. de febr. Cockburn de morbis navigantium, obs. 19.
Quartana scorbutica, Sauv. sp. 14. Barthol. de med. Dan. diff. iv. Tim. L. VIII. cas. 18.

The Remitting QUARTAN. Sp. II.

159 Tetartophya, Sauv. gen. 85. Seg. 699. Lin. 21.
Quartana remittens auctorum.
Var. 1. Tetartophya simplex, Sauv. sp. 1.
2. Amphimerina semiquartana, Sauv. sp. 23.
3. Tetartophya semitertiana, Sauv. sp. 5.
4. Tetartophya maligna, Sauv. sp. 6. Lauter. Hist. med. cas. 21. M. Donat. L. III. cap. 14. ex M. Gatenaria Horst. L. I. obs. 15.
5. Tetartophya carotica, Sauv. sp. 4. Werlhof. de febr. Bianchi Hist. hep. pars III. constit. ann. 1718, p. 751.
6. Tetartophya splenalgica, Sauv. sp. 2.
7. Tetartophya hepatalgica, Sauv. sp. 3. Car. Pis. in prefat. p. 33.
8. Amphimerina spasmodica, Sauv. sp. 16.

To the tertian or quartan fevers also belong the Eraticæ of authors. As all those above mentioned differ only in the slight circumstance of the type from the intermitting and remitting tertians already described at length, it is unnecessary here to take up time in describing every minute circumstance related by physicians concerning them, especially as it could contribute nothing towards the laying down a better method of cure than what hath been already suggested.

GENUS III. QUOTIDIANA; the QUOTIDIAN FEVER.

Quotidiana auctorum, Sauv. gen. 86. Lin. 15. Vog. I. Hoffm. II. 33. Junck. tab. 79.

The Genuine QUOTIDIAN. Sp. I. var. 1. A.

Quotidiana simplex, Sauv. sp. 1.

Quotidiana legitima, Seennert. de febr. cap. 18.

Description. This kind of fever generally comes on about six or seven o'clock in the morning, beginning with a considerable degree of cold and shivering, which lasts for about an hour; and is often accompanied with vomiting or spontaneous diarrhoea, or both. It is succeeded by a pretty strong heat, accompanied with thirst, restlessness, and pain of the head. When the heat abates a little, a spontaneous sweat commonly follows, and the whole paroxysm rarely exceeds six hours. It returns, however, every day almost always at the same hour, unless it be evidently disturbed.

Causes of, and persons subject to, the disease. The same general causes are to be assigned for the quotidian as for other intermittents. This kind occurs but rarely; and is said to attack people of a phlegmatic temperament rather than any other: also old people rather than young, and women rather than men.

The prognosis and method of cure are not different from those of tertians and quartans.

The Partial QUOTIDIAN. Sp. I. var. 1. B.

Quotidiana partialis, Sauv. sp. 16. Cnoffel, E. N. C. D. I. A. III. obs. 205. Edin. Med. Ess. vol. i. art. 31. vol. ii. art. 16.
Quotidiana cephalalgica, Sauv. sp. 6. Mort. pyretol. exerc. i. hist. 27. Van Swieten in Boerh. p. 534.
Cephalalgia intermittens, Sauv. sp. 7.
Cephalæa febricosa, Sauv. sp. 4.
Quotidiana ophthalmica, Morton, ibid. hist. 17. Van Swieten, ibid.

Ophthalmia febricosa, Sauv. sp. 23.

These distempers attack only some particular part of the body, as the head, the eye, arm, &c. producing periodical affections of those parts returning once in 24 hours; they are to be cured by cinchona, as other intermittents. They are known to belong to this class, by the evident intermission of the pain or other affection of the part. The quotidian hysterica, Sauv. sp. 3. quotidian catarrhalis, Sauv. sp. 9. and quotidian strangurosa, Sauv. sp. 11. seem to be symptomatic disorders.

The Remitting QUOTIDIAN. Sp. II.

Amphimerina, Sauv. gen. 84. Lin. 20.
Quotidiana continua, Vog. 15.
Quotidianæ remittentes et continuæ auctorum.
Amphimerina latica, Sauv. sp. 1.
Febris continua lymphatica, Etmuller, Coll. conf. cas. 32. River. Obs. cent. i. obs. 57.
Amphimerina singultuosa, Sauv. sp. 14.
Febris continua Lyngodes, Vog. 26.

Concerning these also nothing remains necessary to be mentioned in this place, having already so fully discussed the remitting fevers in all the different parts of the

the world. Many other varieties of these fevers mentioned by different authors are to be accounted merely symptomatic.

Continuae, Sauv. clas. ii. ord. 1. Vog. clas. i. ord. 2.
Sag. 666. Boerh. 727.

Continentes, Lin. clas. ii. ord. 1. Stahl. Cas. mag.
35. Cas. min. 87. Junck. 58. Senneri. de feb.
L. ii. cap. 2. et 10.

163 Synocha, Sauv. gen. 80. Lin. 12. Junck. 58.
Synocha, five febris acuta sanguinea, Hoffm. II. 105.
Synochus, Vog. 16.
Continua non putris, Boerh. 720.
Ephemeræ, Sauv. g. 79. Boerh. 728. Junck. 57.
Diaria, Lin. 11.
Febris inflammatoria auctorum.

Description. The most simple kind of synocha is the ephemera or diary fever. It begins without any sensation of cold or shivering, unless there be some internal inflammation, or the small-pox or measles happen to be present. A continual heat without any intermission constitutes the essence of this disease. The heat, however, is more tolerable than in the synocha properly so called. In some, the pains of the head are pungent and throbbing, answering to the pulsations of the arteries; but in others they are dull and heavy. The face is red and bloated; and there is a remarkable lassitude of the limbs, with a strong, full, and frequent pulse. The urine is red, and deposits a sediment almost of the colour of orange-peel; and in the very first day of the disease, signs of concoction (according to the Hippocratic phrase) appear. The fever commonly goes off with a gentle sweat; but sometimes, though more rarely, with a hemorrhagy by the nose. Its shortest period is 24 hours; but if it goes beyond the fourth day, it is then a synocha properly so called.

The simple synocha, according to Vogel, begins with cold and shivering, succeeded by vehement heat, redness, and dryness of the skin. The face, especially, is very red, and the thirst intense. The head is either pained or heavy. The patient either doth not sleep at all, or is disturbed with dreams. A moist sweat then breaks out all over the skin. The pulse is full, quick, and frequent; the judgement is sometimes a little disturbed; young people are apt to be terrified with imaginations; and they for the most part incline to sleep: the respiration is difficult, and the belly colicky; at the same time that a tenacious kind of lassitude is perceived over the whole body. A complete crisis takes place either on the fourth or at the farthest on the eleventh day. The characteristic marks of the simple synocha, therefore, are, A redness of the face, moisture of the skin, a strong and frequent pulse.

Causes of, and persons subject to, this disease. As we have already remarked of intermitents, so must we also now remark of continued fevers, that it is impossible to discover those minute causes which occasion the difference of type betwixt one inflammatory fever and another, though most authors pretend to enumerate these with

great certainty. Thus Juncker tells us, that the cause of the simple ephemera is plethora, together with any Synocha. Synocha. 263
immmoderate agitation and commotion of the fluids while in that state. Vogel reckons among the causes of his febris diaria, passions of the mind, pain, want, exposure to the sun, &c.; a repulsion or absorption of certain humours; wounds, fractures, luxations, &c.; so that in general we may reckon every thing tending to increase the action of the arterial system to be in certain circumstances a cause of inflammatory fever.—Hence we find those are most subject to the synocha whose constitution is either naturally robust, or who are exposed to those causes which tend to produce an increased action of the arterial system; such as hard labour, high living, &c.

Prognosis. The most simple kind of synocha, that is, the ephemera or diary fever, is commonly cured without the assistance of medicine, and therefore the prognosis is for the most part favourable: yet, if it be improperly treated by heating medicines, it may easily be converted into the other kind; or, if there be a putrid disposition of the fluids, into a fever of a very dangerous nature. The same thing is to be understood even of the most violent kind; for simple inflammatory fevers are not dangerous unless complicated with an affection of some particular part, as the pleura, stomach, &c.

Cure. Dr Cullen objects to the plan of those who are for leaving the cure of continued fevers to the operations of nature; because these operations are neither certain in themselves, nor are they so well understood as to enable us to regulate them properly; and it is likewise possible to supersede them by art. The plan therefore on which he proceeds is, to form his indications of cure upon the means of obviating the tendency to death in fevers; and these he reduces to three. 1. To moderate the violence of re-action.—2. To remove or obviate the causes of debility; and, 3. To obviate or correct the tendency of the fluids to putrefaction.

The first indication may be answered, 1. By all those means which diminish the action of the heart and arteries. 2. By those which take off the spasm of the extreme vessels, which, according to his theory, is the chief cause of violent re-action.

1. The action of the heart and arteries may be diminished, 1. By avoiding or moderating those irritations which, in one degree or other, are almost constantly applied to the body. 2. By the use of certain sedative powers. 3. By diminishing the tension or tone of the arterial system.

[4.] The irritations above-mentioned are the impressions made upon our senses, the exercise of the body and mind, and the taking in of aliments. The avoiding of these as much as possible, or the moderating their force, makes what is properly called the antiphlogistic regimen, proper to be employed in almost every continued fever. This regimen is to be directed in the following manner.

1. Impressions on the external senses, as stimulant to the system, and a chief support of its activity, should be avoided as much as possible; especially such as are of a stronger kind, and which give pain and uneasiness. No impression is to be more carefully guarded against than that of external heat; and at the same

Febres. same time every other means of increasing the heat of the body is to be shunned. Both these precautions are to be taken as soon as a hot stage is fully formed, and to be attended to during its continuance, except in certain cases, where a determination to sweating is necessary, or where the stimulant effects of heat may be compensated by circumstances which determine it to produce a relaxation and revulsion.

2. All motion of the body is to be avoided as much as possible, and that posture only chosen which employs the fewest muscles, and keeps none of them long in a state of contraction. Speaking, as it accelerates respiration, is particularly to be avoided. It must also be observed, that every motion of the body is more stimulant in proportion as the patient is weaker.

3. The exercise of the mind is also to be avoided, as being a stimulus to the body; but here an exception is to be made in the case of a delirium coming on, when the presenting of accustomed objects may divert the irregular train of ideas then arising in the mind.

4. The presence of recent aliment in the stomach proves always a stimulus to the system, and ought therefore to be as moderate as possible. A total abstinence for some time may be of service; but as this cannot be long continued with safety, we must avoid the stimulus of aliment by choosing that kind which gives the least. Alimentary matters are also to be accounted more stimulant in proportion to their alkaline qualities; and this leads us to avoid all animal, and use only vegetable food. For the same reason, aromatic and spirituous liquors are to be avoided; and in answering the present indication, we must abstain from all fermented liquors except those of the lowest quality. Other stimuli are, the sensation of thirst, crudities or corrupted humours in the stomach, a preternatural retention of the faeces in the intestines, and a general acrimony of all the humours, which is in most fevers to be suspected. These are to be removed by such methods as the urgency of the symptoms require, by diluting liquors, vomiting, the use of acids, laxative clysters, and large quantities of antiseptic drinks.

[2.] The second method of moderating the violence of reaction is by the employment of certain sedative powers, with a view to diminish the activity of the whole body, and particularly that of the sanguiferous system. The first of these to be mentioned is the application of cold. Heat is the chief support of the activity of the animal-system; and the system is therefore provided with a power of generating heat: but at the same time we may observe, that this would go to excess, were it not constantly moderated by a cooler temperature in the surrounding atmosphere. When, therefore, the generating power of heat in the system is increased, as is commonly the case in fevers, it is necessary not only to avoid all further means of increasing it, but also to apply air of a cooler temperature; or at least to apply it more entirely and freely than in a state of health. This is shown, from some late observations, to be a very powerful means of moderating the violence of reaction: but what is the mode of its operation, to what circumstances of fever it particularly applies, or what limitations it requires, are not yet fully ascertained.

Another sedative power very frequently employed in fevers, is that of certain medicines known in the materia medica by the name of refrigerants. The chief of these are acids of all kinds when sufficiently diluted, and which are, in several respects, remedies adapted to continued fevers. Those especially in use are the sulphuric and vegetable; and on many accounts the latter are to be preferred. Another set of refrigerants are the neutral salts formed of the sulphuric, nitrous or vegetable acids, with alkalies either fixed or volatile. All these neutrals, while they are dissolved in water, generate cold; but as that cold ceases soon after the dissolution is finished, and as the salts are generally exhibited in a dissolved state, their refrigerant power in the animal body does not all depend upon their power of generating cold with water. Nitre is the refrigerant chiefly employed; but all the others, compounded as above mentioned, partake more or less of the same quality. Besides these neutrals, some metallic salts have also been employed in fevers, particularly the acetite of lead: but the refrigerant powers of this salt are by no means ascertained, and its deleterious qualities are too well known to admit of its being freely used.

[3.] The third general method of diminishing the reaction, is by lessening the tension, tone, and activity of the sanguiferous system. As the activity of the system in a great measure depends upon the tone, and this again upon the tension, of the vessels, given to them by the quantity of fluids they contain, it is evident, that the diminution of the quantity of these must diminish the activity of the sanguiferous system. The most efficacious means of diminishing the quantity of fluids is by the evacuations of blood-letting and purging. The former is evidently one of the most powerful means of diminishing the activity of the whole body, and especially of the sanguiferous system; and it must therefore be the most effectual means of moderating the reaction in fevers. When the violence of reaction, and its constant attendant a phlogistic diathesis, are sufficiently evident; when these constitute the principal part of the disease, and may be expected to continue through the whole of it, as in the cases of synocha; then blood-letting is the principal remedy, and may be employed as far as the symptoms of the disease may seem to require, and the constitution of the patient will bear. It must, however, be remarked, that a greater evacuation than is necessary may occasion a slower recovery, and render the person more liable to a relapse, or bring on other diseases. It is also to be observed, that this evacuation is the more effectual, as the blood is more suddenly drawn off, and as the body is at the same time more free from all irritation, and therefore when it is in a posture in which the fewest muscles are in action.

With regard to purging, when we consider the quantity of fluids constantly present in the cavity of the intestines, and the quantity which may be drawn off from the innumerable excretories that open into this cavity, it will be obvious, that a very great evacuation may be made in this way; and if this be done by a stimulus that is not at the same time communicated to the rest of the body, it may, by emptying both the cavity of the intestines and the arteries which furnish

Febris. furnish the excretions poured into it, induce a considerable relaxation in the whole system; and is therefore suited to moderate the violence of reaction in fevers. But it is to be observed, that as the fluid drawn from the excretories opening into the intestines is not all drawn immediately from the arteries, and as what is even more immediately drawn from these is drawn off slowly; so the evacuation will not, in proportion to its quantity, occasion such a sudden depletion of the red vessels as blood-letting does; and therefore cannot act so powerfully in taking off the phlogistic diathesis of the system.

At the same time this evacuation may induce a considerable degree of debility; and therefore, in those cases in which a dangerous state of debility is likely to occur, purging is to be employed with a great deal of caution; and this caution is more difficult to be observed than in the case of blood-letting: and it is further to be noticed, that as purging takes off in some measure the determination of the blood to the vessels on the surface of the body, it seems to be less adapted to the cure of fevers.

II. The other method of moderating the violence of reaction in fevers is by the exhibition of those remedies suited to take off the spasm of the extreme vessels, supposed to be the irritation which chiefly supports the reaction. The means to be employed for this purpose are either internal or external.

First. The internal means are, 1. Those which determine the force of the circulation to the extreme vessels on the surface of the body, and by restoring the tone and activity of these vessels, overcome the spasm on their extremities. 2. Those medicines which have the power of taking off spasm in any part of the system, and which are known under the title of ANTI-SPASMODICS.

(1.) Those remedies which are fit to determine to the surface of the body are, 1. Diluents. 2. Neutral salts. 3. Sudorifics. 4. Emetics.

1. Water enters, in a large proportion, into the composition of all the animal fluids, and a large quantity of it is always diffused through the whole of the common mass. In a sound state, the fluidity of the whole mass depends upon the quantity of water present in it. Water therefore is the proper diluent of our mass of blood, and other fluids are diluent only in proportion to the quantity of water they contain.

In a healthy state, also the fulness of the extreme vessels and the quantity of excretion are in proportion to the quantity of water present in the body. But in fever, though the excretions be in some measure interrupted, they continue in such quantity as to exhale the more fluid parts of the blood; and, while a portion of them is at the same time necessarily retained in the larger vessels, the smaller, and the extreme vessels, both from the deficiency of fluid and their own contracted state, are less filled, and therefore allowed to remain in that condition. To remedy this contracted state, nothing is more necessary than a large supply of water or watery fluids taken in by drinking or otherwise; for as any superfluous quantity of water is forced off by the several excretories, such a force applied may be a means of dilating the extreme vessels, and of overcoming the spasm affecting their extremities. Accordingly, the throwing in a large quan-

ity of watery fluids, has been, at all times, a remedy much employed in fevers; and in no instance more remarkably than by the Spanish and Italian physicians, in the use of what they call the dieta aquosa. This practice consists in taking away every other kind of aliment and drink, and in giving, in divided portions, every day for several days together, six or eight pounds of plain water, generally cold, but sometimes warm. This, however, is to be done only after the disease has continued for some time, and at least for a week.

2. A second mean of determining to the surface of the body, is by the use of neutral salts. These neutrals, in a certain dose, taken into the stomach, produce soon after a sense of heat upon the surface of the body; and, if the body be covered close and kept warm, a sweat is readily brought out. The same medicines taken during the cold stage of a fever, very often put an end to it, and bring on the hot one; and they are also remarkable for stopping the vomiting which so frequently attends the cold stage of fevers. All this shows, that neutral salts have a power of determining the blood to the surface of the body, and may therefore be of use in taking off the spasm which subsists there in fevers. The neutral most commonly employed in fevers, is that formed of an alkali with the native acid of vegetables. But all the other neutrals have more or less of the same virtue; and perhaps some of them, particularly the ammoniacal salts, possess it in a stronger degree. As cold water taken into the stomach often shows the same diaphoretic effects with the neutral salts, it is probable that the effect of the latter depends upon their refrigerant powers.

3. A third method of determining to the surface of the body, and taking off the spasm subsisting there, is by the use of sudorifics and by sweating. The propriety of this practice has been much disputed; and many specious arguments may be adduced both for and against it. In its favour may be urged, 1. That in healthy persons, in every case of increased action of the heart and arteries, a sweating takes place, and is, seemingly, the means of preventing the bad effects of such increased action. 2. That, in fevers, their most usual solution and termination is by spontaneous sweating. 3. That, even when excited by art, it has been found useful at certain periods, and in certain species of fever.—On the other hand, it may be urged against the practice of sweating, 1. That in fevers, as a spontaneous sweating does not immediately come on, there are some circumstances different from those in the state of health, and which may render it doubtful whether the sweating can be safely excited by art. 2. That in many cases the practice has been attended with bad consequences. The means commonly employed have a tendency to produce an inflammatory diathesis; which, if not taken off by the sweat succeeding, must be increased with much danger. Thus sweating employed to prevent the accessions of intermitting fevers has often changed them into a continued form, which is always dangerous. 3. The utility of the practice is doubtful; as sweating, when it happens, does not always give a final termination, as must be manifest in the case of intermitting, and in many continued fevers which are sometimes in the beginning attended with sweatings which do not prove final; and, on the contrary, whether they be spontane-

neous or excited by art, they seem often to aggravate the disease.

From these considerations, it is doubtful if the practice of sweating can be admitted very generally; but, at the same time, it is also very doubtful if the failure of the practice, or the mischiefs said to arise from it, have not been owing to the improper conduct of the practitioner. With respect to the last, it is almost agreed among physicians, 1. That sweating has been generally hurtful when excited by stimulant, heating, and inflammatory medicines. 2. That it has been hurtful when excited by much external heat, and continued with a great increase of the heat of the body. 3. That it is always hurtful when it does not relieve; and rather increases the frequency and hardness of the pulse, the anxiety and difficulty of breathing, the headache, and delirium. 4. That it is always hurtful if it be urged when the sweat is not fluid, and when it is partial and on the superior parts of the body only.

In these cases, it is probable, that either an inflammatory diathesis is produced, which increases the spasm on the extreme vessels; or that, from other causes, the spasm is too much fixed to yield easily to the increased action of the heart and arteries: and upon either supposition it must be obvious, that urging the sweat may produce determinations to some of the internal parts, with very great danger.

Notwithstanding these doubts, however, it still remains true, 1. That sweating has been often useful in preventing the accessions of fevers when they have been certainly foreseen, and a proper conduct employed. 2. That even after fevers have in some measure come on, sweating has interrupted their progress when properly employed, either at the very beginning of the disease, or during its approach and gradual formation. 3. That even after pyrexie have continued for some time, sweating has been successfully employed in curing them, as is particularly exemplified in the case of a rheumatism. 4. That certain fevers produced by a very powerful sedative contagion, have been generally treated most successfully by sweating.

These instances are in favour of sweating, but give no general rule; and it must be left to further experience to determine how far any general rule can be established in this matter. In the mean time, if the practice of sweating is to be attempted, the following rules may be laid down for the conduct of it: 1. That a sweat should be excited without the use of stimulant inflammatory medicines. 2. That it should be excited with as little external heat, and with as little increase of the heat of the body, as possible. 3. That, when excited, it should be continued for a due length of time; not less than 12 hours, and sometimes for 24 or 48 hours; always, however, supposing that it proceeds without the dangerous circumstances already mentioned. 4. That for some part of the time, and as long as the person can easily bear, it should be carried on without admitting of sleep. 5. That it should be rendered universal over the whole body; and therefore particularly that care should be taken to bring the sweating to the lower extremities. 6. That the practice should be rendered safer by moderate purging excited at the same time. 7. That it should not

be suddenly checked by cold anyhow applied to the Synocha. body.

When attention is to be given to these rules, the sweating may be excited, 1. By warm bathing, or a fomentation of the lower extremities. 2. By frequent draughts of tepid liquors, chiefly water, rendered more grateful by the addition of a light aromatic, or more powerful by that of a small quantity of wine. 3. By giving some doses of neutral salts. 4. Most effectually, and perhaps most safely, by a large dose of an opiate, joined with a portion of neutral salts, and of an emetic.

The fourth mean of determining to the surface, of the body, and thereby taking off the spasm affecting the extreme vessels, is by the use of emetics. These, particularly of the antimonial kind, have been employed in the cure of fevers ever since the introduction of chemical medicines; but though of late their use has become very general, their efficacy is still disputed, and their manner of operating is differently explained.

Vomiting is in many respects useful in fevers; as it evacuates the contents of the stomach, as it emulges the biliary and pancreatic ducts, and evacuates the contents of the duodenum, and perhaps also of a large portion of the intestines; as it agitates the whole of the abdominal viscera, it expedites the circulation in them, and promotes their several secretions; and, lastly, as it agitates also the viscera of the thorax, it has like effects there.

It is not to this cause, however, that we are to impute the effect vomiting has in determining to the surface of the body. This must be attributed to the particular operation of emetics upon the muscular fibres of the stomach, whereby they excite the action of the extreme arteries on the surface of the body, and by this means effectually determine the blood to these vessels, remove the atony, and take off the spasm affecting them. For this purpose they are exhibited in two different ways; that is, either in such doses as may excite full and repeated vomitings, or in such doses as may excite sickness and nausea only, with little or no vomiting at all.

Full vomiting is well suited to determine to the surface of the body, and thereby to obviate the atony and spasm which lay the foundation of fever. Thus, vomiting excited a little before the expected accession of the paroxysm of an intermittent, has been found to prevent the paroxysm altogether. It has been observed also, that when contagion has been applied to a person, and first discovers its operation, an emetic given has prevented the fever which might otherwise have been expected.

These are the advantages to be obtained by exciting vomiting at the first approach of fevers, or of the paroxysm of fevers; and they may also be applied after fevers are formed, to take off, perhaps entirely, the atony and spasm, or at least to moderate these, so that the fever may proceed more gently and safely. It is seldom, however, that vomiting is found to produce a final solution of fevers; and after they are once formed, it is commonly necessary to repeat the vomiting several times; but this is attended with inconvenience, and sometimes with disadvantage. The operation of full

Febris. full vomiting is transitory, and the exercise of vomiting is a debilitating power; and therefore, when the vomiting does not remove the atony and spasm very entirely, it may give occasion to their recurrence with greater force. For these reasons, after fevers are fully formed, some physicians have thought proper to employ emetics in nauseating doses only. These are capable of exciting the action of the extreme vessels, and their operation is more permanent. At the same time they often show their power by exciting some degree of sweat, and their operation is rendered more safe by their commonly producing some evacuation by stool. But nausea continued for any great length of time, is to most patients a sensation highly distressing, and almost insufferable.

The emetics chiefly in use at present are, ipecacuanha and antimony. The former may be employed for determining to the surface of the body: but, even in very small doses, it so readily excites vomiting, that it is with difficulty employed for the purpose of nauseating only; and in whatever manner employed, there is reason to suspect that its effects are less permanent, and less powerfully communicated from the stomach to the rest of the system, than those of antimony. This last is therefore generally preferred; and its preparations, seemingly various, may all be reduced to two heads; one comprehending those in which the reguline part is in a condition to be acted upon by acids, and therefore on meeting with acids in the stomach it becomes active; and another, comprehending those preparations in which the reguline part is already joined with an acid, rendering it active. Of each kind there are great numbers, but not differing essentially from one another; the two most worthy of notice are, the calx nitrata antimonii, and emetic tartar, or tartrite of antimony, of the Edinburgh Dispensatory. Both these are very efficacious medicines; but the latter seems preferable, because its dose is capable of being better ascertained; though the former, on account of its slower operation, may have some advantages, and in certain cases be more efficacious as a purgative and sudorific.

The calx nitrata antimonii, when first introduced into the pharmacopoeia of the Edinburgh college was supposed to be very nearly, if not precisely, the same with a medicine which has of late been highly celebrated in the cure of fevers, Dr James's powder. But from more accurate observations, there is now reason to believe that the pulvis antimonialis of the London Pharmacopoeia, formed by the calcination of antimony with hartshorn, approaches more nearly to that celebrated arcanum. But at any rate, the calx antimonii nitrata, the pulvis antimonialis, and James's powder, are probably not essentially different from each other. The two latter, however, have the most near resemblance; and accordingly the Edinburgh college, in their Pharmacopoeia, have introduced an article under the title of antimonium calcareo-phosphoratum, which they consider as so much similar to James's powder, that they have used as a synonyme for it, the title of pulvis Jacobi.

The time most proper for exhibiting these medicines is a little before the accession, when that can be certainly known. In continued fevers the exacerbations are not always very observable; but there is reason to

believe, that one commonly happens about noon or soon after it; and that these, therefore, are the most proper times for exhibiting emetics.

With respect to the manner of administration, that of the calx nitrata is simple, as the whole of what is thought a proper dose may be given at once; and no more can be properly given till the next accession. The administration of the emetic tartar is different. It is to be given in small doses, not sufficient to excite vomiting; and these doses are to be repeated after short intervals for several times, till sickness, nausea, and some, though not much, vomiting come on. The difference of administration must depend upon the dose, and the length of the interval at which it is given. If it be intended that the medicine should certainly operate by stool, the doses are made small, and the intervals long. On the contrary, when vomiting is proper, or when much purging ought to be avoided, and therefore some vomiting must be admitted, the doses are made larger, and the intervals shorter. With respect to both kinds of preparations, the repetition is to be made at the times of accession, but not very often: for if the first exhibitions, duly managed, have little effect, it is seldom that the after exhibitions have much; and it sometimes happens that the repeated vomiting, and especially repeated purging, does harm by weakening the patient.

(2.) The other set of internal medicines which are supposed useful in taking off the spasm of the extreme vessels, are those named antispasmodics. But whatever may be the virtues of some of them in this way, such is their power of stimulating at the same time, that very few of them can with safety be administered in fevers of an inflammatory nature. Almost the only one which can with safety be exhibited in these cases is camphor; and the operations of this are by no means well ascertained. Dr Huxham mentions it as a corrector of the acrimony of cantharides; and assures us, that it very effectually promotes a diaphoresis. But from the remarks of other practitioners, we have no just reason to suppose that it acts perceptibly in a dose of five or six grains, though in 15 or 20 it produces a particular kind of intoxication.

Secondly. The external means suited to take off the spasm of the extreme vessels, are blistering and warm bathing.

1. What are the effects of blistering so frequently employed in fevers, is not yet agreed among physicians. Dr Cullen is of opinion, that the small quantity of cantharides absorbed from a blistering plaster, is not sufficient to change the consistence of the mass of blood; and therefore, that such a quantity can neither do good by resolving phlogistic lentor if it exists, nor do harm by increasing the dissolution of the blood arising from a putrid tendency in it. The effects of cantharides upon the fluids, therefore, may be entirely neglected. The inflammation produced by the application of cantharides to the skin, affords a certain proof of their stimulant power: but in many persons the effect of that stimulus is not considerable; in many it is not communicated to the whole system; and even when it does take place in the whole system, it seems to be taken off very entirely by the effusion and evacuation of serum from the blistered part. It may be concluded, therefore, that neither much good is to be expected,

nor much harm to be apprehended, from the stimulant power of blistering; and the certainty of this conclusion is established by the great benefit arising from the proper practice of blistering in inflammatory diseases. Much has been imputed to the evacuation made by blistering; but it is never so considerable as to affect the whole system; and therefore can neither, by a sudden depletion, relax the sanguiferous system, nor by any revulsion affect the general distribution of the fluids. The evacuation, however, is so considerable as to affect the neighbouring vessels; and the manifest utility of blistering near the part affected in inflammatory diseases leads us to think, that blistering, by deriving to the skin, and producing an effusion there, relaxes the spasm of the deeper seated vessels. It is in this manner, most probably, that the tumor of a joint, from an effusion into the cellular texture under the skin, takes off the rheumatic pain formerly affecting that joint. Analogous to this, probably, is the good effect of blistering in continued fevers, arising from the relaxation of the spasm of the extreme vessels by a communication of the blistered part with the rest of the skin. A blister may be employed at any period in continued fevers; but it will be of most advantage in the advanced state of such fevers, when, the reaction being weaker, all ambiguity from the stimulating power of blistering is removed, and when it may best concur with other circumstances tending to a final solution of the spasm.

From this view of the matter, it will appear, that the part of the body to which blisters ought to be applied is indifferent, except upon the suspicion of topical affection, when the blistering is to be made as near as possible to the part affected. Whether synapsisms and other rubeofactenta act in a manner analogous to what has been supposed of blistering may be doubtful; but their effects in rheumatism and other inflammatory diseases render it probable.

2. The other external means of taking off the spasm of the extreme vessels is warm bathing. This was frequently, and in different circumstances, employed by the ancients; but has, till very lately, been neglected by modern physicians. As the heat of the bath stimulates the extreme vessels, and, with the concurrence of moisture, also relaxes them, it seems to be a safe stimulus, and well suited to take off the spasm affecting these vessels. It may be applied to the whole body by immersion; but this is in many respects inconvenient. From extensive experience it appears, that most of the purposes of warm bathing can be obtained by a fomentation of the legs and feet, if properly administered, and continued for a due length of time, not less than an hour. The marks of the good effects of such a fomentation are, the patient's bearing it easily, its relieving delirium, and inducing sleep.

GENUS V. TYPHUS; the Typhous FEVER.
Typhus, Sauv. gen. 82. Sag. 677.

I. Typhus mitior, or the Slow Nervous FEVER. Sp. I. var. 1.

Febris maligna heclica convulsiva, five lues nervosa, Willis, de morb. convulsiv. cap. 8.

Febris pestilens, Fracastor, de morb. contag. l. ii. cap. 4.

Febris pestilens sine caractere veneni, Forst, l. vi. obs. 26. Typhus.

Febris heclica pestilens, Forst, l. vi. obs. 32.

Febris nova ann. 1635, Sydenham, Sched. monitor.

Febris putrida nervosa, Winirringh. Com. Nosolog. ad ann. 1720, 1721.

Febris lenta nervosa, Huxham on fevers, chap. 8.

Febris contagiosa, Lind on fevers and infection, passim.

Typhus nervosus, Sauv. sp. 2.

Typhus comatosus, Sauv. sp. 3.

Triteophya typhodes Mangeti, Sauv. sp. 11. Raym. Fort. de febribus.

Description. Of all the descriptions we have of the nervous fever, that of Dr Huxham is perhaps the best. According to him, the patient at first grows somewhat listless, and feels slight chills and shudders, with uncertain flushes of heat, and a kind of weariness all over, like what is felt after great fatigue. This is always attended with a sort of heaviness and dejection of spirit, and more or less of a load, pain, or giddiness of the head; a nausea and distaste of every thing soon follows, without any considerable thirst, but frequently with retching to vomit, though little but insipid phlegm is brought up. Though a kind of lucid interval of several hours sometimes intervenes, yet the symptoms return with aggravation, especially towards night; the head grows more giddy or heavy; the heat greater; the pulse quicker, but weak; with an oppressive kind of breathing. A great torpor, or obtuse pain and coldness, affects the hinder part of the head frequently, and oftentimes a heavy pain is felt on the top all along the coronary suture; this, and that of the back part of the head, generally attend nervous fevers, and are commonly succeeded by some degree of a delirium. In this condition the patient often continues for five or six days, with a heavy, pale, funk countenance; seemingly not very sick, and yet far from being well; restless, anxious, and commonly quite void of sleep, though sometimes very drowsy and heavy; but although he appears to those about him actually to sleep, he is utterly insensible of it. The pulse during all this time is quick, weak, and unequal; sometimes fluttering, and sometimes for a few moments slow; nay, even intermitting, and then, with a sudden flush in the face, immediately very quick, and perhaps soon after surprisingly calm and equal; and thus alternately. The heats and chills are as uncertain and unequal; sometimes a sudden colour and glow arise in the cheeks, while the tip of the nose and ears are cold, and the forehead at the same time in a cold dewy sweat. Nay, it is very common, that a high colour and heat appear in the face, when the extremities are quite cold. The urine is commonly pale, and often limpid; frequently of a whey colour, or like vapid small beer, in which there is either no manner of sediment, or a kind of loose matter like bran irregularly scattered up and down in it. The tongue at the beginning is seldom or never dry or discoloured, but sometimes covered with a thin whitish mucus: at length, indeed, it often appears very dry, red, and chapped, or of the colour of pomegranate rind; but this chiefly at the close of the disease: yet, however dry the tongue and lips seem, the patient seldom complains of thirst, though sometimes of a heat in the tongue. About the seventh or eighth day, the giddiness,

Fever. Giddiness, pain, or heaviness of the head become much greater, with a constant noise in it, or tinnitus aurium; which is very disturbing to the sick, and frequently brings on a delirium. The load on the præcordia, anxiety and faintness, grow much more urgent; and patients often fall into an actual deliquium, especially if they attempt to sit up; cold sweats suddenly come out on the forehead, and on the backs of the hands (though at the same time there be too much heat in the cheeks and palms), and as suddenly go off. If the urine now grow more pale and limpid, a delirium is certainly to be expected, with universal tremors and subfultus tendinum; the delirium is seldom violent, but as it were a confusion of thought and action, muttering continually and faltering in their speech. Sometimes they awake only in a hurry and confusion, and presently recollect themselves, but forthwith fall into a muttering dozy state again. The tongue grows often very dry at the height, especially in its middle part, with a yellowish tinge on each side, and trembles greatly when the sick attempts to put it out. Frequently profuse sweats pour forth all at once, about the ninth, tenth, or eleventh day, commonly coldish and clammy on the extremities; oftentimes very thin stools are discharged, and then nature sinks apace; the extremities grow cold, the nails pale or livid; the pulse may be said to tremble and flutter, rather than to beat, the vibrations being so exceedingly weak and quick that they can scarce be distinguished; though sometimes they creep on surprisingly slow, and very frequently intermit. The sick become quite insensible and stupid, scarce affected with the loudest noise or the strongest light; though, at the beginning, strangely susceptible of the impressions of either. The delirium now ends in a profound coma, and that soon in death. The stools, urine, and tears, run off involuntarily, and denounce a speedy dissolution, as the tremblings and twitchings of the nerves and tendons are precludes to a general convulsion, which at once snaps the thread of life. In one or other of these ways are the sick carried off, after having languished for 14, 18, or 20 days; nay, sometimes much longer. Most patients grow deaf and stupid towards the end of this disease (some extremely deaf), though too quick and apprehensive at the beginning; insomuch that the least noise or light greatly offended them. Many from their immoderate fears seem to hurry themselves out of life, where little danger is apparent at the beginning: nay, some will not allow themselves to sleep, from a vain fear of dozing quite away; and others from the vast hurry, anxiety, and confusion of which they are sensible either during sleep or at their waking.

Causes of, and persons subject to, this disorder. The nervous fever is most frequently the consequence of contagion. It most commonly attacks persons of weak nerves, a lax habit of body, and a poor thin blood; those who have suffered great evacuations, a long dejection of spirits, immoderate watchings, studies, fatigue, &c.; also those who have used much crude unwholesome food, vapid impure drinks, or who have been confined long in damp foul air; who have broken the vigour of their constitutions by salivations, too frequent purging, immoderate venery, &c. Hence we see how the disease is connected with an extreme debility of the nervous system; for when people

are prepared for this fever by having their nerves already weakened, the contagious particles immediately attack the nervous system, without so much affecting the state of the blood or juices, though the latter are greatly affected in the putrid malignant fevers.

Prognosis. In nervous fevers, the prognosis is very much the same with that of the putrid malignant kind. And although death be not so frequent as in that modification of fever, yet it may justly be considered as a very fatal disease.

Cure. As this fever is produced by contagion affecting the nervous system of a person already debilitated, and thus producing weakness in an extreme degree, we have now occasion to consider Dr Cullen's two indications of cure omitted under the Synochus; namely, to remove the cause and obviate the effects of debility, and to correct the putrescent tendency of the fluids; for though, in the beginning of nervous fevers, the tendency to putrefaction be not remarkable, it becomes exceedingly great towards their conclusion.

[1.] In answering the first indication, Dr Cullen observes, that most of the sedative powers inducing debility cease to act soon after they have been first applied; and therefore the removing them is not an object of the present indication. There is only one which may be supposed to continue to act for a long time, and that is the contagion applied; but we know nothing in the nature of contagion that can lead us to any measures for removing or correcting it. We know only its effects as a sedative power inducing debility, or as a ferment inducing a tendency to putrefaction in the fluids, the former of which at present falls under our consideration.—The debility induced in fevers by contagion, or other causes, appears especially in the weaker energy of the brain; but in what this consists, or how it may be restored, we do not well know; but as nature, seemingly for this purpose, excites the motion of the heart and arteries, we must ascribe the continuance of the debility to the weaker reaction of the sanguiferous system: the means, therefore, which we employ for obviating debility, are immediately directed to support and increase the action of the heart and arteries; and the remedies employed are tonics or stimulants.

In contagious diseases we know, both from the effects which appear, and from dissections, that the tone of the heart and arteries is considerably diminished; and that tonic remedies are therefore properly indicated. We are to consider these remedies as of two kinds; 1. The power of cold; 2. That of tonic medicines.

The power of cold as a tonic in fevers may be employed in two ways: either as thrown into the stomach, or as applied to the surface of the body. As we have already observed that the power of cold may be communicated from any one part to every other part of the system, so it will be readily allowed that the stomach is a part as fit as any other for this communication, and that cold drink taken into the stomach may prove an useful tonic in fevers. This the experience of all ages has confirmed; but at the same time it has been frequently observed, that, in certain circumstances, cold drink taken into the stomach has proved very hurtful; and therefore that its use in fevers requires some limitations.

Febric. torsions. What these limitations should be, and what are all the circumstances which may forbid the use of cold drink, it is difficult to determine; but it seems clearly forbidden in all cases where a phlogistic diathesis prevails in the system, and more especially when there are topical affections of an inflammatory nature.

The other method of employing cold as a tonic, is by applying it to the surface of the body, as a refrigerant power fit to moderate the violence of reaction; but probably it may here also be considered properly as a tonic, and useful in cases of debility.— Not only cool air, but cold water also may be applied to the surface of the body as a tonic. The ancients frequently applied it with advantage to particular parts as a tonic; but it is a discovery of modern times, that, in the case of putrid fevers attended with much debility, the body may be washed all over with cold water. This was first practised at Breslaw in Silesia, as appears from a dissertation under the title of Epidemia Verna, que Wratislaviam anno 1737 afflixit, to be found in the Acta Nat. Curios. vol. x. And from other writers it appears, that the practice has passed into some of the neighbouring countries. But in Britain the use of cold water externally applied has of late been more extensively introduced than into any other country of Europe. For this we are chiefly indebted to the late ingenious Dr Currie of Liverpool. He has recommended the dashing cold water over the whole surface of the body, as a means not only of obviating heat, delirium, and other symptoms most urgent; but of putting an immediate stop to the disease. And there can be no doubt that the practice has often been attended with the most salutary consequences. But it is by no means so generally advantageous as Dr Currie and some others are inclined to believe. It is in but very rare instances that an artificial termination of fever can thus be obtained; and even as obviating symptoms, it is not unfrequently attended with bad consequences. It can never be employed with safety unless where the heat is very urgent. And perhaps all the advantages of cold immersion may be obtained merely from cold washing, a practice now very common in Britain.

The medicines which have been employed in fevers as tonics are various. If the acetite of lead hath been found useful, it is probably as a tonic rather than as a refrigerant; and the ess. venereis, or other preparations of iron which have been employed, can act as tonics only. The preparations of copper, from their effects in epilepsy, are presumed to possess a tonic power; but whether their use in fevers be founded on their tonic or emetic powers, is uncertain. And upon the whole there may no doubt occur some instances of fevers being cured by tonics taken from the fossil kingdom; but the vegetable tonics are the most efficacious, and among these the cinchona certainly holds the first place.

The cinchona has commonly been considered as a specific, or a remedy of which the operation was not understood. We must observe, however, that, as in many cases the effects of the bark are perceived soon after its being taken into the stomach, and before it can possibly be conveyed to the mass of blood, we may conclude, that its effects do not arise from its operating

on the fluids; and must therefore depend upon its acting on the nerves of the stomach, and being thereby communicated to the rest of the nervous system. This operation seems to be a tonic power, the bark being a remedy in many cases of debility, particularly in gangrene; and if its operation may be explained from its possessing a tonic power, we may easily perceive why it is improper when a phlogistic diathesis prevails; and from the same view we can ascertain in what cases of continued fever it may be admitted. These cases are either where considerable remissions have appeared, when it may be employed to prevent the return of exacerbations, on the same footing as it is used in intermitting fevers; or in the advanced state of fevers, when all suspicion of an inflammatory condition is removed, and a general debility prevails in the system; and its being then employed is sufficiently agreeable to the present practice.

Another set of medicines to be employed for obviating debility and its effects, are the direct stimulants. These, in some measure, increase the tone of the moving fibres; but are different from the tonics, as they more directly excite and increase the action of the heart and arteries. This mode of operation renders their use ambiguous; and when an inflammatory diathesis is present, the effects of the stimulants may be very hurtful; but it is still probable, that in the advanced state of these fevers, when debility prevails, they may be useful.

Of all the stimulants which may be properly employed, wine seems to be the most eligible. It has the advantage of being grateful to the palate and stomach, and of having its stimulant parts so much diluted, that it can be conveniently given in small doses; and therefore it may be employed with sufficient safety. — It may be suspected that wine has an operation analogous to that of opium; and on good grounds. But we can distinctly remark its stimulant power only; which renders its effects in the phrenetic delirium manifestly hurtful; and in the mild delirium depending on debility, as remarkably useful.

[2.] We must now proceed to the other indication of cure, namely, to correct or obviate the tendency in the fluids to putrefaction. This may be done, 1. By avoiding any new application of putrid or putrescent matter. 2. By evacuating the putrid or putrescent matter already present in the body. 3. By correcting the putrid or putrescent matter remaining in the body by diluents and antiseptics. 4. By supporting the tone of the vessels, and thereby resisting further putrefaction, or obviating its effects. 5. By moderating the violence of reaction, considered as a means of increasing putrefaction.

The further application of putrid or putrescent matter may be avoided, 1. By removing the patient from places filled with corrupted air. 2. By preventing the accumulation of the patient's own effluvia, by a constant ventilation, and by a frequent change of bedclothes and body linen. 3. By the careful and speedy removal of all excremental matters from the patient's chamber. 4. By avoiding animal food.

The putrid or putrescent matter already present in the body, may be evacuated partly by frequent evacuations of the contents of the intestines; and more effectually still by supporting the excretions of perspiration.

Fever. ration and urine by the plentiful use of diluents. That which remains in the body may be rendered more mild and innocent by the use of diluents, or may be corrected by the use of antiseptics. These last are of many and various kinds; but which of them are conveniently applicable, or more particularly suited to the case of fevers, is not well ascertained. Those most certainly applicable and useful are acescent aliment, particularly fruits, acids of all kinds, and neutral salts.

The progress of putrefaction may be considerably retarded, and its effects obviated, by supporting the tone of the vessels; and this may be done by tonic medicines, of which the chief are cold, and the Peruvian bark, as already mentioned. The violence of reaction increasing the tendency to putrefaction, may be moderated by the means already mentioned under Synocha.

These are the proper indications to be observed in the cure of the flow nervous fever; and they are chiefly fulfilled by cleanliness, cool air, and diluents; which, perhaps upon the whole are more useful in fevers, than all other practices put together. Dr Huxham observes, that evacuations (especially bleeding), are improper even at the beginning. Even a common purgative given at this time hath been followed by surprising languor, syncope, and a train of other ill symptoms. It may, however, sometimes be necessary to cleanse the stomach and primæ viæ by a gentle emetic, or a mild laxative. Indeed, where nausea, sickness and load at stomach are urgent, as is frequently the case in the beginning of this fever, a vomit is necessary. Clysters of milk, sugar, and salt, may be injected with safety and advantage every second or third day, if nature wants to be prompted to stool. The temperate, cordial, diaphoretic medicines, are certainly, according to our author, most proper in these fevers; and a well-regulated, supporting, diluting diet is necessary. The latter of itself, judiciously managed, will go a great way in the cure, especially if assisted by well-timed and well-applied blisters, and a due care to keep the patient as quiet as possible both in body and mind. But it should be noted, that strong opiates are commonly very pernicious, however much the want of sleep and restlessness may seem to demand them. Mild diaphoretics, such as neutral draughts or elixir paregoricum, have much better effects; which, by raising a gentle easy sweat, or at least a plentiful perspiration, calm the hurry of the spirits, and a refreshing sleep ensues. Where the confusion and dejection of spirits are very considerable, blisters have been advised to be applied to the neck, occiput, or behind the ears; and during all this a free use of thin wine whey, some pleasant pisan or gruel, with a little pure wine, must be directed. Indeed the patients, in this case should drink frequently: though such quantities may not be necessary as in the ardent or even putrid malignant fevers; yet they should be sufficient to carry on the work of dilution, support the sweats, and supply the blood with fresh and wholesome fluids, in place of that noxious matter which is continually passing off. In this view also a thin chicken-broth is of service, both as food and physic, especially towards the decline of the disease; and for the same reason thin jellies of hartshorn, fago, and panada, are useful, adding a little wine to them, and the juice of orange or lemon.

It is observable, that the sick are never so easy as when they are in a gentle sweat; for this soon removes the hurry of spirits, exacerbations of heat, &c. But profuse sweats should never be encouraged, much less induced, by very strong heating medicines, especially in the beginning or advance of the fever; for they too much exhaust the vital powers, and are followed by a vast dejection of spirits, tremors, startings of the tendons, and sometimes end in rigors, cold clammy sweats, syncope, or a comatose disposition. Sometimes irregular partial heats and flushes succeed, with great anxiety, restlessness, delirium, difficulty of breathing, and a vast load and oppression in the precordia, so as to incline the less cautious observer to think there may be something pneumonic in it; but even here we must beware of bleeding, as the pulse will be found very small and unequal, though very quick. Nor is bleeding contraindicated only by the weakness and fluttering of the pulse, but also by the pale, limpid, and watery urine which is commonly attendant. These symptoms denote the load, anxiety, and oppression on the precordia to proceed from an affection of the nervous system, and not from a pneumonic obstruction or inflammation. The breathing in this case, though thick and laborious, is not hot, but a kind of sighing or sobbing respiration, nor is there often any kind of cough concomitant; so that it has been conjectured to proceed from some spasm on the vitals. Here therefore the nervous cordial medicines are indicated, and blisters to the thighs, legs, or arms.

The above-mentioned difficulty of breathing, anxiety, and oppression, many times precede a miliary eruption, which often appears on the seventh, ninth, or eleventh day of the fever, and sometimes later. Indeed great anxiety and oppression on the precordia always precede putrid eruptions of any kind in all sorts of fevers. This eruption should be promoted by soft easy cordials and proper diluents; to which should be sometimes added some gentle aromatics. These tend to calm the universal uneasiness commonly complained of, and also very effectually promote a diaphoresis, with which the miliary eruptions freely and easily advance. But however advantageous these commonly are, profuse sweats are seldom or never so, even though attended with a very large eruption. Two or three crops of these miliary pustules have been known to succeed one another, following profuse sweats, not only without advantage, but with great detriment to the patients, as they were thereby reduced to an extreme degree of weakness; so that they may justly be reckoned symptomatic rather than any thing else, and the consequent eruption is often merely the symptom of a symptom.

In these profuse colliquative sweatings a little generous red wine (diluted somewhat, if necessary) may be given with the greatest advantage; as it presently moderates the sweats, supports the patient, and keeps up the miliary papule if they happen at all. Towards the decline of the fever also, where the sweats are abundant and weakening, small doses of the tincture of cinchona with saffron and snakeroot may be given with the greatest advantage, frequently interposing a dose of rhubarb to carry off the putrid colliquies in the first passages; which withal makes the remissions or intermissions that often happen in the decline of nervous fevers.

fevers more distinct and manifest, and gives a fairer opportunity of throwing in the bark; for in the proper exhibition of this medicine we are to place our chief hope of curing both the nervous and putrid malignant fevers.

166 II. Typhus gravior, or the putrid, pestilential, or malignant FEVER. Sp. 1. var. 2.

Febris pestilens, P. Sal. Diversf. de febre pestilenti.

Febris pestilens Aegyptiorum, Alpin. de med. Aegypt. l. i. cap. 14.

Typhus Aegyptiacus, Sauv. sp. 6.

Febris pestilens maligna, Sennert. de febribus, l. iv. cap. 10.

Febris maligna pestilens, River, l. xvii. sect. iii. cap. 1.

Febris pestilens maligna, ann. 1643, Willis, de febribus, cap. 14.

Typhus carcerum, Sauv. sp. 1.

Febris nautica pestilentialis, Huxham de aëre ad ann. 1740.

Miliaris nautica, Sauv. sp. 9.

Febris putrida contagiosa in carceribus genita, Huxham de aëre ad ann. 1742.

Miliaris purpurata, Sauv. sp. h.

Febris carcerum et nosocomiorum. Pringle, Diseases of the army, p. 294. Van Swieten, Maladies des armés, p. 136.

Typhus castrensis, Sauv. sp. 5.

Febris castrensis, quam vulgō cephalalgiam epidemiciam vocant, Henr. Maii et A. Ph. Keph. Diss. apud Hallerum, tom. v.

Febris Hungarica five castrensis, Juncker, 74. et plurium auctorum.

Febris castrensis Gallorum in Bohemiā, ann. 1742, Serinei. Diss. apud Haller. tom. v.

Febris petechialis, Sennert. l. iv. cap. 13. River. prax. l. xvii. sect. iii. cap. 1. Hoffm. ii. p. 84. Juncker, 73. Huxham on fevers, chap. 8. Ludwig. Inst. med. clin. N° 146. Schreiber von erkenntniss, und cur der Krank heiten, p. 126. Monro, Diseases of military hospitals, p. 1.

Febris catarrhalis maligna petechizans, Juncker, 72. Hoffm. ii. 75. Eller de cogn. et cur. morb. sect. vi.

Febris quæ lenticulos, puncticula, aut peticulos vocant, Fracastorius de morb. contag. lib. ii. cap. 6.

Febris peticularis Tridenti, ann. 1591. Roboretus de febr. peticul.

Febris petechialis epidemica Coloniae, ann. 1672. Dawckers, Idia febris petechialis.

Febris petechialis epidemica Posonii, 1683, C. F. Loeu in App. ad A. N. C. vol. ii.

Febris petechialis epidemica Mutinæ, 1692. Ramazzini. Const. Mutinensis, oper. p. 177.

Febris maligna petechizans, ann. 1698. Hoffm. ii. p. 80.

Febris petechialis Wratislavie, ann. 1699. Helwich, Ephem. Germ. D. III. A. VII. et VIII. obs. 132. p. 616.

Febris epidemica Lipsiæ, 1718. M. Adolph. A. N. C. III. obs. 131. p. 296.

Febris endemica et epidemica Coragienfis, ann.

1708, 1718, et seq. Rogers, Essay on Epidemic Typhus. diseases.

Febris continua epidemica Coragienfis, ann. 1719. et seq. M. O'Connell, Obs. de morbis.

Febris petechialis epidemica Cremonæ, 1734. Valcharenghi Med. ration. sect. 3.

Febris petechizans Petropoli, 1735. Weitbrecht. Diss. apud Haller. tom. v.

Febris petechialis, ann. 1740, 1741, in Hassia, Ritter. A. N. C. vol. vii. obs. 4.

Febris maligna petechialis Rintelli, 1741. Fustel-nau, A. N. C. vol. vii. obs. 5.

Febris petechialis epidemica Silefie, 1741, et seq. Bandhorst. Diss. apud Haller. tom. v.

Febris petechialis epidemica Viennæ, 1757. Hofenohr. Hist. med. cap. 2.

Febris petechialis epidemica Lipsiæ, 1757. Ludwig. Adversar. tom. i. pars 1.

Febris petechialis epidemica variis Germaniæ locis ab ann. 1755 ad 1761. Strack de morbo cum petechiis.

Description. This disease has been supposed to differ from the former in degree only; and there are many circumstances which would lead us to conclude, that both frequently originate from a contagion precisely of the same nature. In the same manner we see, during different seasons, and in different circumstances, various degrees of malignity in smallpox. Though every instance of the disease depends on the introduction of a peculiar and specific contagion into the body, yet this contagion in particular epidemics evidently possesses peculiar malignancy. The same is probably the case with the typhoid fever: But whether this observation be well founded or not, there cannot be a doubt that the typhus gravior or putrid fever is a disease of the most dangerous nature, as, besides the extreme debility of the nervous system, there is a rapid tendency of the fluids to putrefaction, which sometimes cuts off the patient in a few days, nay, in the warm climates, in 12 or 14 hours; or if the patient recovers, he is for a long time, even in this country, in an exceedingly weak state, and requires many weeks to recover his former health.

The putrid fevers, according to Huxham, make their attack with much more violence than the flow nervous ones; the rigors are sometimes very great, though sometimes scarce felt; the heats much sharper and permanent; yet, at first, sudden, transient, and remittent: the pulse more tense and hard, but commonly quick and small; though sometimes slow, and seemingly regular for a time, and then fluttering and unequal. The headache, nausea, and vomiting, are much more considerable even from the beginning. Sometimes a severe fixed pain is felt in one or both temples, or over one or both eyebrows; frequently in the bottom of the orbits of the eyes. The eyes always appear very dull, heavy, sometimes yellowish, and very often a little inflamed. The countenance seems bloated, and more dead-coloured than usual. Commonly the temporal arteries throb much, and a tinnitus aurium is very troublesome: a strong vibration also of the carotid arteries frequently takes place in the advance of the fever, though the pulse at the wrist may be small, nay even slow: this is a certain sign of an impending delirium,

rium, and generally proceeds from some considerable obstructions in the brain.

The prostration of spirits, weakness, and faintness, are often surprisingly great and sudden, though no inordinate evacuation happens; and this too sometimes when the pulse seems tolerably strong. The respiration is most commonly laborious, and interrupted with a kind of sighing or sobbing, and the breath is hot and offensive.

Few or none of these fevers are without pain in the back and loins; always an universal weariness or soreness is felt, and often much pain in the limbs. Sometimes a great heat, load, and pain, affect the pit of the stomach, with perpetual vomiting of porraceous or black bile, and a most troublesome singultus; the matter discharged is frequently of a very nauseous smell. The tongue, though only white at the beginning, grows daily more dark and dry; sometimes of a shining livid colour, with a kind of dark bubble at top; sometimes exceeding black; and so continues for many days together; nor is the tint to be got off many times for several days, even after a favourable crisis: at the height of the disease, it generally becomes very dry, stiff, and black, or of a dark pomegranate colour. Hence the speech is very inarticulate, and scarce intelligible. The thirst in the increase of the fever is commonly very great, sometimes unquenchable; and yet no kind of drink pleases, but all seem bitter and mawkish; at other times, however, no thirst is complained of, though the mouth and tongue are exceedingly foul and dry; this is always a dangerous symptom, and ends in a frenzy or coma. The lips and teeth, especially near the height, are covered with a very black tenacious fordes. At the commencement of the fever, the urine is often crude, pale, and vapid, but grows much higher coloured in the advance, and frequently resembles a strong lixivium, or citrine urine, tinged with a small quantity of blood; it is without the least sediment or cloud, and so continues for many days together: by degrees it grows darker, like dead strong high-coloured beer, and smells very rank and offensive. In petechial fevers, the urine has often been seen almost black and very fetid. The stools, especially near the height, or in the decline of the fever, are for the most part intolerably fetid, green, livid, or black, frequently with severe gripes and blood. When they are more yellow or brown, the less is the danger; but the highest when they run off insensibly, whatever their colour may be. It is likewise a very bad symptom when the belly continues tense, swollen, and hard, after profuse stools; for this is generally the consequence of an inflammation or mortification of the intestines. A gentle diarrhoea is often very beneficial, and sometimes seems to be the only way which nature takes to carry off the morbid matter.

Sometimes black, livid, dun, or greenish spots appear on different parts of the skin, particularly on the breast, which always indicate a high degree of malignity; but the more florid the spots are, the less danger is to be feared. It is also a good sign when the black or violet petechiae become of a brighter colour. The large, black, or livid spots, are almost always attended with profuse haemorrhages; and the small, dusky, brown spots, like freckles, are not much less dangerous than

the livid or black; though they are seldom accompanied with fluxes of blood: excessively profuse, cold, clammy sweats are often concomitant, by which also they sometimes vanish, though without any advantage to the patient. The eruption of the petechiae is uncertain; sometimes they appear on the fourth or fifth day, though sometimes not till the eleventh, or even later. The vibices, or large dark, blue, or greenish marks, seldom appear till very near the fatal period. Frequently also we meet with an efflorescence like the measles in malignant fevers, but of a much more dull and livid hue; in which the skin, especially on the breast, appears as it were marbled or variegated. This in general is an ill symptom, and is often attended with fatal consequences.

Sometimes about the 11th or 14th day, on the occurrence of profuse sweats, the petechiae disappear, and vast quantities of white miliary pustules break out. This is seldom found of any considerable advantage; but an itching, smarting, red rash, commonly gives great relief; and so do the large, fretting, watery bladders, which many times rise upon the back, breast, shoulders, &c. A scabby eruption likewise about the lips and nose is one of the filatory symptoms; and the more hot and angry it is, so much the better. But of much more uncertain and dangerous event are the brown-coloured aphthæ; nor are those that are exceeding white and thick, like lard, of a very promising aspect. They are soon succeeded by great difficulty of swallowing, pain and ulceration of the fauces, oesophagus, &c. and with an incessant singultus: the whole prima via become at last affected; a bloody dysentery comes on, followed by a sphacelation of the intestines; as is evident from the black, fainous, and bloody stools, extremely fetid and infectious. Vibices, or large, black, and bluish marks resembling bruises, are frequently seen towards the close of the fever; and, when attended with lividity and coldness of the extremities, are certain tokens of approaching death. In some cases, the blackness has been known to reach almost to the elbows, and the hands have been dead-cold for a day or two before the death of the patient.

Such are the general appearances of the putrid malignant fever in this country, among those who enjoy a free air, and are not crowded together, or exposed to the causes of infection: but, in jails, hospitals, or other places where the sick are crowded, and in some measure deprived of the benefit of the free air, the symptoms are, if possible, more terrible. Sir John Pringle, who had many opportunities of observing it, tells us, that the jail or hospital fever, in the beginning, is not easy to be distinguished from a common fever. The first symptoms are slight interchanges of heat and cold, a trembling of the hands, sometimes a sense of numbness in the arms, weakness of the limbs, loss of appetite; and the disorder increasing towards night, the body grows hot, the sleep is interrupted, and not refreshing. With these symptoms, for the most part, there is some pain or confusion in the head; the pulse at first is a little quicker than natural, and the patients find themselves too much indisposed to go about business, though too well to be wholly confined. When the fever advances, the above-mentioned symptoms are in a higher degree; and in particular the

patient complains of a lassitude, nausea, pains in his back, a more constant pain and confusion in his head, attended with an uncommon dejection of spirits. At this time the pulse is never sunk, but beats quick, and often varies in the same day both as to strength and fulness. It is little affected by bleeding, if a moderate quantity of blood be taken away; but if the evacuation be large, and especially if it be repeated, to answer a false indication of inflammation, the pulse, increasing in frequency, is apt to sink in force, and often irrecoverably, whilst the patient becomes delirious. But we must observe, that, in every case, independent of evacuations, the pulse sooner or later sinks, and then gives certain evidence of the nature of the disease. The appearance of the blood is various; for though it be commonly little altered, yet sometimes it will be fizy, not only on the first attack, but after the fever is formed. The worst appearance is when the crassamentum is dissolved; though this does not happen till the advanced state of the fever: indeed this seems not easy to be ascertained, as blood has been so seldom taken away at that time. The urine is also various. Sometimes it is of a reddish or flame colour, which it preserves a long time; but it is oftener pale, and changes from time to time in colour as well as crudity, being sometimes clear, sometimes clouded: towards the end, upon a favourable crisis, it becomes thick, but does not always deposit a sediment. If the sick lie warm, and have had no preceding flux, the belly is generally bound; but when they lie cold, as they often do in field-hospitals, the pores of the skin being shut, a diarrhoea is a common symptom, but is not critical. In the worst cases, a flux appears in the last stage; then the stools are involuntary, colliquative, ichorous, or bloody, and have a cadaverous smell; the effects of a mortification of the bowels, and the sign of approaching death. When the hospitals are filled with dysenteric patients, some of the nurses will be infected with the flux only, and others with this fever, ending in these bloody and gangrenous stools.

In the beginning the heat is moderate; and even in the advanced state, on first touching the skin, it seems inconsiderable: but upon feeling the pulse for some time, we are sensible of an uncommon heat (the calor mordicans, as it has been called), leaving an unpleasant sensation on the fingers for a few minutes. A day or two before death, if care be not taken, the extremities become cold, and the pulse is then hardly to be felt. The skin is generally dry and parched; though sometimes there are longer or shorter sweats, especially in the beginning. Such as are produced by medicine are of no use, except on the first attack, at which time they will often remove the fever; and natural sweats are never critical till the distemper begins to decline. These last are rarely profuse, but gentle, continued, and equally diffused over the body: sometimes the disease will terminate by an almost imperceptible moisture of the skin; the sweats are usually fetid, and offensive even to the patient himself.

The tongue is commonly dry; and, without constant care of the nurse, becomes hard and brown, with deep chaps: but this symptom is common to most fevers. At other times, though rarely, the tongue is soft and moist to the last, but with a mixture of a greenish or yellowish colour. The thirst is sometimes great, but

more frequently moderate. In the advanced state, the breath is offensive, and a blackish furring gathers about the roots of the teeth.

Some are never delirious, but all lie under a stupor or confusion; few retain their senses till death: many lose them early, and from two causes; either from moderate bleeding, or the premature use of warm and spirituous medicines. They rarely sleep; and, unless delirious, have more of a dejected and thoughtful look than what is commonly seen in other fevers. The face is late in acquiring either a ghastly or a very morbid appearance; yet the eyes are always muddy, and generally the white is of a reddish cast as if inflamed. The confusion of head commonly rises to a delirium, especially at night; but, unless by an unreasonable hot regimen, it seldom turns to rage, or to those high flights of imagination common in other fevers. When the delirium comes to that height, the face is flushed, the eyes red, the voice is quick, and the patient struggles to get up. But when that symptom is owing to large evacuations, or only to the advanced state of the disease, the face appears meagre; the eye-lids in slumbers are only half shut; and the voice, which is commonly low and slow, sinks to a degree scarce to be heard. From the beginning there is generally a great dejection and failure of strength. A tremor of the hands is more common than a starting of the tendons; and if the subfultus occurs, it is in a lesser degree than in many other fevers. In every stage of the disease, as the pulse sinks, the delirium and tremors increase; and in proportion as the pulse rises, the head and spirits are relieved. Sometimes in the beginning, but for the most part in the advanced state, the patient grows dull of hearing, and at last almost deaf. When the fever is protracted, with a slow and low voice, the sick have a particular craving for something cordial, and nothing is so cordial or so acceptable as wine. They long for no food, yet willingly take a little panada if wine be added. But such as are delirious, with a quick voice, wild looks, a subfultus tendinum, or violent actions, though their pulse be sunk, yet bear neither hot medicines, wine, nor the common cordials.

Vomiting, and complaints of a load and sickness at stomach, though usual symptoms, are not essential to the disease; nor are pleuritic stiches, difficulty in breathing, or flying pains, to be referred so much to it as to the constitution of the patient, or to a preceding cold.

A petechial efflorescence is a frequent, though not an inseparable, attendant of this fever. It sometimes appears of a brighter or paler red, at other times of a livid colour, but never rises above the skin. The spots are small; but generally so confluent, that at a little distance the skin appears only somewhat redder than ordinary, as if the colour was uniform; but upon a nearer inspection interstices are seen. For the most part this eruption is so little conspicuous, that unless it be looked for attentively, it may escape notice. The spots appear thickest on the back and breast, less on the legs and arms, and Sir John Pringle never remembers to have seen any on the face. As to the time of their appearance, he agrees entirely with Dr. Huxham. These spots are never critical, nor are they reckoned among the mortal symptoms; but only concur with other signs to ascertain the nature of the disease. The nearer they

Fevers they approach to purple, the more they are to be dreaded. In a few cases, instead of spots, purple streaks and blotches were observed. Sometimes the petechiae did not appear till after death; and there was one case in which, after bleeding, the petechiae were seen only on the arm below the ligature, and nowhere else on the skin.

The hospital fever, though accounted one of the continued kind, yet has generally some exacerbation at night, with a remission and often partial sweats in the day; and after a long continuance it is apt to change into a hectic, or an intermitting form. The length of the disease is uncertain. Sometimes it was terminated, either in death or recovery, in seven days after the patient took to his bed; but in the hospitals it generally continued from 14 to 20, and some died or recovered after four weeks. From the time of the sinking of the pulse until death or a favourable crisis, there is perhaps less change to be seen from day to day in this than in most other fevers. When its course is long, it sometimes terminates in suppurations of the parotid or axillary glands; and when these do not appear, it is probable that the fever is kept up by the formation of some internal abscess. The parotid glands themselves do not suppurate, but only some of the lymphatic glands that lie over them. Sir John Pringle observed one instance of a swelling of this kind on both sides, without any previous indisposition, when the person, not suspecting the cause, and applying discutient cataplasms, was, upon the tumor subsiding, seized with the hospital-fever. Many patients after the crisis of this fever complain of a pain in the limbs and want of rest; and almost all of them mention great weakness, confusion in their head, vertigo, and a noise in their ears.

Ten of the bodies of those who died of this distemper in Houghton's regiment were opened. In some, all the cavities were examined; in others, only the brain and the bowels. In some of them, the brain appeared to be suppurated. The first of this kind Sir John Pringle met with at Ghent; but the man being brought into the hospital from the barracks no earlier than two days before he died, he could only conjecture from the symptoms and the imperfect accounts he had of him, that his death was owing to a fever of this kind, after lingering near a mouth in it. About three ounces of purulent matter were found in the ventricles of the brain, and the whole cortical and medullary substance was uncommonly flaccid and tender; nay, some of the same kind of matter was found in the substance of the upper part of the cerebellum: yet this person, with some stupor and deafness, had his senses till the night before he died; so far, at least, that he answered distinctly when roused and spoken to; but about that time the muscles of his face began to be convulsed. Of two other instances of men who undoubtedly died of this fever, in one the cerebrum was suppurated, in the other the cerebellum. In the former case, the patient was under a stupor, with deafness from the beginning; but was never delirious, nor altogether insensible. His pulse sunk early; and about ten days before his death his head began to swell, and continued very large till within two days before he died, when it subsided a little. For several days before his end, he would taste nothing but cold water, and during his illness he lay constantly

upon one side. The head being opened, an abscess as large as an egg was found in the substance of the fore-part of the right hemisphere of the brain, full of thin matter like whey. At that time five more, all of the same fever, had the like swelling of their heads, but recovered. In the other case, the abscess in the cerebellum was about the size of a small pigeon's egg, and contained also a thin ichorous matter; nor had this patient ever been so thoroughly insensible as not to answer reasonably when spoken to. Two days before he died his urine turned pale.

These suppurations, however, were not constant; for another who died about the same time, and had been ill about the same number of days with the like symptoms, the pale water excepted, had no abscess either in the brain or cerebellum. Two were opened afterwards, in whom the cortical substance of the brain had an inflammatory appearance, but no suppuration. In one of them the large intestines were corrupted: that man went off with a looseness; and just before he died, an ichorous matter was discharged from his nose. In the military hospital at Ipswich, one who unexpectedly died of this fever after having been seemingly in a fair way of recovery, had no suppuration in his brain; but in another, who died after an abscess in both orbits, the brain was found flaccid, and about two ounces of a thin serum in the ventricles.

Causes of, and persons subject to, this disorder. The cause of this fever, as well as that of the slow-nervous fever, is an infection or contagion from some diseased animal-body, or from corrupted vegetables; and therefore is very little, if at all, different from those pestilential disorders which have arisen after battles, where great numbers of dead bodies were allowed to lie above ground, and infect the air with their effluvia. This is confirmed by an observation of Forellus, who was eye-witness to a distemper of this kind (which indeed he calls a plague) owing to the same cause, attended with buboes and a high degree of contagion. The same author also gives an account of a malignant fever breaking out at Egmont in North-Holland, occasioned by the rotting of a whale which had been left on the shore. We have a like observation of a fever affecting the crew of a French ship, by the putrefaction of some cattle which they had killed on the island of Nevis in the West Indies. These men were seized with a pain in their head and loins, great weakness, and a disorder of the stomach, accompanied with fever. Some had carbuncles; and on others purple spots appeared after death.

Galen assigns two causes for pestilential fevers: 1. The great heat of the weather, when the humours happen to be in a more putrescent state than usual. 2. A putrid state of the air, arising either from a multitude of dead bodies left unburied, as after a battle, or from the evaporation of corrupted lakes and marshes.

One of the most remarkable diseases incident to an army is related by Diodorus, as breaking out among the Carthaginians at the siege of Syracuse. That author not only relates some of its most distinguishing symptoms, but reasons well about its cause. He observes, that pains in the back and eruptions (φλυκταις) were common; that some had bloody stools; that others were seized with a delirium, so as to run about and beat all that came in their way; that the physicians

cians knew no cure; and that it was the more fatal as the sick were abandoned by every body on account of the contagion. As to the cause, the author takes notice of the multitude of people confined within a narrow compass; of the situation of the camp in low and wet ground; of the scorching heats in the middle of the day, succeeded by the cold and damp air from the marshes in the night-time; to these he adds, the putrid steams arising first from the marshes, and afterwards from the bodies of those who lay unburied.— This distemper seems to have been a compound of the marsh and pestilential fever.

Forelius remarks, that, from the putrefaction of the water only, the city of Delft, where he practised, was scarce ten years together free from the plague or some pestilential distemper. He adds, that the magistrates, upon his representation of the cause, erected a wind-mill for moving and refreshing the water. At that time Holland was much more subject to inundations and the stagnation of water than at present. In 1694, a fever broke out at Rochfort in France, which, on account of the uncommon symptoms and great mortality, was at first believed to be the plague. But M. Chirac, who was sent by the court to inquire into its nature, found the cause to arise from some marshes that had been made by an inundation of the sea; and observed, that the corrupted steams, which smelled like gun-powder, were carried to the town by the wind, which had long blown from that quarter. About two-thirds of those who were taken ill died. In such as were opened, the brain was found either inflamed or loaded with blood; the fibres of the body were uncommonly tender; and the bowels had either suppuration or were mortified.

It is needless to mention more instances of pestilential fevers being brought on by the steams of corrupted substances, whether animal or vegetable. In general it may be remarked, that the putrefaction of these substances in a dry air is more apt to bring on a fever of the continued form; but in a moist air has a greater tendency to produce remitting fevers. But it must also be observed, that, even in cases where the most malignant fevers prevail, all persons are not equally disposed to receive the infection, though equally exposed to it with others. Some, through mere vigour of body and mind, cannot be infected with the most contagious diseases; while, on the other hand, those whose bodies are debilitated by a former disease, by study, low diet, or want, or those who have laboured under any of the depressing passions of the mind for some time, seldom or never escape. Men, therefore, who have been weakened by accidents (as those who have undergone a mercurial salivation) are very apt to fall into this distemper. Those who are taken into crowded hospitals, ill of the smallpox, however good the sort may be, fall readily into this fever, and run a greater risk of dying of it than others. The second fever is attended with double danger, seeing the patient has been so much weakened by the first. A sure sign of the corruption of the air in an hospital is when many of the nurses fall sick.

Pronostic. In these fevers we cannot draw a prognostic from any symptom by itself; and perhaps all of them together are more fallible than in others. Ge-

nerally the following are good: To have little delirium; the strength little impaired; turbid urine in the decline of the disease; and at that time a gentle sweat or moisture diffused over the body, or even the skin soft and the tongue moist; or to have some loose stools succeeded by a diaphorese; the pulse to rise by wine or cordials, with an abatement of the stupor, tremor, and other affections of the brain. Deafness is rather a good sign. A sediment in the urine, without other changes for the better, is no sure sign of recovery; and some have recovered in whose urine there was no sediment.— The bad signs are, a subsultus tendinum; the eyes much inflamed and staring; the speech quick, and the sound of the voice altered; a high delirium; perpetual watchfulness; constant sickness at the stomach, and vomitings; frequent stools, with a sinking pulse, and the disorder of the head increased; coldness of the extremities, and a tremulous motion of the tongue. It is observed to be among the worst signs when the patient complains of blindness; when he swallows with difficulty, or cannot put out his tongue when desired to do it; when he can lie on his back only, and pulls up his knees; or when insensible he endeavours to uncover his breast, or makes frequent attempts to get out of bed without assigning any reason. If to any of these are added ichorous, cadaverous, and involuntary stools, it is a sign of a mortification of the bowels and approaching death. It will not seem strange to find most of these prognostics common to the advanced state of other fevers, when we consider, that from whatever cause fevers begin, by a long continuance the humours are corrupted, and the brain and nerves affected much in the same manner as in those which arise from infection.

Prevention and cure. As distempers of the putrid kind never arise without an infection received from some quarter or other, the methods of prevention must evidently be reduced to two general heads. 1. To avoid receiving the infection into the body; and, 2. To put the body in such a situation as may enable it to resist the infection when received. On both these methods scarce any writer hath equalled Dr Lind of Haslar, whose opinions and directions therefore we shall give pretty fully.

As putrid diseases are very common and violent in the hot countries, it is very necessary for Europeans who visit these climates to be well informed, in the first place, of the signs of an unhealthy country, that they may be upon their guard as soon as they enter any foreign region. These signs are by this author enumerated as follows.

1. A sudden and great alteration in the air, at sunset, from intolerable heat to a chilling cold. This is perceived as soon as the sun is down, and is for the most part accompanied with a very heavy dew: it shows an unhealthy swampy soil, the nature of which is such, that no sooner the sun-beams are withdrawn, than the vapours emitted from it render the air damp, raw, and chilling, in the most sultry climates; so that even under the equator, in some unhealthy places, the night-air is very cold to an European constitution.

2. Thick noisome fogs, chiefly after sunset, arising from the valleys, and particularly from the mud, slime, or other impurities. In hot countries, the smell of these.

Fevers. these fogs may be compared to that of a new-cleaned ditch. Diseases therefore, arising from this cause, generally take place in the night, or before sunrising.

3. Numerous swarms of flies, gnats, and other insects which attend stagnated air and unhealthy places covered with wood.

4. When all butchers meat soon corrupts, and in a few hours becomes full of maggots; when metals are quickly corroded on being exposed to the air; and when a corpse becomes intolerably offensive in less than six hours; these are proofs of a close, hot, and unwholesome country. And in such places, during excessive heats and great calms, it is not altogether uncommon for Europeans, especially such as are of a gross habit of body, to be seized at once with the most alarming and fatal symptoms of what is called the yellow fever, without even any previous complaint of sickness or other symptoms of the disease. There has first been perceived an uneasy itching sensation, commonly in the legs; and upon pulling down the stockings, streams of thin dissolved blood followed, a ghastly yellow colour quickly diffused itself over the whole body, and the patient has been carried off in less than forty-eight hours.

5. A sort of sandy soil, commonly a small, loose, white sand, as that at Pensacola, Whydah, and the island of Bonavista, which is found by experience to be injurious to health. The pestiferous vapour arising, during the summer months and in the heat of the day, from such a sandy soil, is best characterized by its effects in the extensive deserts of Asia and Africa. It there constitutes what is called the Samiel-wind; a blast which, in the parched desert, proves instantly fatal both to man and beast; but when it passes over a soil well covered with grass and vegetables, has its effects greatly mitigated; it is, however, even then, productive of sickness: thus the southerly winds, while they blow from the deserts of Libya during the summer, at Algiers, Tunis, and Tripoli, produce an unhealthy season; and at Madras the winds, which, in the months of April and May, pass over a large tract of sand, are always hot, disagreeable, and unwholesome.

During these land-winds, sudden gusts of a more hot and suffocating nature are often observed to come from these sands once or twice, or even more frequently, in a day, which seem to be this vapour in a purer form. These gusts pass very quickly, and affect persons who happen to stand with their faces towards them in the same manner as the hot air which issues from a burning furnace, or from a heated oven, and obliges them immediately to turn away from it in order to recover breath. The effect of this hot suffocating blast or vapour on the human body, even when mitigated by passing through a moist atmosphere, is the same as that of intense cold; it shuts up every pore of the skin, and entirely stops the perspiration of such as are exposed to it. These blasts come only in the daytime, and always from the deserts. Water is the only known corrector or antidote against them: hence, coarse thick clothes, kept constantly wet, and hung up at the windows or doors, greatly mitigate their violence. A house so built as to have no windows or doors towards the deserts, is an excellent protection against their pernicious effects. The hot land-winds constantly

blow at Madras and other places on the coast of Coromandel, at that season, from midnight till noon; the sea-breezes then begin, which relieve the difficulty in breathing, and the obstructed perspiration, which the former occasioned.

That the heat of these land-winds, as also of the sudden gusts which accompany them, proceed from large tracts of sand heated by the sun, is evident from the increased heat and suffocating quality of those winds, in proportion as the day advances, and as the heat of the season is increased. The opposite winds, blowing from each side of the Balagate mountains, are a farther proof of this. These mountains, running from north to south, divide the hitherto Peninsula of India into two equal parts, and separate what is called the Malabar from the Coromandel coast. To the former they are very near, but at a great distance from the latter. The winds blowing from those hills are on the Malabar coast always remarkably cool; but on the coast of Coromandel, in the months of April, May, June, and July, are extremely hot and suffocating, as they pass over a large tract of intermediate sand, heated during those months by an almost vertical sun. Hence the Malabar coast is always covered with an agreeable verdure; whereas the Coromandel coast, during the continuance of these hot winds, seems a barren wilderness, nothing appearing green except the trees. On the contrary, the winds that pass over these sands, after being wet with the rains, are the coldest which blow at Madras. Bottles of liquor inclosed in bags of coarse cloth, kept constantly wet, and suspended in the shade, where those hot winds may have access to them, become as cold as if they had been immersed in a solution of nitre; an effect owing undoubtedly to the constant evaporation of water from the surface.

It is an observation of the natives on the coast of Coromandel, which is confirmed by the experience of many Europeans, that the longer the hot land-winds blow, the healthier are the ensuing months; these winds, as they express it, purifying the air. Are not the winds therefore the cause why the air on the coast of Coromandel, except during their continuance, is more healthy than in other parts of India where these winds do not blow? Does not this also suggest a very probable reason, why the plague in Egypt generally ceases in the beginning of June; the periodical hot winds which come from the deserts of Nubia and Ethiopia having then rendered the air of Egypt pure and wholesome? Many have ascribed that effect to the north winds; as the plague not only ceases when they blow, but all infected goods, household-furniture, and wearing apparel, are then said to become entirely free from the contagion: these, however, cannot be the cause, as the most destructive plague is abated in its violence, if not wholly eradicated, before they set in. With equal propriety we may reject the opinion that the overflowing of the Nile is productive of that salutary effect, as the plague generally ceases before the increase of that river is perceptible.

Thus the plague, the greatest calamity which can afflict mankind, seems to be destroyed by those hot winds, which are otherwise so pernicious to animal and vegetable life. And although, during the continuance of these winds, the most fruitful fields wear the

the aspect of a parched desert, yet no sooner the rains fall, but vegetation is restored, the plants revive, and a beautiful verdure is again spread over the face of the country.

Having thus given an account of the signs of an unhealthy country, Dr Lind next proceeds to mention such employments as are particularly dangerous to Europeans on their first arrival. One of these is the cutting down of trees, shrubs, &c. or clearing the ground, as it is called. Of the unhealthiness of this employment he gives two instances. At the conclusion of the late peace, the captain of a ship of war went on shore at the island of Dominica, with 12 of his men, to cut down the wood, and to clear a piece of ground which he intended to have purchased: but, in a few days, sickness obliged him to desist from this dangerous work; the captain and 11 of his men being seized with violent fevers, which terminated in obstinate intermittons, and of which several died. The survivors suffered so much in their constitutions, that, even after they came to England, the return of an east-wind was apt to bring on a violent fit of the ague. The Ludlow-Castle, a ship of war of 40 guns, in a voyage to the coast of Guinea, also lost 25 of her men at Sierra Leona, who were employed in cutting down wood for the ship. This is an occupation which has often proved destructive to Europeans in those climates, and in which they ought never to be employed, especially during the rainy season; there being numberless instances of white persons, when cutting down the woods at that season, who have been taken ill in the morning, and dead before night.

Another evil, less known, and less suspected, but no less dangerous, is the sending Europeans in open boats after sunset, where the soil is swampy, or where there are great night-fogs. The single duty alone of fetching fresh-killed butchers meat at night for the use of our ships companies in the East and West Indies, has destroyed every year several thousand seamen. In those parts of the world, butchers meat must be brought on board at night immediately after it is killed, otherwise it will not be fit for use the next day; but a contract made with the natives to send it on board at that time, which might be done for a trifling sum, would be the means of preserving many useful lives. During the sickly season at Batavia, a boat belonging to the Medway, which attended on shore every night, was three times successively manned, not one having survived that service. They were all taken ill in the night, when on shore, or when returning on board; so that at length the officers were obliged to employ none but the natives on that business. Great numbers of men have perished from being employed in this manner at Bengal, where the European ships often anchor in the most unhealthy spots of the river; and even when the great night-fogs arise, after the rainy season, the men are often obliged to perform such night-services in boats. Now since it is so dangerous for Europeans in unhealthy countries, particularly during a season of sickness, to be exposed in an open boat to the foggy night-air, it must appear that sending them unsheltered, in open boats, far up rivers, in unhealthy southern climates, for the sake of wood, water, trade, or other purposes, must be attended with the most destructive and fatal consequences.

Burying the dead in swampy countries is another occupation which has proved fatal to many, and which ought to be entrusted to negroes or the natives of the country. The effluvia from the ground when newly opened, whether from graves or ditches, are far more dangerous than from the same swampy soil when the surface is undisturbed; nay, in some places, it has been found almost certain death for an European to dig a grave, unless long seasoned to the country. In such a place, the attendance of friends at funerals ought to be dispensed with.

In all cases where it is practicable, the ships which visit these unhealthy countries should anchor at as great a distance as possible from shore; or if obliged to anchor near marshy grounds or swamps, especially during summer or in hot weather, and when the wind blows directly from thence, the gun-ports which would admit the noxious land-breeze ought to be kept shut, especially at night. Or if the ship rides with her head to the wind, a thick sail ought to be put upon the fore-mast, along which the smoke from the fire-place might be made constantly to play and ascend. If the sail should occasion a little smoke between decks, this inconvenience will be sufficiently compensated by its keeping off the direct stream of the swampy shore effluvia; which now being obliged to form a curve before they reach the more distant parts of the vessel, must needs be greatly diverted and scattered.

The best preventative against the mischievous impressions of a putrid fog, or of a marshy exhalation, is a close, sheltered, and covered place; such as the lower apartments in a ship, or a house in which there are no doors or windows facing the swamps. If in such places a fire be kept either at the doors and other inlets to a house, or in the chambers, as is practised in some unhealthy countries during the rainy or foggy season, it will prove an excellent and effectual protection against the injuries of a bad air. On board of ships also fires may be made at the hatchways; and of the good effects of this we have the following example. When the Edgar, a ship of war of 60 guns, was upon the coast of Guinea in the year 1768, her men were very sickly, and many of them died: however it was observed, that in a sloop of war, which was constantly in company with her, few were taken ill, and not one died during the whole voyage. This could be ascribed to no other cause, but that in the sloop the fire-place for cooking victuals was on the same level with the deck where the men lay; and every morning when the fire was lighted, especially when there was but little wind, the smoke from the cook-room spread itself all over the ship, and particularly over those parts where the men lay; but from the construction of the fire-place of the Edgar, no smoke from it ever came between her decks.

Persons on board any ship whatever, are much more safe, and their situation is much preferable to that of those who make distant inland excursions in small boats upon the rivers, and who are for the most part ignorant of the cause of those maladies which destroy them. The intolerable heat at noon often obliges such persons to go in a manner half naked; while a free and plentiful perspiration issues from every pore. A near approach to putrid swamps at this time is apt to produce an immediate sickness, vomiting, and afterwards

Febric. afterwards a low nervous or malignant fever. If they happen to pass them at night, or lie near them in an open boat, the air from those swamps is perceived to be quite chill and cold; in so much that warm thick clothing becomes absolutely requisite to guard the body against the impressions of so great an alteration in the air, and against its cold and inclement quality: for the effects of it then, even on the most healthy and vigorous constitution, is frequently a chilling cold fit of an ague, terminating in a fever with delirium, bilious vomitings, and purging, or even death itself.

Where such exposure becomes unavoidable, the only method is to defend the body as much as possible against the pernicious miasma with which the air abounds.—All those who are employed in cutting down woods, or in other laborious and dangerous services in hot climates, during the heat of the day, ought to have their heads covered with a bladder dipped in vinegar, and to wash their mouths often with the same liquor; never to swallow their spittle, but rather to chew a little rhubarb or some other bitter, and spit it out frequently; to stop their nostrils with a small bit of linen or tow dipped in camphorated vinegar; and to infuse some Peruvian bark, garlic, and rhubarb, in brandy, of which a dram is to be taken, either by itself or diluted with water, morning and evening.

In the evening before sunset they should leave off work, and not return to their labour in the morning till the sun has dispersed the unwholesome dews and vapours. Those who must of necessity remain on shore, and sleep in dangerous places, should take care not to sleep upon the ground exposed to the dews, but in hammocks in a close tent, standing upon a dry sand, gravel, or chalk, near the sea shore, and where there is no subterraneous water for at least four feet below the surface of the ground. The door of this tent should be made to open towards the sea; and the back part of it, which receives the land breeze, must be well secured by double canvas, or covered with branches of trees. But in such circumstances, a hut, when it can be procured, is preferable to a tent, especially if it be well thatched, so as to prove a defence both against the excessive heat of the sun by day, and the noxious dews which fall at night. Here the men may be enjoined to smoke tobacco. When the air is thick, moist, and chill, the earth being overspread with cold dew, a constant fire must be kept in and about the tent or hut, as the most excellent means of purifying such unwholesome air, and of preserving the health of those who either sleeping or waking are exposed to its influence. The sentinels who guard the water-carks, ought likewise at such a time to have a fire burning near them. All old and forsaken habitations, natural caves and grottos in the earth, where the men may be induced to take up their abode, must before their admission be perfectly dried and purified with sufficient fires. Fire and smoke are undoubtedly the great purifiers of all tainted and unwholesome air, and the most excellent preservatives against its noxious influence. It is the custom of the negroes in Guinea, and also of some Indians (who both sleep for the most part on the ground), to have a fire, producing a little smoke, constantly burning in their huts where they sleep. This not only corrects the moisture of the

night, but also, by occasioning more smoke than heat, renders the damp from the earth less noxious; of which Dr. Lind gives the following remarkable instance. A Guinea ship being up one of the rivers for the sake of trade, it was found to be very dangerous to sleep on shore; without which their trade could not be so conveniently carried on. First the captain, then the mate, and two or three of the seamen, were taken ill; each of them the morning after they had lain on shore. By these accidents the men were greatly intimidated from lying ashore; till the surgeon boldly offered to try the experiment on himself. Next morning when he awoke, he found himself seized, as the rest, with a giddiness and pain in the head. He immediately acquainted one of the negroes with his condition, who carried him to his hut, and set him down in the smoke of it; when his shiverings and giddiness soon left him. He then took a dram of the bark bitter, and found himself greatly relieved, especially by breathing some time in the smoke.—Thus instructed by the negro, he ordered a large fire to dry the hut he slept in; and afterwards had every night a small fire sufficient to raise a gentle smoke, without occasioning a troublesome heat: and by this means he and several others, using the same precautions, slept many nights on shore without any inconvenience.

Fire and smoke indeed are found to be certain correctors, or rather destroyers, of infection in all cases, whether arising from the noxious effluvia of marshes, or from the contagion of diseased bodies. Even those most extraordinary and fatal damps called harmattans, are unable to resist the salutary effects of smoke. In other cases, Dr. Lind remarks, that, under some circumstances, the source of an infection in a sick chamber or any other place, may be removed or destroyed by accidental means, for which we cannot account, and which we often cannot ascertain. But it oftener happens, that it is very difficultly rooted out; and that exact cleanliness, with the benefit of a pure air, often proves insufficient to remove the evil. Smoke, however, has never been known to fail. It is not to be doubted, that, excepting the true plague, there has been an infection fully as pestilential and as mortal in some ships as in any other place whatever; yet it has never been heard, that any ship, after having been carefully smoked, did not immediately become healthy: and if afterwards they turned sickly, it was easy to trace that sickness from other infected ships, jails, and the like places.

There are three methods practised for purifying vessels after the men have been removed out of them. The first is by burning of tobacco. A quantity of tobacco is spread on several fires, made with such old pieces of rope as are called junk. These are dispersed into different places of the ship, and their heat and smoke afterwards closely confined below for a considerable time.—The second method is by charcoal fires strewed with brimstone. The heat and steam of these burning materials must also be long and close shut up: but, although this fume, properly applied, has been found by experience to purify most effectually tainted apartments, ships, clothes, &c. yet there are some kinds of vermin which it will not destroy, particularly lice. The third method of purification is performed by the addition of arsenic to the materials of the second process.

cess in the following manner. After carefully stopping up all the openings and every small crevice of the ship (as was also necessary in the preceding processes), a number of iron pots, properly secured, are to be placed in the hold, orlope, gun-deck, &c. Each of these is to contain a layer of charcoal at the bottom, then a layer of brimstone, and so alternately three or four layers of each, upon which the arsenic is to be sprinkled, and on the top of it some oakum dipped in tar is to be laid to serve as a match. The men, upon setting fire to the oakum, must speedily leave the place, shutting close the hatchway by which they came up.

From the known and experienced efficacy of these processes, it appears, that fire and smoke are powerful agents for annihilating infection; and, it may be presumed, even the plague itself. This is in some measure agreeable to what we learn from the ancient records of physic. But the preposterous use, or rather abuse, of fire on such occasions, has caused its effects to be disregarded by some, and to be suspected of mischief by others. The modern practice of burning large fires in the open air, in the streets, and about the walls of towns infected with the plague or other contagion, is founded on principles groundless and erroneous; and has therefore been found by experience not only unsuccessful, but hurtful. But though this must be allowed, it does not thence by any means follow, that when once a house hath been infected, and the patients removed from it, the doors and windows at the same time being shut, that such fires will then prove hurtful; or that, by this method of purification, all the seeds of contagion may not be effectually destroyed. Whenever, therefore, persons die of a spotted fever, a malignant sore throat, the small-pox, or any distemper found to be communicable from the sick to the sound, the corpse ought quickly after death to be removed into another room; that in which the person died should be well aired, by having the windows opened, till a charcoal fire be kindled, with some rolls of sulphur upon it; after which, both doors and windows should be kept shut for a considerable time, not less than eight or ten hours, till the room be thoroughly smoked. In several ships, where there are the fairest opportunities of trying and judging things of this nature, the contagion of the small-pox has been entirely stopped by wood-fires, sprinkled with brimstone, kept burning and closely confined in the infected place. In a word, a judicious and proper application of fire and smoke is a powerful agent for the destruction and utter extinction of the most malignant sources of disease; and they are besides great purifiers of all bad and tainted air.

Next to the smoke of wood for purifying a tainted air, that of gun-powder is to be esteemed the best; and it has this further good property, that it is entirely inoffensive to the lungs. The cascarilla-bark, when burning, gives a most agreeable scent to the chamber of the sick; thus it is at least an elegant preservative, and may prevent bad smells from taking effect. The steam of camphorated vinegar, warmed, is still more powerful for this purpose. But, besides correcting the ill quality of the air, and purifying the chamber, another good effect is produced from such steams and smoke as are inoffensive to the lungs. As soon as the vapour becomes dense, the nurses and patients become desirous of the admission of fresh air by the door or windows.

Now it is certain, that the air in the chambers of the sick cannot be too often changed, provided the patient be well covered, and the curtains of his bed, if necessary, be drawn close. No argument is so forcible to obviate the danger of foul air in a room or ward (occasioned by the obliuancy of nurses or relations), as ordering it to be frequently fumigated or smoked: A practice more frequent in other countries than in this, but of great benefit to the sick.

Lastly, with regard to the method of purifying goods, moveables, clothes, &c. which are supposed to harbour infection, it must be observed, that the usual custom of only unpacking and exposing such materials to the open air, is in many instances insufficient to destroy the latent seeds of disease. It is certain indeed, that in most cases the contagious particles are more readily and fatally communicated from the clothes of a sick person than from his body. The spreading abroad, therefore, of contaminated clothes to dry or to be aired, without a previous fumigation of them, may be of dangerous and fatal consequence. All such suspected substances should be first fumigated in a close place, and in the same manner as an infected chamber, after which they may be spread abroad and exposed to the air. In infectious diseases, especially fevers, the linen of the sick, or such clothes about them as will admit of being washed, ought never at first to be put in warm water, as it is dangerous to receive the steam that may hence arise. It is necessary to steep them first either in cold water or in cold soap-lees for several hours, that the filth may be washed off.

But although the destruction of contagion by smoke is unquestionably a very important practice, yet it cannot now be said, that it is the most powerful agent for this purpose. By the ingenious observations and experiments of M. Morveau in France, and of Dr Smyth Carmichael in England, it is now ascertained, that we possess still more powerful means of destroying contagions, either in the muriatic or nitrous acid gas. The former may easily be detached from common sea salt, and the latter from nitre, by means of the sulphuric acid. Rooms may, with the utmost safety and ease, be filled with these fumes, although the sick be not removed from them. But for disinfecting a room, ward, or ship, when empty, the most powerful article yet discovered is the oxygenated muriatic acid gas, detached from a mixture of manganese and sea salt, by means of the sulphuric acid.

We must now proceed to give an account of the method of cure, after these means of preventing the infection from being received into the body have either been neglected or proved ineffectual. Here it is of the utmost importance to take the disease in the very beginning, before it has time to corrupt the fluids to such a degree as to endanger life. In slight degrees of infection, a vomit properly administered, especially if succeeded by a blister, never fails to remove the disorder, and prevent the fever which would otherwise unavoidably follow. Of this Dr Lind gives the following instances. A lady afflicted with the bilious cholic, had intolerably fetid discharges of corrupted matters upwards and downwards. A gentlewoman, only in passing the room, was immediately seized with a retching and sickness, which continued 24 hours. The nurse who attended was suddenly seized

Febric. zed with a giddiness and vomiting from the bad smell, which, as she expressed it, reached into her stomach. The vomiting became more severe at night, accompanied with a purging and frequent shiverings. By means of an emetic both evacuations were stopped: notwithstanding which, for some days afterwards, she continued to have frequent tremors, and a violent headache, with a low irregular pulse; and did not recover so soon as the patient.

Such slight degrees of infection have been often observed to be derived from patients of a gross habit of body, when labouring under inflammatory disempers, and even other complaints. A man was sent to Haslar Hospital, supposed to have a fever. He was furiously delirious, with a quick full pulse. Notwithstanding plentiful evacuations, this delirium continued for two months with short intervals: when the case was found to be plainly maniacal. A nurse, upon raising this person up in her arms, perceived an intolerably bad smell, and was instantly seized with shiverings, sickness, and headache. Finding herself very ill, she took a vomit in six hours afterwards, and passed the night in profuse sweats by means of a sudorific draught. Next morning the violence of the headache was but little abated; upon every attempt to move, she complained of a burning heat and pain in her forehead, and became giddy. Her inclination to drink was frequent, and her pulse low and quick. A blister was immediately applied to the back; as soon as the blister took effect, the headache and thirst entirely left her, and the pulse was calm. Next day she arose and was well.

Many similar instances of infection have been observed from putting the dead into their coffins. In particular, one man, from performing that duty to his mestmate, was so ill, even after the operation of the vomit, as to require a blister. In the course of one week two nurses were infected by a person in the small-pox. Both were seized in like manner with shiverings, sickness, and headache; the one upon receiving the patient's breath, the other upon making his bed. In one, a pain darted into her breast; in the other, into the breast and in the small of the back. The complaints of the former were speedily removed by a vomit, though she continued to have irregular returns of shiverings for three days afterwards. But in the latter, though the headache, sickness, and rigors, were greatly abated by the vomit, yet a constant heat and thirst, with a low pulse, and a violent pain in the breast, indicated the necessity of applying a blister to the affected parts, which next morning removed all her complaints.

A person is often immediately sensible of his having received infection from the first attack: they generally compare the first impression to an earthy, disagreeable smell, reaching down, as they express it, into their stomach, as from a grave newly opened, but not quite so raw as the cadaverous stench; and the effects of it, shivering and sickness, are instantaneous. It is a smell difficult to describe; but it is well known to the nurses and attendants about the sick, as it usually accompanies fevers of extreme malignity, and, with the peculiar discharges from the blistered parts, may be reckoned among the most constant symptoms of a bad fever. Some compare the smell to that of rotten straw.

VOL. XIII. Part I.

It often resembles the disagreeable smell of a person labouring under the confluent small-pox at their turn, though not so strong. One person, on receiving the infection, was sensible of something like an electric shock through his body. But many are not sensible of any effect from infection at first; and an infection from a fever will sometimes continue for many days, nay weeks, discovering itself chiefly by irregular shiverings, sometimes so severe as to oblige the patients to have recourse to their beds once or twice a day; sometimes every other day. Among a number thus affected, it also appears, that such as are put into unseasoned chambers, or have sat down on the cold ground, lain in raw damp apartments, &c. are immediately seized with a sickness at stomach, sometimes with a dangerous purging, and often with fevers accompanied with bad symptoms, which others have entirely escaped.

It now remains to consider the proper method of curing putrid fevers, on the supposition that the infection has been allowed to operate till the blood becomes radically tainted, and of consequence the nervous system affected to such a degree, that its power cannot be restored by any of the simple practices above mentioned. Here all authors agree, that a change of air, when it can be effected, is highly advantageous, and often contributes more towards the removing of the disease than all the medicines that can be exhibited. The utility of this change will appear from what has been formerly said; and we shall only further mention one instance from Dr Lind, in which the effects of bad air appear to a degree almost incredible. "It is remarkable (says he), that, in the last war, the English ships which touched at Batavia suffered more by the malignant and fatal diseases of that climate, than they did in any other part of India, if we except a fatal scurvy which once raged in that fleet at sea. Soon after the capture of Manila, the Falmouth, a ship of 50 guns, went to Batavia, where she remained from the latter end of July to the latter end of January; during which time she buried 100 soldiers of the 79th regiment and 75 of the ship's company; not one person in the ship having escaped a fit of sickness, except her commander Captain Brereton. The Panther, a ship of 60 guns, was there in the years 1762 and 1764; and both times during the rainy season. In the former of these years, she buried 70 of her men; and 92 of them were very ill when she left the place. In the year 1764, during a short stay, 25 of her men died. The Medway, which was in company with her, lost also a great number of men. Nor was the sickness at that time confined to the ships: the whole city afforded a scene of disease and death: streets crowded with funerals, bells tolling from morning to night, and horses jaded with dragging the dead in heres to their graves. At that time a slight cut of the skin, the least scratch of a nail, or the most inconsiderable wound, turned quickly to a spreading putrid ulcer, which in 24 hours consumed the flesh even to the bone. This fact is so extraordinary, that upon a single testimony, credit would hardly be given to it; yet on board the Medway and Panther they had the most fatal experience of it, and suffered much from it."

But where a change of air is impracticable or ineffectual, and where the fever has already made some progress, Sir John Pringle generally took away some blood if the pulse was full. When the symptoms run

N n

high,

high, a plentiful evacuation of that kind seemed indicated; yet it was observed, that large bleedings generally did harm, by sinking the pulse, and affecting the head. Nor was a moderate bleeding to be repeated without caution; even those whose blood was fizy, unless their lungs were inflamed, were the worse for a second bleeding. If the head only suffered, it was much safer to use leeches than to open a vein in the arm; but in the delirium with a sunk pulse, even leeches were hurtful. Many recovered without letting blood, but few who lost much of it.

Emetics also must be used with caution; for though they may be of service by way of prevention, yet in the advanced state of the disease, when the patient has all along complained of a sickness at stomach, they are evidently unsafe. Here the antiseptic quality of fixed air is of much use, and the neutral draughts given in the act of effervescence are generally attended with happy effects. Nay, clysters of fixed air itself have been found very serviceable. Even in very bad stages of the distemper, where a putrid and colliquative looseness has taken place, clysters of fixed air have been known to alleviate the symptoms. We must not, however, put too much confidence in medicines of this kind. Mild tonic cordials, especially wine and cinchona, are the only resources in these disorders. Concerning the former, Sir John Pringle observes, in the low state of these fevers, and in great sinkings, which either come after unseasonable bleedings or long want of nourishment, it was a most grateful and efficacious cordial, to which nothing was comparable. The common men had an allowance, from a quarter to half a pint in a day, of a strong kind, made into whey, or added to the panada which was their ordinary food. But to others out of the hospital, he usually prescribed Rhenish or a small French wine, whereof some consumed near a quart per day, and part of that undiluted. Nay, so great was the virtue of wine in this stage of the fever, that several were known to recover from the lowest condition, when, refusing the bark on account of its taste, they took nothing but a little panada with wine, and a volatile diaphoretic mixture, every two or three hours by turns. Perhaps there is no rule more necessary in this state, than not to let the patient when low remain long without taking something cordial and nourishing; as many have been observed past recovery, by being suffered to pass a whole night without any support about the time of the crisis. In the advanced state of this fever the sick are remarkably low; and therefore Hoffman advises in such cases, that they should be constantly kept in bed, and not permitted even to sit up in it. In the last stage of this fever, as well as in that of the sea-scurvy, it would seem that the force of the heart was too small to convey the blood to the brain, except when the body is in a horizontal posture.

But, however necessary wine and cinchona may be in the low stage of this fever, we must remember, that these remedies are to be administered only as antiseptics and supporters of the vis vita, without aiming at thoroughly raising the pulse or relieving the head, or at forcing a sweat by them, before nature points that way, and which Sir John Pringle seldom observed before the 14th day.

In the low state of the hospital fever, a stupor was a

constant attendant, which was very apt, in the evening, to change to a slight delirium. If this was all, nothing was done. But if the delirium increased upon using wine, if the eyes looked wild, or the voice became quick, there was reason to apprehend a phrenitis; and accordingly it was observed, that at such times all internal heating medicines aggravated the symptoms; and in these cases, blisters were of the greatest service. Fomentations of vinegar and warm water for the feet, Sir John Pringle is of opinion, would answer better than either sinapisms or blisters, provided they were long enough and often enough applied. In the inflammatory fevers, he has known these fomentations have little effect for the first hour, and yet succeed afterwards. For internal medicine, cinchona was omitted for some time, but the patient was continued with an acidulated drink, viz. barley-water and vinegar; and treated also with camphire, pulvis contrayevae compositus, and nitre, as was usual in the beginning of the fever. If the delirium was of the low kind, a decoction of cinchona and wine were the only remedies; for in no instance was the delirium perfectly removed till the time of the crisis. It must also be observed, that a delirium may arise in putrid fevers from two opposite errors; one from large and repeated bleedings, and the other from wine and the cordial medicines being taken too early. It appears, therefore, how nice the principles are that regard the cure; as neither a hot nor a cool regimen will answer with every patient, or in every state of the disease.

If a diarrhoea came on in the decline of the fever, it was moderated, but not suppressed, by adding an opiate to the usual medicines. For though the looseness may be considered as critical; yet as the sick were too low to bear evacuations, there was a necessity for restraining it in some measure; and it has often been observed, that when it has been treated in this manner, about the usual time of the crisis, the patient has fallen into a gentle sweat, which has carried off the disease. In the worst cases of this fever, and especially when it coincides with the dysentery, the stools are frequently bloody; in which dangerous state, if any thing could be done, it was attempted by medicines of the same kind. In proportion to the putrid nature of the stools, opiates and astringents were used with the greater caution.

If the disease terminate in a suppuration upon one of the parotid glands, the abscess was opened without waiting for a fluctuation, which might never happen; the pus being often here so viscid, that after it was ripe, the part felt nearly as hard as if the suppuration had not begun.

Almost every patient, after the fever, complained of want of rest, frequently of a vertigo or confusion of the head, of a continuation of the deafness, or of other symptoms commonly called nervous. An opiate was then given at night; and in the day some strengthening medicines, such as cinchona and the sulphuric acid. In these cases, the bark was found not only to be the best strengthener, but the surest preservative against a return of the disease. For this last intention the convalescent was ordered about three drams a-day for six or seven days together; and afterwards, if he remained longer in the hospital, some smaller quantity daily. But if there was any appearance of a hec-

tic fever from an inward abscess, the case was treated accordingly. Upon comparing some of the remaining symptoms of those who recovered, with the condition of the brain in those who died and were opened, Sir John Pringle was induced to think, that some part even of that substance might suppurate, and yet the person recover.

Sometimes the patient falls into an irregular intermittent; which, if not of a hectic nature from an internal abscess, may proceed from neglecting to clear the primæ viæ. For it is easy to conceive, that after a long fever of such a putrid nature, often attended with languor of the bowels, the faeces may be so much accumulated, and so corrupted, as to occasion new disorders. In such cases, after proper evacuation by a purge, cinchona was almost an infallible remedy.

The Yellow Fever.

Typhus cum flavidine cutis.

Typhus icteroides, Sauv. sp. 7.

Febris flava Indiae Occidentalis, Warren. Malignant Fever of Barbadoes, Hillary's Diseases of Barbadoes. Lining on the Yellow Fever of South Carolina, Edin. Phys. and Liter. Essays, vol. ii. McKittrick de Febre Flava Indiae Occidentalis, Edin. 1766.

Description. This is one of the most fatal diseases to which the inhabitants of warm climates are subject, and is the same with that called, from one of its worst symptoms, the black vomit, which is so terribly destructive in some of the warm parts of America, particularly at Carthage; and which of late has proved so fatal in Philadelphia, New York, and the British West India islands, as described by Drs Rush, Chisholm, Clerk, and other late writers. This, though by some considered as a new disease, is evidently from the same contagion which has produced fatal fevers on many former occasions.

The yellow or putrid bilious fever has been in particular minutely described by Dr Hillary. It most commonly seizes the patient at first with a faintness, then with a sickness at stomach, accompanied in general with a giddiness of the head; and soon after with a slight chilliness and horror, very rarely with a rigor. These symptoms are soon followed by a violent heat and high fever, attended with acute darting pains in the head and back. A flushing in the face, with an inflamed redness and a burning heat in the eyes, great anxiety and oppression about the præcordia, are the pathognomonic signs of the distemper, especially when attended with sickness at stomach, violent retchings, and bilious yellow vomitings, with frequent sighing. The pulse is now generally very quick, high, soft, and sometimes throbbing, but never hard: in some it is very quick, soft, low, and oppressed; the respiration quick, full, and sometimes difficult; the skin very hot, and sometimes dry, though more frequently moist. Blood taken from the patient, even at the very beginning of the disease, is often of an exceeding florid red colour, without the least appearance of size; and the crassamentum, when it has stood till it is cold, will scarce cohere, but fluctuates; the serum is often yellow.

Most of the above-mentioned symptoms continually increase, and are much aggravated: the retching and vomiting become almost incessant; the anxiety great,

and sighing frequent; great restlessness; continual tossing; no ease in any posture; little sleep, and that disturbed and uneasy, and without any refreshment to the sick. When they are fainting, they turn yellow about the face and neck, instead of turning pale; and as the fainting goes off, they recover their natural colour. These symptoms generally continue to the third day, though sometimes not longer than the first or second; in others to the end of the fourth: the first shows the greater dissolution of the blood, and the greater malignity of the disease; the last, the contrary; which the improper manner of treating the disease sometimes hastens and increases, or the proper method retards. This may be called the first stadium of the disease, and generally ends on the third day.

Blood taken from the sick on the second or third day, is much more dissolved, the serum more yellow, and the crassamentum florid, loose, scarcely cohering, but undulates like sixty water when shaken, and sometimes has dark blackish spots on its surface, showing a strong gangrenous diathesis.

About the third day, the pulse, which was quick and full before, now generally sinks greatly, and becomes very low: though sometimes it remains very quick, yet in others it is not much quicker than when the patient was in health, but is always low; the vomiting becomes almost incessant if not so before, and the matter thrown up is black; the patient then becomes comatose, with interrupted delirium. The thirst in some is very great, in others but little; the pulse still low and quick, attended with cold clammy sweats, and sometimes with delirium. The eyes, which were inflamed and red before, and began to be of a more dusky colour, now turn yellow; and this yellowness also soon after appears round the mouth, eyes, temples, and neck, and in a short time diffuses itself all over the body. But this yellowness is so far from being always an encouraging prognostic, as some would have it, that it most commonly proves a mortal symptom. Sometimes indeed, though seldom, this suffusion of bile upon the surface has proved critical; but then it did not come on till the eighth or ninth day, nor appear till the coma and all the other bad symptoms began to abate; and then in proportion as the yellowness increases, all the bad symptoms decrease. But the case is most commonly quite the reverse; especially when the yellowness comes soon on: and then it ulcers in the most fatal symptoms of the disease, viz. a deep coma, a low, vermicular, and intermitting pulse, great hemorrhages from various parts of the body, a delirium with laborious and interrupted respiration, great anxiety, deep sighing, restlessness, a subfultus tendinum, coldness of the extreme parts first, and then all over the body, a faltering of the speech, tremors, and convulsions, which are soon after followed by death. So that from the first appearance of the yellowness we may say the patient is in the last stage of the disease, whether it terminates in death or recovery.

It has been observed, that, in some strong sanguine constitutions, when the patients have not been bled to a sufficient quantity in the beginning of the disease, the pulse has continued full, strong, and rapid, but never hard; the face flushed, eyes inflamed; the tongue dry, with great thirst and heat, till the second or last stage of the fever is come on, when the pulse has suddenly

suddenly sunk, and death soon after ensued. Yet in others, who seemed to be of a plethoric habit, the tongue has been moist all along, though they have been delirious most of the time, and the heat of their skin and the strength and quickness of their pulse have continued, after the first stage of the disease was over, pretty near to that of their natural state in health, till within a few hours of death; and when they have had a coma on them, one who is not well acquainted with the nature of this disease would, from the pulse, heat, breathing, and other symptoms, have taken them to be in a natural sleep. Others, when the pulse has begun to sink, and the fatal period seemed to be just approaching, to the great surprise of all present have recovered their senses, sat up and talked pretty cheerfully for an hour or two, and in the midst of this seeming security have been suddenly seized with convulsions which carried them off immediately.

In the latter stage of this fever, the blood is so attenuated and dissolved, that we frequently see it flowing not only out of the nose and mouth, but from the eyes, and even through the pores of the skin; great quantities also of black, half-baked, or half-mortified blood, are frequently voided both by vomiting and by stool, with great quantities of yellow and blackish putrid bile by the same passages; and the urine, which was before of a high icteritious colour, is now almost black, and is frequently mixed with a considerable quantity of half-dissolved blood. The pulse, which was much sunk before, now becomes very low, unequal, and intermitting; the breathing difficult and laborious; and the anxiety inexpressible; an oppression with a burning heat about the precordia comes on, though the extremities are cold, and often covered with cold clammy sweats: a constant delirium follows; and then a total loss of the outward senses as well as the judgement, with livid spots in many parts of the body, especially about the precordia; and sometimes gangrenes in other parts of the body, which are very soon succeeded by death.

In a short time after death, the body appears much more full of livid, large, mortified spots, particularly about the precordia and hypochondriæ, especially the right; which parts seem, even from the first seizure, to be the principal seat of this terrible disease; and, upon opening the bodies of those who die of it, we generally find the gall-bladder and biliary ducts turgid, and filled with a putrid blackish bile; and the liver, stomach, and adjoining parts, full of livid or blackish mortified spots; and the whole corpse soon putrefies after death, and can be kept but a few hours above ground.

Dr Lind is of opinion, that the remarkable dissolution of the blood, the violent haemorrhages, black vomit, and the other symptoms which characterize the yellow fever, are only accidental appearances in the common fever of the West Indies; that they are to be esteemed merely as adventitious, in the same manner as purple spots and bloody urine are in the smallpox, or as a hiccough in the dysentery: like these they only appear when the disease is attended with a high degree of malignity, and therefore always indicate great danger. This opinion, he thinks, is confirmed by an observation of Dr Wind's, that in 1750 the crew of a Dutch ship of war were distressed by the yellow fe-

ver, accompanied with the black vomit; but when the ship left the harbour, and changed the noxious land air for one more healthy, the fever continued, but was not accompanied with the black vomit.

Diseases similar to this fever, Dr Lind informs us, may arise in any part of the world where the air is intensely hot and unwholesome; and therefore he treats as chimerical the notion of its being imported from one part of the world to another. An example of this happened at Cadiz in Spain, in the months of September and October 1764, when excessive heat, and want of rain for some months, gave rise to violent, epidemic, bilious disorders, resembling those of the West Indies, of which 100 persons often died in a day. At this time the winds blew principally from the south, and after sunset there fell an unusual and very heavy dew. But his opinion on this subject is liable to strong objections. And however the disease may originate, yet the late introduction of it from Spain into the fortress of Gibraltar, from which, by proper attention, it had been excluded in former epidemics, demonstrates the contagious nature of this fever beyond all possibility of doubt.

It has been a matter of much dispute, whether the yellow fever is of an infectious nature or not. Some time ago it became an object of consideration before the Right Hon. the Lords Commissioners of Trade and Plantations, where it was urged among other reasons, for not removing the seat of government and justice in the island of Jamaica from Spanish Town to Kingston, that there was danger from Greenwich hospital, situated near Kingston, of an infection from the yellow fever being frequently communicated to that town. On this affair a physician was consulted, who had long practised in that island, and who gave it as his opinion, that from the yellow fever in that island there was no infection. This was the opinion not only of that gentleman, but of many others who had an opportunity of being well acquainted with this fever in Jamaica. But this opinion probably only arose from these practitioners having confounded the ordinary remittent fever of the West Indies, which is often accompanied with bilious symptoms, and is from thence often denominated the yellow fever, with the typhus icteroides, a disease essentially different from the bilious remittent which often prevails both in the West and East Indies. Dr Lind gives a remarkable instance of its being of an infectious nature.—A gentleman dying at Barbadoes of a yellow fever, his wearing apparel and linen, packed up in a chest, were sent to his friends at Philadelphia; where, upon opening the chest, the family was taken ill; and the clothes being unluckily hung abroad to be aired, they presently diffused the contagion of the yellow fever over the whole town, by which 200 persons died.

In the description of the same fever by Dr Lining, as it appeared in South Carolina, there are several particulars considerably different from that by Dr Hillary. According to the former, people complained for a day or two before the attack, of a headache, pain in the loins and extremities, especially in the knees and calves of the legs, loss of appetite, debility, and a spontaneous lassitude. Some, however, were seized suddenly, without any such previous symptoms. After a chilliness and horror, with which this disease generally invades, a fever succeeded. The pulse was very frequent, till near the termination of the fever, and was generally full,

Febris full, hard, and consequently strong: in some, it was small and hard; in others, soft and small; but in all those cases, it frequently varied in its fulness and hardness. Towards the termination of the fever, the pulse became smaller, harder, and less frequent. In some there was a remarkable throbbing in the carotids and in the hypochondria; in the latter of which it was sometimes so great, that it caused a constant tremulous motion of the abdomen. The heat generally did not exceed 102 degrees of Fahrenheit's thermometer; in some it was less; it varied frequently, and was commonly nearly equal in all parts, the heat about the precordia being seldom more intense than in the extremities when these were kept covered. On the first day of the disease, some had frequent returns of a sense of chilliness, though there was not any abatement of the heat. In a few, there happened so great a remission of the heat for some hours, when at the same time the pulse was soft and less frequent, and the skin so moist, that one from these circumstances might reasonably have hoped that the fever would only prove a remittent or intermittent. About the end of the second day, the heat began to abate. The skin was sometimes (though rarely) dry; but oftener, and indeed generally, it was moist, and disposed to sweat. On the first day, the sweating was commonly profuse and general; on the second day, it was more moderate: but on both these, there happened frequent and short remissions of the sweatings; at which times the febrile heat increased, and the patient became more uneasy. On the third day, the disposition to sweat was so much abated, that the skin was generally dry; only the forehead and backs of the hands continued moist. The respiration was by no means frequent or difficult; but was soon accelerated by motion, or the fatigue of drinking a cup of any liquid. The tongue was moist, rough, and white, even to its tip and edges. On the second day, its middle in some was brown. On the third day, the whiteness and roughness of the tongue began to abate. The thirst in very few was great. A nausea, vomiting, or frequent retchings to vomit, especially after the exhibition of either medicines or food, came on generally the third day, as the fever began to lessen; or rather as the fulness of the pulse, heat, and disposition to sweat, began to abate. Some indeed, but very few, on the first day, had a vomiting, either bilious or phlegmatic. Very few complained of anxiety or oppression about the precordia or hypochondria, nor was there any tension or hardness about the latter. On the first day they generally dozed much, but were afterwards very watchful. Restlessness and almost continual jactations came on the second day. A great despondency attended the sick, and the strength was much prostrated from the first attack. The pain in the head, loins, &c. of which they had complained before the attack, was much increased, and in some the pain in the forehead was very acute and darting; but those pains went generally off the second day. The face was flushed; and the eyes were hot, inflamed, and unable to bear much light. On the first day, many of them at times were a little delirious, but afterwards not until the recede of the fever. The blood drawn by venesection had not any inflammatory crust; in warm weather, it was florid like arterial blood, and continued in one soft homogeneous-like mass, without any

separation of the serum after it was cold. When there was any separation, the crassamentum was of a very lax texture. The stools, after the first day, were fetid, inclined to a black colour, and were very rarely bilious, soft, or liquid, excepting when forced by art; for an oblitinate costiveness attended the febrile state. The urine was discharged in a large quantity, was pale, sometimes limpid, and rarely of a higher than a straw colour, except when the weather was very warm, and then it was more saturated, of a deep colour, and discharged in smaller quantities. It had a large cloud, except when it was very pale or limpid; but more generally it had a copious white sediment, even on the first day of the fever. On the second day, the urine continued to be discharged very copiously; in some it was then turbid, and deposited a more copious sediment than on the first day; this sediment was sometimes of a brownish colour; in which case it was generally followed by bloody urine, either about the end of the second or beginning of the third day. The colour and quantity of the urine, discharged in equal times, were remarkably variable, being now limpid, then of a deeper colour; now discharged in a larger, then in a smaller quantity; which could not be ascribed to any change made either in the quantity or quality of the drink.

The fever accompanied with those symptoms terminated on the third day, or generally in less than 72 hours from the first attack, not by any assimilation or coction and excretion of the morbid matter: for if by the latter, there would have been some critical discharge by sweat, urine, stool, or otherwise, none of which happened; and if by the former, nothing then would have remained but great debility. This fever, however, did not terminate in either of these salutary ways, excepting in some, who were happy enough to have the disease conquered in the beginning by proper evacuations, and by keeping up a plentiful sweat, till the total solution of the fever, by proper mild diaphoretics and diluents. But in those who had not that good fortune, however tranquil things might appear, yet the face of affairs was quickly changed: for this period was soon succeeded by the second stadium; a state, though without any fever, much more terrible than the first: the symptoms in which were the following. The pulse, immediately after the recede of the fever, was very little more frequent than in health, but hard and small. However, though it continued small, it became, soon afterwards, slower and very soft; and this softness of the pulse remained as long as the pulse could be felt. In many, in this stage of the disease, the pulse gradually subsided, until it became scarce perceptible; and this, notwithstanding all the means used to support and fill it; and when this was the case, the icteritious-like suffusion, the vomiting, delirium, restlessness, &c. increased to a great degree. In some, the pulse, after being exceedingly small and scarce perceptible, recovered considerably its fulness; but that favourable appearance was generally of but short continuance. The heat did not exceed the natural animal heat; and when the pulse subsided, the skin became cold, and the face, breast, and extremities acquired somewhat of a livid colour. The skin was dry when the weather was cold, but was moist and clammy when the weather was hot. The respiration was

was natural, or rather slow. The tongue was moist, and much cleaner than in the former stage; its tip and edges, as also the gums and lips, were of a more florid red colour than usual. Very few complained of thirst, though they had a great desire for cold liquors. The vomiting or retching to vomit increased, and in some was so constant that neither medicines nor aliment of any kind were retained. Some vomited blood; others only what was last exhibited mixed with phlegm; and others again had what is called the black vomit. The retching to vomit continued a longer or shorter time according to the state of the pulse; for as that became fuller, and the heat greater, the retching to vomit abated, and à contra. The inquietude was very obstinate; and when they dozed, their slumbers were but short and unrefreshing. There were some who were drowsy; but these always awakened, after the shortest slumbers, with a great dejection of spirits and strength. The jauctions or restlessness were surprising: it was frequently scarce possible to keep the patients in bed; though, at the same time, they did not complain of any anxiety or uneasiness; but if asked how they did? the reply was, Very well. The debility was so great, that, if the patient was raised erect in the bed, or, in some, if the head was only raised from the pillow, while a cup of drink was given, the pulse sunk immediately, and became sometimes so small, that it could scarce be felt; at this time, they became cold, as in a horripilatio, but without the anserine-like skin: their lips and skin, especially about the neck, face, and extremities, together with their nails, acquired a livid colour. The delirium returned and increased; it was generally constant in those whose pulse was small and subsiding. The inflammation of the tunica conjunctiva or white of the eyes increased much, but without pain. A yellowness in the white of the eyes, if it did not appear before in the febrile state, became now very observable, and that icteritious tinct was soon diffused over the whole surface of the body, and was continually acquiring a deeper saffron-like colour. In some, indeed, no yellowness was observable, excepting in the white of the eyes, until a little before death, when it increased very quickly, especially about the breast and neck. There were many small specks, not raised above the skin, which appeared very thick in the breast and neck, but less so in the extremities, and were of a scarlet, purple, or livid colour. In women the menstrua flowed, and sometimes excessively, though not at their regular period.

There was such a putrid dissolution of the blood in this stadium of the disease, that, there were haemorrhages from the nose, mouth, ears, eyes, and from the parts which were blistered with cantharides. Nay, in the years 1739 and 1745, there were one or two instances of an haemorrhage from the skin, without any apparent puncture or loss of any part of the scarf-skin.

An obstinate costiveness continued in some; in others, the stools were frequent and loose; in some they were black, liquid, large, and greatly fatiguing; in others, when the stools were moderate, even though they were black, they gave great relief; in others, again, the stools nearly resembled tar in smoothness, tenacity, colour, and consistence.

The urine was discharged in a large quantity, in proportion to the drink retained by the patient: it

was pale if the patient was not yellow; but if yellow, then it was of a deep saffron-colour: in either case, it had a sediment, or at least a large cloud, which remained at the bottom of the glass; in some, it was very turbid; in others it was bloody: and the quantity of blood discharged with the urine bore always some proportion to the state of the pulse; when that became fuller, the quantity of blood in the urine was diminished; when the pulse subsided, the bloody urine increased, and even returned after it had ceased some days, soon after the pulse became smaller. This stage of the disease continued sometimes seven or eight days before the patient died.

When this stadium of the disease terminated in health, it was by a recess or abatement of the vomiting, haemorrhages, delirium, inquietude, jauctions, and icteritious-like suffusion of the skin and white of the eyes; while, at the same time, the pulse became fuller, and the patient gained strength, but very slowly. But when it terminated in death, those symptoms not only continued, but sooner or later increased in violence, and were succeeded with the following, which may be termed the third stadium of the disease, which quickly ended in death. The pulse, though soft, became exceedingly small and unequal; the extremities grew cold, clammy, and livid; the face and lips, in some, were flushed; in others, they were of a livid colour; the livid specks increased so fast, that in some the whole breast and neck appeared livid; the heart palpitated strongly; the heat about the precordia increased much; the respiration became difficult, with frequent sighing; the patient now became anxious, and extremely restless; the sweat flowed from the face, neck, and breast; blood flowed from the mouth, or nose, or ears, and in some from all those parts at once; the deglutition became difficult; the hiccoughs and subsultus tendinum came on, and were frequent; the patients trifled with their fingers, and picked the naps of the bedclothes; they grew comatose, or were constantly delirious. In this terrible state, some continued eight, ten, or twelve hours before they died, even after they had been so long speechless, and without any perceptible pulsation of the arteries at the wrists; whereas, in all other acute diseases, after the pulse in the wrists ceases, death follows almost immediately. When the disease was very acute, violent convulsions seized the unhappy patient, and quickly brought this stadium to its fatal end. After death, the livid blotches increased fast, especially about the face, breast, and neck, and the putrefaction began very early, or rather increased very quickly.

Such was the progress of this terrible disease through its several stadia. But in hot weather, and when the symptoms in the first stage were very violent, it passed through those stages with such precipitation that there was but little opportunity of distinguishing its different stadia, the whole tragedy having been finished in less than 48 hours. It was remarkable, that, 1. The infection was increased by warm and lessened by cold weather. 2. The symptoms in the several stadium were more or less violent, according to the heat or coolness of the weather. In hot days, the symptoms were not only more violent, but in those who seemed in moderate weather to be on the recovery, or at least in no danger, the symptoms were all so greatly heightened, when

Febris. when the weather grew considerably warmer, as frequently to become fatal. In cool days, the symptoms were not only milder, but many who were apparently in great danger in hot days were saved from the very jaws of death by the weather becoming happily cooler. 3. The disease was generally more fatal to those who lay in small chambers not conveniently situated for the admission of fresh air, to those of an athletic and full habit, to strangers who were natives of a cold climate, to those who had the greatest dread of it, and to those who before the attack of the disease had overheated themselves by exercise in the sun, or by excessive drinking of strong liquors; either of which indeed seemed to render the body more susceptible of the infection. Lastly, The disease proved most certainly fatal to valetudinarians, or to those who had been weakened by any previous disease.

Causes of, and persons subject to, this disease. The yellow fever attacks principally Europeans, especially those who have but lately arrived in the hot climates. Negroes are entirely exempt from it, though the mulattoes and tawnies are as liable to be seized with it as the whites themselves. The cause of the disease seems to be a particular kind of contagion; but Dr Lind seems to be of opinion, that the immediate cause of the symptoms is a disposition in the glutinous part of the blood to separate from the others, and to become putrescent. In some persons who have been bled in the yellow fever, the blood has been observed very viscous; the crassamentum covered with a yellow gluten half an inch in thickness, and impenetrable to the finger unless cut by the nail; the serum being at the same time of the consistence of a thin syrup, and of a deep yellow tint. This serum tasted bitter, and resembled a composition of foot. The appearances on dissection, with his conclusions from them, we shall give in his own words: "In a man who died on the eleventh day of a yellow fever, whose body emitted no bad smell 36 hours after death, and was still yellow, I found all the bowels of the abdomen found; the liver and spleen were remarkably so; as also the stomach and intestines. There was no suffusion of the bile either in the intestines or stomach. The gall-bladder, of the natural size, contained the usual quantity of bile, somewhat thicker than common, and grumous (B).

"Upon examining further, this disease was found to have lain wholly on the left side, where, within the breast, was found near a quart of yellowish water, in which were many large flakes of yellowish gluten, appearing, by comparison, precisely the same with the thick pellicle which had covered the blood taken from his arm. These flakes bore in several places a resemblance to a membranous substance beginning to be converted into a purulent jelly. The pleura, both on its inside and outside, as also its continuation, the investing membrane of the lungs, were covered with cakes of this gluten, hanging in some places loosely, in others adhering more strongly: and all in different

states of yellow or purulent corruption. The right cavity of the breast, and all the other parts of his body, were found entirely free from disease.

"His complaints had been chiefly in his breast; and a small quantity of blood, taken from him two days before his death, was covered with an impenetrable, yellow, thick gluten; the red portion below it being quite loose.

"In those fevers, I have also seen (says Dr Lind) the disease entirely confined to the heart and pericardium. In one who died on the tenth day of the fever, without having been yellow, a quantity of pus and purulent crusts were found mixed with the water of the pericardium. The heart in different places was excoriated; and, together with the inside of the pericardium, was lined with a thick membranous cake, similar to that already mentioned on the lungs and pleura. In some places this cake had a purulent, in others a gelatinous appearance, exactly resembling the coagulum of the blood. His complaints had been, a great oppression on the breast, and an extreme difficulty of breathing. In a third person, who died on the thirteenth day of the fever, above two quarts of pus and purulent jelly were found in the cavity of the belly. The source of such an extraordinary quantity of matter was not from any preceding inflammation, nor any impoisthume, that we could discover; but from innumerable ulcerations on the surface of the intestines, omentum, mesentery, and peritoneum. Neither did those ulcerations (or excoriations, as they rather appeared in several places) seem to be the primary fountains of the matter, but to have been occasioned by its acrimony.

"This purulent appearance seems to arise merely from an extravasation of one of the component parts of the blood, the gluten or fibrine as it is now called. Blood taken from persons in a fever, and frequently even from persons in perfect health, after standing in a clean vessel for a short time, commonly separates into three distinct portions; viz. the serum, or water of the blood, the red concreted mass, and a viscous pellicle termed the size, which spreads itself on the top of the red concretum. Some time ago, when making experiments with the blood taken from persons in the scurvy, I was surprised to find it often covered with that fizy crust. This induced me to extend my experiments to large quantities of blood from different subjects, which I had opportunities of inspecting at once in so large an hospital. For this purpose I one morning ordered ten patients in the scurvy to be bled, taking two ounces from each. A larger quantity was taken, for its inspection, from two men in health. That day I had occasion to prescribe bleeding to a woman in labour, two hours before her delivery; to a girl of sixteen years of age afflicted with a lunacy proceeding from the chlorosis; to three patients in the rheumatism; and to a person labouring under an obstruction of the liver.

"From a nice comparison, and an examination of the blood in these cases, I found in general, that the more

(B) In others who died in this yellow state, the bile in the gall-bladder was found of a thick ropy consistence like pitch, but the liver never appeared in the least affected. Dr Lind at first in several bodies opened the head only; but afterwards judged that all the cavities ought to be inspected.

Febres. more size there was on the top, and the thicker and more viscous this white pellicle showed itself, the concretion below it was of a more loose coherence. This was not so observable when only some slight white streaks appeared on the top. But when much size had separated itself, the red mass became very soft at the bottom of the vessel, and less compact in its different parts, in proportion to their distance from the surface, towards which this whitish portion had ascended.

"From this and from other experiments it appears, that this crust or pellicle is the natural gluten which becomes strongly disposed, in certain circumstances and diseases, to separate itself. And whereas the serum and red concretion are easily incorporated together, it will be found, that this glue, after its separation, becomes immiscible with either. We have, by gentle drying, converted it into a perfectly tough elastic membrane; and, by the means of a small portion of the red mass being left adhering to it, into a substance resembling muscular flesh; and it is capable of undergoing various changes into corruption, in the same manner as either of these.

"Now, I can see no reason why this gluten, in its morbid state, may not separate itself from the circulating blood, and be deposited in the cavities of the body, as readily as the serum does in dropsies; the former having always a less disposition than the latter to incorporate with the mass.

"In dissecting persons who died of fevers in London and Minorca, and where no infection was suspected, appearances similar to these have also fallen under the inspection of those accurate anatomists Drs Hunter and Cleghorn. Hence it may be presumed very difficult to distinguish fevers that are produced by infection, from some others. I cannot, however, be induced to think, as those gentlemen seem to do, that these preternatural substances which were found in the cavities of the body are the consequence, but rather that they are the cause, of the inflammation and excoriations. I believe these substances to be at first diseased extravasated gluten, and conjecture their different states greatly to depend upon the different times at which they were deposited.

"I have remarked, in a variety of dead bodies, three different kinds of extravasation; these occurred in such as had died of the scurvy, of consumption, and of fevers. In the former of those diseases, red coagulated blood is found extravasated in almost all parts of the body, not only into the tela cellulosa, but into the bellies of the muscles, particularly of the legs and thighs, which often become quite stuffed and even distorted with large grumous masses. The intestines and mesentery are often spotted also with extravasated blood; and I have seen large ecchymoses on the stomach. Those appearances at first sight resembled so many distinct mortifications; and by this appearance some anatomists have been deceived; but, upon a nice examination, the texture of the parts is found to be sound and firm. There is likewise, in that disease, sometimes, an extravasation of water, chiefly collected in the tela cellulosa.

"But as, in the limbs of scorbutic persons, it is extremely difficult to make a good dissection by reason of such quantities of extravasated blood that everywhere obstruct the operator; so, on the contrary, the lower

extremities of those who have died consumptive, with Dyspnea. swelled legs, are, of all subjects, in the best state to afford a satisfactory view of the muscles. The water enclosed in their legs having insinuated itself, by passing the tela cellulosa, into the spaces between the muscles, the muscles are easily separated from each other; and their several origins and insertions may be distinctly traced by means of their having been cleansed and washed by the water in the investing cellular membrane. Thus there are extravasations of three sorts; viz. First, The grumous mass in the scurvy; and this I have often remarked where no serum was observed. Secondly, The serum alone in anasarca swellings. The third and last is what was taken notice of in those who died of fevers, being the gluten of the blood, accompanied for the most part with some serum; both of them altogether confined to the large cavities of the body.

"I conjecture, that in those fevers there is always an ulcerous or purulent disposition in the blood; and that the gluten is greatly diseased. I have frequently seen it have a true purulent appearance soon after it was drawn off, when the patient seemed not very ill.

"And I further conjecture, that the mischief often lies within the breast; as also that the great benefit derived from the very early application of blisters, in a great measure flows from so many ulcerations and vents being timely provided for the free discharge of those purulent and tainted particles from the body.

"If an infection depends, as many have imagined, on the admission of certain foreign particles into the blood, this gluten seems to be primarily affected by it; and a discharge of this, by washing those particles out of the body, tends in a great measure to remove that disease.

"It is an observation of the best practical writers, that ulcers and fetons are most excellent preservatives against receiving an infection, even that of the plague itself. And indeed a suppuration and plentiful discharge from a proper ulcer, whether produced by nature or by art, seems to open a channel the best appropriated for an exit out of the body to some of the most malignant poisons. Thus the most favourable crisis in the plague, and in most pestilential fevers, happens when nature excites tumors kindly suppurating in the groin or armpits, by whose beneficial and plentiful discharge the deadly poison is expelled from the constitution.

"I have observed it to be amongst the most certain characteristics of the worst fevers, that the blisters either do not rise and fill, or discharge such yellow, greenish, fetid, and highly offensive stuff, that even experienced nurses could give a pretty certain conjecture from the blisters of the different degrees of malignity in the fever. We have more than once endeavoured to conceal the bad state of some patients in the hospital; but a discovery was always made of their condition in the washhouse, from the linen sent there stained with the discharges from the blistered parts. And indeed a careful inspection of the state and discharge from the blisters, together with their effects, furnishes us, in those diseases, with some of the most certain diagnostics of their nature, and prognostics of their event."

Prognosis. This dissemper, where it attacks with violence,

violence, is generally fatal; the prognosis therefore must be commonly unfavourable, and always uncertain; neither can any thing more be said on this subject, than that an abatement of the symptoms already enumerated affords a favourable prognostic, and an increase of them the contrary.

Cure. The cure of this terrible disease, according to Dr Hilary, is very easy and simple. His indications are, 1. To moderate the too great and rapid motion of the fluids, and abate the too great heat and violence of the fever in the two first days of the disease, as much and as safely as we can. 2. To evacuate and carry out of the body as much of the putrid bile and other humours, and as expeditiously and safely as possible. 3. To put a stop to the putrescent disposition of the fluids, and to prevent the gangrenes from coming on, by suitable antiseptics.

The first indication is answered by bleeding, which, in the first stage of this fever, is sometimes absolutely necessary in some degree: the quantity to be taken away must be determined by the age and strength of the patients, the degree of plethora, fulness of the pulse, &c. When called at the beginning, he orders 12, 14, 16, 18, or 20 ounces of blood to be taken away on the first or second day; and if the patient's pulse rise after the first bleeding, or if the fever still continue high and the pulse full, he repeats the bleeding once on the days above mentioned. But bleeding a third time is seldom or never required; neither is bleeding on the third day almost ever necessary; and when it is performed on that day, it ought to be done with the greatest caution and judgement: neither should a vein be opened after the third day in this fever, unless some very extraordinary symptoms and circumstances require it; which seldom or never happen. On that day, indeed, the pulse generally sinks, and the blood is in such a dissolved state, that bleeding must be accounted highly pernicious. Nevertheless, it is indispensably necessary in the beginning of the disemper; and if omitted at that time, the violent heat and motion of the blood increase the putrescence of the humours to such a degree as to bring on the fatal consequences much sooner than would otherwise have happened. If blood-letting be thus advised by Dr Hilary, it has been still more strongly recommended by Dr Rush, who, in his first publication on the subject of the dreadful yellow fever which proved so fatal at Philadelphia, represented it as an almost infallible remedy for the disease. But the observations and experience of others have by no means confirmed the practice which he recommended.

After bleeding, we come to the second indication of cure, namely, to evacuate as much of the bilious and putrid humours as soon and as safely as we can. The great irritation of the stomach, by the putrid bilious humours constantly attending this fever, with almost continual retchings and violent vomitings, seem to indicate the giving of an emetic: but the stomach is always observed to be so violently stimulated and irritated, and most commonly inflamed, by the acrimony of the putrescent bile, that any emetic, even the most mild and gentle, given in the smallest dose, brings on an incessant vomiting, which continues, in spite of all remedies, till a mortification and death ensue. Instead of this, it is proper to give large draughts of warm

water, which, without any additional stimulus to the stomach, evacuates its acrid and putrid contents, commonly with great relief to the patient: the warm water also acts as an emollient lotus to the inflamed coats of the stomach; and thus abates the inflammation, and prevents gangrene and mortification from coming on.

After the patient has by this means vomited seven or eight times, or oftener, and discharged a great quantity of yellow and blackish bilious matter, a grain or a grain and a half of thebaic extract is given, in order to procure some respite from the violent retching, vomiting, and anxiety. The person is desired to take nothing into his stomach for two hours after this, by which means it is seldom or never rejected; and thus all the symptoms are considerably abated, the retching and vomiting either totally cease or are very much lessened, so that medicines may now be exhibited which the stomach would not have retained before. These are cooling acid juleps, or other antiseptic remedies; but neither nitre nor any of its preparations will commonly be found to stay on the stomach, nor, according to Dr Hilary, are the nitrous medicines, or even the common antiemetic draughts, proper to be given in this disease, even though they should agree with the stomach, on account of their attenuating property.

If the patient has not a stool or two after drinking the warm water and vomiting, it is necessary to give a gentle purging clyster; and when six or eight hours rest have been obtained, a gentle antiphlogistic and antiseptic purge, in order to evacuate by stool as much of the bilious matter as we possibly can. Or if the patient has a purging before, which sometimes though very rarely happens, a dose of toasted rhubarb is given, and an antiseptic anodyne after it has operated, to abate and check the too great purging, but not to stop it, as this evacuation has been always observed to be of service, provided it be not very violent.

After this indication is completely answered, the next is to exhibit such proper antiseptic medicines as may stop the putrescent disposition of the fluids. Here the cinchona would seem to be the most proper remedy; but unluckily the stomachs of the patients in this disease are so much irritated, and so apt to reject every thing, that it cannot be retained in any form whatever. In this case Dr Percival recommends columbo root, the infusion of which is found to be a powerful antiemetic and antiputrescent medicine, and might perhaps so far alter the state of the stomach as to make it bear the bark. Dr Hilary, however, who was ignorant of the virtues of columbo, substituted the radix serpentinae Virginianae with success. A slight infusion of this root not only sat easily on the stomach of the patients, but moderately raised the pulse and fever, both of which are now too low. The following receipt was found the most agreeable and efficacious.

R. Rad. serpent. Virginian. 3ij.

Croc. Ang. 3 ss. M. et infunde vase clauso in aq. bul. q. per horam unam ut col. 3vj. Adde aq. menth. simp. 3ij. Vin. Maderiens. 3iv. Syr. croc. vel syr. e mecon. 3i. Elix. vitriol. acid. q. s. ad grat. acid. sap. Exhibe cochlearia duo vel tria singulis horis vel bihoris, vel saepius pro re nata.

By the use of this medicine, and soft light nourishment taken in small quantities, the pulse is usually kept

up and the distemper goes off. But if, after taking this a little while, we find that the pulse does not rise, but on the contrary that a coldness of the extreme parts comes on, the medicines must be made more warming, by increasing the quantity of the snakeroot and saffron, or by adding vinum croceum, confectio cardiaca, or the like, but not by the use of volatile spirits and salts, which hurt by their stimulating and dissolving qualities. Blisters Dr Hilary reprobates in the strongest terms, and affirms that he has seen the place where a blister was applied turned perfectly black and sphacelated; so that if the spine and end of the ribs had not hindered, a large square passage would have been opened into the cavity of the thorax, had the patient lived a few hours after it.

At the same time that the strength of the patient is kept up by the medicines above mentioned, or by others similar, he gave repeated gentle purgatives every second or third day, and sometimes, when the symptoms were very urgent, every day, for four or five days successively. But if proper methods be taken in the beginning of the disease, it is seldom that such a repetition of purging is necessary.

Dr Hilary's plan of treating the yellow fever is, in our opinion, as judicious as any that has yet been proposed. But, among the late writers, some have recommended mercury, particularly under the form of calomel, as the most efficacious remedy which can be employed. In some cases it has certainly been given to an almost incredible extent, in a very short time, without exciting either purging or salivation. And it cannot be denied, that patients have not unfrequently recovered under the use of it. But calomel can no more be reckoned an infallible remedy for this disease than blood-letting.

Since the introduction of cold affusion, in the cure of typhus fevers, by Dr Currie, it has been imagined by some, that this practice would afford a very efficacious remedy in the typhus icteroides, as well as in the typhus mitior. But experience has not yet confirmed the utility of this practice.

Some have suggested the internal use of the oxygenated muriatic acid, properly diluted, as an article from which great benefit may be expected in the yellow fever. This practice deserves, we think, a fair trial: but the utility of it still remains to be determined by experience.

To the genus of typhus also belong all those fevers attended with very profuse and debilitating sweats, and which have sometimes, not without good reason, been accounted plagues; such as the English sweating-sickness, Miliaris sudatoria, Sauv. sp. 5. Ephemeræ sudatoria, Sauv. sp. 7. Ephemeræ Britannica, Causæ de ephem. Britan.

Synochus, Sauv. gen. 81. Lin. 13.

Lenta, Lin. 14.

Phrenitis, Vog. 18.

Febris continua putrida, Boerh. 730.

This is a contagious distemper, being a complication of a synocha and typhus; for the description and cure of which, we must of consequence refer to what hath been already said concerning these diseases.

Hætica, Sauv. gen. 83. Lin. 24. Vog. 80. Sag. 684.

This disease is reckoned by Dr Cullen to be merely symptomatic; as indeed seems very probable, since it generally accompanies absorption of pus into the blood from internal suppurations, or indeed from such as are external, provided they be very large or of a bad kind.

Description. The best, perhaps the only proper, description of this disorder we have is that by Dr Heberden. According to him, the appearance of the hætic fever is not unlike that of the genuine intermittent; from which, however, the disease is very different in its nature, while at the same time it is much more dangerous. In the true intermittent, the three stages of cold, heat, and sweat, are far more distinctly marked, the whole fit is much longer, the period which it observes is more constant and regular, and the intermissions are more perfect, than in the hætic fever. For in the latter, even during the clearest remission, there is usually a feverish quickness perceptible in the pulse, which seldom fails to exceed the utmost limit of a healthy one by at least 10 strokes in a minute.

The chillness of the hætic fever is sometimes succeeded by heat, and sometimes immediately by a sweat without any intermediate state of heat. The heat will sometimes come on without any remarkable chillness preceding; and the chillness has been observed to go off without being followed either by heat or sweat. The duration of these stages is seldom the same for three fits together; and as it is not uncommon for one of them to be wanting, the length of the whole fit must vary much more than in the true intermittent; but in general it is much shorter.

A patient subjected to hætic fever is little or nothing relieved by the occurrence of the sweat; but is often as anxious and restless under it as during the chillness or heat. When the sweat is over, the fever will sometimes continue; and in the middle of the fever the chillness will return; which is a most certain mark of this disease.

The hætic fever will return with great exactness, like an intermittent, for two or perhaps three fits; but Dr Heberden informs us, that he does not remember ever to have known it keep the same period for four fits successively. The paroxysm will now and then keep off for 10 or 12 days; and at other times, especially when the patient is very ill, it will return so frequently on the same day, that the chillness of a new fit will follow immediately the sweat of the former. It is not unusual to have many threatenings of a shivering in the same day; and some degree of drowsiness is apt to attend the cessation of a fit.

The urine in a true intermittent is clear during the fits and turbid during the intervals; but in the hætic fever it is liable to all kinds of irregularity. It will be equally clear or turbid in both stages; or turbid in the fits and clear in the intervals; and sometimes it will be, as in a true intermittent, clear during the fever, and thick at the going off.

Hætic patients often complain of pains like those of the rheumatism, which either affect by turns almost every

every part of the body, or else return constantly to the same part; which is often at a great distance from the seat of the principal disorder, and, as far as is known, without any peculiar connection with it. Those pains are so violent in some patients, as to require a large quantity of opium. As far as Dr Heberden has observed, they are most common where the hectic arises from some ulcer open to the external air, as in cancers of the face, breast, &c. Joined with this fever, and arising probably from one common cause, he has been surprised to see swellings of the limbs, neck, or trunk of the body, rise up almost in an instant, as if the part was all at once grown fatter. These swellings are not painful, hard, or discoloured, and they continue for several hours.

Dr Heberden has seen this fever attack those who seemed in tolerable health, in a sudden and violent manner, like a common inflammatory one; and like that, also, in a very short time bring them into imminent danger of their lives; after which it has begun to abate, and to afford hopes of a perfect recovery. But though the danger might be over for the present, and but little of a fever remain; yet that little has soon demonstrated, that it was kept up by some great mischief within, and, proving unconquerable by any remedies, has gradually undermined the health of the patient, and never ceased except with his life. This manner of its beginning, however, is a rare occurrence. It much oftener dissembles its strength at first; and creeps on so slowly, that the subjects of it, though they be not perfectly well, yet for some months hardly think themselves ill; complaining only of being sooner tired with exercise than usual, of want of appetite, and of falling away. But gentle as the symptoms may seem, if the pulse be quicker than ordinary, so as to have the artery to beat 90 times and perhaps 120 times in a minute, there is the greatest reason to be apprehensive of the event. In no disorder, perhaps, is the pulse of more use to guide our judgement than in the hectic fever: yet even here we must be upon our guard, and not trust entirely to this criterion; for one in about twenty patients, with all the worst signs of decay from some incurable cause, which irresistibly goes on to destroy his life, will show not the smallest degree of quickness, nor any other irregularity of the pulse, to the day of his death.

Causes, &c. This fever will supervene whenever there is a great collection of matter formed in any part of the body; but it more particularly attends upon the inflammation of a scirrhus gland, and even upon one that is slight and only just beginning; the fever growing worse in proportion as the gland becomes more inflamed, ulcerated, or gangrenous. And such is the lingering nature of those glandular disorders, that the first of those stages will continue for many months, and the second for some years.

If this scirrhus inflammation be external, or in the lungs, or some of the abdominal viscera, where the disturbance of their functions plainly points out the seat of the disorder, no doubt can be entertained concerning the cause of the fever. But if the part affected be not obvious to the senses, and its precise functions be not known, the hectic, which is there only part of the train of another disease, may be mistaken for the primary or only affection.

Lying-in women, on account of the violence sustained in delivery, generally die when affected with this fever. Women of the age of near 50 and upwards are particularly liable to it. For, upon the cessation of their natural discharge, the glands of the breasts, ovaries, or womb, too commonly begin to grow scirrhus, and proceed to be cancerous. Not only these, but the glandular parts of all the abdominal viscera, are disposed to be affected at this particular time, and to become the seats of incurable disorders.

The injuries done to the stomach and liver by hard drinking are attended with similar symptoms, and terminate in the same manner.

Dr Heberden observes, that the slightest wound by a fine-pointed instrument is known upon some occasions to bring on the greatest disturbances, and the most alarming symptoms, nay even death itself. For not only the wounded part will swell and be painful, but by turns almost every part of the body; and very distant parts have been known to come even to suppuration. These symptoms are constantly accompanied with this irregular intermittent, which lasts as long as any of them remain.

Prognosis. This anomalous fever is never less dangerous than when it originates from a kindly suppuration, into which all the diseased parts are melted down, and for which there is a proper outlet.

The symptoms and danger from some small punctures, with their concomitant fever, most frequently give way in a few days; though in some persons they have continued for two or three months, and in others have proved fatal.

The inflammation of internal scirrhus glands, or of those in the breasts, sometimes goes off, and the fever, which depended upon it, ceases; but it much oftener happens, that it proceeds to cancerous and gangrenous ulcers, and terminates only in death. Death is also, almost universally, the consequence of hectic fever from tubercles of the lungs, which have in general at least been considered as glandular bodies in a scirrhus state.

Cure. It is not to be expected that the same remedies will in every case be adapted to a fever which, arising from very different causes, is attended with such a variety of symptoms. A mixture of assafetida and opium has in some persons seemed singularly serviceable in this fever, when brought on by a small wound; but in most other cases the principal if not the sole attention of the physician must be employed in relieving the symptoms, by tempering the heat, by preventing both costiveness and purging, by procuring sleep, and by checking the sweats. If, at the same time, continues Dr Heberden, he put the body into as good general health as may be, by air, exercise, and a proper course of mild diet, he can perhaps do nothing better than to leave all the rest to nature. In some few fortunate patients, nature appears to have such resources, as may afford reason for entertaining hopes of cure, even in very bad cases. For some have recovered from this fever attended with every symptom of an abdominal viscus incurably diseased, after all probable methods of relief from art had been tried in vain, and after the flesh and strength were so exhausted as to leave scarce any hopes from nature. In these deplora-

ble circumstances, there has arisen a swelling not far from the probable seat of the disorder, and yet without any discoverable communication with it. This swelling has come to an abscess; in consequence of which the pulse has soon returned to its natural state, as have also the appetite, flesh, and strength. What nature has performed in those rare cases, Dr Heberden acquaints us, he has often endeavoured to imitate, by making issues or applying blisters near the seat of the disease; but he cannot say with the same success.

It seems at present, Dr Heberden observes, to be the opinion of many practitioners, that gangrenes will be stopped, and suppuration become more kindly, by the use of Peruvian bark; and therefore this remedy is always either advised or permitted in the irregular fever joined with suppurations and gangrenes. But he affirms he does not remember ever to have seen any good effect from cinchona in this fever unattended with an apparent ulcer; and even in gangrenes it so often fails, that in successful cases, where it has been administered, there must be room for suspicion that the success was owing to another cause. Dr Heberden acknowledges at the same time, that he never saw any harm from cinchona, in these, or indeed in any other cases, except a slight temporary purging or sickness, where it has happened to disagree with the stomach, or where the latter has been loaded by taking the medicine too fast, especially in dry boluses wrapped in water-paper.

In hectic illnesses, where all other means have proved ineffectual, a journey to Bath is usually proposed by the friends, and wished for by the sick; but Dr Heberden justly observes, that, besides the fatigue and many inconveniences of a journey to a dying person, the Bath waters are peculiarly hurtful in this fever, which they never fail to increase, and thereby aggravate the sufferings and hasten the death of the patient.

Phlegmasie membranose et parenchymatose, Sauv.
Clas III. Ord. I. II. Sag. 605.
Morbi febriles phlogistici, Lin. Clas III.
Febres continus compositae inflammatorie, Vog.
Morbi acuti febriles, Boerh. 770.
Febres inflammatorie, Hoffm. II. 105. Junck. 61.

The phlegmasie, or topical inflammations, are a very numerous assemblage of diseases. Their great characteristics are, the general symptoms of fever, and a topical inflammation, attended with the lesion of some important function. In most instances, when blood is drawn, it is found upon coagulation to be covered with a buffy coat. Under this order, many important genera are comprehended, each requiring a separate consideration.

Phlegmone auctorum, Sauv. gen. 15. Lin. 39. Vog. 351.
Inflammatio, Lin. 231. Boerh. 370. Junck. 20.
This disease is a synocha fever, accompanied with an

inflammation of some particular part either external or internal, and consequently it varies very much in its form and the degree of danger attending it, according to the situation and functions of the part affected with topical inflammation. To this species, therefore, belong the following diseases:

Furunculus, Sauv. gen. 18. Vog. 352.
Terminthus, Vog. 381.
Pupula, Lin. 275. Sauv. p. 6.
Varus, Vog. 436. Lin. 269. Sauv. p. 7.
Bacchia, Lin. 270.
Gutta rosea, Sauv. gen. 4.
Gutta rosacea, Vog. 437.
Hordeolum, Sauv. gen. 27. Lin. 276. Vog. 434.
Otalgia, Sauv. gen. 197. Lin. 34. Vog. 148.
Dolor otalgicus, Hoffm. II. 336.
Parulis, Vog. 362.
Mastodynia, Sauv. gen. 210. Vog. 153.
Paronychia, Sauv. gen. 21. Lin. 238. Vog. 345.
Arthroce, Sauv. gen. 78. Lin. 256.
Piedarthroce, Vog. 419.
Spina ventosa, Boerh. 526.
Phimosis, Sauv. gen. 22. Lin. 297. Vog. 348.
Paraphimosis, Vog. 349.

For the cure of inflammations, Dr Cullen lays down the following indications. 1. To remove the remote causes when they are evident and continue to operate. 2. To take off the phlogistic diathesis affecting the whole system, or the particular part. 3. To take off the spasm of the particular part, by remedies applied to the whole system, or to the part itself.

The means of removing the remote causes will readily occur, from considering the particular nature and circumstances of the different kinds. Acrid matters must be removed, or their action must be prevented, by the application of demulcents. Compressing and overstretching powers must be taken away; and from their several circumstances, the means of doing so will be obvious.

The means of taking off the phlogistic diathesis of the system are the same with those already mentioned under the cure for synocha. The means of taking off the spasm also from the particular part, are much the same with those already mentioned. Only it is to be remembered, that topical bleedings, such as cupping with scarifications, applying leeches, &c. are in this case much more indicated; and that some of the other remedies are to be directed more particularly to the part affected, as shall be more fully considered when we treat of those diseases attended with particular inflammations.

When a tendency to suppuration is perceived, the proper indication is to promote the production of perfect pus as much as possible. For this purpose various remedies, supposed to possess a specific power, have been proposed: but it does not appear that any of them are possessed of a virtue of this kind; and, in Dr Cullen's opinion, all that can be done is to favour the suppuration by such applications as may support a moderate heat in the part, by some tenacity confine the perspiration, and by an emollient quality may weaken the cohesion of the teguments, and favour their erosion. As all abscesses are occasioned by the effusion of fluids, and as in the case of certain effusions a suppuration becomes

comes not only unavoidable but desirable, it may be supposed that most of the means of procuring a resolution, by diminishing the force of circulation, &c. ought to be avoided. But as we observe on the one hand, that a certain degree of increased impetus, or of the original symptoms of inflammation, is necessary to produce a proper suppuration; so it is then especially necessary to avoid those means of resolution which may diminish too much the force of circulation. And on the other hand, as the impetus of the blood, when violent, is found to prevent the proper suppuration; so, in such cases, though a tendency to suppuration may have begun, it may be proper to continue those means of resolution which moderate the force of the circulation. With respect to the opening of abscesses when completely formed, see the article SURGERY.

When an inflammation has taken a tendency to gangrene, that event is to be prevented by every possible means; and these must be different according to the nature of the several causes: but after a gangrene has in some degree taken place, it can be cured only by the separation of the dead from the living parts. This in certain circumstances can be performed, and most properly, by the knife. In other cases it can be done by exciting a suppurative inflammation on the verge of the living part, whereby its cohesion with the dead part may be everywhere broken off, so that the latter may fall off by itself. While this is doing, it is proper to prevent the further putrefaction of the part, and its spreading wider. For this purpose various antiseptic applications have been proposed: but Dr Cullen is of opinion, that while the teguments are entire, these applications can hardly have any effect; and therefore, that the fundamental procedure must be to scarify the part so as to reach the living substance, and, by the wounds made there, to excite the suppuration required. By the same incisions also we give access to antiseptic, which may both prevent the progress of the putrefaction in the dead, and excite the inflammation necessary on the verge of the living parts.

When the gangrene proceeds from loss of tone, and when this, communicated to the neighbouring parts, prevents that inflammation which, as we have said, is requisite to the separation of the dead parts from the living, it will be necessary to obviate this loss of tone by tonic medicines given internally; and for this purpose cinchona has been found to be most effectual. But when the gangrene arises from the violence of inflammation, the bark may not only fail of proving a remedy, but may do harm: for its power as a tonic is especially suited to those cases of gangrene which proceed from an original loss of tone, as in the case of palsy and oedema; or in those cases where a loss of tone takes place after the original inflammatory symptoms are removed.

On the other hand, Mr Bell is of opinion, that incisions made with a view to admit the operation of antiseptic remedies in gangrenes, as well as the remedies themselves, must be pernicious from the irritation they occasion, and from the danger of wounding blood-vessels, nerves, or tendons, and also by allowing a free passage for the putrescent fluids into the parts not yet affected. And unless they be carried so deep as to reach the found parts, applications of the antiseptic kind can never have any effect in answering the pur-

pose for which they were intended. The same author also remarks, that all the advantages commonly observed from the great number of applications recommended for gangrene, are obtained with more ease, and generally too with more certainty, from the use of some gentle stimulating embrocation; which, by exciting a slight irritation upon the surface, especially when assisted by a free use of cinchona, produces for the most part such a degree of inflammation as is wished for. With this view he has frequently known a weak solution of sal ammoniac, a dram of the salt to two ounces of vinegar and six of water, form a mixture of very proper strength for every purpose of this kind. But the degree of stimulus can easily be either increased or diminished according to circumstances, by using a larger or smaller proportion of the salt.

Whenever, either by the means recommended, or by a natural exertion of the system, a slight inflammation appears between the diseased and sound parts, we may in general, with tolerable certainty, expect, that in due time the parts will be separated; and when a full suppuration is once fairly established, there can be little doubt that the mortified parts will be soon and easily removed.

A complete separation being effected, the sore is to be treated in the manner described under the article SURGERY; with a proper attention, at the same time, to the support of the general system by the continuance of nourishing diet, and cinchona with such quantities of wine as may seem necessary.

With regard to the bark, however, it is proper to take notice of another case of mortification in which it is likewise unsuccessful, as well as in that attended with a high degree of inflammation; and that is, in those mortifications of the toes and feet, common in old people, or which arise from any cause increasing the rigidity of the vessels to such a degree as to prevent the motion of the fluids through them. In this case Mr Pott has discovered, that all kinds of warm applications are very unsuccessful; but by the free use of opium, together with sedatives and relaxants externally applied, he has frequently seen the tumefaction of the feet and ankles subside, the skin recover its natural colour, and all the mortified parts separate in a very short time, leaving a clean sore. But as to scarifications, or any other attempt to separate artificially the mortified from the sound parts, he thinks them very prejudicial, by giving pain; which is generally of itself violent in this disease, and which seems to have a great share in producing the other evils.

The other terminations of inflammation either do not admit of any treatment except that of preventing them by resolution, or properly belong to the article SURGERY.

Sp. II. PHLOGOSIS ERYTHEMA.

Erythema, Sauv. gen. 11.
Erysipelas auctorum, Vog. 343.
Hieropyr. Vog. 344.
Anthrax, Sauv. gen. 19. Lin. 272. Vog. 353.
Carbo et carbunculus auctorum.
Erythema gangrenosum, Sauv. sp. 7.
Erythema à frigore.
Erythema pernio, Sauv. sp. 4.
Pernio, Lin. 259. Vog. 350.

Erythema

Erythema ambustio, Sauv. sp. 2.
Erysipelas ambustio, Sauv. sp. 4.
Combustura, Lin. 245.
Combustio, Boerh. 476.
Encausis, Vog. 347.
Erythema ab acri alieno applicato.
Erysipelas Sinenfe, Sauv. sp. 7.
Erythema ab acri inquinilo.
Erythema intertrigo, Sauv. sp. 5.
Intertrigo, Lin. 247. Vog. 502.
Erythema à compressione.
Erythema paratrima, Sauv. sp. 6.
Erythema à punctura, Sauv. sp. 9.
Erysipelas à vespis, Sauv. sp. 19.
Pitydracia à vespis, Sauv. sp. 2.
Erythema cum phlegmone.
Erysipelas phlegmonodes auctorum.
Erythema cum cœdimate.
Erysipelas symptomaticum, Sauv. sp. 6.

Ophthalmia angularis, Sauv. sp. 14.
Ophthalmia tuberculosa, Sauv. sp. 3.
Ophthalmia trichialis, Sauv. sp. 2.
Ophthalmia cancrofa, Sauv. sp. 15.
Ophthalmia à synechia, Sauv. sp. 16.
Ophthalmia à lagophthalmo, Sauv. sp. 17.
Ophthalmia ab elcomate, Sauv. sp. 18.
Ophthalmia ab ungue, Sauv. sp. 19.
Ophthalmia à corneæ fistula, Sauv. sp. 20.
Ophthalmia uveæ, Sauv. sp. 22.
Ophthalmia metastatica, Sauv. sp. 24.
Ophthalmia scrophulosa, Sauv. sp. 9.
Ophthalmia siphilitica, Sauv. sp. 11.
Ophthalmia febricosa, Sauv. sp. 23.

The word erythema does not apply to any primary disease, but to a great number of those cutaneous inflammations denominated by another general term, viz. the erysipelas, or "St. Anthony's fire;" and which being commonly symptomatic of some other inflammation or disorder, are to be removed only by removing the primary disease: the erythema is found scarcely to bear any kind of warm application to itself; and is very apt, if treated as a primary disease, to terminate in a gangrene of the part affected, or some other disorder still more dangerous. The difference between the phlegmon or preceding species, and erythema, according to Dr Cullen, is, that, in the former, the inflammation seems particularly to affect the vessels on the internal surface of the skin, communicating with the lax adjacent cellular texture; whence a more copious effusion, and that too of serum convertible into pus, takes place. In the erythema the affection is of the vessels on the external surface of the skin communicating with the rete mucosum. This affection does not admit of any effusion but what separates the cuticle, and gives occasion to the formation of a blister, while the smaller size of the vessels admits only of the effusion of a thin fluid very seldom convertible into pus. For the cure of the fever attended with erythema or erysipelas, see below; and for the external treatment of erythema, see SURGERY.

From reading this long list of distinctions which authors have invented in the ophthalmia, it is evident, that by far the greatest part of them are symptomatic, or merely the consequences of other disorders present in the habit; and therefore the remedies must be directed towards the removal of these primary disorders; and when they are gone the ophthalmia will be removed of course. Dr Cullen observes, that the inflammation of the eye may be considered as of two kinds; according as it is seated in the membranes of the ball of the eye, when it is named ophthalmia membranarum; or as it is seated in the sebaceous glands placed in the tarsus, or edges of the eyelids, in which case it may be termed ophthalmia tarsi. These two kinds are very frequently connected together, as the one may excite the other; but they are still to be distinguished according as the one or the other may happen to be the primary affection.

1. The inflammation of the membranes of the eye affects especially, and most frequently, the adnata, and appears in a turgescence of its vessels; so that the red vessels which are naturally there, become not only increased in size, but many more appear than in a natural state. This turgescence of the vessels is attended with pain, especially upon the motion of the ball of the eye; and this irritation, like every other, applied to the surface of the eye, produces an effusion of tears from the lachrymal gland.

The inflammation commonly, and chiefly, affects the adnata spread on the anterior part of the bulb of the eye; but usually spreads also along the continuation of the adnata on the inside of the palpebræ; and as that is extended on the tarsus palpebrarum, the excretories of the sebaceous glands opening there are also frequently affected. When the affection of the adnata is considerable, it may be communicated to the subjacent membranes of the eye, and even to the retina itself; which thereby acquires so great sensibility, that every impression of light becomes painful. The inflammation of the membranes of the eye is in different degrees, according as the adnata is more or less affected, or according as the inflammation is either of the adnata alone, or of the subjacent membranes also; and upon these differences, different species have been established; but they seem all to differ only in degree, and are to be cured by the same remedies more or less employed.

The proximate cause of ophthalmia is not different from that of inflammation in general; and the different circumstances of ophthalmia may be explained by

Ophthalmia, Sauv. gen. 196. Lin. 43. Vog. 347.
Sag. 231. Junck. 24.
Chemosis, Vog. 46.
Ophthalmites, Vog. 47.
Inflammatio oculorum, Hoffm. II. 165.
Ophthalmia taraxis, Sauv. sp. 1.
Ophthalmia humida, Sauv. sp. 8.
Ophthalmia chemosis, Sauv. sp. 12.
Ophthalmia erysipelatos, Sauv. sp. 7.
Ophthalmia pustulosa, Sauv. sp. 6.
Ophthalmia phlyctenodes, Sauv. sp. 21.
Ophthalmia choroeidea, Sauv. sp. 13.
Ophthalmia tenebricosa, Sauv. sp. 10.
Ophthalmia trachoma, Sauv. sp. 4.
Ophthalmia sicca, Sauv. sp. 5.

Phlegma-
tis. by the difference of its remote causes, and by the different parts of the eye which it happens to affect; as may be understood from what has been already said. We shall therefore proceed to give an account of the method of cure.

The great objects to be aimed at in the treatment of ophthalmia, are, in the first place, the resolution of the inflammation which has already taken place; and, secondly, the removal of those consequences which frequently arise from the inflammation, especially if it have been of long standing. But besides these, while it has appeared from former observation, that there is a peculiar disposition to the disease, practices may often be successfully employed to combat this disposition, and thus prevent the return of the affection.

The ophthalmia membranarum requires the remedies proper for inflammation in general; and when the deeper-seated membranes are affected, and especially when a pyrexia is present, large general bleedings may be necessary. But this last is seldom requisite, and, for the most part, the ophthalmia is an affection merely local, accompanied with little or no pyrexia. General bleedings therefore have little effect upon it, and the cure is chiefly to be obtained by topical bleedings, that is, blood drawn from the vessels near the inflamed part; and opening the jugular vein, or the temporal artery, may be considered as in some measure of this kind. It is commonly sufficient to apply a number of leeches round the eye; but it is perhaps still better to draw blood by cupping and scarifying from the temples. In many cases, the most effectual remedy is to scarify the internal surface of the inferior eyelid, and to cut the turgid vessels upon the adnata itself.

Besides bloodletting, purging, as a remedy suited to inflammation in general, has been considered as peculiarly adapted to inflammation in any part of the head, and therefore to ophthalmia; and it is sometimes useful: but, for the reasons given before with respect to general bleeding, purging in the case of ophthalmia does not prove useful in any proportion to the evacuation excited.—For relaxing the spasm in the part, and taking off the determination of the fluids to it, blistering near the part has commonly been found useful. When the inflammation does not yield to the application of blisters after topical bleeding, great benefit is often obtained by supporting a discharge from the blistered part, under the form of an issue, by which means a more permanent determination of blood from the part is obtained.

It is probably also on the same principle that the good effects obtained from the use of errhine medicines in obstinate cases of ophthalmia are to be accounted for. By these errhines, in particular, which occasion and support for some time a great discharge from the nose, great benefit has often been obtained. The powder of asarabacca, or the infusion of hippocastanum, snuffed up the nose at bedtime in proper doses, are often productive of the best effects, when many other remedies have been tried in vain.

Ophthalmia, as an external inflammation, admits of topical applications. All those, however, which increase the heat and relax the vessels of the part, prove hurtful; and the admission of cool air to the eye, and the application of cooling and astringent medicines,

which at the same time do not produce irritation, prove useful. Of all these the solution of acetite of lead, assiduously applied, is perhaps the best. In the cure of this distemper, indeed, all irritation must carefully be avoided, particularly that of light; and the only certain means of doing this is by keeping the patient in a very dark chamber.

2. In the ophthalmia tarsi, the same medicines may be necessary, as have been already recommended for the ophthalmia membranarum. However, as the ophthalmia tarsi may often depend upon an acrimony deposited in the sebaceous glands of the part, so it may require various internal remedies according to the variety of the acrimony in fault; for which we must refer to the consideration of scrophula, siphylis, or other diseases with which this ophthalmia may be connected; and where these shall not be evident, certain remedies more generally adapted to the evacuation of acrimony, such as mercury, may be employed. In the ophthalmia tarsi, it almost constantly happens that some ulcerations are formed on the tarsus. These require the application of mercury and copper, which alone may sometimes cure the whole affection; and they may be useful even when the disease depends upon a fault of the whole system.

Both in the ophthalmia membranarum, and in the ophthalmia tarsi, it is necessary to obviate that gluing together of the eyelids which commonly happens in sleep; and which may be done by insinuating a little of any mild unctuous medicine between the eyelids before the patient shall go to sleep.

The lighter kinds of inflammations from the dust or the sun, may be removed by fomenting with warm milk and water, adding a small portion of brandy; and by anointing the borders of the eyelids with unguentum tuius, or the like, at night, especially when those parts are excoriated and sore. But in bad cases, after the inflammation has yielded a little to evacuations, the cataplasma aluminis of the London Pharmacopoeia spread on lint, and applied at bedtime, has been found the best external remedy. Before the use of the latter, the solution of sulphate of zinc is preferred with advantage; and in violent pains it is of service to foment frequently with a decoction of white poppy-heads. One of the most common and most disagreeable consequences of ophthalmia, is an ossification of the cornea, so far obliterating the passage of light as to diminish or prevent vision. This is sometimes so considerable as to admit of removal by operation: but in lighter cases it may often be removed by the application of different gentle escharotics; and in this way, without the least danger of any inconvenience, good effects are often obtained, from gently introducing into the eye at bedtime a powder consisting of equal parts of supertartrate of potash and sugar, reduced together to a fine powder.

Where there is a disposition to frequent returns of this affection, cinchona is often employed with success in combating it: But nothing in general answers better than frequent and regular cold bathing of the eyes.

Besides the various species of ophthalmia which were before known in Britain, another has lately been introduced, that contagious ophthalmia, viz. with which the British

Phlegma-
fac. British troops were affected in Egypt, and which they have imported into this island on their return from thence.

Of this affection many interesting accounts have been published. Perhaps the best is an elaborate treatise by Mr Edmonston, who has had many opportunities of witnessing the affection, and extensive practice in the treatment of the disease, both in Egypt and in Britain. To his work therefore we may refer those who with for the most full information respecting it. We shall only observe, that now, no doubt can be entertained respecting the contagious nature of the disease; and that therefore the first great object necessary in the treatment is the complete separation of the diseased from the sound.

775 GENUS IX. PHRENITIS.

PHRENSY, or Inflammation of the BRAIN.

Phrenitis, Sauv. gen. 101. Lin. 25. Sog. gen. 301.

Boerh. 771. Hoffm. II. 131. Junck. 63.

Phrenismus, Vog. 45.

Cephalitis, Sauv. gen. 109. Sog. gen. 310.

Sphacelismus, Lin. 32.

Phrenitis vera, Sauv. sp. 1. Boerh. 771.

Phrenitis idiopathica, Junck. 63.

Cephalalgia inflammatoria, Sauv. sp. 9.

Cephalitis spontanea, Sauv. sp. 3.

Cephalitis firialis, Sauv. sp. 4.

Siriasis, Vog. 34.

Cephalitis Lutriziana, Sauv. sp. 5.

Dr Cullen observes, that the true phrenitis, or inflammation of the membranes or substance of the brain, is very rare as an original disease: but, as a symptom of others, much more frequent; of which the following kinds are enumerated by different authors:

Phrenitis synochi pleuritice, Sauv. sp. 2.

Phrenitis synochi sanguinee, Sauv. sp. 4.

Phrenitis calentura, Sauv. sp. 11.

Phrenitis Indica, Sauv. sp. 12.

Cephalitis Egyptiaca, Sauv. sp. 1.

Cephalitis epidemica anno 1510, Sauv. sp. 6.

Cephalitis verminosa, Sauv. sp. 7.

Cephalitis cerebelli, Sauv. sp. 8.

Phrenitis miliaris, Sauv. sp. 3.

Phrenitis variolosa, Sauv. sp. 5.

Phrenitis morbilliosa, Sauv. sp. 6.

Phrenitis à plica, Sauv. sp. 8.

Phrenitis aphrodisiaca, Sauv. sp. 9.

Phrenitis à tarantismo, Sauv. sp. 14.

Phrenitis hydrophobia, Sauv. sp. 15.

Phrenitis à dolore, Sauv. sp. 13.

Cephalitis traumatica, Sauv. sp. 2.

Description. The signs of an impending phrenitis are, immoderate and continual watchings; or if any sleep be obtained, it is disturbed with dreams, and gives no refreshment; acute and lasting pains, especially in the hind part of the head and neck; little thirst; a great and slow respiration, as if proceeding from the bottom of the breast; the pulse sometimes small and slow, sometimes quick and frequent; a suppression of urine; and forgetfulness. The distemper when present may be known by the following signs:

The veins of the head swell, and the temporal arteries throb much; the eyes are fixed, sparkle, and have a fierce aspect; the speech is incoherent, and the patient behaves very roughly to the bystanders, with furious attempts to get out of bed, not indeed continually, but returning as it were by paroxysms; the tongue is dry, rough, yellow, or black; there is a coldness of the external parts; a proneness to anger; chattering of the teeth; a trembling of the hands, with which the sick seem to be gathering something, and actually do gather the naps off the bed-clothes.

Causes of, and persons subject to, this disorder. People of a hot and bilious habit of body, and such as are of a passionate disposition, are apt to be affected with phrenitis. In the same danger are those who make much use of spices, or are given to hot and spirituous liquors; who have been exposed more than usual to the sun, or obliged to undergo immoderate studies or watchings; who are subject to headaches, or in whom some customary hemorrhages have been stopped; or the disease may arise from some injury offered to the head externally. Sir John Pringle observes, that the phrenitis, when considered as an original disease, is apt to attack soldiers in the summer-season when they are exposed to the heat of the sun, and especially when asleep and in liquor. A symptomatic phrenitis is also more frequent in the army than elsewhere, on account of the violence done to all fevers when the sick are carried in waggons from the camp to an hospital, where the very noise or light alone would be sufficient, with more delicate natures, to raise a phrensy. From these and similar causes, a state of active inflammation, affecting some parts within the cranium, is produced: and there can be no doubt, that from this all the symptoms of the disease arise, and particularly that peculiar delirium which characterizes it. But in what manner local diseases, even of the brain itself, produce affections of the mind, we are still totally in the dark.

Prognosis. Every kind of phrenitis, whether idiopathic or symptomatic, is attended with a high degree of danger; and, unless removed before the fourth day, a gangrene or sphacelus of the meninges readily takes place, and the patient dies delirious. The following are the most fatal symptoms: A continual and furious delirium, with watching; thin watery urine, white faces, the urine and stools running off involuntarily, or a total suppression of these excretions; a ready disposition to become stupid, or to faint; trembling, rigor, chattering of the teeth, convulsions, hiccough, coldness of the extremities, trembling of the tongue, shrill voice, a sudden cessation of pain, with apparent tranquillity. The following are favourable: Sweats, apparently critical, breaking out; a seeming effort of nature to terminate the disease by a diarrhoea; a large hemorrhage from the nose; swellings of the glands behind the ears; haemorrhoids.

Cure. From what has been said of the theory of this disease, the cure must entirely depend on obtaining a resolution of the inflammation. The objects chiefly to be aimed at with this view are, 1. The removal of such exciting causes as continue to operate. 2. The diminution of the momentum of the blood in the circulating system in general. 3. The diminution of impetus at the brain in particular: and, 4. The avoiding

Phlegmonous. ing circumstances which tend either to accelerate the motion of the blood or to give determination to the head.

Different practices may be used with these intentions; but the most powerful remedies are to be immediately employed. Large and repeated bleedings are especially necessary; and these too taken from vessels as near as possible to the part affected. The opening the temporal artery has been recommended, and with some reason: but as the practice is attended with inconveniences, perhaps the opening of the jugular veins may in general prove more effectual; with which, however, may be joined the drawing of blood from the temples by cupping and scarifying. It is also probable, that purging may be of more use in this than in some other inflammatory affections, as it may operate by revulsion. For the same purpose of revulsion, warm pediluvia are a remedy, but rather ambiguous. The taking off the force of the blood in the vessels of the head by an erect posture is generally useful. Blistering is also useful, but chiefly when applied near to the part affected. In short, every part of the antiphlogistic regimen is here necessary, and particularly the admission of cold air. Even cold substances applied to the head have been found useful; and the application of such refrigerants as vinegar is certainly proper. Opiates are thought to be hurtful in every inflammatory state of the brain. On the whole, however, it must be remarked, that practitioners are very uncertain with regard to the means proper to be used in this disease; and the more so, that the symptoms by which the disease is commonly judged to be present, appear sometimes without any internal inflammation; and on the other hand, dissections have shown that the brain has been inflamed, where few of the peculiar symptoms of inflammation had appeared before death.

Cynanche, Sauv. gen. 110. Lin. 33. Sag. gen. 300. Angina, Vog. 49. Hoffm. II. 125. Junck. 30. Angina inflammatoria, Boerh. 798.

Cynanche tonsillaris, Sauv. sp. 1. Angina inflammatoria, sp. 5. Boerh. 805.

Description. This is an inflammation of the mucous membrane of the fauces, affecting principally that congeries of mucous follicles which forms the tonsils; and from thence spreading along the velum and uvula, so as frequently to affect every part of the mucous membrane. The disease appears by some tumour and redness of the parts; is attended with a painful and difficult deglutition; a troublesome clamminess of the mouth and throat; a frequent but difficult excretion of mucus; and the whole is accompanied with pyrexia. The inflammation and tumour are commonly at first most considerable in one tonsil; and afterwards, abating in that, increase in the other. This disease is not contagious.

Causes of, and persons subject to this disorder. This disease is commonly occasioned by cold externally applied, particularly about the neck. It affects especially the young and sanguine; and a disposition to it is often

acquired by habit. It occurs especially in the spring and autumn, when vicissitudes of heat and cold frequently take place.

Prognosis. This species of cynanche terminates frequently by resolution, sometimes by suppuration, but hardly ever by gangrene; though in some cases sloughy spots appear on the fauces: the prognosis therefore is generally favourable.

Cure. As the principal morbid affection in this disease, on which all its characterising symptoms immediately depend, is the active inflammation in the tonsils and neighbouring parts, the object first and principally to be aimed at in the cure is to obtain a resolution of this inflammation. Sometimes, however, it is necessary to have recourse to practices, with the view of obviating urgent symptoms before a resolution can be effected: and in other cases, where a resolution cannot be obtained, it must be the aim of the practitioner to promote a speedy and favourable suppuration. After suppuration has taken place, the proper means of promoting a discharge of the purulent matter will conclude the cure. Here some bleeding may be necessary; but large and general evacuations are seldom beneficial. The opening of the ranular veins is an insignificant remedy, according to Dr Cullen, but is recommended as efficacious by Sir John Pringle: more benefit, however, may in general be derived from leeches to the external fauces. The inflammation may be often relieved by moderate astringents, and particularly by acids applied to the parts affected. In many cases, nothing has been found to give more relief than the vapour of warm water received into the fauces.

Besides these, blistering, and still more frequently rubefacient medicines, are applied with success, as well as antiphlogistic purgatives; and every part of the antiphlogistic regimen is to be observed, except the application of cold. Sir John Pringle recommends a thick piece of flannel moistened with two parts of common sweet oil, and one of spirit of hartshorn (or in a larger proportion, if the skin will bear it), to be applied to the throat, and renewed once every four or five hours. By this means the neck, and sometimes the whole body, is put into a sweat, which after bleeding either carries off or lessens the inflammation. When the disease has a tendency to suppuration, nothing will be more useful than receiving into the fauces the steams of warm water. Benefit is also obtained from poultices applied to the external fauces. When the abscess is attended with much swelling, if it break not spontaneously, it ought to be opened by a lancet; and this does not require much caution, as even the inflammatory state may be relieved by some scarification of the tonsils. When this disease runs very rapidly to such a height as to threaten suffocation, it is sometimes necessary to have recourse to bronchotomy as the only mean of saving the life of the patient. But there is reason to believe that this operation has sometimes been employed where it was not necessary: and we may safely venture to say, that it is but seldom requisite; insomuch that Dr Cullen tells us, he has never in his practice seen any case requiring bronchotomy.

The malignant, putrid, or ulcerous SORE THROAT.

Cynanche maligna, Sauv. sp. 3.

P p

Cynanche ulcerosa, Savv. var. a. Journ. de Med. 1758.

Cynanche gangrenosa, Savv. var. b. Journ. de Med. 1756.

Ulcera faucium et gutturis anginosa et lethalia, Hisp. Garrotillo, Lud. Mercat. consult. 24.

Angina ulcerosa, Fothergill's Account of the ulcerous sore throat, edit. 1751. Huxham on the malignant ulcerous sore throat, from 1751 to 1753.

Febris epidemica cum angina uisculosa, Douglas's Practical History. Boston 1736.

Angina epidemica, Ruffel, Oecon. Natur. p. 105.

Angina gangrenosa, Witthering's Dissert. Inaug. Edinb. 1766.

Angina suffocativa, Bard's Inquiry, New York, 1771.

Angina maligna, Johnstone on the malignant Angina, Worcester, 1779.

History and Description. This distemper is not particularly described by the ancient physicians; though perhaps the Syrian and Egyptian ulcers mentioned by Aretaeus Cappadox, and the pestilent ulcerated tonsils we read of in Aetius Amideus, were of this nature. Some of the scarlet fevers mentioned by Morton seem also to have approached near to it. In the beginning of the last century, a disease exactly similar to this is described by the physicians of that time, as raging with great violence and mortality in Spain and some parts of Italy; but no account of it was published in this country till the year 1748, when a very accurate one was drawn up by Dr Fothergill, and in 1752 by Dr Huxham. The latter observes, that this disease was preceded by long, cold, and wet seasons; by which probably the bodies of people were debilitated, and more apt to receive contagion, which possibly also might be produced by the stagnant and putrid waters.

The attack of this disease was very different in different persons. Sometimes a rigor, with fulness and soreness of the throat, and painful stiffness of the neck, were the first symptoms complained of. Sometimes alternate chills and heats, with some degree of giddiness, drowsiness, or headache, ushered in the distemper. It seized others with more severe feverish symptoms; great pain of the head, back, and limbs; a vast oppression of the præcordia, and continual sighing. Some grown persons went about for days in a drooping state, with much uneasiness and anxiety, till at last they were obliged to take to their beds.—Thus various was the disease, says Dr Huxham, at the onset. But it commonly began with chills and heats, load and pain of the head, soreness of throat, and hoarseness; some cough, sickness at stomach, frequent vomiting and purging, in children especially, which were sometimes very severe; though a contrary state was more common to the adult. There was in all a very great dejection of spirits, very sudden weakness, great heaviness on the breast, and faintness, from the very beginning. The pulse in general was quick, small, and fluttering, though sometimes heavy and undulating. The urine was commonly pale, thin, and crude; however, in many grown persons, it was passed in small quantities and high-coloured, or like turbid whey. The eyes were heavy, reddish, and as it were weeping;

the countenance very often full, flushed, and bloated, though sometimes pale and sunk. Cynanche

How slight soever the disorder might appear in the day-time, at night the symptoms became greatly aggravated, and the feverish habit very much increased, nay, sometimes a delirium occurred on the very first night; and this exacerbation constantly returned through the whole course of the disease. Indeed, when it was considerably on the decline, our author says he has been often pretty much surprised to find his patient had passed the whole night in a phrensy, whom he had left tolerably cool and sedate in the day.

Some few hours after the seizure, and sometimes contemporary with it, a swelling and soreness of the throat was perceived, and the tonsils became very tumid and inflamed, and many times the parotid and maxillary glands swelled very much, and very suddenly, even at the very beginning; sometimes so much as even to threaten strangulation. The fauces also very soon appeared of a high florid red, or rather of a bright crimson, colour, very shining and glossy; and most commonly on the uvula, tonsils, velum palatinum, and back part of the pharynx, several whitish or ash-coloured spots appeared scattered up and down, which oftentimes increased very fast, and soon covered one or both the tonsils, uvula, &c. those in the event proved sloughs of superficial ulcers (which sometimes, however, ate very deep into the parts). The tongue at this time, though only white and moist at the tip, was very foul at the root, and covered with a thick, yellowish or brown coat. The breath also now began to be very nauseous; which offensive smell increased hourly, and in some became at length intolerable, and that too sometimes even to the patients themselves.

The second or third day every symptom became much more aggravated, and the fever much more considerable; and those that had struggled with it tolerably well for 30 or 40 hours, were forced to submit. The restlessness and anxiety greatly increased, as well as the difficulty in swallowing. The head was very giddy, pained, and loaded; there was generally more or less of a delirium; sometimes a pervigilium and perpetual phrensy, though others lay very stupid, but often starting and muttering to themselves. The skin was very hot, dry, and rough; there was very rarely any disposition to sweat. The urine was pale, thin, crude; often yellowish and turbid. Sometimes vomiting was urgent, and sometimes a very great looseness, in children particularly. The sloughs were now much enlarged, and of a darker colour, and the surrounding parts tended much more to a livid hue. The breathing became much more difficult; with a kind of a rattling stertor, as if the patient was actually strangling, the voice being exceeding hoarse and hollow, exactly resembling that from venereal ulcers in the fauces: this noise in speaking and breathing was so peculiar, that any person in the least conversant with the disease might easily know it by this odd noise; from whence indeed the Spanish physicians gave it the name of garotillo, expressing the noise made by persons when they are strangled with a rope. Dr Fothergill never observed in one of them the shrill barking noise that we frequently hear in inflammatory cynanche. The breath.

Phlegma-
sic. breath of all the diseased was very nauseous; of some insufferably fetid, especially in the advance of the distemper to a crisis; and many about the fourth or fifth day spit off a vast quantity of stinking purulent mucus tinged sometimes with blood: and sometimes the matter was quite livid, and of an abominable smell. The nostrils likewise in many were greatly inflamed and excoriated, continually dripping down a very sharp ichor or sanious matter, so excessively acrid, that it not only corroded the lips, cheeks, and hands of the children that laboured under the disease, but even the fingers and arms of the very nurses that attended them: as this ulceration of the nostrils came on, it commonly caused an almost incessant sneezing in the children; but few adults were affected with it, at least to any considerable degree. It was surprising what quantities of matter some children discharged this way, which they would often rub on their face, hands, and arms, and blister them all over. A sudden stoppage of this rheum from the mouth and nostrils actually choked several children; and some swallowed such quantities of it, as occasioned excoriations of the intestines, violent gripings, dysentery, &c. nay, even excoriations of the anus and buttocks. Not only the nostrils, fauces, &c. were greatly affected by this extremely sharp matter, but the wind-pipe itself was sometimes much corroded by it, and pieces of its internal membrane were spit up, with much blood and corruption; and the patients lingered on for a considerable time, and at length died tabid; though there were more frequent instances of its falling suddenly and violently on the lungs, and killing in a peripneumonic manner.

Dr Huxham was astonished sometimes to see several swallow with tolerable ease, though the tumour of the tonsils and throat, the quantity of thick mucus, and the rattling noise in breathing, were very terrible; which he thinks pretty clearly shows, that this malignant angina was more from the acrimony and abundance of the humours than the violence of the inflammation.

Most commonly the angina came on before the exanthemata; but many times the cuticular eruption appeared before the sore-throat, and was sometimes very considerable, though there was little or no pain in the fauces: on the contrary, a very severe angina seized some patients that had no manner of eruption; and yet, even in these cases, a very great itching and desquamation of the skin sometimes ensued; but this was chiefly in grown persons, very rarely in children. In general, however, a very considerable efflorescence broke out on the surface of the body, particularly in children; and it most commonly happened the second, third, or fourth day: sometimes it was partial, sometimes it covered almost the whole body, though very seldom the face: sometimes it was of an erysipelatus kind; sometimes more pustular: the pustules frequently eminent, and of a deep fiery red colour, particularly on the breast and arms; but often they were very small, and might be better felt than seen, and gave a very odd kind of roughness to the skin. The colour of the efflorescence was commonly of a crimson hue, or as if the skin had been smeared over with juice of raspberries, and this even to the fingers ends; and the skin appeared inflamed and swollen, as it were; the arms, hands, and fingers, were often evidently so, and very stiff, and somewhat pain-

ful. This crimson colour of the skin seemed indeed peculiar to this disease. Though the eruption seldom failed of giving some manifest relief to the patient, as to anxiety, sickness at stomach, vomiting, purging, &c. yet there was observed an universal fiery eruption on some persons, without the least abatement of the symptoms, nay almost every symptom seemed more aggravated, particularly the fever, load at breast, anxiety, and delirium; Dr Huxham knew more than one or two patients die in the most raging phrensy, covered with the most universal fiery rash he ever saw: so that, as in the highly confluent smallpox, it seemed only to denote the quantity of the disease, as he terms it.

He had under his care a young gentleman, about 12 years of age, whose tongue, fauces, and tonsils, were as black as ink, and he swallowed with extreme difficulty; he continually spit off immense quantities of a black, sanious, and very fetid matter, for at least eight or ten days:—about the seventh day, his fever being somewhat abated, he fell into a bloody dysentery, though the bloody, sanious, fetid expectoration still continued, with a most violent cough. He at length indeed got over it, to the very great surprise of every one that saw him. Now, in this patient, a severe and universal rash broke out upon the second and third day; and the itching of his skin was so intolerable, that he tore it all over his body in a most shocking manner: yet this very great and timely eruption very little relieved his fever and phrensy, or prevented the other dreadful symptoms mentioned.

An early and kindly eruption, however, was most commonly a very good omen; and, when succeeded by a very copious desquamation of the cuticle, one of the most favourable symptoms that occurred: but when the eruption turned of a dusky or livid colour, or prematurely or suddenly receded, every symptom grew worse, and the utmost danger impended, especially if purple or black spots appeared up and down, as sometimes happened; the urine grew limpid, and convulsions came on, or a fatal suffocation soon closed the tragedy.

The disease was generally at the height about the fifth or sixth day in young persons, in the elder not so soon; and the crisis many times was not till the 11th or 12th, and then very imperfect; some adults, however, were carried off in two or three days; the distemper either falling on the lungs, and killing in a peripneumonic manner; or on the brain, in which case the patient either died raving or comatose. In some, the disease brought on a very troublesome cough, purulent expectoration, hæmoptoe, and hectic fever; in which they lingered on for several weeks, and then died tabid.

If a gentle easy sweat took place on the third or fourth day; if the pulse became more slow, firm, and equal; if the sloughs of the fauces cast off in a kindly manner, and appeared at the bottom tolerably clean and florid; if the breathing was more soft and free, and some degree of vigour and quickness returned in the eyes; all was well, and a salutary crisis followed soon by a continuance of the sweat, and a turbid, subsiding, farinaceous urine, a plentiful expectoration, and a very large desquamation of the cuticle. But if a rigor came on, and the exanthemata suddenly disappeared or turned livid;

livid; if the pulse grew very small and quick, and the skin remained hot and parched as it were, the breathing more difficult, the eyes dead and glassy, the urine pale and limpid, a phrensy or coma succeeded, with a coldish clammy sweat on the face or extremities; life was despaired of, especially if a singultus and choking or gulping in the throat attended, with sudden, liquid, involuntary, livid stools, intolerably fetid. In some few patients Dr Huxham observed, some time before the fatal period, not only the face bloated, sallow, shining and greasy as it were, but the whole neck very much swollen, and of a cadaverous look; and even the whole body became in some degree œdematous; and the impression of a finger would remain fixed in a part, the skin not rising again as usual; an indication that the blood stagnated in the capillaries, and that the elasticity of the fibres was quite lost.

Medical writers are still much divided in opinion, whether the cynanche maligna is to be considered as the same disease with the scarlatina anginosa, afterwards to be treated of, or not. This question will afterwards come to be more fully discussed. At present we may only observe, that although ulcerous sore throats of a malignant nature often appear sporadically, yet that the disease above described appears only as an epidemic, and is always the consequence of contagion.

We have, therefore, no doubt that the cynanche maligna of Huxham, Fothergill, and Cullen, is precisely the same disease with the scarlatina anginosa of Sauvage, Withering, and other late writers. This is abundantly demonstrated by the diversities which take place in the appearance of the disease among children of the same family during the same epidemic.

Prognosis. This may be easily gathered from the above description. The malignant and putrid tendency of the disease is evident, and an increase of the symptoms which arise from that putrescent disposition of the body must give an unfavourable prognosis. On the contrary, a decrease of these, and an apparent increase of the vis vita, are favourable: in general, what is observed to be favourable in the nervous and putrid malignant fevers, is also favourable in this, and vice versa.

Causes. Since the accurate accounts given by Dr Fothergill and Huxham of the epidemics which prevailed about 50 years ago, this disease has frequently been observed at times epidemic in almost every different part of Britain. Like small-pox, measles, and chincough, it seems in every case to be the effect of a peculiar and specific contagion. It has been observed to prevail, equally generally in every situation, and at every season; and on exposure to the contagion, no age, sex, or condition, is exempted from it. But the having once had the disease, seems in this affection to afford the same security against future contagion as in the small-pox: at least instances, where it can be said that the same individual has been twice affected with it, are both very rare and very doubtful, as well as in small-pox.

Cure. Like other febrile contagions, the malignant ulcerous sore throat is terminated only by a natural course; and the chief business of the practitioner is to combat unfavourable occurrences. In this the septic tendency of the disease is chiefly to

be kept in view. The debility with which it is attended renders all evacuations by bleeding and purging improper, except in a few instances where the debility is less, and the inflammatory symptoms more considerable. The fauces are to be preserved from the effects of the acrid matter poured out upon them, and are therefore to be frequently washed out by antiseptic gargles or injections; and the putrescent state of the whole system should be guarded against and corrected by internal antiseptics, especially by the Peruvian bark given in the beginning and continued through the course of the disease. Great benefit is also often derived from the liberal use of the mineral acids. Both the sulphuric and muriatic, in a state of proper dilution, have been highly extolled by different medical writers, and are productive of the best effects in actual practice, when they can be introduced to a sufficient extent. In particular, the oxygenated muriatic acid, as recommended by Mr Braithwaite, has been found productive of the greatest advantages. Emetics, both by vomiting and nauseating, prove useful. When any considerable tumor occurs, blisters applied externally will be of service, and in any case may be proper to moderate the inflammation.

Very lately, the internal use of the capicum annuum, or Cayenne pepper as it is commonly called, has been highly celebrated in this affection; and it is particularly said to have been employed with singular success in the West Indies.

But of all the remedies lately proposed, none has been more highly extolled than the external use of cold water. It has even been contended by some that by dashing cold water on the surface of the body, an immediate artificial cure of this disease may be obtained. We are, however, fully persuaded, that cold water will no more destroy the contagion of this disease than of smallpox; and we cannot help thinking that the practice is seldom necessary, and sometimes hurtful.

Sp. III. CYNANCHE TRACHEALIS.

The CROUP.

Cynanche trachealis, Sauv. sp. 5.
Cynanche laryngea auctorum, Eller. de cogn. et curand. morb. sect. 7.
Angine inflammatorie, sp. 1. Boerh. 801.
Angina latens et difficilis, Dodon. obs. 18.
Angina interna, Tulp. l. 1. obs. 51.
Angina perniciosa, Greg. Horst. Obs. l. iii. obs. 1.
Suffocatio stridula, Home on the Croup.
Asthma infantum, Millar on the Asthma and Chincough.
Asthma infantum spasmodicum, Rusb. Dissertation, Lond. 1770.
Cynanche stridula, Gravesford Dissert. Inaug. Edin. 1771.
Angina epidemica anno 1743. Molloy apud Ratty's History of the weather.
Morbus strangulatorius, Starr, Phil. Trans. No 495.
Morbus truculentus infantum, Francos. ad Viadrum et in vicinia grassans ann. 1758. C. a Bergen. A nova. N. C. tom. ii. p. 157.
Catarrhus suffocativus Barbadenis ann. 1758. Hilary's Diseases of Barbadoes.
Angina.

The best description of this disease we have in Dr Cullen's Practice of Physic. He informs us, that it consists in an inflammation of the glottis, larynx, or upper part of the trachea, whether it affect the membranes of these parts or the muscles adjoining. It may arise first in these parts, and continue to subsist in them alone; or it may come to affect these parts from the cynanche tonsillar, or maligna, spreading into them.

In either way it has been a rare occurrence, and few instances of it have been marked and recorded by physicians. It is to be known by a peculiar croaking sound of the voice, by difficult respiration, with a sense of straitening about the larynx, and by a pyrexia attending it.

From the nature of these symptoms, and from the dissection of the bodies of persons who died of this disease, there is no doubt of its being of an inflammatory kind. It does not, however, always run the course of inflammatory affections; but frequently produces such an obstruction of the passage of the air, as suffocates, and thereby proves suddenly fatal.

It particularly proves fatal, in consequence of the trachea being obstructed by a membranous substance lining the inside of it, and very nearly approaching in appearance to the inflammatory exudation often discovered on the intestinal canal in those dying of enteritis.

If we judge rightly of the nature of this disease, it will be obvious, that the cure of it requires the most powerful remedies of inflammation to be employed upon the very first appearance of the symptoms. When a suffocation is threatened, whether any remedies can be employed to prevent it, is not yet determined by sufficient experience: but it is evident, that in certain cases the life of the patient can be preserved only by the removal of that matter which obstructs the passage of air through the trachea.

The accounts which books have hitherto given us of inflammations of the larynx, and the parts connected with it, amount to what we have now said; and many instances are recorded of the disease happening in adult persons: but there is a peculiar affection of this kind happening to infants, which has been little taken notice of till lately. Dr Francis Home is the first who has given any distinct account of this disease; but, since he wrote, several other authors have taken notice of it, and have given different opinions concerning it.

This disease seldom attacks infants till after they have been weaned. After this period, the younger they are, the more they are liable to the disease. The frequency of it becomes less as children become more advanced; and there are few instances of children above 12 years of age being affected with it. It attacks children of the midland countries, as well as those who live near the sea; but it occurs much more frequently at certain places than at others. It does not appear to be contagious; and its attacks are frequently repeated in the same child. It is often ma-

nifestly the effect of cold applied to the body; and therefore appears most frequently in the winter and spring seasons. It very commonly comes on with the ordinary symptoms of a catarrh; but sometimes the peculiar symptoms of the disease show themselves at the very first.

These peculiar symptoms are the following: A hoarseness, with some shrillness and ringing sound, both in speaking and coughing, as if the noise came from a brazen tube. At the same time, there is a sense of pain about the larynx, some difficulty of respiration, with a whizzing sound in inspiration, as if the passage of the air were straitened. The cough which attends it, is commonly dry; and if any thing be spit up, it is matter of a purulent appearance, and sometimes films resembling portions of a membrane. With all these symptoms, there is a frequency of pulse, a restlessness, and an uneasy sense of heat. When the internal fauces are viewed, they are sometimes without any appearance of inflammation; but frequently a redness, and even swelling, appears; and sometimes there is an appearance of matter like to that rejected by coughing, together with the symptoms now described, and particularly with great difficulty of breathing, and a sense of strangling in the fauces, by which the patient is sometimes suddenly taken off.

Many dissections have been made of infants who had died of this disease, and almost constantly there has appeared a preternatural substance, apparently membranous, lining the whole internal surface of the upper part of the trachea, and extending in the same manner downwards into some of its ramifications. This preternatural membrane may be easily separated, and sometimes has been found separated in part from the subjacent proper membrane of the trachea. This last is commonly found entire, that is, without any appearance of erosion or ulceration; but it frequently shows the vestiges of inflammation, and is covered by a matter resembling pus, like to that rejected by coughing; and very often a matter of the same kind is found in the bronchiae, sometimes in considerable quantity.

From the remote causes of this disease; from the catarrhal symptoms commonly attending it; from the pyrexia constantly present with it; from the same kind of preternatural membrane being found in the trachea when the cynanche maligna is communicated to it; and from the vestiges of inflammation on the trachea discovered upon dissection; we must conclude, that this disease consists in an inflammatory affection of the mucous membrane of the larynx and trachea, producing an exudation analogous to that found on the surface of inflamed viscera, and appearing partly in a membranous crust, and partly in a fluid form resembling pus.

Though this disease consists in an inflammatory affection, it does not commonly end either in suppuration or gangrene. The most troublesome circumstance of it seems to consist in a spasm of the muscles of the glottis, threatening suffocation.

When this disease terminates in health, it is by resolution of the inflammation, by ceasing of the spasm of the glottis, by an exsiccation of the matter exuding from the trachea, and of the crusts formed there,

there, and frequently it ends without any expectoration, or at least with such only as attends an ordinary catarrh. But in some instances, a salutary termination has very speedily taken place, in consequence of the discharge of the membranous substance from the trachea, even under its proper tubular form.

When the disease ends fatally, it is by a suffocation seemingly depending upon a spasm affecting the glottis; but sometimes, probably, depending upon a quantity of matter filling the bronchiae, or obstructing the trachea.

As we suppose the disease to be an inflammatory affection, so we attempt the cure of it by the usual remedies of inflammation. Bleeding, both general and topical, has often given immediate relief, and, by being repeated, has entirely cured the disease. Blistering also, near to the part affected, has been found useful. Upon the first attack of the disease, vomiting, immediately after bleeding, seems to be of considerable use, and sometimes suddenly removes the disease. But emetics are still more useful in advanced periods. By the employment of these, the matter obstructing the trachea, and inducing spasmodic affections, has often been successfully removed, when the situation of the patient seemed to be almost desperate. And as in the progress of the disease fresh effusions of this matter are very apt to take place, the frequent repetition of emetics becomes necessary. It is often necessary to have recourse to those operating the most expeditiously, such as sulphate of zinc even in large doses. In every stage of the disease, the antiphlogistic regimen is necessary, and particularly the frequent use of laxative glysters. Some practitioners consider mercury, particularly under the form of calomel, as an almost infallible remedy in this disease. It has particularly been extolled by Mr James Anderson, an eminent surgeon in Edinburgh. But we are sorry to say that in some cases at least, after the fairest trial, it has been found to fail. Though we suppose that a spasm affecting the glottis is often fatal in this disease, antispasmodic medicines have not in general been found of great service. Some, however, have strongly recommended the use of asafetida under the form of injection; others place great confidence in oil, or oily mixtures, taken by the mouth; but more immediate benefit is derived from tepid bathing, and the employment of sulphuric ether, both externally and internally.

By these, when the disease is spasmodic, it is often successfully removed. But by much the most dangerous form of the disease is the inflammatory state giving the exudation. And when this inflammatory exudation has even been removed from the upper part of the trachea, yet it has sometimes proved fatal, from the inflammation and exudation extending to the branches of the aspera arteria. By such an occurrence, the writer of the present article had the misfortune to lose a favourite son; an aimable youth, in the fourteenth year of his age, who was highly admired and sincerely regretted by all to whom he was known.

130 Sp. IV. CYNANCHE PHARYNGEA.

Cynanche pharyngea, Sauv. sp. 6. Eller de cogn. et cur. sect. 7.

Angine inflammatoire, sp. 4. Boerh. 804.

This is not materially different from the cynanche

tonsillaris; only that the inflammation is said to begin in the pharynx, though Dr Cullen says he never knew an instance of it. The symptoms are almost the same, and the cure is precisely so with that of the cynanche tonsillaris.

Sp. V. CYNANCHE PAROTIDÆA.

Cynanche parotidæa, Sauv. sp. 14. Gallis OREILLONS ET OURLES, Tissot Avis au peuple, N° 116. Encyclopédie, au mot Oreillons.

Angina externa, Anglis the MUMPS, Russell econ. natur. p. 114. Scotis the BRANKS.

Catarrhus Bellinfulanus, Sauv. sp. 4.

Osservazioni di Girol. Gaspari, Venez. 1731.

Osservazioni di Targ. Tozetti, Racolta 1ma, p. 176.

This is a disease well known to the vulgar, but little taken notice of by medical writers. It is often epidemic, and manifestly contagious. It comes on with the usual symptoms of pyrexia, which is soon after attended with a considerable tumor of the external fauces and neck. The swelling appears first as a glandular moveable tumor at the corner of the lower jaw; but it soon becomes uniformly diffused over a great part of the neck, sometimes on one side only, but more commonly on both. The swelling continues to increase till the fourth day; but from that period it declines, and in a few days more goes off entirely. As the swelling of the fauces recedes, it not unfrequently happens that some tumor affects the testicles in the male sex, or the breasts in the female. These tumors are sometimes large, hard, and somewhat painful; but are seldom either very painful or of long continuance. The pyrexia attending this disease is commonly slight, and goes off with the swelling of the fauces; but sometimes, when the swelling of the testicles does not succeed to that of the fauces, or when the one or the other has been suddenly repressed, the pyrexia becomes more considerable, is often attended with delirium, and has sometimes proved fatal.

As this disease commonly runs its course without either dangerous or troublesome symptoms, so it hardly requires any remedies. An antiphlogistic regimen, and avoiding cold, are all that will be commonly necessary. But when, upon the receding of the swellings, the pyrexia comes to be considerable, and threatens an affection of the brain, it will be proper, by warm fomentations, to bring back the swelling; and by vomiting, bleeding, or blistering, to obviate the consequences of its absence.

GENUS XI. PNEUMONIA.

Febris pulmonica, Hoffm. II. 136.

Sp. I. PERIPNEUMONIA.

Peripneumony, or Inflammation of the LUNGS.

Peripneumonia, Sauv. gen. 112. Lin. 34. Vog. 51. Sag. gen. 311. Boerh. 820. Juncker 67.

Peripneumonia pura five vera Auctorum, Sauv. sp. 1.

Peripneumonia gastrica, Sauv. sp. 11. Morgagni. de caus. et sed. Epist. xx. art. 30, 31.

Peripneumonia catarrhalis, Sauv. sp. 6.

Peripneumonia

Peripneumonia notha, Sydenh. sect. 6. cap. 4.
Boerh. 867. Morgagni de caus. et sed. Epist.
xxi. 11.—15.
Peripneumonia putrida, Sauv. sp. 2.
Peripneumonia ardens, Sauv. sp. 3.
Peripneumonia maligna, Sauv. sp. 4.
Peripneumonia typhodes, Sauv. sp. 5.
Amphimerina peripneumonica, Sauv. sp. 15.

The Pleurisy, or Inflammation of the PLEURA.

Pleuritis, Sauv. gen. 103. Lin. 27. Veg. 56. Sag.
gen. 303. Boerh. 875. Junck. 67.
Paraphrenesis, Sauv. gen. 102. Lin. 26.
Paraphrenitis, Veg. 55. Boerh. 907.
Diaphragmitis, Sag. gen. 304.
Pleuritis vera, Sauv. sp. 1. Boerh. 875. Verna
princeps morb. acut. pleuritis, l. 1. cap. 2. 3.
Zeviani della parapleuritide, cap. 3. Morgagni
de sed. et caus. morb. Epist. xx. art. 56. xxi. 45.
Wendt de pleuritide, apud Sandifort, thes. ii.
Pleuritis pulmonis, Sauv. sp. 2. Zeviani. dell. para-
pleur. iii. 28, &c.
Pleuropneumonia, pleuro-peripneumonia, peripneu-
mo-pleuritis Auctorum. Baronius de pleuri-pneu-
monia. Ill. Halleri opuscul. patholog. obs. 13.
Morgagni de sed. et caus. Epist. xx. et xxi. pas-
sim. Cleghorn, Minorca. p. 247. Triller de pleuri-
tide, aph. 1, 2, 3, cap. i. 8. Huxham, Dissert.
on pleurites, &c. chap. i. Ill. Pringle, Dis. of
the army.
Pleuritis convulsiva, Sauv. sp. 13. Bianchi. Hist. hep.
vol. i. p. 234.
Pleuritis hydrothoracica, Sauv. sp. 15. Morgagni de
caus. et sed. xx. 34.
Pleuritis dorsalis, Sauv. sp. 3. Verna, p. 3. cap. 8.
Pleuritis mediaastini, Sauv. sp. 3. P. Sal. Dio. de
affec. part. cap. 6. Friend, Hist. Med. de Aven-
zoare.
Mediaastina, Veg. 52.
Pleuritis pericardii, Sauv. sp. 5. Verna, p. iii.
cap. 9.
Parapleuritis, Zeviani della parapleuritide.
Pleurodyne parapleuritis, Sauv. sp. 19.
Paraphrenesis diaphragmatica, Sauv. sp. 1. De Haen.
Rat. med. i. 7. iii. p. 31.
Paraphrenesis pleuritica, Sauv. sp. 2.
Paraphrenesis hepatica, Sauv. sp. 3.

Under the general head of Pneumonia, Dr Cullen, comprehends all inflammations of the thoracic viscera, or membrane lining the inside of that cavity; as the symptoms do not always sufficiently distinguish the seat of the affection, nor does a difference in the situation of the affected place make any difference in the cure.

Description. Pneumonic inflammation, however various in the seat, always discovers itself by pyrexia, difficult breathing, cough, and pain in some part of the thorax. It almost always comes on with a cold stage, and is accompanied with the other symptoms of pyrexia; though in some few instances the pulse may not be more frequent, nor the heat of the body increased beyond what is natural. Sometimes the pyrexia is

from the beginning accompanied with the other symptoms; but frequently it is formed some hours before them, and particularly before the pain be felt. The pulse for the most part is frequent, full, strong, hard, and quick; but, in a few instances, especially in the advanced state of the disease, it is weak, soft, and at the same time irregular. The difficulty of breathing is most considerable in inspiration, both because the lungs do not easily admit of a full dilatation, and because the dilatation increases the pain attending the disease. The difficulty of breathing is also greater when the patient is in one posture of the body rather than another. It is generally greater when he lies on the side affected; though sometimes the contrary happens. Very often the patient cannot lie upon either side, and can find ease only when lying on the back; and sometimes he cannot breathe readily, except when in somewhat of an erect posture. The cough, in different cases, is more or less urgent or painful. It is sometimes dry, or without any expectoration, especially in the beginning of the disease; but more commonly it is, even from the beginning, moist, and the matter spit up various both in consistence and colour, and frequently it is streaked with blood. The pain is also different in different cases, and felt in different parts of the thorax, but most frequently in one side. It has been said to affect the right side more frequently than the left; but this is uncertain, and we are sure that the left side has been very often affected. Sometimes it is felt as if it was under the sternum; sometimes in the back between the shoulders; and when in the sides, its place has been higher or lower, more forward or backward; but the place of all most frequently affected is about the sixth or seventh rib, near the middle of its length, or a little more forward. The pain is often severe and pungent; but sometimes more dull and obtuse, with a sense of weight rather than of pain. It is most especially severe and pungent when occupying the place last mentioned. For the most part it continues fixed in one part, but sometimes shoots from the side to the scapula on one hand, or to the sternum and clavicle on the other.

Dr Cullen supposes that the disease is always seated, or at least begins, in some part of the pleura, taking that membrane in its greatest extent, as now commonly understood; that is, as covering not only the internal surface of the cavity of the thorax, but also as forming the mediaastinum, and as extended over the pericardium, and over the whole surface of the lungs. But as the symptoms never clearly indicate where the seat of the disease is, there is but little foundation for the different names by which it has been distinguished. The term pleurisy is improperly limited to that inflammation which begins in and chiefly affects the pleura costalis. This Dr Cullen thinks is a rare occurrence; and that the pneumonia much more frequently begins in the pleura investing the lungs, producing all the symptoms which belong to what hath been called the pleuritis vera. The word peripneumony has been applied to an inflammation beginning in the parenchyma, or cellular texture of the lungs, and having its seat chiefly there. But to Dr Cullen it seems very doubtful if any acute inflammation of the lungs, or any disease which has been called peripneumony, be of that kind. It seems probable, that

that every acute inflammation begins in membranous parts; and in every dissection of persons who have died of peripneumony, the external membrane of the lungs, or some part of the pleura, has appeared to have been considerably affected. An inflammation of the pleura covering the upper surface of the diaphragm, has been distinguished by the appellation of paraphrenitis, as supposed to be attended with the peculiar symptoms of delirium, visus sardonius, and other convulsive motions: but it is certain, that an inflammation of that portion of the pleura, and affecting also even the muscular substance of the diaphragm, has often taken place without any of the symptoms above-mentioned; and neither the dissections which have fallen under Dr Cullen's observation, nor any accounts of dissections, support the opinion that an inflammation of the pleura covering the diaphragm is attended with delirium more commonly than any other pneumonic inflammation.—It is to be observed, however, that though the inflammation may begin in one particular part of the pleura, the morbid affection is commonly communicated to the whole extent of the membrane.

The pneumonic inflammation, like others, may terminate by resolution, suppuration, or gangrene: but it has also a termination peculiar to itself; namely, when it is attended with an effusion of blood into the cellular texture of the lungs, which, soon interrupting the circulation of the blood through the viscus, produces a fatal suffocation. This indeed appears to be the most common termination of pneumonic inflammation when it ends fatally; for upon the dissection of almost every person who has died of this disease, it appears that such an effusion had happened. From the same dissections we learn, that pneumonic inflammation commonly produces an exudation from the internal surface of the pleura, which appears partly as a soft viscid crust, often of a compact membranous form, covering every where the surface of the pleura, and particularly those parts where the lungs adhere to the pleura costalis, or mediastinum; and this crust seems always to be the cement of such adhesion. The same exudation shows itself also by a quantity of a serous fluid commonly found in the cavity of the thorax; and some exudation or effusion is usually found to have been made into the cavity of the pericardium. It seems likewise probable, that an effusion of this kind is sometimes made into the cavity of the bronchiae; for in some persons who have died after labouring under a pneumonic inflammation for a few days only, the bronchiae have been found filled with a considerable quantity of serous and thickish fluid, which must be considered rather as the effusion abovementioned, having had its thinner parts taken off by respiration, than as a pus so suddenly formed in the inflamed part. It is, however, not improbable, that this effusion, as well as that made into the cavities of the thorax and pericardium, may be a matter of the same kind with that which in other inflammations is poured into the cellular texture of the parts inflamed, and there converted into pus; but in the thorax and pericardium it does not always put on this appearance, because the crust covering the surface prevents the absorption of the thinner part. This absorption, however, may be compensated in the bronchiae, by the drying power of the air; and therefore the effusion into them may af-

fume a more purulent appearance. In many cases of pneumonic inflammation, when the expectoration is very copious, it is difficult to suppose that the whole proceeds from the mucous follicles of the bronchiae; and it seems probable that a great part of it may come from the effused serous fluid just mentioned; and this too will account for the appearance of the expectoration being so often purulent. Perhaps the same thing will account for that purulent matter found in the bronchiae, which Mr de Haen says he had often observed when there was no ulceration in the lungs, and which he accounts for in a very strange manner, namely, by supposing a pus formed in the circulating blood.

Dr Cullen is of opinion, that the effusion into the bronchiae above-mentioned often concurs with the effusion of red blood into the cellular substance of the lungs to occasion the fatal suffocation which frequently terminates peripneumony: that the effusion of serum alone may have this effect; and that the serum poured out in a certain quantity, rather than any debility in the powers of expectoration, is the cause of that cessation of spitting which precedes the fatal event; for in many cases the expectoration has ceased, when no other symptoms of debility have appeared, and when, upon dissection the bronchiae have been full of liquid matter. Nay, it is even probable, that in some cases such an effusion may take place without any symptoms of violent inflammation; and in other cases the effusion taking place may seem to remove the symptoms of inflammation which had appeared before, and thus account for those unexpected fatal terminations which have sometimes happened.

Pneumonic inflammation seldom terminates by resolution, without being attended with some evident evacuation. An hemorrhagy from the nose happening on some of the first days of the disease has sometimes put an end to it; and it is said, that an evacuation from the hemorrhoidal veins, a bilious evacuation by stool, and an evacuation of urine with a copious sediment, have severally had the same effect; but such occurrences have been rare. The evacuation most frequently attending, and seeming to have the greatest effect in promoting resolution, is an expectoration of a thick, white, or yellowish matter, a little streaked with blood, copious, and brought up without much or violent coughing. Very frequently the resolution of this disease is attended with, and perhaps produced by, a sweat, if it be warm, fluid, copious, over the whole body, and attended with an abatement of the frequency of the pulse, heat of the body, and other febrile symptoms. Although, from the history now given, it appears that pleurisy and peripneumony cannot with propriety be considered as different diseases, yet it is certain that in different cases this affection occurs with an assemblage of symptoms separate and distinct. Thus even Dr Cullen himself, in his Nosology, has defined pleuritis to consist in pyrexia, attended with pungent pain of the side, painful respiration, difficulty of lying down, particularly on the affected side, and distressing cough, in the beginning dry, but afterwards humid, and often with bloody expectoration. While again he has defined peripneumony to consist in pyrexia, attended with a dull pain under the sternum and between the shoulders, anxiety, difficulty of breathing, hu-

Phlegma-
sis. mid cough, expectoration generally bloody, a soft pulse, and a tumid livid appearance of the countenance. It is highly probable, that the first of these sets of symptoms chiefly arises from a state of active inflammation, and the second from effusion. Thus, in certain cases, the symptoms may appear perfectly separate and distinct; but more frequently both inflammation and effusion are united; and thus the symptoms in both definitions are in general combined in the same patient. But still pleuritis, strictly so called, may be considered as characterized by the acute pungent pain at a particular spot of the chest, and that pain much aggravated on a full inspiration; while proper peripneumonia is distinguished by the dull gravative pain extended over the whole chest, and by the laborious respiration.

Causes of, and persons subject to, this disorder. The remote cause of pneumonic inflammation is commonly cold applied to the body, obstructing perspiration, and determining to the lungs, while at the same time the lungs themselves are exposed to the action of cold. These circumstances operate chiefly when an inflammatory diathesis prevails in the system; and therefore those principally affected with this disease are persons of the greatest vigour, in cold climates, often in the winter season, but particularly in the spring, when vicissitudes of heat and cold are frequent. This disease, however, may arise in any season when such varieties take place. Other remote causes also may have a share in producing this distemper; such as every means of obstructing, straining, or otherwise injuring, the pulmonary organs. The pneumonic inflammation has sometimes been so much an epidemic, that it hath been suspected of depending on a specific contagion; but Dr Cullen never met with an instance of its being contagious.

Prognosis. In pneumonic inflammations, a violent pyrexia is always dangerous. The danger, however, is chiefly denoted by the difficulty of breathing. When the patient can lie on one side only; when he can lie on neither side, but only on his back; when he cannot breathe with tolerable ease, except when the trunk of his body is erect; when even in this posture the breathing is very difficult, and attended with a turgescence and flushing of the face, with partial sweats about the head and neck, and an irregular pulse; these circumstances mark the difficulty of breathing in different degrees; and consequently, in proportion, the danger of the disease. A frequent violent cough, aggravating the pain, is always the symptom of an obstinate disease; and as the disease is seldom or never resolved without some expectoration, so a dry cough must always be an unfavourable symptom.

The proper characteristics of the expectoration have been already laid down; and though an expectoration which has not these marks must indicate a doubtful state of the disease, yet the colour alone can give no certitude in prognostic. An acute pain, very much interrupting inspiration, is always the mark of a violent disease; but not of a more dangerous disease than an obtuse pain, attended with very difficult respiration, demonstrating effusion into the cells.

When the pains, which had at first affected one side only, shall afterwards spread into the other; or when, leaving the side first affected, they pass entirely into the other; these are always marks of a dangerous disease.

A delirium coming on during a pneumonic inflammation is always a symptom denoting much danger.

When pneumonic disorders terminate fatally, it is on one or other of the days of the first week, from the third to the seventh. This is the most common case; but, in a few instances, death has happened at a later period. When the disease is violent, but admitting of resolution, this also happens frequently in the course of the first week; but in a more moderate disease the resolution is often put off to the second week. The disease generally suffers a remission on some of the days from the third to the seventh: which, however, may be often fallacious, as it sometimes returns again with as much violence as before; and in such a case with great danger. Sometimes it disappears on the third day, while an erysipelas makes its appearance on some external part; and if this continue fixed, the pneumonic inflammation does not recur. If the disease continue beyond the 14th day, it will terminate in a suppuration, or PHTHISIS. The termination by gangrene is much more rare than has been imagined: and when it does occur, it is usually joined with the termination by effusion; the symptoms of the one being hardly distinguishable from those of the other.

Cure. This must proceed upon the general plan mentioned under SYNOCHA; but, on account of the importance of the part affected, the remedies must be employed early, and as fully as possible: and these are chiefly directed with one of three views, viz. for obtaining a resolution of the inflammation in the thorax; for mitigating the urgent symptoms before a resolution can be effected, and for counteracting or obviating the consequences of the disease. Venesection is the remedy chiefly to be depended on; and may be performed in either arm, as the surgeon finds most convenient; and the quantity taken away ought in general to be as large as the patient's strength will allow. The remission of pain, and the relief of respiration, during the flowing of the blood, may limit the quantity to be then drawn; but if these symptoms of relief do not appear, the bleeding should be continued to a considerable extent, unless symptoms of a beginning syncope come on. It is seldom that one bleeding, however large, will cure this disease; and though the pain and difficulty of breathing may be much relieved by the first bleeding, these symptoms commonly and after no long interval recur, often with as much violence as before. In this case the bleeding is to be repeated even on the same day, and perhaps to the same quantity as before. Sometimes the second bleeding may be larger than the first. There are persons who, by their constitution, are ready to faint even upon a small bleeding; and in such persons this may prevent the drawing so much blood at first as a pneumonic inflammation may require; but as the same persons are found to bear after-bleedings better than the first, this allows the second and subsequent bleedings to be larger, and to such a quantity as the symptoms of the disease may seem to require.

Bleedings are to be repeated according to the state of the symptoms, and they will be more effectual when practised in the course of the first three days than afterwards; but they are not to be omitted though four days of the disease may already have elapsed. If the physician has not been called in time, or the first bleed-

ings have not been sufficiently large, or even though they should have procured some remission, yet upon the return of the urgent symptoms, bleeding may be repeated at any time within the first fortnight, or even after that period, if a suppuration be not evident, or if after a seeming solution the disease shall have returned.

With respect to the quantity of blood which may be taken away with safety, no general rules can be given; as it must be very different according to the state of the disease, and the constitution of the patient. In an adult male of tolerable strength, a pound of blood is a full bleeding. Any quantity above 20 ounces is a large, and any quantity below 12 is a small, bleeding. An evacuation of four or five pounds, in the course of two or three days, is generally as much as most patients will bear; but if the intervals between the bleedings, and the whole of the time during which the bleedings have been employed, have been long, the quantity taken upon the whole may be greater.

When a large quantity of blood has been taken from the arm, and it is doubtful if more can be taken in that manner with safety, some blood may still be taken by cupping and scarifying. This will especially be proper, when the recurrence of the pain, rather than the difficulty of breathing, becomes the urgent symptom; and then the cupping and scarification should be made as near as possible to the pained part.

An expectoration sometimes takes place very early in this disease; but if the symptoms continue urgent, the bleedings must be repeated notwithstanding the expectoration: but in a more advanced state, and when the symptoms have suffered a considerable remission, we may then trust the cure to the expectoration alone. It is not observed that bleeding, during the first days of the disease, stops expectoration; on the contrary, it has been often found to promote it; and it is only in a more advanced state of the disease, when the patient has been already exhausted by large evacuations and a continuance of his illness, that bleeding seems to put a stop to expectoration; and even then, this stoppage seems not to take place so much from the powers of expectoration being weakened by bleeding, as by its favouring the serous effusion in the bronchiae, already taken notice of.

Besides bleeding, every part of the antiphlogistic regimen ought here to be carefully employed: the patient must keep out of bed as much as he can bear; must have plenty of warm diluting drinks, impregnated with vegetable acids, accompanied with nitre or some other cooling neutral salt; and the belly also ought to be kept open by emollient clysters or cooling laxative medicines. Vomiting in the beginning is dangerous; but in a somewhat advanced state of the disease emetics have been found the best means of promoting expectoration. Fomentations and poultices to the pained part have been found useful; but blistering is found to be much more effectual. A blister, however, ought not to be applied till at least one bleeding has been premised, as venesection is less effectual when the irritation of a blister is present. If the disease be moderate, a blister may be applied immediately after the first bleeding; but in violent cases, where it may be presumed that a second bleeding may soon be necessary after the first, it will be proper to delay the blister till after the second bleeding, when it may be

supposed that the irritation occasioned by the blister will be over before another bleeding becomes necessary. It may frequently be of use in this disease to repeat the blistering; and in that case the plasters should always be applied somewhere on the thorax, for when applied to more distant parts they have less effect. The keeping the blistered parts open, and making what is called a perpetual blister, has much less effect than a repeated blistering.

Many methods have been proposed for promoting expectoration, but none appear to be sufficiently effectual; and some of the expectorants, being acrid stimulant substances, are not very safe. The gums usually employed seem to be too heating; the squills less so; but they are not very powerful, and sometimes inconvenient, by the constant nausea they occasion. The volatile alkali may be of service as an expectorant, but it ought to be reserved for an advanced state of the disease. Mucilaginous and oily demulcents appear to be useful, by allaying that acrimony of the mucus which occasions too frequent coughing; and which coughing prevents the stagnation and thickening of the mucus, and thereby its becoming mild. The receiving into the lungs the steams of warm water, impregnated with vinegar, has often proved useful in promoting expectoration; and, for this purpose, the machine called the INHALER, lately invented by Dr Mudge of Plymouth, promises to be of great service. But of all others, the antimonial emetics, given in nauseating doses, are perhaps the most powerful for promoting expectoration. The kermes mineral has been greatly recommended; but does not seem to be more efficacious than tartrate of antimony or antimonial wine; and the dose of the kermes is much more uncertain than that of the others.

Though this disease often terminates by a spontaneous sweating, this evacuation ought not to be excited by art, unless with much caution. When, after some remission of the symptoms, spontaneous sweats arise, they may be encouraged; but it ought to be without much heat, and without stimulant medicines. If, however, the sweats be partial and clammy only, and a great difficulty of breathing still remain, it will be very dangerous to encourage them.

Physicians have differed much with regard to the use of opiates in pneumonic affections. It appears, however, that in the beginning of the disease, and before bleeding and blistering have produced some remission of the pain, and of the difficulty of breathing, opiates have had a bad tendency, by their increasing the difficulty of breathing and other inflammatory symptoms. But in a more advanced state of the disease, when the difficulty of breathing has abated, and when the urgent symptom is a cough, proving the chief cause of the continuance of pain and want of rest, opiates may be employed with great advantage and safety. The interruption of the expectoration which they seem to occasion, is for a short time only; and they seem often to promote it, as they occasion a stagnation of what was by frequent coughing dissipated insensibly; and therefore give the appearance of what physicians have called concocted matter.

Opium combined with calomel has of late been highly extolled in this and other inflammatory diseases by Dr Hamilton of Lynn Regis; who has given a full ac-

Phlegma-
fix. count of the success attending his practice with this remedy, for the space of 16 years, in the 9th volume of the Edinburgh Medical Commentaries. And since his recommendation, the same remedy has often been employed by others with great benefit.

Phthisis sometimes follows pneumonia, though the case is not frequent. The symptoms of it so much resemble ordinary phthisis, that it can most properly be treated of under that head.

This is another consequence of a pneumonia terminating unfavourably, and is occasioned by the effusion of a quantity of purulent matter into the cavity of the thorax, producing a lingering and painful disorder, very often incurable.

Description. The first sign of an empyema is a cessation of the pain in the breast, which before was continual: this is followed by a sensation of weight on the diaphragm; and a fluctuation of matter, sometimes making a noise that may be heard by the bystanders: the acute fever is changed into a hectic, with an exacerbation at night: a continual and troublesome dry cough remains. The respiration is exceedingly difficult, because the lungs are prevented by the matter from fully expanding themselves. The patient can lie easily on that side where the matter is effused, but not on the other, because then the weight of the matter on the mediastinum produces uneasiness. The more the hectic heat is augmented, the more is the body emaciated, and its strength decayed. In some there is danger of suffocation when they stoop down, which goes off when they alter that posture of the body; and in some there is a purulent spitting.—These symptoms are accompanied with great anxiety, palpitations of the heart, and faintings. Sometimes the patients have a sensation like a hot vapour ascending from the cavity of the thorax to their mouth. Others, in a more advanced state of the disease, have a putrid taste in the mouth. At the same time, profuse night sweats waste the body, and greatly weaken the patient. The face at first grows red on that side where the matter lies, at last the Hippocratic face comes on, and the eyes become hollow. The pulse is quick, but more frequently intermitting. Sometimes the nails are crooked, and pustules appear on the thorax; and frequently, according to the testimony of Hippocrates, the feet swell, and, on the affected side of the breast, there is an inflation and swelling of the skin.

Causes, &c. An empyema may arise either from the bursting of a vomica of the lungs, or from a suppuration taking place after the inflammatory stage of pneumonia; or sometimes from a suppuration in the case of a quinsy, when the inflammation had extended to the aspera arteria, from whence arises a kind of bloody sputum, and the patients are afflicted with an empyema, unless they die on the 7th day of the disease, according to the observation of Hippocrates. It may arise also from external violence, as wounds of the thorax, &c. blood extravasated, corrupted, or changed into pus.

Like the vomica, it is a rare distemper, but may attack Peritonitis-all those subject to pneumonia.

Prognosis. Very few recover after an empyema has been once formed, especially if the operation of paracentesis be neglected. After this operation is performed, if a great quantity of bloody fetid pus be discharged, if the fever continue, and if the patient spit up a purulent, pale, frothy, livid, or green matter, with a decay of strength, there is no hope: But when a small quantity of pus, of a white colour, not very fetid, is discharged; when the fever and thirst presently cease, the appetite returns, and faeces of a good consistence are discharged, the strength also returning in some degree; there is then hope of a perfect recovery. If the matter be not dried up in seven weeks time, the disease readily changes to a fistulous ulcer, which is very difficult to cure. An empyema affecting both sides of the thorax is more dangerous than that which affects only one.

Cure. This consists in evacuating the purulent matter contained in the cavity of the thorax, which is best done by the operation of paracentesis of the thorax. See SURGERY. Afterwards the ulcer is to be treated with abstergent and consolidating medicines, and the same internal ones are to be given as in a PHTHISIS.

Description. This disease is attended with all the symptoms of pneumonia, but in a higher degree; it is besides said to be accompanied with hydrophobic symptoms, fainting, palpitation of the heart, a seeming madness, a funk and irregular pulse, watery eyes, and a dejected countenance, with a dry and black tongue. On dissection, the heart and pericardium are found very much inflamed, and even ulcerated, with many polypous concretions.

Causes, &c. The same as in the pneumonia.

Prognosis. In the carditis the prognosis is more unfavourable than in the pneumonia; and indeed, unless the disease very quickly terminates, it must prove fatal, on account of the constant and violent motion of the heart, which exasperates the inflammation, and increases all the symptoms.

Cure. Here bleeding is necessary in as great a degree as the patient can possibly bear, together with blistering, and the antiphlogistic regimen likewise carried to a greater height than in the pneumonia; but the general method is the same as in other inflammatory diseases.

Sp. I. Inflammation of the PERITONÆUM properly so called.

Peritonitis, Vog. 62. Lieutad. Hist. anat. med. lib. i. Q 9 2 obs.

obs. 3. Raperus apud eund. lib. i. obs. 341. Morgagni. de sed. LVII. 20.

Sp. II. Inflammation of the PERITONEUM extended over the Omentum.

Epiploitis, Sauv. gen. 106. Sag. gen. 303.

Omentitis, Vog. 61.

Omenti inflammatio, Boerh. 985. et III. Van Swieten, Comm. Storé. An. Med. I. 132. Holme on the puerperal fever.

Sp. III. Inflammation of the PERITONEUM stretched over the Mesentery.

Mesenteritis, Vog. 60.

Enteritis mesenterica, Sauv. sp. 4.

GENUS XV. GASTRITIS.

Inflammation of the STOMACH.

A. GASTRITIS PRINCIPALIS, or the genuine Gastritis.

Gastritis legitima, Sauv. sp. 1. Eller. de cogn. et cur. morb. sect. xii. Haller. obs. 14. hist. 3. Lieut. Hist. Anat. Med. lib. i. 74.

Gastritis erysipelatosa, Sauv. sp. 4.

Cardialgia inflammatoria, Sauv. sp. 13. Tralles, de opio, sect. ii. p. 231.

These diseases Dr Cullen has thought proper to consider all under the general head of GASTRITIS, as there are no certain signs by which they can be distinguished from each other, and the method of cure must be the same in all.

Description. The inflammation of the stomach is attended with great heat and pain in the epigastric region, extreme anxiety, an almost continual and painful hiccough, with a most painful vomiting of every thing taken into the stomach. Sometimes a temporary madness ensues; and there is an influence in the Edinburgh Medical Essays of the disorder being attended with an hydrophobia. The pulse is generally more sunk than in other inflammations, and the fever inclines to the nature of a typhus. The disorder is commonly of the remitting kind, and during the remissions the pulse frequently intermits. During the height of the disease, a mortal phrensy frequently supervenes. The disease terminates on the fourth, seventh, or ninth day, or from the eleventh to the fifteenth; and is more apt to end in a gangrene than pneumonic inflammations, and more frequently in a scirrhous than in an abscess.

Causes, &c. The inflammation of the stomach may arise from any acrid substance taken into it; from a vehement passion, too large draughts of cold liquor, especially when the person is very hot; from a surfeit; a stoppage of perspiration; repulsion of the gout; inflammations of the neighbouring viscera; or from external injuries, such as wounds, contusions, &c.—It affects chiefly those of a plethoric habit and hot bilious constitution.

Prognosis. This disease is always very dangerous, and the prognosis doubtful, which also must always be in proportion to the severity of the symptoms. A cessation of pain, coldness about the precordia, great

debility, with a languid and intermitting pulse, with an abatement of the hiccough, denote a gangrene and speedy death. From the sensibility of the stomach also, and its great connexion with the rest of the system, it must be obvious, that an inflammation of it, by whatever causes produced, may be attended with fatal consequences; particularly, by the great debility it produces, it may prove suddenly fatal, without running through the usual course of inflammations.—Its tendency to admit of resolution may be known by its having arisen from no violent cause, by the moderate state of the symptoms, and by a gradual remission of these symptoms in the course of the first or at most of the second week of the disease. The tendency to gangrene may be suspected from the symptoms continuing with unremitting violence, notwithstanding the use of proper remedies; and a gangrene already begun may be known by the symptoms above mentioned, particularly great debility and sudden cessation of pain. The tendency to suppuration may be known by the symptoms continuing but in a moderate degree for more than one or two weeks, and by a considerable remission of the pain, while a sense of weight and anxiety still remain. When an abscess has been formed, the frequency of the pulse is first abated; but soon after it increases, with frequent cold shivering, and an exacerbation in the afternoon and evening; followed by night sweats, and other symptoms of hectic fever. These at length prove fatal, unless the abscess open into the cavity of the stomach, the pus be evacuated by vomiting, and the ulcer soon healed.

Cure. It appears from dissections, that the stomach may very often be inflamed when the characteristic marks of it have not appeared; and therefore we are often exposed to much uncertainty in the cure. But when we have sufficient evidence that a state of active inflammation has taken place in the stomach, the principal object to be aimed at is to obtain a resolution. Before, however, this can be accomplished, it will often be necessary to employ measures with the view of obviating urgent symptoms. When the symptoms appear in the manner above described, the cure is to be attempted by large and repeated bleedings employed early in the disease; and from these we are not to be deterred by the weakness of the pulse, for it will commonly become fuller and softer after the operation. A blister ought also to be applied to the region of the stomach; and the cure will be assisted by fomentations of the whole abdomen, and by frequent emollient and laxative clysters. The irritability of the stomach in this disease will admit of no medicines being thrown into it; and if any can be supposed necessary, they must be exhibited in clysters. Diluting drinks may be tried; but they must be of the very mildest kind, and given in very small quantities at a time. Opiates, in whatever manner exhibited, cannot be retained in the stomach during the first days of the disease; but when the violence of the disease shall have abated, and when the pain and vomiting recur at intervals only, opiates given in clysters are frequently employed with advantage; and after bleeding and blisters no remedy is more effectual either in allaying the pain or vomiting. As soon as the stomach will retain any laxative, gentle refrigerant cathartics, taken by the mouth, such as the soda phosphorata, soda tartarifata, or the like,

Phlebotomy are productive of great benefit. A tendency to gangrene in this disease is to be obviated only by the means just now mentioned; but when it does actually supervene, it admits of no remedy. A tendency to suppuration is to be obviated by the same means employed early in the disease. After a certain period it cannot be prevented by any means whatever; and, when actually begun, must be left to nature; the only thing that can be done by art being to avoid all irritation.

154 B. GASTRITIS ERYSIPELATOZA, or the Erysipelatous Gastritis.

Description. This species of inflammation takes place in the stomach much more frequently than the former. From dissections it appears that the stomach has been often affected with inflammation, when neither pain nor fever had given any notice of it; and such is justly looked upon to have been of the erysipelatous kind. This kind of inflammation also is especially to be expected from acrimony of any kind applied to the stomach; and would certainly occur much more frequently, were not the interior surface of this organ commonly defended by mucus exuding in large quantity from the numerous follicles placed immediately under the villous coat. On many occasions, however, the exudation of mucus is prevented, or the liquid poured out is of a less viscid kind, so as to be less fitted to defend the subjacent nerves; and it is in such cases that acrid matters may readily produce an erysipelatous affection of the stomach.

In many cases this kind of inflammation cannot be discovered, as it takes place without pain, pyrexia, or vomiting; but in some it may; namely, when it spreads into the oesophagus, and appears on the pharynx and on the whole internal surface of the mouth. When therefore an erysipelatous inflammation affects the mouth and fauces, and there shall be at the same time in the stomach an unusual sensibility to all acrids, and also a frequent vomiting, there can be little doubt of the stomach's being affected in the same manner. Even when no inflammation appears in the fauces, if some degree of pain be felt in the stomach, if there be a want of appetite, an anxiety and frequent vomiting, an unusual sensibility with regard to acrids, some thirst, and frequency of pulse, there will then be room to suspect an inflammation in the stomach; and such symptoms, after some time, have been known to discover their cause by the inflammation rising to the fauces or mouth. Inflammation of this kind is often disposed to pass from one place to another on the same surface, and, in doing so, to leave the place it had at first occupied. Such an inflammation has been known to spread successively along the whole tract of the alimentary canal; occasioning, when in the intestines, diarrhoea, and in the stomach, vomitings; the diarrhoea ceasing when the vomitings came on, and the vomitings on the coming on of the diarrhoea.

Causes, &c. An erysipelatous inflammation may arise from acrid matters taken into the stomach; or from some internal causes not yet well known. It frequently occurs in putrid diseases, and in those recovering from fevers.

Cure. When the disease is occasioned by acrid mat-

ters taken internally, and these may be supposed still present in the stomach, they are to be washed out by drinking a large quantity of warm and mild medicines, and exciting gentle vomiting. At the same time, if the nature of the acrimony and its proper corrector be known, this should be thrown in; or if a specific corrector be not known, some general demulcents should be employed.

These measures, however, are more suited to prevent than to cure inflammation after it has taken place. When this last may be supposed to have happened, if it be attended with a sense of heat, with pain and pyrexia, according to the degree of these symptoms, the measures proposed for the cure of the other kind are to be more or less employed. When an erysipelatous inflammation of the stomach has arisen from internal causes, if pain and pyrexia occur, bleeding may be employed in persons not otherwise weakened; but in case of its occurring in putrid diseases, or where the patients are already debilitated, bleeding is inadmissible; all that can be done being to avoid irritation, and only throwing into the stomach what quantity of acids and acescent aliments it shall be found able to bear. In some conditions of the body in which this disease is apt to occur, cinchona and bitters may seem to be indicated; but an erysipelatous state of the stomach with seldom allow them to be used.

Genus XVI. ENTERITIS.

Inflammation of the INTESTINES.

Enteritis, Sauv. gen. 105. Lin. 29. Vog. 57. Seg. gen. 307.

Intestinalum inflammatio, Boerh. 959.

Febris intestinalum inflammatoria ex mesenterio, Hoffm. ii. 170.

Sp. I. ENTERITIS PLEXOMONODOMA, or the Acute Enteritis.

Enteritis iliaca, Sauv. sp. 1.

Enteritis colica, Sauv. sp. 2. Boerh. 963.

Description. This disease shows itself by a fixed pain in the abdomen, attended with fever, vomiting, and costiveness. The pain is often felt in different parts of the abdomen, but more frequently spreads over the whole, and is particularly violent about the navel.

Causes, &c. Inflammations of the intestines may arise from the same causes as those of the stomach; though commonly the former will more readily occur from cold applied to the lower extremities, or to the belly itself. It is also found supervening on the spasmodic colic, incarcerated hernia, and volvulus.

Prognosis. Inflammations of the intestines have the same terminations with those of the stomach, and the prognosis in both cases is much the same.

Cure. The cure of enteritis is in general the same with that of gastritis; but in this disease there is commonly more opportunity for the introduction of liquids, of acid, acescent, and other cooling remedies, and even of laxatives; but as a vomiting frequently attends the enteritis, care must be taken not to excite that vomiting by the quantity or quality of any thing thrown into the stomach. With regard to the suppuration,

ration and gangrene of the intestines following the enteritis, the observations made respecting these terminations of gastritis are equally applicable in this disease.

Sp. II. ENTERITIS ERYSIPELATOSA, or Erysipelatous Enteritis.

Concerning this nothing farther can be said, than what hath been already delivered concerning the gastritis.

Hepatitis, Sauv. gen. 113. Lin. 35. Vog. 58. Seg. gen. 312. Boerh. 914. Hoffm. ii. 14. Junck. 66.

Description. The inflammation of the liver is thought to be of two kinds, acute and chronic; but the latter very often does not discover itself except by an abscess found in the liver after death, and which is supposed to have been occasioned by some degree of inflammation; for this reason the chronic inflammation often escapes observation, and we shall here only treat of the acute hepatitis.

The acute hepatitis is attended with considerable fever; a frequent, strong, and hard pulse; high coloured urine; an acute pain in the right hypochondrium, increased by pressing upon the part. The pain is very often in such a part of the side as to make it appear like a pleurisy; and frequently, like that, is increased on inspiration. The disease is also commonly attended with a cough, which is generally dry, though sometimes moist; and when the pain thus resembles a pleurisy, the patient cannot lie easily except upon the side affected. The pain is frequently extended to the clavicle, and to the top of the shoulder; and is attended sometimes with hiccough, and sometimes with vomiting. Some have added jaundice, or a yellowness of the eyes, to the symptoms of this distemper; but experience shows that it has often occurred without any such symptom.

When hepatitis is of the chronic kind, depending more on an accumulation and effusion in the liver, than on an increased action of its small vessels, the patient complains rather of a sense of weight than of pain; and the fever is by no means either acute or constant: but it often returns in paroxysms somewhat resembling the attacks of an intermittent. This disease is very slow in its progress, frequently continuing for many months, and at last terminating in a very considerable suppuration. In most cases, however, it may be discovered by careful examination of the region of the liver externally. By this means, a considerable enlargement of that viscus may in general be detected.

Causes, &c. The remote causes of hepatitis are not always to be discerned, and many have been assigned on a very uncertain foundation. It is principally a disease of warm climates. It has been supposed that the disease may be an affection either of the extremities of the hepatic artery, or those of the vena portarum; and the supposition is by no means improbable. The opinion, however, most commonly adopted is, that the acute hepatitis is an affection of the external membrane of the liver, and the chronic kind an af-

fection of the parenchyma of that viscus. The acute hepatitis may be seated either on the convex or concave surface of the liver; and in the former case a more pungent pain and hiccough may be produced, and the respiration is more considerably affected. In the latter there occurs less pain; and a vomiting is produced, commonly by some inflammation communicated to the stomach. The inflammation on the concave surface of the liver may be readily communicated to the gall-bladder and biliary ducts: and this, perhaps, is the only case of idiopathic hepatitis attended with jaundice.

Prognosis. The inflammation of the liver, like others, may end by resolution, suppuration, or gangrene; and the tendency to the one or to the other of those events may be known from what has been already mentioned concerning the prognosis in gastritis. The resolution of hepatitis is often the consequence of, or is attended with, evacuations of different kinds. A haemorrhage sometimes from the nose, and sometimes from the haemorrhoidal vessels, gives a solution of the disease. Sometimes the same thing is accomplished by a bilious diarrhoea; and sometimes the resolution is attended with sweating, and an evacuation of urine depositing a copious sediment. Sometimes it may be cured by an erysipelas appearing in some external part. When the disease has ended in suppuration, the pus collected may be discharged by the biliary ducts; or, if the suppuration does not adhere anywhere closely to the neighbouring parts, it may be discharged into the cavity of the abdomen: but if, during the first state of inflammation, the affected part of the liver shall have formed a close adhesion to some of the neighbouring parts, the discharge after suppuration may be various, according to the different seat of the abscess. When seated on the convex part of the liver, if the adhesion be to the peritoneum lining the common teguments, the pus may make its way through these, and be discharged outwardly: or if the adhesion shall have been to the diaphragm, the pus may penetrate through this, and into the cells of the lungs; from whence it may be discharged by coughing. When the abscess is seated on the concave part of the liver, in consequence of adhesions, the pus may be discharged into the stomach or intestines; and into these last, either directly, or by the intervention of the biliary ducts. Upon a consideration of all these different circumstances, therefore, together with the general principles of inflammation, must the prognosis of this disease be established.

Cure. For the cure of hepatitis, we must have recourse to the general means of resolving other inflammatory disorders. Bleeding is to be used according to the degree of fever and pain. Blisters are to be applied: fomentations of the external parts, emollient clysters, gentle laxatives, diluents and refrigerants, are also useful. The cure, however, particularly in warm climates, where the disease is much more common than it is in Britain, is chiefly trusted to mercury. Not only in cases of the chronic kind, but in acute hepatitis also, after an attempt has been made to alleviate the urgent symptoms by bleeding and blistering, recourse is immediately had to this powerful mineral. It is employed by different practitioners, and in

Phlegma; in different cases, under various forms. Some are very fond of the use of calomel. But the preference is in general given, and perhaps with justice, to friction with mercurial ointment over the region of the liver. But under whatever form it may be employed, it is necessary that it should be introduced to such an extent as to keep the patient on the verge of salivation for some length of time; the duration being regulated by the circumstances of the case.

From the liberal use of mercury, there can be no doubt that a successful resolution has been obtained in many cases, which would otherwise have infallibly terminated in suppuration. But notwithstanding the most careful employment of it in some cases, suppuration will ensue; and then it is very doubtful whether any benefit will be derived from the continuance of it. But when a suppuration has been formed, and the abscess points outwardly, the part must be opened, the pus evacuated, and the ulcer healed according to the ordinary methods in use for healing abscesses and ulcers in other parts.

Chronic hepatitis often terminates in scirrhus. Against this, after mercury has failed, nitric acid taken internally has sometimes been employed with success.

Splenitis, Savv. gen. 114. Lin. 36. Vog. 59.

Junck. 67. Sag. gen. 313.

Lienis inflammatio, Boerh. 958. et Van Swieten, Comm.

Splenitis phlegmonodæa, Savv. sp. 1. Forest, l. xx. obl. 5, 6. De Haen, apud Van Swieten, p. 958.

Pleuritis splenica, Savv. sp. 19.

Splenalgia suppuratoria, Savv. sp. 3.

Description. This disease, according to Juncker, comes on with a remarkable shivering, succeeded by a most intense heat and very great thirst; a pain and tumour are perceived in the left hypochondrium, and the paroxysms for the most part assume a quartan form. When the patients expose themselves for a little to the free air, their extremities immediately grow very cold. If a haemorrhage happens, the blood flows out of the left nostril. The other symptoms are the same with those of the hepatitis. Like the liver, the spleen is also subject to a chronic inflammation, which often happens after agues; and the tumour which succeeds the inflammation is in many cases very considerable, and is called the ague cake, though that name is also frequently given to a scirrhous tumour of the liver succeeding intermitents.

Causes, &c. The causes of this distemper are in general the same with those of other inflammatory disorders; but those which determine the inflammation to that particular part more than another, are very much unknown. It attacks persons of a very plethoric and sanguine habit of body rather than others.

Prognosis. What has been said of the inflammation of the liver applies also to that of the spleen, though the latter is less dangerous than the former. Here also

a vomiting of black matter, which in other acute diseases is such a fatal symptom, sometimes proves critical, according to the testimony of Juncker. Sometimes the haemorrhoids prove critical; but very often the inflammation terminates by scirrhus.

Cure. This is not at all different from what has been already laid down concerning the hepatitis.

Nephritis, Savv. gen. 115. Lin. 37. Vog. 65.

Sag. gen. 314.

Nephritis vera, Savv. sp. 1.

Description. The nephritis has the same symptoms which take place in other inflammations; but its distinguishing mark is the pain in the region of the kidney, which is sometimes obtuse, but more frequently pungent. The pain is not increased by the motion of the trunk of the body so much as a pain of the rheumatic kind affecting the same region. It may also frequently be distinguished by the pain shooting along the course of the ureter, and it is often attended with a drawing up of the testicle, and a numbness of the limb on the side affected; though indeed these symptoms most commonly attend the inflammation arising from a calculus in the kidney or ureter. The disease is also attended with frequent vomiting, and often with costiveness and colic pains. The urine is most commonly of a deep red colour, and is voided frequently and in a small quantity at a time. In more violent cases the urine is commonly colourless.

Causes, &c. The remote causes of this disease may be various; as external contusion, violent or long-continued riding; strains of the muscles of the back incumbent on the kidneys; various acrids in the course of circulation conveyed to the kidneys; and perhaps some other internal causes not yet well known: the most frequent is that of calculous matter obstructing the tubuli uriniferi, or calculi formed in the pelvis of the kidneys, and either sticking there or falling into the ureter.

Prognosis. This is not different from that of other inflammatory diseases.

Cure. When any of those causes operating as inducing the inflammation still continue to act, the first object in the cure must be the removal of these; but the principal intention to be had in view, is the resolution of the inflammation which has already taken place. But when, notwithstanding efforts for this purpose, the disease terminates in suppuration, it must be the endeavour of the practitioner to promote the discharge of purulent matter, and the healing of the ulceration in the kidney.

These different objects are principally accomplished by bleeding, external fomentation, frequent emollient clysters, antiphlogistic purgatives, and by the free use of mild and demulcent liquids. The use of blisters is scarce admissible, or at least will require great care to avoid any considerable absorption of the cantharides.

The other species of nephritis enumerated by authors are only symptomatic.

Cystitis, Sauv. gen. 108. Lin. 31. Vog. 66. Sog. gen. 309.

Inflammatio vesicæ, Hoffm. ii. 157.

Cystitis spontanea, Sauv. sp. 1.

Cystitis à cantharidibus, Sauv. sp. 2.

Cystitis traumatica, Sauv. sp. 3.

The inflammation of the bladder from internal causes is a very rare distemper; and when it does at any time occur, is to be cured in the same manner with other inflammations, avoiding only the use of blisters. When the disease arises from the internal use of these flies, camphor is recommended, besides other cooling medicines, and particularly cooling and emollient clysters.

Hysteritis, Lin. 38. Vog. 63.

Metritis, Sauv. gen. 107. Sog. gen. 315.

Inflammatio et febris uterina, Hoffm. II. 156.

Description. This disease is often confounded with that called the puerperal or child-bed fever; but is essentially distinct from it, as will be shown in its proper place. The inflammation of the uterus is often apt to terminate by gangrene: there is a pain in the head, with delirium; and the uterine region is so exceedingly tender, that it cannot bear the most gentle pressure without intolerable pain. When the fundus uteri is inflamed, there is great heat, throbbing, and pain, above the pubes; if its posterior part, the pain is more confined to the loins and rectum, with a tenesmus; if its anterior part, it shoots from thence towards the neck of the bladder, and is attended with a frequent irritation to make water, which is voided with difficulty; and if its sides or the ovaria are affected, the pains will then dart into the inside of the thighs.

Causes, &c. Inflammations of the uterus, and indeed of the rest of the abdominal viscera, are very apt to take place in child-bed women; the reason of which seems to be the sudden change produced in the habit, and an alteration in the course of the circulating blood by the contraction of the uterus after delivery. The pressure of the gravid uterus being suddenly taken off from the aorta descendens after delivery, the resistance to the impulse of the blood passing through all the vessels derived from it, and distributed to the contiguous viscera, will be considerably lessened: it will therefore rush into those vessels with a force superior to their resistance; and, by putting them violently on the stretch, may occasion pain, inflammation, and fever. This contraction of the uterus also renders its vessels impervious to the blood which had freely passed through them for the service of the child during pregnancy; and consequently a much larger quantity will be thrown upon the contiguous parts, which will still

add to their distention, and increase their tendency to Rheumatism.

Prognosis. An inflammation of the uterus may in general be expected to produce an obstruction of the lochia; but the fever produced seldom proves fatal, unless the inflammation be violent, and end in a gangrene.

Cure. This is to be attempted by the same general means already recommended, and the management of this disorder entirely coincides with that of the puerperal fever.

Rheumatismus, Sauv. gen. 185. Lin. 62. Vog. 138.

Boerh. 1400. Junck. 19.

Dolores rheumatici et arthritici, Hoffm. II. 317.

Myositis, Sog. gen. 301.

Rheumatismus acutus, Sauv. sp. 1.

Rheumatismus vulgaris, Sauv. sp. 2.

A. The LUMBAGO, or Rheumatism in the Muscles of the Loin.

Lumbago rheumatica, Sauv. gen. 212. Sog. p. 1.

Nephralgia rheumatica, Sauv. sp. 4.

B. The SCIATICA, Ischias, or Hip-Gout.

Ischias rheumaticum, Sauv. 213. sp. 10.

C. The Bastard PLEURISY, or Rheumatism in the Muscles of the Thorax.

Pleurodyne rheumatica, Sauv. gen. 148. sp. 3.

Pleuritis spuria, Boerh. 878.

The other species, which are very numerous, are all symptomatic; as,

Lumbago plethorica, Sauv. sp. 3.

Ischias sanguineum, Sauv. sp. 2.

Pleurodyne plethorica, Sauv. sp. 1.

Rheumatismus hystericus, Sauv. sp. 7.

Ischias hystericum, Sauv. sp. 3.

Pleurodyne hysterica, Sauv. sp. 6.

Rheumatismus saltatorius, Sauv. sp. 8.

Pleurodyne statulenta, Sauv. sp. 4.

Pleurodyne à spasmate, Sauv. sp. 9.

Rheumatismus scorbuticus, Sauv. sp. 4.

Lumbago scorbutica, Sauv. sp. 5.

Pleurodyne scorbutica, Sauv. sp. 11.

Ischias syphiliticum, Sauv. sp. 7.

Pleurodyne venerea, Sauv. sp. 5.

Lumbago sympathica, Sauv. p. 13.

Lumbago à faburâ, Sauv. sp. 8.

Pleurodyne à cocochyliâ, Sauv. sp. 7.

Rheumatismus saltatorius verminosus, Sauv. sp. 8.

Ischias verminosum, Sauv. sp. 8.

Pleurodyne verminosa, Sauv. sp. 2.

Rheumatismus metallicus, Sauv. sp. 10.

Lumbago à hydrothorace, Sauv. sp. 14.

Lumbago pseudoischuria, Sauv. sp. 16.

Pleurodyne à rupto œsophago, Sauv. sp. 20.

Pleurodyne rachitica, Sauv. sp. 13.

Ischias à sparganosi, Sauv. sp. 5.

Pleurodyne catarrhalis, Sauv. sp. 14.

Rheumatismus

Rheumatismus necroscos, Savv. sp. 14.
Rheumatismus dorsalis, Savv. sp. 11.
Lumbago à fatyriali, Savv. sp. 15.
Rheumatismus febriculosus, Savv. sp. 9.
Lumbago febrilis, Savv. sp. 4.
&c. &c.

Description. The rheumatism is particularly distinguished by pains affecting the joints, and for the most part the joints alone; but sometimes also the muscular parts. Very often they shoot along the course of the muscles from one joint to another, and are always much increased by the action of the muscles belonging to the joint or of joints affected. The larger joints are those most frequently affected, such as the hip joint and knees, of the lower extremities, and the shoulders and elbows of the upper ones. The ancles and wrists are also frequently affected; but the smaller joints, such as those of the toes or fingers, seldom suffer. Sometimes the disease is confined to one part of the body, yet very frequently it affects many parts; and then it begins with a cold stage, which is immediately succeeded by the other symptoms of pyrexia, and particularly by a frequent, full, and hard pulse. Sometimes the pyrexia is formed before any pains are perceived; but more commonly pains are felt in particular parts before any symptoms of fever occur. When no pyrexia is present, the pain may be confined to one joint only; but when any considerable pyrexia takes place, though the pain may chiefly be felt in one joint, yet it seldom happens that it does not affect several joints, often at the very same time, but for the most part shifting their place, and having abated in one joint they become more violent in another. They do not commonly remain long in the same joint, but frequently shift from one to another, and sometimes return to joints formerly affected; and in this manner the disease often continues for a long time. The fever attending these pains has an exacerbation every evening, and is most considerable during the night, when the pains also become more violent; and it is at the same time that the pains shift their place from one joint to another. These seem to be also increased during the night by the body being covered more closely, and kept warmer.

A joint, after having been for some time affected with pain, commonly becomes also affected with some swelling and redness, which is painful to the touch. It seldom happens that a swelling coming on does not take off the pain entirely, but it rarely secures the joint against a return of it. This disease is commonly attended with more or less sweating, which occurs early, but is seldom free or copious, and seldom proves critical, though it may give temporary relief of the pain. The urine is high-coloured, and in the beginning without sediment. This, however, does not prove entirely critical, for the disease often continues long after such a sediment has appeared in the urine. The blood is always fizy. The acute rheumatism differs from all other inflammatory diseases, in not being liable to terminate in suppuration: this almost never happens; but the disease sometimes produces effusions of a transparent gelatinous fluid into the sheaths of the tendons: but if these effusions be frequent, it is certain that the liquor must often be absorbed; for it very seldom happens, that considerable or permanent tumours have been pro-

duced, or such as required to be opened and to have the contained fluid evacuated. Such tumors, however, have sometimes occurred, and the opening made in them has produced ulcers very difficult to heal.

Sometimes rheumatism will continue for several weeks; but it seldom proves fatal, and it is rare that the pyrexia continues to be considerable for more than two or three weeks. While the pyrexia abates in its violence, if the pains of the joints continue, they are less violent; more limited in their place, being confined commonly to one or a few joints only; and are less ready to change their place.

It is often a very difficult matter to distinguish rheumatism from gout: but in rheumatism there in general occurs much less affection of the stomach; it affects chiefly the larger joints, and several of these are often affected with fever pain at the same time: it occurs at an earlier period of life than gout; it is not observed to be hereditary; and it can in general be traced to some obvious exciting cause, particularly to the action of cold.

Causes, &c. This disease is frequent in cold, and more uncommon in warm climates. It appears most frequently in autumn and spring; less frequently in winter, while the frost is constant; and very seldom during the heat of summer. It may, however, occur at any season, if vicissitudes of heat and cold be for the time frequent. For the most part, the acute rheumatism arises from the application of cold to the body when unusually warm; or when the cold is applied to one part of the body, whilst the other parts are kept warm; or lastly, when the application of the cold is long continued, as when moist or wet clothes are applied to any part of the body.—These causes may affect persons of all ages; but the rheumatism seldom appears either in very young or in elderly persons, and most commonly occurs from the age of puberty to that of 35. These causes may also affect persons of any constitution, but they most commonly affect those of a sanguine temperament.

With respect to the proximate cause of rheumatism, there have been various opinions. It has been imputed to a peculiar acrimony; of which, however, there is no evidence; and the consideration of the remote causes, the symptoms, and cure, render it very improbable. A disease of a rheumatic nature, however, may be occasioned by an acrid matter applied to the nerves, as is evident from the toothache, a rheumatic affection generally arising from a carious tooth. Pains arising from deep-seated suppurations may also resemble the rheumatism; and many cases have occurred in which such suppurations occasioned pains resembling the lumbago and ischias; but from what has been already said, it seems improbable that ever any pure rheumatic case should end in suppuration.

The proximate cause of rheumatism has by many been supposed to be a lentor in the fluids obstructing the vessels of the part; but in the observations formerly made, sufficient reasons have been already laid down for rejecting the doctrine of lentor. While we cannot therefore find either evidence or reason for supposing that the rheumatism depends on any change in the state of the fluids, we must conclude that the proximate cause of it is the same with that of other inflammations not depending upon a direct stimulus.

In the case of rheumatism, it is supposed that the most common remote cause of it, that is, cold applied, operates especially on the vessels of the joints, these being less covered by a cellular texture than those of the intermediate parts of the limbs. It is further supposed, that the application of cold produces a constriction of the extreme vessels, and at the same time an increase of tone or phlogistic diathesis in the course of them, from which arises an increased impetus of the blood, and at the same time a resistance to the free passage of it, and consequently inflammation and pain. It is also supposed, that the resistance formed excites the vis medicatrix to a further increase of the impetus of the blood; and to support this, a cold stage arises, a spasm is formed, and a pyrexia and phlogistic diathesis are produced in the whole system.

Hence the cause of rheumatism appears to be exactly analogous to that of inflammations depending on an increased afflux of blood to a part while it is exposed to the action of cold. But there seems to be further in this disease some peculiar affection of the muscular fibres. These seem to be under some degree of rigidity; and therefore less easily admit of motion, and are pained upon the exertions of it. This also seems to be the affection which gives opportunity to the propagation of pains from one joint to another, and which are most severely felt in the extremities terminating in the joints, because beyond these the oscillations are not propagated. This affection of the muscular fibres explains the manner in which strains and spasms produce rheumatic affections; and, on the whole, shows, that with an inflammatory affection of the sanguiferous system, there is also in rheumatism a peculiar affection of the muscular fibres, which has a considerable share in producing the phenomena of the disease. And it would even appear, that in what has commonly been called acute rheumatism, in contradistinction to the chronic, of which we are next to treat, there exists not only a state of active inflammation in the affected parts, but also of peculiar irritability; and that this often remains after the inflammation is very much diminished or has even entirely ceased. Hence a renewal of the inflammation and recurrence of the pain take place from very slight causes; and in the treatment of the disease both the state of inflammation and irritability must be had in view.

Cure. For counteracting the state of active inflammation, the chief aim of the practitioner must be to diminish the general impetus of the circulation, and the impetus at the part particularly affected. For counteracting the state of irritability, he must endeavour to remove the disposition to increased action in the vessels; to prevent the action of causes exciting painful sensations; and to obviate their influence on the part. The cure therefore requires, in the first place, an antiphlogistic regimen, and particularly a total abstinence from animal food, and from all fermented or spirituous liquors; substituting a mild vegetable or milk diet, and the plentiful use of soft diluting liquors. On this principle also, blood-letting is the chief remedy of acute rheumatism. The blood is to be drawn in large quantity; and the bleeding is to be repeated in proportion to the frequency, fulness, and hardness of the pulse, and the violence of the pain. For the most

part, large and repeated bleedings during the first ^Rheumatism. days of the disease seem to be necessary, and accordingly have been very much employed: but to this some bounds are to be set; for very profuse bleedings occasion a slow recovery, and are ready to produce a chronic rheumatism.

To avoid that debility of the system which general bleedings are apt to occasion, the urgent symptom of pain may be often relieved by topical bleedings; and when any swelling or redness has come upon a joint, the pain may very certainly be relieved by this evacuation: but as the pain and continuance of the disease seem to depend more upon the phlogistic diathesis of the whole system than upon the affection of particular parts, so topical bleedings will not supply the place of the general bleedings proposed above in most instances.

To take off the phlogistic diathesis prevailing in this disease, purging may be useful, if procured by medicines which do not stimulate the whole system, as neutral salts, and other medicines which have a refrigerant power. Purging, however, is not so useful as bleeding in removing the phlogistic diathesis; and when the disease has become general and violent, frequent stools are inconvenient, and even hurtful, by the motion and pain which they occasion.

Next to blood letting, nothing is of so much service, both in alleviating the pains in this disease and in removing the phlogistic diathesis, as the use of sudorifics: and of all the medicines belonging to this class, what has commonly been known by the name of Dover's powder, a combination of powder of ipecacuan and opium, is the most convenient and the most effectual. Copious sweating, excited by this medicine, and supported for 10 or 12 hours by tepid diluents, such as decoction of the woods, or the like, will in most instances produce a complete remission of the pain: and by this practice, combined with blood-letting and proper regimen, the disease may often be entirely removed.

If, however, after complete intermissions from pain for some length of time have been obtained by these means, it be found that there is a great tendency to a return of the pains without any obvious cause, recourse may be had with very great benefit to the use of the Peruvian bark. By the early use of this, where a complete intermission from pain is obtained, the necessity of repeated blood-letting and sweating is often superfluous; but where a complete remission cannot be obtained, it has been suspected by some to be hurtful: and in these cases, when blood-letting and sudorifics have been pushed as far as may be thought prudent, without being productive of the desired effect, very great benefit is often derived from the use of calomel combined with opium, as recommended in the Edinburgh Medical Commentaries, by Dr Hamilton of Lynn-Regis.

In this disease, external applications are of little service. Fomentations in the beginning of the disease rather aggravate than relieve the pains. The rubefacients and camphire are more effectual: but they commonly only move them from one part to another, and do not prove any cure of the general affection. Blistering may also be very effectual in removing the pain.

Palegma-
lix. pain from a particular part; but will be of little
use, except where the pains are much confined to one
place.

209
ARTHRODYNIA, or Chronic RHEUMATISM.
Rheumatismus chronicus Auctorum.

Description. When the pyrexia attending the acute rheumatism has ceased; when the swelling and redness of the joints are entirely gone, but pains still continue to affect certain joints, which remain stiff, feel uneasy upon motion, changes of weather, or in the night time only, the disease is then called the chronic rheumatism, as it often continues for a very long time.

The limits between the acute and chronic rheumatism are not always exactly marked. When the pains are still ready to shift their place; when they are especially severe in the night time; when, at the same time, they are attended with some degree of pyrexia, and with some swelling, and especially some redness of the joints; the disease is to be considered as partaking of the nature of the acute rheumatism. But when there is no longer any degree of pyrexia remaining; when the pained joints are without redness; when they are cold and stiff; when they cannot easily be made to sweat; or when, while a free and warm sweat is brought out on the rest of the body, it is only clammy and cold on the pained joints; and when, further, the pains of these are increased by cold, and relieved by heat, applied to them; the case is to be considered as that of a purely chronic rheumatism: or perhaps more properly the first of the conditions now described may be termed the state of irritability, and the second the state of atony.

The chronic rheumatism, or rather the atonic, may affect different joints; but is especially apt to affect those which are surrounded with many muscles, and those of which the muscles are employed in the most constant and vigorous exertions. Such is the case of the vertebrae of the loins, the affection of which is named lumbago; or of the hip-joint, when the disease is named ischias or sciatica.

Violent strains and spasms occurring on sudden and somewhat violent exertions, bring on rheumatic affections, which at first partake of the acute, but very soon change into the nature of the chronic, rheumatism.— Such are frequently the lumbago, and other affections, which seem to be more seated in the muscles than in the joints. The distinction of the rheumatic pains from those resembling them which occur in the syphilis and scurvy must be obvious, either from the seat of the pains, or from the concomitant symptoms peculiar to those diseases. The distinction of the rheumatism from the gout will be more fully understood from what is laid down under the genus Podagra.

Causes, &c. The phenomena of the purely chronic rheumatism lead us to conclude, that its proximate cause is an atony both of the blood-vessels and of the muscular fibres of the part affected, together with such a degree of rigidity and contraction in the latter as frequently attend them in a state of atony: and indeed this atony, carried to a certain extent, gives rise to a state of paralysis, with an almost total loss of motion in the affected limbs. The paralytic state of rheumatism therefore may be pointed out as a fourth

condition of the disease, often claiming the attention ^Rheumatism. of the practitioner.

Cure. From the view just now given of the proximate cause of chronic rheumatism, the chief indication of cure must be, to restore the activity and vigour of the part, which is principally to be done by increasing the tone of the moving fibres, but which may sometimes also be aided by giving condensation to the simple solid. When, however, the disease has degenerated into the state of paralysis, the objects to be aimed at are, the restoration of a due condition to the nervous energy in the part affected; the obtaining free circulation of blood through the vessels of the part; and the removal of rigidity in membranes and ligaments.

For answering these purposes, a great variety of remedies, both external and internal, are had recourse to. The chief of the external are, the supporting the heat of the part, by keeping it constantly covered with flannel; the increasing the heat of the part by external heat, applied either in a dry or humid form; the diligent use of the stelli-brush, or other means of friction; the application of electricity in sparks or shocks; the application of cold water by affusion or immersion; the application of essential oils of the most warm and penetrating kind; the application of salt brine; the employment of the warm bath or of the vapour baths, either to the body in general or to particular parts; and, lastly, the employment either of exercise of the part itself as far as it can easily bear, or by riding or other modes of gestation.

The internal remedies are, large doses of essential oils drawn from resinous substances, such as turpentine; substances containing such oils, as guaiac; volatile alkaline salts, &c. These or other medicines are directed to procure sweat; and calomel, or some other preparation of mercury, in small doses, may be continued for some time. But of all the remedies which have been found useful in atonic rheumatism, perhaps the best is cinchona. It is particularly serviceable in the earlier periods of the disease. It has often been highly efficacious in preventing the degeneracy of the inflammatory into the atonic state of the disease; and by some practitioners, particularly Dr Haygarth of Bath, it has been highly extolled in acute rheumatism. Besides these, there are several other remedies recommended. The cicuta, aconitum, and hyoscyamus, have in particular been highly extolled; and an infusion of the rhododendron chrysanthum is said to be employed by the Siberians with very great success. An account of the Siberian mode of practice is given by Dr Matthew Guthrie of Peterburgh, in the fifth volume of the Edinburgh Medical Commentaries, and has been followed with success at other places. Among other internal remedies for rheumatism, the use of arsenic has of late been recommended by Dr Bardley of Liverpool. It is advised to be given under the form of the mineral solution proposed by Dr Fowler as a remedy in intermittent fever and in periodic headaches. Under this form, it is now ascertained by extensive experience that arsenic may be taken internally with as much safety as any other active medicine; and in some cases of rheumatism in which it has been employed at Edinburgh, there is reason to believe that it has been productive of benefit.

Odontalgia, Sauv. gen. 198. Lin. 45. Vog. 145. Seg. gen. 159. Junck. 25.
Odontalgia sive rheumatismus odontalgicus, Hoffm. II. 330.
Odontalgia cariosa, Sauv. sp. 1.
Odontalgia scorbutica, Sauv. sp. 4.
Odontalgia catarrhalis, Sauv. sp. 3.
Odontalgia arthritica, Sauv. sp. 6.
Odontalgia gravidarum, Sauv. sp. 2.
Odontalgia hysterica, Sauv. sp. 8.
Odontalgia stomachica, Sauv. sp. 9.

Description. This well known disease makes its attack by a most violent pain in the teeth, most frequently in the molares, more rarely in the incisores, reaching sometimes up to the eyes, and sometimes backward into the cavity of the ear. At the same time there is a manifest determination to the head; and a remarkable tension and inflation of the vessels takes place, not only in the parts next to that where the pain is seated, but over the whole head.

Causes, &c. The toothach is sometimes merely a rheumatic affection, arising from cold, but more frequently from a carious tooth. It is also a symptom of pregnancy, and takes place in some nervous disorders; it may attack persons at any time of life, though it is most frequent in the young and plethoric.

Cure. Many empirical remedies have been proposed for the cure of the toothach, but none have in any degree answered the purpose. When the affection is purely rheumatic, blistering behind the ear will almost always remove it; but when it proceeds from a carious tooth, the pain is much more obstinate. In this case it has been recommended to touch the pained part with a hot iron, or with sulphuric acid, in order to destroy the aching nerve; to hold strong spirits in the mouth; to put a drop of oil of cloves into the hollow of the tooth, or a pill of equal parts of opium and camphor; but one of the most useful applications of this kind is strong nitrous acid, diluted with three or four times its weight of spirit of wine, and introduced into the hollow of a tooth from which great pain arises, either by means of a hair pencil or a little cotton. Cinchona has also been recommended, and perhaps with more justice, on account of its tonic and antiseptic powers; but very often all these remedies will fail, and the only infallible cure is the extraction of the tooth. See SURGERY.

Podagra, Vog. 175. Boerh. 1254.
Febris podagrica, Vog. 69.
Arthritis, Sauv. gen. 183. Lin. 60. Vog. 139. Seg. gen. 142.
Dolor podagricus et arthriticus verus, Hoffm. II. 339.
Dolores arthritici, Hoffm. II. 317.
Affectus spastico-arthritici, Junck. 46.

Arthritis podagrica, Sauv. sp. 1.

Arthritis rachialgica, Sauv. sp. 11.
Arthritis aestiva, Sauv. sp. 4.

Arthritis melancholica, Sauv. sp. 6.
Arthritis hiemalis, Sauv. sp. 2.
Arthritis chlorotica, Sauv. sp. 5.
Arthritis aëthmatica, Sauv. sp. 9.

Description. What we call a paroxysm of the gout is principally constituted by an inflammatory affection of some of the joints. This sometimes comes on suddenly, without any warning, but is generally preceded by several symptoms; such as the ceasing of a sweating which the feet had been commonly before affected with; an unusual coldness of the feet and legs; a frequent numbness, alternating with a sense of prickling along the whole of the lower extremities; frequent cramps of the muscles of the legs; and an unusual turgescence of the veins.

While these symptoms take place in the lower extremities, the body is affected with some degree of torpor and languor, and the functions of the stomach in particular are more or less disturbed. The appetite is diminished; and flatulency, or other symptoms of indigestion, are felt. These symptoms take place for several days, sometimes for a week or two, before a paroxysm comes on; but commonly, upon the day immediately preceding it, the appetite becomes keener than usual.

The circumstances of paroxysms are chiefly the following. They come on most commonly in the spring, and sooner or later according as the vernal heat succeeds sooner or later to the winter's cold, and, perhaps, sooner or later also, according as the body may happen to be more or less exposed to vicissitudes of heat and cold.

The attacks are sometimes felt first in the evening, but more commonly about two or three o'clock in the morning. The paroxysm begins with a pain affecting one foot, most frequently in the ball or first joint of the great toe, but sometimes in other parts of the foot. With the attack of this pain, there is commonly more or less of a cold shivering; which, as the pain increases, gradually ceases; and is succeeded by a hot stage of pyrexia, which continues for the same time with the pain itself. From the first attack, the pain becomes, by degrees, more violent, and continues in this state with great restlessness of the whole body till next midnight, after which it gradually remits; and, after it has continued for twenty-four hours from the commencement of the first attack, it commonly ceases almost entirely; and, with the coming on of a gentle sweat, allows the patient to fall asleep. The patient, upon coming out of this sleep in the morning, finds the pained part affected with some redness and swelling, which, after having continued for some days, gradually abate.

When a paroxysm has thus come on, although the violent pain after 24 hours be considerably abated, the patient is not entirely relieved from it. For some days

Phlegma-
tic.

days he has every evening a return of more considerable pain and pyrexia, and these continue with more or less violence till morning. After going on, in this manner, for several days, the disease sometimes goes entirely off, not to return till after a long interval.

When the disease, after having thus remained for some time in a joint, ceases entirely, it generally leaves the person in very perfect health, enjoying greater ease and alacrity in the functions of both body and mind than he had for a long time before experienced.

At the beginning of the disease, the returns of it are sometimes only once in three or four years: but as it advances, the intervals become shorter, and at length the attacks are annual; afterwards they come twice each year; and at length recur several times during the course of autumn, winter, and spring; and as, when the fits are frequent, the paroxysms become also longer, so, in the advanced state of the disease, the patient is hardly ever tolerably free from it, except perhaps for two or three months in summer.

The progress of the disease is also marked by the parts which it affects. At first, it commonly affects one foot only; afterwards every paroxysm affects both feet, the one after the other; and as the disease proceeds, it not only affects both feet at once, but, after having ceased in the foot which was last attacked, returns again into the first, and perhaps a second time also into the other. Its changes of places are not only from one foot to another, but from the feet into other joints, especially those of the upper extremities; so that there is hardly a joint of the body which, on one occasion or another, is not affected. It sometimes affects two different joints at the very same time; but more commonly it is at any one time severe in a single joint only, and passes in succession from one joint to another; so that the patient's affliction is often protracted for a long time.

When the disease has often returned, and the paroxysms have become very frequent, the pains are commonly less violent than they were at first; but the patient is more affected with sickness, and the other symptoms of the atonic gout, which shall be hereafter mentioned.

After the first paroxysm of the disease, the joints which have been affected are entirely restored to their former suppleness and strength; but after the disease has recurred very often, the joints affected do neither so suddenly nor entirely recover their former state, but continue weak and stiff; and these effects at length proceed to such a degree, that the joints lose their motion entirely.

In many persons, but not in all, after the disease has frequently recurred, concretions of a chalky nature are formed upon the outside of the joints, and for the most part immediately under the skin. The matter seems to be deposited at first in a fluid form, afterwards becoming dry and firm. In their firm state, these concretions are a hard earthy substance, very entirely soluble in acids. After they have been formed, they contribute, with other circumstances, to destroy the motion of the joint.

In most persons who have laboured under the gout for many years, a nephritic affection comes on, and discovers itself by all the symptoms which usually at-

tend calculous concretions in the kidneys, and which we shall have occasion to describe in another place. Podagra. All that is necessary to be observed here is, that the nephritic affection alternates with paroxysms of the gout; and that the two affections, the nephritic and the gouty, are hardly ever present at the same time. This also may be observed, that children of gouty or nephritic parents commonly inherit one or other of these diseases; but whether the principal disease of the parent may have been either gout or nephritis alone, some of the children have the one and some the other. In some of them, the nephritic affection occurs alone, without any gout supervening; and this happens to be frequently the case with the female children of gouty parents.

In the whole of the history already given, we have described the most common form of the disease, and which therefore, however diversified in the progress of it, may be still called the regular state of the gout.— Upon some occasions, however, the disease assumes different appearances: but as we suppose the disease to depend always upon a certain diathesis, or disposition of the system; so every appearance which we can perceive to depend upon that same disposition, we still consider as symptomatic, and view the disease to be a case of the gout. The principal circumstance, in what we term the regular gout, is the inflammatory affection of the joints; and whatever symptoms we can perceive to be connected with, or to depend upon, the disposition which produces that inflammatory affection, but without its taking place or being present at the same time, we name the irregular gout.

Of such irregular gout there are three different states, which may be named the atonic, the retrocedent, and the misplaced gout.

The first is, when the gouty diathesis prevails in the system; but, from certain causes, does not produce the inflammatory affection of the joints. In this case, the morbid symptoms which appear, are chiefly affections of the stomach, such as loss of appetite, indigestion, and its various attendants of sickness, nausea, vomiting, flatulency, acid eruptions, and pains in the region of the stomach. These symptoms are frequently accompanied with pains and cramps in several parts of the trunk and the upper extremities of the body, which are relieved by the discharge of wind from the stomach. Together with these affections of the stomach, there commonly occurs a colliquation; but sometimes a looseness, with colic pains. These affections of the alimentary canal are often attended with all the symptoms of hypochondriasis, such as dejection of mind, a constant and anxious attention to the slightest feelings, an imaginary aggravation of these, and an apprehension of danger from them.

In the same atonic gout, the viscera of the thorax also are sometimes affected, and palpitations, faintings, and asthma, occur.

In the head also occur headaches, giddiness, apoplectic and paralytic affections.

When the several symptoms now mentioned occur in habits having the marks of a gouty disposition, this may be suspected to have laid the foundation for them; and especially when either, in such habits, a manifest tendency to the inflammatory affection has formerly appeared, or when the symptoms mentioned

are intermixed with, and are relieved by some degree of the inflammatory gout. In such cases there can be no doubt of considering the whole as a state of the gout.

Another state of the disease we name the retrocedent gout. This occurs when an inflammatory state of the joints has, in the usual manner, come on, but without arising to the ordinary degree of pain and inflammation; or at least without these continuing for the usual time, or without their receding gradually in the usual manner; these affections of the joints suddenly and entirely cease, while some internal part becomes affected. The internal part most commonly attacked is the stomach; which then is affected with anxiety, sickness, vomiting, or violent pain: but sometimes the internal part is the heart, which gives occasion to a syncope; sometimes it is the lungs, which are affected with asthma; and sometimes it is the head, giving occasion to apoplexy or palsy. In all these cases there can be no doubt that the symptoms are all a part of the same disease, however different the affection may seem to be in the parts which it attacks.

The third state of irregular gout, which we name the misplaced, is when the gouty diathesis, instead of producing the inflammatory affection of the joints, produces an inflammatory affection of some internal part, and which appears from the same symptoms that attend the inflammations of those parts arising from other causes.

Whether the gouty diathesis does ever produce such inflammation of the internal parts without having first produced it in the joints, or whether the inflammation of the internal part be always a translation from the joints previously affected, we dare not determine; but, even supposing the latter to be always the case, we think the difference of the affection of the internal part must still distinguish the misplaced from what we have named the retrocedent gout.

With regard to the misplaced gout, Dr Cullen, whom we here follow, tells us, that he never met with any cases of it in his practice, nor does he find any distinctly marked by practical writers, except that of a pneumatic inflammation.

There are two cases of a translated gout; the one of which is an affection of the neck of the bladder, producing pain, strangury, and a catarrhus vesice: the other is an affection of the rectum, sometimes indicated by pain alone in that part, and sometimes by hemorrhoidal symptoms. In gouty persons such affections have been known to alternate with inflammatory affections of the joints; but whether these belong to the retrocedent or to the misplaced gout, Dr Cullen pretends not to determine.

It is commonly supposed, that there are some cases of rheumatism which are scarcely to be distinguished from the gout: but these, Dr Cullen thinks, are but few; and that the two diseases may be for the most part distinguished with great certainty, by observing the predisposition, the antecedent circumstances, the parts affected, the recurrences of the disease, and its connection with the system; which circumstances, for the most part, appear very differently in the two diseases.

Causes, &c. The gout is generally an hereditary disease: but some persons, without any hereditary dis-

position, seem to acquire it; and in some an hereditary disposition may be counteracted from various causes. It attacks the male sex especially; but it sometimes, though more rarely, attacks also the female. The females liable to it are those of the more robust and full habits; and it very often happens to those before the menstrual evacuation has ceased. Dr Cullen hath also found it occurring in several females whose menstrual evacuations were more abundant than usual.

The gout seldom attacks eunuchs; and when it does, seems to fall upon those who happen to be of a robust habit, to lead an indolent life, and to live very full. It attacks especially men of robust and large bodies, who have large heads, are of full and corpulent habits, and whose skins are covered with a thick rete mucosum, which gives a coarse surface. To speak in the style of the ancient physicians, the gout will seldom be found to attack those of a sanguine, or such as are of a purely melancholic temperament; but very readily those of a choleric-sanguine temperament. It is, however, very difficult to treat this matter with precision. The gout seldom attacks persons employed in constant bodily labour, or those who live much upon vegetable aliment. It does not commonly attack men till after the age of 35; and generally not till a still later period. There are indeed instances of the gout appearing more early; but these are few in comparison of the others. When the disease does appear early in life, it seems to be in those who have the hereditary disposition very strong, and to whom the remote causes hereafter mentioned have been applied in a very considerable degree.

As the gout is an hereditary disease, and affects men particularly of a certain habit, its remote causes may be considered as predisposing and occasional. The predisposing cause, as far as expressed by external appearances, has been already marked; and physicians have been very confident in assigning the occasional causes: but in a disease depending so much upon a predisposition, the assigning occasional causes must be uncertain; as in the predisposed the occasional causes may not always appear, and in persons not predisposed they may appear without effect; and this uncertainty must particularly affect the case of the gout.

The occasional causes of the disease seem to be of two kinds. First, Those which induce a plethoric state of the body. Secondly, Those which in plethoric habits, induce a state of debility. Of the first kind are a sedentary, indolent manner of life, and a full diet of animal food. Of the second kind of occasional causes which induce debility are excess in venery; intemperance in the use of intoxicating liquors; indigestion, produced either by the quantity or quality of the aliments; much application to study or business, night-watching, excessive evacuations; the ceasing of usual labour; a sudden change from a very full to a very spare diet; the large use of acids and acescents; and, lastly, cold applied to the lower extremities. The former seem to act by increasing the predisposition; the latter are commonly the exciting causes, both of the first attacks, and of the repetitions of the disease.

With respect to the proximate cause of the gout, it has generally been thought that it depends on a certain

Phlegma-
sac. tain morbid matter always present in the body; and that this matter, by certain causes, thrown upon the joints or other parts, produces the several phenomena of the disease.

This doctrine, however ancient and generally received, appears to Dr Cullen to be very doubtful. For,

First, There is no direct evidence of any morbid matter being present in persons disposed to the gout. There are no experiments or observations which show that the blood or other humours of gouty persons are in any respect different from those of the sound. Previous to attacks of the gout, there appear no marks of any morbid state of the fluids; for the disease generally attacks those persons who have enjoyed the most perfect health, and appear to be in that state when the disease comes on. At a certain period of the disease, a peculiar matter indeed appears in gouty persons; but this, which does not appear in every instance, and which appears only after the disease has subsided for a long time, seems manifestly to be the effect, not the cause, of the disease. Further, Though there be certain acids which, taken into the body, seem to excite the gout, it is probable that these acids operate otherwise in exciting the disease, than by affording the material cause of it. In general, therefore, Dr Cullen thinks there is no proof of any morbid matter being the cause of the gout.

Secondly, The suppositions concerning the particular nature of the matter producing the gout, have been so various, and so contradictory, as to allow us to conclude, that there is truly no proof of the existence of any of them. With respect to many of these suppositions, they are so inconsistent with chemical philosophy, and with the laws of the animal economy, that they must be entirely rejected.

Thirdly, The supposition of a morbid matter as the cause, is not consistent with the phenomena of the disease, particularly with its frequent and sudden translations from one part to another.

Fourthly, The supposition is further rendered improbable by this, that, if a morbid matter did exist, its operation should be similar in the several parts which it attacks; whereas it seems to be very different, being stimulant, and exciting inflammation, in the joints; but sedative and destroying tone in the stomach; which, upon the supposition of the same particular matter acting in both cases, is not to be explained by any difference in the part affected.

Fifthly, Some facts alleged in proof of a morbid matter, are not confirmed; such as those which would prove the disease to be contagious. There is, however, no proper evidence of this, the facts given being not only few, but exceptionable, and the negative observations innumerable.

Sixthly, Some arguments brought in favour of a morbid matter are founded upon a mistaken explanation. The disease has been supposed to depend upon a morbid matter, because it is hereditary. But the inference is not just: for most hereditary diseases do not depend upon any morbid matter, but upon a particular conformation of the structure of the body transmitted from the parent to the offspring; and this last appears to be particularly the case in the gout. It may be also observed, that hereditary diseases depending upon a

morbid matter, appear always much more early in life than the gout commonly does.

Seventhly, The supposition of a morbid matter being the cause of the gout, has been hitherto useless, as it has not suggested any successful method of cure. Particular theories of gout have often corrupted the practice, and have frequently led from those views which might have been useful, and from that practice which experience has approved. Further, Though the supposition of a morbid matter has been generally received, it has been as generally neglected in practice. When the gout has affected the stomach, nobody thinks of correcting the matter supposed to be present there, but merely of restoring the tone of the moving fibres.

Eighthly, The supposition of a morbid matter is quite superfluous: for it explains nothing, without supposing that matter to produce a change in the state of the moving powers; and a change in the state of the moving powers, produced by other causes, explains every circumstance without the supposition of a morbid matter; and it may be observed, that many of the causes exciting the gout, do not operate upon the state of the fluids, but directly and solely upon that of the moving powers.

Lastly, Dr Cullen contends that the supposition of a morbid matter is superfluous; because, without that, the disease can be explained, he thinks, in a manner more consistent with its phenomena, with the laws of the animal economy, and with the method of cure which experience has approved. We now proceed to give this explanation; but, before entering upon it, we must premise some general observations which Dr Cullen states.

The first observation is, That the gout is a disease of the whole system, or depends upon a certain general conformation and state of the body, which manifestly appears from the facts above mentioned. But the general state of the system depends chiefly upon the state of its primary moving powers; and therefore the gout may be supposed to be an affection of these.

The second observation is, That the gout is manifestly an affection of the nervous system; in which the primary moving powers of the whole system are lodged. The occasional or exciting causes are almost all such as act directly upon the nerves and nervous system; and the greater part of the symptoms of the atonic or retrocedent gout are manifestly affections of the same system. This leads us to seek for an explanation of the whole of the disease, in the laws of the nervous system, and particularly in the changes which may happen in the balance of its several parts.

The third observation is, That the stomach, which has so universal a consent with the rest of the system, is the internal part that is the most frequently, and often very considerably, affected by the gout. The paroxysms of the disease are commonly preceded by an affection of the stomach; many of the exciting causes act first upon the stomach; and the symptoms of the atonic and retrocedent gout are most commonly and chiefly affections of the same organ. This observation leads us to remark, that there is a balance subsisting between the state of the internal and that of the external parts; and, in particular, that the state of the stomach is connected with that of the external parts, so that the state

state of tone in the one may be communicated to the other.

These observations being premised, Dr Cullen offers the following pathology of the gout.

In some persons there is a certain vigorous and plethoric state of the system, which at a certain period of life is liable to a loss of tone in the extremities. This is in some measure communicated to the whole system, but appears more especially in the functions of the stomach. When this loss of tone occurs while the energy of the brain still retains its vigour, the vis medicatrix naturæ is excited to restore the tone of the parts; and accomplishes it, by exciting an inflammatory affection in some part of the extremities. When this has subsided for some days, the tone of the extremities and of the whole system is restored, and the patient returns to his ordinary state of health.

This is the course of things in the ordinary form of the disease, which we name the regular gout; but there are circumstances of the body, in which this course is interrupted or varied. Thus, when the atony has taken place, if the reaction do not succeed, the atony continues in the stomach, or perhaps in other internal parts; and produces that state which Dr Cullen, for reasons now obvious, named the atonic gout.

A second case of variation in the course of the gout is, when to the atony the reaction and inflammation have to a certain degree succeeded, but from causes either internal or external the tone of the extremities and perhaps of the whole system is weakened; so that the inflammatory state, before it had either proceeded to the degree, or continued for the time, requisite for restoring the tone of the system, suddenly and entirely ceases: whence the stomach, and other internal parts, relapse into the state of atony; and perhaps have that increased by the atony communicated from the extremities: all which appears in what has been termed the retrocedent state of the gout.

A third case of variation from the ordinary course of the gout, is, when to the atony, usually preceding, an inflammatory reaction fully succeeds, but has its usual determination to the joints prevented by some circumstances; and is therefore directed to some internal part, where it produces an inflammatory affection, and that state of things which we have named the misplaced gout.

Though this theory of Dr Cullen's be supported with much ingenuity, yet we may confidently venture to assert, that on this subject he has been less successful in establishing his own opinions, than in combating those of others; and this theory, as well as others formerly proposed, is liable to numerous and insurmountable objections. According to the hypothesis, a vigorous and plethoric habit should in every case exist prior to the appearance of gout; which is by no means consistent with fact: nor is it true that a vigorous and plethoric habit is liable at a certain age to a loss of tone in the extremities; which is another necessary condition in the hypothesis. Loss of tone often occurs in the extremities without exerting any peculiar influence on the stomach; and why a loss of tone in the stomach should excite the vis medicatrix naturæ to restore it, by exciting an inflammatory affection in some part of the extremities, is very inconceivable. Were the hypothesis true, every dyspeptic

patient should infallibly be affected with gout; which however, is by no means the case. In short, every step in the theory is liable to insurmountable objections; and it by no means, any more than former hypotheses, explains the phenomena of the disease, particularly what Dr Cullen has himself so accurately pointed out, the connection of gouty with calculous complaints.

A very ingenious work has lately been published by an anonymous author, entitled "a Treatise on Gravel and upon Gout;" in which the sources of each are investigated, and effectual means of preventing or removing these diseases recommended. In this treatise an attempt is made to prove, that both diseases depend upon a peculiar concretizing acid, the acid of calculi, or the lithic or uric acid, as it has been styled by some. He supposes this acid, constantly present to a certain degree in the circulating fluids, to be precipitated by the introduction of other acids; and in this manner he explains the influence of acid wines and other liquors, as claret, cyder, &c. inducing gout; for he considers the circumstance chiefly constituting the disease as being an inflammation in parts of which the functions have been interrupted by the redundant acid precipitated. Although this theory be supported with much ingenuity, yet it is also liable to many objections. The sudden attack of the affection; its sudden transition from one part of the body to another; the instant relief of one part when another comes to be affected; and the various anomalous forms which the disease puts on, having an exact resemblance to different affections; are altogether irreconcilable to the idea of its depending on any fixed obstruction at a particular part arising from concretizing acid. Nor does the plan of prevention and cure which he proposes, and which consists chiefly in abstinence from acid, and in the destruction of acid, by any means correspond in every particular to the best established facts respecting the treatment of gout; to which we next proceed.

Cure. In entering upon this, we must observe, in the first place, that a cure has been commonly thought impossible; and we acknowledge it to be very probable, that the gout, as a disease of the whole habit, and very often depending upon original conformation, cannot be cured by medicines, the effects of which are always very transitory, and seldom extend to the producing any considerable change of the whole habit.

It would perhaps have been happy for gouty persons if this opinion had been implicitly received by them; as it would have prevented their having been so often the dupes of self-interested pretenders, who have either amused them with inert medicines, or have rashly employed those of the most pernicious tendency. Dr Cullen, who has treated of the cure of the disease with great judgement, as he has done the theory with much ingenuity, is much disposed to believe the impossibility of a cure of the gout by medicines; and more certainly still inclined to think, that, whatever may be the possible power of medicines, yet no medicine for curing the gout has hitherto been found. Although almost every age has presented a new remedy, all hitherto offered have, very soon after, been neither neglected as useless, or condemned as pernicious.

But, though unwilling to admit the power of medicines, yet he contends, that a great deal can be done towards

phlegma-
tis. towards the cure of the gout by a regimen: and he is firmly persuaded, that any man who, early in life, will enter upon the constant practice of bodily labour, and of abstinence from animal food, will be preserved entirely from the disease.

Whether there be any other means of radically curing the gout, the Doctor is not able to say. There are histories of cases of the gout, in which it is said, that by great emotions of mind, by wounds, and by other accidents, the symptoms have been suddenly relieved, and never again returned; but how far these accidental cures might be imitated by art, or would succeed in other cases, is at least extremely uncertain.

The practices proper and necessary in the treatment of the gout, are to be considered under two heads: First, As they are to be employed in the intervals of paroxysms; or, secondly, As during the time of these. In the intervals of paroxysms, the indications are, to prevent altogether the return of paroxysms; or at least to render them less frequent and more moderate. During the time of paroxysms, the indications are, to moderate the violence and shorten the duration of them as much as can be done with safety.

It has been already observed, that the gout may be entirely prevented by constant bodily exercise, and by a low diet; and Dr Cullen is of opinion, that this prevention may take place even in persons who have a hereditary disposition to the disease. Even when the disposition has discovered itself by several paroxysms of inflammatory gout, he is persuaded that labour and abstinence will absolutely prevent any returns of it for the rest of life. These, therefore, are the means of answering the first indication to be pursued in the intervals of paroxysms.

Exercise in persons exposed to the gout, in Dr Cullen's opinion, operates by answering two purposes: One of these is the strengthening of the tone of the extreme vessels; and the other, the guarding against a plethoric state. For the former, if exercise be employed early in life, and before intemperance has weakened the body, a very moderate degree of it will answer the purpose; and, for the latter, if abstinence be at the same time observed, less exercise will be necessary.

With respect to exercise, this in general is to be observed, that it should never be violent; for if violent, it cannot be long continued, and must always endanger the bringing on an atony in proportion to the violence of the preceding motions.

It is also to be observed, that the exercise of gestation, though considerable and constant, will not, if it be entirely without bodily exercise, answer the purpose of preventing the gout. For this end, therefore, the exercise must be in some measure that of the body; and must be moderate, but at the same time constant and continued through life.

In every case and circumstance of the gout in which the patient retains the use of his limbs, bodily exercise, in the intervals of paroxysms, will be always useful; and in the beginning of the disease, when the disposition to it is not yet strong, exercise may prevent a paroxysm which otherwise would have come on. In more advanced states of the disease, however, when there is some disposition to a paroxysm, much walking

will bring it on; either as it weakens the tone of the lower extremities, or as it excites an inflammatory disposition in them; and thus it seems to be that sprains or contusions often bring on a paroxysm of the gout.

Abstinence, the other part of the regimen for preventing the gout, is of more difficult application. If an abstinence from animal food be entered upon early in life, while the vigour of the system is yet entire, Dr Cullen has no doubt of its being both safe and effectual; but if the motive for this diet shall not have occurred till the constitution has been broken by intemperance, or by the decline of life, a low diet may then endanger the induction of an atonic state.

Further, If a low diet be entered upon only in the decline of life, and be at the same time a very great change from the former manner of living, the withdrawing of an accustomed stimulus of the system may readily throw it into an atonic state.

The safety of an abstemious course will be greater or less according to the management of it. Animal food especially disposes to the plethoric and inflammatory state, and that food is to be therefore especially avoided; but, on the other hand, vegetable aliment of the lowest quality is in danger of weakening the system too much by not affording sufficient nourishment, and more particularly of weakening the tone of the stomach by its accecyency. It is therefore a diet of a middle nature that is to be chosen; and milk is precisely of this kind, as containing both animal and vegetable matter.

As approaching to the nature of milk, and as being a vegetable matter containing the greatest portion of nourishment, the farinaceous feeds are next to be chosen, and are the food most proper to be joined with milk.

With respect to drink, fermented liquors are useful only when they are joined with animal food, and that by their accecyency; and their stimulus is only necessary from custom. When, therefore, animal food is to be avoided, fermented liquors are unnecessary; and by increasing the accecyency of vegetables, these liquors may be hurtful. The stimulus of fermented or spirituous liquors is not necessary to the young and vigorous, and when much employed impairs the tone of the system. These liquors, therefore, are to be avoided, excepting as custom and the declining state of the system may have rendered them necessary. For preventing or moderating the regular gout, water is the only proper drink.

With respect to an abstemious course, it has been supposed, that an abstinence from animal food and fermented liquors, or the living upon milk and farinacea alone for the space of one year, might be sufficient for a radical cure of the gout: and it is possible that, at a certain period of life, in certain circumstances of the constitution, such a measure might answer the purpose. But this is very doubtful: and it is more probable, that the abstinence must, in a great measure, be continued, and the milk diet be persisted in, for the remainder of life. It is well known, that several persons who had entered on an abstemious course, and had been thereby delivered from the gout, have, however, upon returning to their former manner of full living, had the disease return upon them with as much

Phlegma- violence as before, or in a more irregular and more dan-
fous. gerous form.

It has been alleged, that, for preventing the return of the gout, blood-letting or scarifications of the feet, frequently repeated, and at stated times, may be practiced with advantage; but of this Dr Cullen tells us he has had no experience; and the benefit of the practice is not, as far as we know, confirmed by the observation of any other practitioner.

Exercise and abstinence are the means of avoiding the plethoric state which gives the disposition to the gout; and are therefore the means proposed for preventing the paroxysms, or at least for rendering them less frequent and more moderate. But many circumstances prevent the steadiness necessary in pursuing these measures: and therefore in such cases, unless great care be taken to avoid the exciting causes, the disease may frequently return, and, in many cases, the preventing of paroxysms is chiefly to be obtained by avoiding those exciting causes already enumerated.

A due attention in avoiding these different causes will certainly prevent fits of the gout; and the taking care that the exciting causes be never applied in a great degree, will certainly render fits more moderate when they do come on. But, upon the whole, it will appear, that a very strict attention to the general conduct of life, is in this matter necessary; and therefore, when the predisposition has taken place, it will be extremely difficult to avoid the disease.

Dr Cullen is firmly persuaded, that, by obviating the predisposition, and by avoiding the exciting causes, the gout may be entirely prevented: but, as the measures necessary for this purpose will, in most cases, be pursued with difficulty, and even with reluctance, men have been very desirous to find a medicine which might answer the purpose without any restraint on their manner of living. To gratify this desire, physicians have proposed, and, to take advantage of it, empirics have feigned, many remedies. Of what nature several of these remedies have been, it is difficult to say: but of those which are unknown, we conclude, from their having been only of temporary fame, and from their having soon fallen into neglect, that they have been either inert or pernicious. We shall therefore make no inquiry after them; and shall now remark only upon one or two known remedies for the gout which have been lately fashionable.

One of these is what has been named in England the Portland powder. This is not a new medicine, but is mentioned by Galen, and, with some little variation in its composition, has been mentioned by the writers of almost every age since that time. It appears to have been at times in fashion, and to have again fallen into neglect; and Dr Cullen thinks that this last has been owing to its having been found to be, in many instances, pernicious. In every instance which he has known of its exhibition for the length of time prescribed, the persons who had taken it were indeed afterwards free from any inflammatory affection of the joints; but they were affected with many symptoms of the atonic gout; and many, soon after finishing their course of the medicine, have been attacked with apoplexy, asthma, or dropsy, which proved fatal.

Another remedy which has had the appearance of

preventing the gout, is alkali in various forms; such as the fixed alkali, both mild and caustic, lime water, soap, and absorbent earths; and of late the alkaline aerated water has been more fashionable than any other. Since it became common to exhibit these medicines in nephritic and calculous cases, it has often happened that they were given to those who were at the same time subject to the gout; and it has been observed, that under the use of these medicines, gouty persons have been longer free from the fits of their disease. That, however, the use of these medicines has entirely prevented the returns of gout, Dr Cullen does not know; because he never pushed the use of them for a long time, being apprehensive that the long-continued use of them might produce a hurtful change in the state of the fluids.

As the prevention of gout depends very much on supporting the tone of the stomach, and avoiding indigestion; so colliquation, by occasioning this, is very hurtful to gouty persons. It is therefore necessary for such persons to prevent or remove colliquation, by a laxative medicine, when needful; but it is at the same time proper, that the medicine employed should be such as may keep the belly regular, without much purging. Aloetics, rhubarb, magnesia alba, oleum ricini, or flowers of sulphur, may be employed, as the one or the other may happen to be best suited to particular persons.

These are the several measures to be pursued in the intervals of the paroxysms; and we are next to mention the measures proper during the time of them.

As during the time of paroxysms the body is in a feverish state, no irritation should then be added to it; every part, therefore, of the antiphlogistic regimen, except the application of cold, ought to be strictly observed.

An exception to the general rule, however, may occur when the tone of the stomach is weak, and when the patient has been before much accustomed to the use of strong drink; for then it may be allowable, and even necessary, to give some animal food and a little wine.

That no irritation is to be added to the system during the paroxysms of gout, except in the cases mentioned, is agreed upon among physicians: but it is a more difficult matter to determine, whether, during the time of paroxysms any measures may be pursued to moderate the violence of reaction and of inflammation. Dr Sydenham has given it as his opinion, that the more violent the inflammation and pain, the paroxysm will be the shorter, as well as the interval between the present and the next paroxysm longer; and, if this opinion be admitted as just, it will forbid the use of any remedies which might moderate the inflammation; which is, to a certain degree, undoubtedly necessary for the health of the body. On the other hand, acute pain presses for relief; and although a certain degree of inflammation may seem absolutely necessary, there is reason to believe, a moderate degree of it may answer the purpose; and it is even probable, that in many cases the violence of inflammation may weaken the tone of the parts, and thereby invite a return of paroxysms. It seems to be in this way, that, as the disease advances, the paroxysms become more frequent.

From these last considerations, it seems probable, that, during the time of paroxysms some measures may be taken to moderate the violence of the inflammation and pain, and particularly, that in first paroxysms, and in the young and vigorous, blood-letting at the arm may be practised with advantage: but this practice cannot be repeated often with safety; because blood-letting not only weakens the tone of the system, but also contributes to produce plethora. However, bleeding by leeches on the foot, and upon the inflamed part, may be practised and repeated with greater safety; and instances have been known of its having been employed with safety to moderate and shorten paroxysms; but how far it may be carried, we have not had experience enough to determine.

Besides blood-letting and the antiphlogistic regimen, it has been proposed to employ remedies for moderating the inflammatory spasm of the part affected, such as warm bathing and emollient poultices. These have sometimes been employed with advantage and safety; but, at other times, have been found to give occasion to a retrocession of the gout.

Blistering is a very effectual means of relieving and dissolving a paroxysm of the gout; but has also frequently had the effect of rendering it retrocedent. The stinging with nettles is analogous to blistering; and probably would be attended with the same danger. The burning with moxa, or other substances, is a remedy of the same kind; but though not found hurtful, there is no sufficient evidence of its proving a radical cure.

Camphor, and some aromatic oils, have the power of allaying the pain, and of removing the inflammation from the part affected: but these remedies commonly make the inflammation only shift from one part to another, and therefore with the hazard of its falling upon a part where it may be more dangerous; and they have sometimes rendered the gout retrocedent.

Among other remedies which have of late been highly extolled during a paroxysm of gout, some have recommended the use of strong purgatives frequently repeated; others have highly extolled the assiduous application of cold water to the affected foot. But we may safely venture to assert that both practices are very doubtful, if not very dangerous.

From these reflections it will appear, that some danger must attend every external application to the parts affected during a paroxysm; and that therefore the common practice of committing the person to patience and flannel alone, is established upon the best foundation. Opiates give the most certain relief from pain; but, when given in the beginning of gouty paroxysms, it has by some been thought that they occasion these to return with greater violence. When, however, the paroxysms shall have abated in their violence, but still continue to return, so as to occasion painful and restless nights, opiates may be given with safety and advantage; especially in the case of persons advanced in life, and who have been often affected with the disease. When, after paroxysms have ceased, some swelling and stiffness still remain in the joints, these symptoms are to be dissipated by the diligent use of the flesh-brush. Purging immediately after a paroxysm will be always employed with the hazard of bringing it on again; but keeping the belly gently open even

during the continuance of the paroxysm is highly proper.

Thus far of the REGULAR gout. We now proceed to consider the management of the disease when it has become IRREGULAR.

In the atonic gout, the cure is to be accomplished by carefully avoiding all debilitating causes; and by employing, at the same time, the means of strengthening the system in general, and the stomach in particular.

For strengthening the system in general, Dr Cullen recommends frequent exercise on horseback, and moderate walking. Cold bathing also may answer the purpose; and may be safely employed, if it appear to be powerful in stimulating the system, and be not applied when the extremities are threatened with any pain.

For supporting the tone of the system in general, when threatened with atonic gout, some animal food ought to be employed, and the more acescent vegetables ought to be avoided. In the same case, some wine also may be necessary; but it should be in moderate quantity, and of the least acescent kinds, and if every kind of wine shall be found to increase the acidity of the stomach, ardent spirits and water must be employed.

For strengthening the stomach, bitters and the Peruvian bark may be used; but care must be taken that they be not constantly employed for any great length of time.

The most effectual medicine for strengthening the stomach is iron, which may be employed under various preparations; but the best appears to be the rust in fine powder, which may be given in large doses.

For supporting the tone of the stomach, aromatics may be exhibited; but should be used with caution, as the frequent and copious use of them have an opposite effect; and they should therefore be given only in compliance with former habits, or for palliating present symptoms.

When the stomach happens to be liable to indigestion, gentle vomits may be frequently given, and proper laxatives should be always employed to obviate or to remove costiveness.

In the atonic gout, or in persons liable to it, to guard against cold is especially necessary; and the most certain means of doing this, is by repairing to a warm climate during the winter season. In the more violent cases, blistering the lower extremities may be useful; but that remedy should be avoided when any pain threatens the extremities. In persons liable to the atonic gout, issues may be established in the extremities as in some measure a supplement to the disease.

A second case of the irregular gout, is the retrocedent.

When this affects the stomach and intestines, relief is to be instantly attempted by the free use of strong wines, joined with aromatics, and given warm; or, if these shall not prove powerful enough, ardent spirits must be employed, and are to be given in a large dose. In moderate attacks, ardent spirits, impregnated with garlic or with asafoetida, may be used; or, even without the ardent spirits, a solution of asafoetida with the volatile alkali, may answer the purpose. Opiates are often an effectual remedy; and may be joined

joined with aromatics, as in the electuarium opiatum; or they may be usefully joined with volatile alkali and camphor. Musk has likewise proved useful in this disease.

When the affection of the stomach is accompanied with vomiting, this may be encouraged, by taking draughts of warm water, at first with wine, and afterwards without it; having at length recourse, if necessary, to some of the remedies above mentioned, and particularly the opiates.

In like manner, if the intestines be affected with diarrhoea, this is to be at first encouraged by taking plentifully of weak broth; and when this shall have been done sufficiently, the tumult is to be quieted by opiates.

When the retrocedent gout shall affect the lungs, and produce asthma, this is to be cured by opiates, by antispasmodics, and perhaps by blistering on the back or breast.

When the gout, leaving the extremities, shall affect the head, and produce pain, vertigo, apoplexy, or palsy, our resources are very precarious. The most probable means of relief is, blistering the head; and, if the gout shall have receded very entirely from the extremities, blisters may be applied to these also. Together with these blisterings, aromatics, and the volatile alkali, may be thrown into the stomach.

The third case of the irregular place is the misplaced; that is, when the inflammatory affection of the gout, instead of falling upon the extremities, falls upon some internal part. In this case, the disease is to be treated by blood-letting, and by such other remedies as would be proper in an idiopathic inflammation of the same parts.

Whether the translation so frequently made from the extremities to the kidneys, is to be considered as an instance of the misplaced gout, seems uncertain: but Dr Cullen is disposed to think it something different; and therefore is of opinion, that, in the nephralgia calculosa produced upon this occasion, the remedies of inflammation are to be employed no farther than they may be sometimes necessary in that disease, arising from other causes than the gout.

Besides what have been mentioned, a variety of other practices may be necessary and proper against the various anomalous symptoms, which are at times produced by irregular gout. But of these we cannot propose to treat. And we may conclude with observing, that in every form of gout, the cure principally depends on avoiding occasional causes, particularly luxury and laziness.

GENUS XXV. ARTHROPUOSIS.

Lumbago psoadica, Sauv. sp. 6. Fordyce, Practice of Physic, part ii. p. 72.

Lumbago apoplematosa, Sauv. sp. 12.

Lumbago ab arthrocace, Sauv. p. 17.

Ischias ex abcessu, Sauv. sp. 6.

Morbus coxarius, De Hara, Rat. Med. Vol. I. c. xxxii.

This is a disease very much resembling the rheumatism; but differing both from it and the gout, in that it occasions suppurations, which they seldom or never do. It frequently, according to Sauvages, attacks the

pleous muscle; and occasions excruciating pains, and then collections of purulent matter.

The only cure, if suppuration cannot be prevented, is to lay open the part where the matter is contained, which would otherwise be absorbed, and occasion a fatal hectic.

ORDER III. EXANTHEMATA.

Exanthemata, Sag. Clafs X.

Phlegmatis exanthematicæ, Sauv. Clafs III. Ord. I.

Morbi exanthematici, Lin. Clafs I. Ord. II.

Febres exanthematicæ, Vog. Clafs I. Ord. II.

GENUS XXVI. ERYSIPELAS.

St ANTHONY'S FIRE.

Erysipelas, Sauv. gen. 97. Lin. 10. Sag. gen. 296. Febris erysipelacea, Vog. 68. Huffm. II. 93.

Sp. I. ERYSIPELAS with Blisters.

Erysipelas roseum, Sauv. sp. 1. Scennert. de febr. lib. ii. c. 15.

Febris erysipelatosa, Sydenham, sect. vi. cap. 5.

Erysipelas typhodes, Sauv. sp. 2.

Erysipelas pestilens, Sauv. sp. 5.

Erysipelas contagiosum, Sauv. sp. 9.

Description. The erysipelas of the face, where this affection very frequently appears, comes on with a cold shivering, and other symptoms of pyrexia. The hot stage of this is frequently attended with a confusion of the head, and some degree of delirium; and almost always with drowsiness, and perhaps coma. The pulse is always frequent, and commonly full and hard.—When these symptoms have continued for one, two, or at most three days, an erythema appears on some part of the face. This at first is of no great extent; but gradually spreads from the part it first occupied to the other parts of the face, till it has affected the whole; and frequently from the face it spreads over the hairy scalp, or descends on some part of the cheek. As the redness spreads, it commonly leaves, or at least is abated in the parts it had before occupied. All the parts which the redness affects are also affected with some swelling, which continues for some time after the redness has abated. The whole face becomes considerably turgid; and the eyelids are often so much swelled as entirely to shut up the eyes. When the redness and swelling have continued for some time, there commonly arise, sooner or later, blisters of a larger or smaller size on several parts of the face. These contain a thin colourless liquor, which sooner or later runs out. The surface of the skin, in the blistered places, sometimes becomes livid and blackish; but this seldom goes deeper, or discovers any degree of gangrene affecting the cutis vera. On the parts of the face not affected with blisters, the cuticle suffers, towards the end of the disease, a considerable desquamation. Sometimes the tumor of the eyelids ends in a suppuration.

The inflammation coming upon the face does not produce any remission of the fever which had before prevailed; and sometimes the fever increases with the spreading and increasing inflammation. The inflammation.

tion commonly continues for eight or ten days; and for the same time, the fever and symptoms attending it also continue. In the progress of the disease, the delirium and coma attending it sometimes go on increasing, and the patient dies apoplectic on the seventh, ninth, or eleventh day of the disease. In such cases it has been commonly supposed, that the disease is translated from the external to the internal parts. But Dr Cullen thinks that the affection of the brain is merely a communication from the external affection, as this continues increasing at the same time with the internal. When a fatal event does not take place, the inflammation, after having affected the whole face, and perhaps the other external parts of the head, ceases, and with that the fever also; and, without any other crisis, the patient returns to his ordinary health. This disease is not commonly contagious; but as it may arise from an acrid matter externally applied, so it is possible that the disease may sometimes be communicated from one person to another; and certainly there are several well authenticated instances of its prevailing in such a manner, even in particular wards of hospitals, as to leave no doubt respecting its contagious nature. Persons who have once laboured under this disease are liable to returns of it.

Prognosis. The event of this disease may be foreseen from the state of the symptoms which denote more or less the affection of the brain. If neither delirium nor coma come on, the disease is seldom attended with any danger; but when these symptoms appear early in the disease, and are in a considerable degree, the utmost danger is to be apprehended.

Cure. The erysipelas of the face is to be cured, according to the opinion of most practitioners, much in the same manner as phlegmonic inflammations; by blood-letting, cooling purgatives, and by employing every part of the antiphlogistic regimen. Many observations, however, would lead us to conclude, that in not a few cases the concomitant fever has here a tendency to the typhoid type; and therefore evacuations, apparently serviceable in the first instance, have afterwards a bad effect. The evacuations of blood-letting and purging are to be employed more or less according to the urgency of symptoms; particularly those which mark an affection of the brain. As the pyrexia continues, and often increases with the inflammation of the face, so the evacuations above mentioned are to be employed at any time of the disease. When, however, the fever, in place of marks of the phlogistic diathesis, particularly a full, hard, and strong pulse, is attended with symptoms of great debility, and with a small pulse easily compressible; evacuations, particularly under the form of blood-letting, must be used with very great caution. Even in such cases, however, the use of refrigerant cathartics may still be persisted in with more safety and greater advantage. But whether evacuations have been employed or not, when symptoms of debility run to a great height, and marks of a putrescent tendency appear, recourse must be had to wine and the cinchona. In cases which at the commencement require evacuation, these are often in the after periods employed with very great benefit.

In this, as in other diseases of the head, when that part happens to be the seat of erysipelas, it is proper to put the patient, as often as he can easily bear it, into somewhat of an erect posture; and as there is always an external affection, so various external applications have been proposed to be made to the part affected; but almost all of them are of doubtful effect.

An erysipelas frequently appears on other parts of the body besides the face, and such other erysipelatus inflammations frequently end in suppuration; but these cases are seldom dangerous. At coming on they are sometimes attended with drowsiness, and even with some delirium; but this seldom happens, and these symptoms do not continue after the inflammation is formed; and Dr Cullen does not remember to have seen an instance of the translation of an inflammation from the limbs to an internal part; and though these inflammations of the limbs be attended with pyrexia, they seldom require the same evacuations as the erysipelas of the face.

Sp. II. ERYSIPELAS with Phlyctena.

Erysipelas zoster, Sauv. sp. 8.

Zona; Anglis, The SHINGLES, Ruffel de tab. gland. p. 124. Hist. 35.

Herpes zoster, Sauv. sp. 9.

This differs from the former in no other way than in being attended with an eruption of phlyctenae or small watery bladders on several parts of the body.—The method of cure is the same.

GENUS XXVII. PESTIS, the PLAGUE.

Pestis, Sauv. gen. 91. Lin. 2. Junck. 78.

Febris pestitentialis, Vog. 33. Hoffm. II. 93.

Pestis benigna, Sauv. sp. 2. Pestis Massiliensis, Clus. III. Traité de la peste, p. 41. Ejusdem pestis, Cl. 3ta, Traité, p. 228.

Pestis remittens, Sauv. sp. 9.

Pestis vulgaris, Sauv. sp. 1. Pestis Massil. Cl. II. Traité, p. 38. Ejusd. Cl. III. et IV. Traité, p. 225, &c. Walischmidt. de peste Hollatice, apud Halleri, Diss. Pract. Tom. V. Chenot. de peste Transylvanica, 1755, 1759, De Haen, Rat. Med. pars xiv.

Pestis Egyptica, Sauv. sp. 11. Alpin. de Med. Egypt.

Pestis interna, Sauv. sp. 3. Pest. Massil. Cl. I. Traité, p. 37—224.

History. Of this disease Dr Cullen declines giving any particular history, because he never saw it; from the accounts of other authors, however, he is of opinion, that the circumstances peculiarly characteristic of it, especially of its more violent and dangerous states, are, 1. The great loss of strength in the animal functions, which often appears early in the disease. 2. The stupor, giddiness, and consequent staggering, which resembles drunkenness, or the headache and various delirium, all of them denoting a great disorder in the functions of the brain. 3. Anxiety, palitination, syncope, and especially the weakness and irregularity of the pulse, denoting a considerable disturbance in the action of the heart. 4. Nausea and vomiting, particularly the vomiting of bile, which flows

an accumulation of vitiated bile in the gall-bladder and biliary ducts, and from thence derived into the intestines and stomach; and which denote a considerable spasm, and loss of tone in the extreme vessels on the surface of the body. 5. The buboes and carbuncles, which denote an acrimony prevailing in the fluids; and, lastly, The petechiae, haemorrhages, and colliquative diarrhoea, which denote a putrescent tendency prevailing in a great degree in the mass of blood.

To these characteristics of the plague enumerated by Dr Cullen, we shall add one mentioned by Sir John Pringle, which, though perhaps less frequent than the others, yet seems worthy of notice. It is this, That in the plague there is an extraordinary enlargement of the heart and liver. In nine dissections of bodies dead of the plague at Marseilles, this extraordinary enlargement of the heart is taken notice of in all of them, and of the liver in seven of them. The account was sent to the Royal Society by M. Didier, one of the physicians to the king of France, and has been published in the Philosophical Transactions. In the first case, the author takes notice, that "the heart was of an extraordinary bigness; and the liver was of double the natural size.—Case 2. The heart was of a prodigious bigness, and the liver much enlarged.—Case 3. The heart double the natural bigness.—Case 4. The heart was very large, and the liver was bigger and harder than ordinary.—Case 5. The heart was of a prodigious bigness.—Case 6. The heart was larger than in its natural state; the liver also was very large.—Case 7. The heart was of a prodigious size, and the liver was very large.—Case 8. The heart was much larger than natural, and the liver of a prodigious size.—Case 9. The heart was double the natural bigness, and the liver was larger than ordinary."—This preternatural enlargement, Sir J. Pringle thinks, is owing to the relaxation of the solid parts, by which means they become unable to resist the impetus of blood, and therefore are easily extended; as in the case of infancy, where the growth is remarkably quick. And a similar enlargement he takes notice of in the scurvy, and other putrid diseases.

A very elaborate work has lately been published on the subject of the plague by Dr Patrick Russel, formerly physician to the British factory at Aleppo. In this work, a very full history is given of the various forms and varieties of the disease. He makes particular observations on the following symptoms, which, in addition to the pestilential eruptions, he considers as the most important concomitants of plague, viz. fever, delirium, coma, impediment or loss of speech, deafness, muddiness of the eyes, white tongue, state of the pulse, respiration, anxiety, pain at the heart, inquietude, debility, fainting, convulsion, appearances of the urine, perspiration, vomiting, looseness, and haemorrhage; and he concludes these remarks with some observations on the occurrence of the plague with pregnant women. To point out more distinctly the stable varieties of the disease, he arranges the pestilential cases which fell under his observation at Aleppo under six classes: and he concludes his description with a very minute and particular account of the pestilential eruptions, appearing under the form either of buboes, carbuncles, or other exanthemata. The presence of the two first, he observes, either separately or conjunctly, leaves the nature

of the distemper unequivocal. But fatal has been the error of rashly pronouncing a distemper not to be a plague from their absence. Buboes affected the inguinal, axillary, parotid, maxillary, and cervical glands. But the first were the most commonly affected, and the two latter seldom observed to swell, without either the parotid swelling at the time, or soon after. Of the carbuncles, Dr Russel describes five different varieties. The other exanthemata, which he observed sometimes, though less frequently, attending the plague, were petechiae, a marbled appearance of the skin, an erysipelatous redness, streaks of a reddish purple or livid colour, vibices or weals, and large blue or purple spots, the maculae magnae of authors. In some cases, an extraordinary concurrence of eruptions took place, which was chiefly observed among children under 10 years of age.

Causes, &c. From a consideration of the symptoms above mentioned, Dr Cullen concludes, that the plague is owing to a specific contagion, often suddenly producing the most considerable debility in the nervous system, or moving powers, and a general putrescency in the fluids. Dr Russel also considers the disease as being universally the consequence of what may be called pestilential contagion; and has judiciously repelled the objections which have been brought against this doctrine.

Prevention. Here we must refer to all those methods of preventing and removing the incipient contagion of putrid fevers, which have been so fully enumerated. Dr Cullen is persuaded that the disease never arises in the northern parts of Europe, but in consequence of being imported from some other country. The magistrate's first care, therefore, ought to be, to prevent the importation; and this may generally be done by a due attention to bills of health, and to the proper performance of quarantines.—With respect to the latter, he is of opinion, that the quarantines of persons may with safety be much less than 40 days; and if this were allowed, the execution of the quarantine would be more exact and certain, as the temptation to break it would be in a great measure avoided. With respect to the quarantine of goods, it cannot be perfect unless the suspected goods be unpacked, duly ventilated, and other means be employed for correcting the infection they may carry; and if all this be properly done, it is probable that the time commonly prescribed for quarantine may be also shortened.

A second measure in the way of prevention is required, when an infection has reached and prevailed in any place, to prevent that infection from spreading into others. This can only be done by preventing the inhabitants or the goods of any infected place from going out of it till they have undergone a proper quarantine.

The third measure, and which ought to be employed with great care, is, to prevent the infection from spreading among the inhabitants of a place in which it has arisen. And in this case, a great deal may be done by the magistrate: 1. By allowing as many of the inhabitants as are free from infection, and are not necessary to the service of the place, to go out of it. 2. By discharging all assemblies, or unnecessary intercourse of the people. 3. By ordering some necessary communications to be performed without contact.

Examen-
mata. contact. 4. By making such arrangements and pro-
visions as may render it easy for the families remaining
to shut themselves up in their own houses. 5. By al-
lowing persons to quit houses where an infection ap-
pears, upon condition that they go into lazarettos.
6. By ventilating and purifying, or destroying, at the
public expence, all infected goods. 7. By avoiding
hospitals, and providing separate apartments for infect-
ed persons.

The fourth and last part of the business of preven-
tion respects the conduct of persons necessarily remain-
ing in infected places, especially those obliged to have
some communication with persons infected. Those
obliged to remain in places infected, but not to have
any near communication with the sick, must avoid all
near communication with other persons or their goods;
and it is probable, that a small distance will serve, if,
at the same time, there be no stream of air to carry
the effluvia of persons or goods to some distance. Those
who are obliged to have a near communication with the
sick ought to avoid any of the debilitating causes
which render the body susceptible of infection, as a
spare diet, intemperance in drinking, excess in venery,
cold, fear, or other depressing passions of the mind.
A full diet of animal food is also to be avoided, be-
cause it increases the irritability of the body, and fa-
vours the operation of contagion; and indigestion, whe-
ther from the quantity or quality of the food, contrib-
utes very much to the same end.

Besides these, it is probable that the moderate use
of wine and spirituous liquors, moderate exercise, and
the cold bath, may be of use; tonic medicines also, of
which cinchona is deservedly accounted the chief, may
be used with some probability of success. If any
thing is to be expected from antiseptics, Dr Cullen
thinks camphor preferable to every other. In gen-
eral, however, every one is to be indulged in the medi-
cine of which he has the best opinion, provided it is
not evidently hurtful. Whether illness be useful in pre-
serving from the effects of contagion, is a matter of
doubt. Dr Ruffel in his treatise enters very fully
into the consideration of the means of prevention,
both with respect to quarantines, lazarettos, and bills
of health. He is of opinion, that the present laws on
these subjects are in many respects defective: and he
thinks, that a set of new regulations would have the
best chance of a deliberate and impartial discussion in
the senate, if the inquiry were taken at a time free
from all apprehension of immediate danger.

Cure. According to Dr Cullen, the indications are
the same as in fever in general, but are not all equally
important. The measures for moderating the violence
of reaction, which operate by diminishing the action of
the heart and arteries, have seldom, he thinks, any
place here, excepting that the antiphlogistic regimen is
generally proper. Some physicians have recommended
bleeding, and Sydenham even seems to think it an ef-
fectual cure; but Dr Cullen supposes, that for the most
part it is unnecessary, and in many cases might do much
hurt. Dr Ruffel, however, who on this subject speaks
from experience and actual observation, is of a differ-
ent opinion. With most of his patients, a single bleed-
ing was employed with advantage; and even where
the sick under his inspection were bled oftener than

once, he did not find that the low state was thereby
hurried on. Purging has also been recommended; and
in some degree it may be useful in drawing off the
putrescent matter frequently present in the intestines;
but a large evacuation in this way may certainly be
hurtful.

The moderating the violence of reaction, as far as
it can be done, by taking off the spasm of the ex-
treme vessels, is a measure, in Dr Cullen's opinion,
of the utmost necessity in the cure of the plague; and
the whole of the means formerly mentioned, as suited
to this indication, are extremely proper. The giving
an emetic, at the first approach of the disease, would
probably be of great service; and it is probable, that,
at some other periods of the disease, emetics might be
useful, both by evacuating bile abounding in the ali-
mentary canal, and by taking off the spasm of the ex-
treme vessels. Indeed Baron Ash, and some other
of the Russian practitioners, represent the early and
repeated use of emetics as the only effectual mode of
cure.

According to the observations of Dr de Mertens,
who wrote a very interesting treatise on the fatal plague
which raged at Moscow in 1771, and which carried off
upwards of 20,000 inhabitants in the space of one
month, emetics were often of the greatest service.

From some principles with respect to fever in gen-
eral, and with respect to the plague in particular, Dr
Cullen is of opinion, that after the exhibition of the
first vomit, the body should be disposed to sweat; but
this sweat should be raised only to a moderate degree,
though it must be continued for 24 hours or more if
the patient bears it easily. The sweating is to be ex-
cited and conducted according to the rules laid down
under SYNOCHIA; and must be promoted by the plenti-
ful use of diluents rendered more grateful by vege-
table acids, or more powerful by being impregnated
with some portion of neutral salts. To support the
patient under the continuance of the sweat, a little
weak broth, acidulated with the juice of lemons, may
be given frequently, and sometimes a little wine if
the heat of the body be not considerable. If sudorific
medicines be judged necessary, opiates will be found
more effectual and safe; but they should not be com-
bined with aromatics, and probably may be more effectual
if joined with a portion of emetics and of neutral
salts. But if, notwithstanding the use of emetics and
sudorifics in the beginning, the disease should still con-
tinue, the cure must turn upon the use of means for ob-
viating debility and putrescency; and for this purpose
tonic medicines, especially cinchona and cold drink, are
the most proper.

Variola, Sauv. gen. 92. Lin. 3. Sag. gen. 290.
Febris variolosa, Vog. 35. Hoffm. II. 49.
Variolæ, Boerh. 1371. Junc. 76.

Variola discreta benigna, Sauv. sp. 2.
Variolæ regulares discretæ, Sydenh. sect. iii. cap. 2.
Variolæ

Variola discreta simplices, Helvet. Obs. sp. 1.
Variola discreta complicata, Sauv. sp. 2. Helvet.
sp. 2.
Variola anomale, Sydenh. sect. iv. cap. 6.
Variola discreta dysenteroides, Sauv. sp. 4. Sy-
denh. sect. iv. cap. 1.
Variola discreta velicularis, Sauv. sp. 5.
Variola discreta crystallina, Mead. de variol. cap. 2.
Variola discreta verrucosa, Sauv. sp. 6. Mead
ibid.
Variola discreta filiquosa, Sauv. sp. 7. Freind
Oper. p. 358.
Variola discreta miliaris, Sauv. sp. 8. Helvet. Obs.
sp. 3.

Variola confluens, Sauv. sp. 9.
Variola regulares confluentes, ann. 1667. Syden-
ham, sect. iii. cap. 2.
Variola confluentes simplices, Helvet. Obs. sp. 1.
Variola confluens crystallina, Sauv. sp. 10.
Variola japonica, Kempfer.
Vesiculae divae Barbarae, C. Pit. Obs. 149.
Variola confluens maligna, Helvet. Obs. sp. 1.
Variola confluens cohaerens, Sauv. sp. 11.
Variola confluens maligna, Helvet. sp. 2.
Variola confluens nigra, Sauv. sp. 12. Sydenham,
sect. v. cap. 4.
Variola confluens maligna, Helvet. sp. 3.
Variola sanguinea, Mead de variolis, cap. 2.
Variola confluens corymbosa, Sauv. sp. 13.
Variola confluens maligna, Helvet. sp. 4.

Description. In the distinct smallpox, the disease begins with a synocha or inflammatory fever. This fever generally comes on about mid-day, with some symptoms of a cold stage, and commonly with a considerable languor and drowsiness. A hot stage is soon formed, and becomes more considerable on the second and third day. During this course children are liable to frequent startings from their slumbers; and adults, if they are kept in bed, are disposed to much sweating. On the third day, children are sometimes affected with one or two epileptic fits. Towards the end of the third day the eruption commonly appears, and gradually increases during the fourth; appearing first on the face, and successively on the inferior parts, so as to be completed over the whole body on the fifth day. From the third day the fever abates, and by the fifth it entirely ceases. The eruption appears first in small red spots hardly eminent, but by degrees rising into pimples. There are generally but few on the face; but, even when more numerous, they are separate and distinct from one another. On the fifth or sixth day, a small vesicle, containing an almost colourless fluid, appears on the top of each pimple. For two days these vesicles increase in breadth only, and there is a small hollow pit in their middle, so that they are not raised into spheroidal pustules till the eighth day. These pustules from their first formation continue to be surrounded with an exactly circular inflamed margin, which when they are numerous diffuses some inflammation over the neighbouring skin, so as to give somewhat of a damask-rose colour to the spaces between the pustules. As the pustules increase in size

the face swells considerably if they are numerous on it; and the eye-lids particularly are so much swelled, that the eyes are entirely shut. As the disease proceeds, the matter in the pustules becomes by degrees more opaque and white, and at length assumes a yellowish colour. On the 11th day the swelling of the face is abated, and the pustules seem quite full. On the top of each a darker spot appears; and at this place the pustule, on the 11th day, or soon after, is spontaneously broken, and a portion of the matter oozes out; in consequence of which the pustule is shrivelled, and subsides; while the matter oozing out dries, and forms a crust upon its surface. Sometimes only a little of the matter oozes out, and what remains in the pustule becomes thick and even hard. After some days, both the crusts and the hardened pustules fall off, leaving the skin which they covered of a brownish red colour; nor doth it resume its natural colour till many days after. In some cases, where the matter of the pustules has been more liquid, the crusts formed from it are later in falling off, and the part they covered suffers some desquamation, which occasions a small hollow or pit.

On the legs and hands the matter is frequently absorbed; so that at the height of the disease, these pustules appear as empty as vesicles. On the 10th and 11th days, as the swelling of the face subsides, a swelling arises in the hands and feet; but which again subsides as the pustules come to maturity. When the pustules on the face are numerous, some degree of pyrexia appears on the 10th and 11th days; but disappears again after the pustules are fully ripened, or perhaps remains in a very slight degree till the pustules on the feet have finished their course; and it is seldom that any fever continues longer in the distinct smallpox. When the pustules are numerous on the face, upon the sixth or seventh day some uneasiness of the throat, with a hoarseness of the voice, comes on, and a thin liquid is poured out from the mouth. These symptoms increase with the swelling of the face; and the liquids of the mouth and throat becoming thicker are with difficulty thrown out; and there is at the same time some difficulty in swallowing, so that liquids taken in to be swallowed are frequently rejected or thrown out by the nose. But all these affections of the fauces are abated as the swelling of the face subsides.

In the confluent smallpox all the symptoms above-mentioned are much more severe. The eruptive fever particularly is more violent; the pulse is more frequent and more contracted, approaching to that state of pulse which is observed in typhus. The coma is more considerable, and there is frequently a delirium. Vomiting also frequently attends, especially at the beginning of the disease. In very young infants epileptic fits are sometimes frequent on the first days of the disease, and sometimes prove fatal before any eruption appears, or they usher in a very confluent and putrid smallpox. But at the same time, it has been justly remarked by Dr Sydenham, and other accurate observers, that epileptic attacks more frequently precede distinct and mild than malignant and confluent smallpox. The eruption appears in the confluent more early on the third day, and it is frequently preceded or accompanied with an erysipelatus efflorescence. Some-
times

Exanthema. times the eruption appears in clusters, like the measles.

When the eruption is completed, the pimples are always more numerous upon the face, and at the same time smaller and less eminent. Upon the eruption the fever suffers some remission, but never goes off entirely; and after the fifth or sixth day it increases again, and continues to be considerable throughout the remaining part of the disease. The vesicles formed on the top of the pimples appear sooner; and while they increase in breadth, they do not retain a circular, but are every way of an irregular figure. Many of them run into one another, inasmuch that very often the face is covered with one vesicle rather than with a number of pustules. The vesicles, as far as they are any way separated, do not arise to a spheroidal form, but remain flat, and sometimes the whole of the face appears an even surface. When the pustules are in any measure separated, they are not bounded by an inflamed margin, but the part of the skin that is free from pustules is commonly pale and flaccid. The liquor that is in the pustules changes from a clear to an opaque appearance, and becomes whitish or brownish, but never acquires the yellow colour and thick consistency that appears in the distinct smallpox. The swelling of the face, which only sometimes attends the distinct smallpox, always attends the confluent kind; it also comes on more early, and arises to a greater height, but abates considerably on the tenth or eleventh day. At this time the pustules or vesicles break and shrivel; pouring out at the same time a liquor, which is formed into brown or black crusts, which do not fall off for a long time after. Those of the face, in falling off, leave the skin subject to a desquamation, which pretty certainly produces pittings. On the other parts of the body the pustules of the confluent smallpox are more distinct than on the face; but never acquire the same maturity and consistency of pus as in the properly distinct kind.—The salivation, which sometimes only attends the distinct smallpox, very constantly attends the confluent; and both the salivation and the affection of the fauces above-mentioned occur, especially in adults, in a higher degree. In infants a diarrhoea comes frequently in place of a salivation.

In this kind of smallpox there is often a very considerable putrefaction of the fluids, as appears from petechiae, from serous vesicles, under which the skin shows a disposition to gangrene, and from bloody urine or other hemorrhages; all of which symptoms frequently attend this disease. In the confluent smallpox also, the fever, which had only suffered a remission from the eruption to the maturation, at or immediately after this period is frequently renewed again with considerable violence. This is what has been called the secondary fever, and is of various duration and event.

Causes, &c. It is evident that the smallpox is originally produced by a contagion; and that this contagion is a ferment with respect to the fluids of the human body, which assimilates a considerable portion of them to its own nature: or, at least, we have every reason to believe that a small quantity of contagious matter introduced, is somehow multiplied and increased in the circulating fluids of the animal body. This quantity passes again out of the body, partly by insensible per-

spiration, and partly by being deposited in pustules: The causes which determine more of the various matter to pass by perspiration, or to form pustules, are probably certain circumstances of the skin, which determine more or less of the various matter to stick in it, or to pass freely through it. The circumstance of the skin, which seems to determine the various matter to stick in it, is a certain state of inflammation depending much on the heat of it: thus we have many instances of parts of the body, from being more heated, having a greater number of pustules than other parts. Thus parts covered with plasters, especially those of the stimulant kind, have more pustules than others.—Certain circumstances also, such as adult age, and full living, determining to a phlogistic diathesis, seem to produce a greater number of pustules, and vice versa. It is therefore probable, that an inflammatory state of the whole system, and more particularly of the skin, gives occasion to a greater number of pustules; and the causes of this may produce most of the other circumstances of the confluent smallpox, such as the time of eruption, the continuance of the fever, the effusion of a more putrescent matter, and less fit to be converted into pus, together with the form and other circumstances of the pustules.

Pronostic. The more exactly the disease retains the form of the distinct kind, it is the safer; and the more completely the disease takes the form of the confluent kind, it is the more dangerous. It is only when the distinct kind shows a great number of pustules on the face, or otherwise by fever or putrefaction, approaching to the circumstances of the confluent, that the distinct kind is attended with any danger.

In the confluent kind the danger is always very considerable; and the more violent and permanent the fever is, the greater the danger; and especially in proportion to the increase of the symptoms of putrefaction. When the putrid disposition is very great, the disease sometimes proves fatal before the eighth day; but in most cases death happens on the eleventh, and sometimes not till the fourteenth or seventeenth day.

Though the smallpox may not prove immediately fatal, the more violent kinds are often followed by a morbid state of the body, sometimes of very dangerous event. These consequences, according to Dr Cullen, may be imputed sometimes to an acrid matter produced by the preceding disease, and deposited in different parts; and sometimes to an inflammatory diathesis produced and determined to particular parts of the body.

Since the introduction of smallpox into Europe, there is perhaps no disease which has produced a greater number of deaths. But, fortunately, a discovery is now made, by which there is reason to hope that this loathsome disease may be altogether exterminated; its prevention, viz. by the inoculation of the vaccine or cowpox.

This most important discovery we owe to the successful exertions of Dr Edward Jenner; to whom, for these exertions, repeated rewards have been voted by the British legislature, but who unquestionably enjoys a much higher reward in the satisfaction of having conferred an ineffable blessing on the human species.

For an account of the progress of this discovery, we must refer our readers to Dr Jenner's publication. Here we shall only observe, that it had long been remarked in some parts of England, particularly in the neighbourhood of Berkley, where Dr Jenner resided, that cows were liable to a pustular disease on their udders, somewhat resembling smallpox; that this disease was communicated by contact to the fingers of those employed in milking the cows; and, finally, that those thus infected with cowpox, were completely protected against the contagion of smallpox.

Founding on these observations, Dr Jenner ascertained by experiment, that the inoculation of vaccine matter was an infallible preventive of smallpox; and that this vaccine matter had equal power in preventing variola, when transferred from one human subject to another, as when obtained immediately from the cow. It is not therefore wonderful that this practice of vaccine inoculation should soon have become general, both in Britain and in every quarter of the world. Nor is it perhaps surprising, that it should have been violently opposed by ignorant and obstinate men. Hence numerous publications have of late appeared both for and against this practice. Many mistakes have undoubtedly been committed by ignorance and inattention; and thus the preventive has been supposed to fail. For the best account both of the method of performing the operation, of conveying the vaccine matter from one place to another, and of the tests of constitutional affection in those cases in which the inflammation is slight, and in which no fever is perceptible, we may refer our readers to a treatise published at Edinburgh in 1802, by Mr James Bryce, entitled Practical Observations on the Inoculation of Cowpox.

Of the efficacy of vaccine inoculation as a preventive of smallpox few candid men will entertain any doubt, after the following report on vaccination, from the Royal College of Physicians in London, ordered to be printed on the 8th of July 1807, by the British parliament.

REPORT, &c.

THE Royal College of Physicians of London, having received his majesty's commands, in compliance with an address from the house of commons, "to inquire into the state of vaccine inoculation in the united kingdom, to report their opinion and observations upon that practice, upon the evidence which has been adduced in its support, and upon the causes which have hitherto retarded its general adoption;"—have applied themselves diligently to the business referred to them.

Deeply impressed with the importance of an inquiry which equally involves the lives of individuals, and the public prosperity, they have made every exertion to investigate the subject fully and impartially. In aid of the knowledge and experience of the members of their own body, they have applied separately to each of the licentiates of the college; they have corresponded with the colleges of physicians of Dublin and Edinburgh; with the colleges of surgeons of London, Edinburgh, and Dublin; they have called upon the societies established for vaccination, for an account of their practice, to what extent it has been carried on, and what has been the result of their experience; and they

have, by public notice, invited individuals to contribute whatever information they had severally collected. They have in consequence been furnished with a mass of evidence communicated with the greatest readiness and candour, which enables them to speak with confidence upon all the principal points referred to them.

I. During eight years which have elapsed since Dr Jenner made his discovery public, the progress of vaccination has been rapid, not only in all parts of the united kingdom, but in every quarter of the civilized world. In the British islands some hundred thousands have been vaccinated, in our possessions in the East Indies upwards of 800,000, and among the nations of Europe the practice has become general. Professional men have submitted it to the fairest trials, and the public have, for the most part, received it without prejudice. A few indeed have stood forth the adversaries of vaccination, on the same grounds as their predecessors who opposed the inoculation for the smallpox, falsely led by hypothetical reasoning in the investigation of a subject which must be supported, or rejected, upon facts and observation only. With these few exceptions, the testimony in favour of vaccination has been most strong and satisfactory, and the practice of it, though it has received a check in some quarters, appears still to be upon the increase in most parts of the united kingdom.

II. The college of physicians, in giving their observations and opinions on the practice of vaccination, think it right to premise, that they advance nothing but what is supported by the multiplied and unequivocal evidence which has been brought before them, and they have not considered any facts as proved but what have been stated from actual observation.

Vaccination appears to be in general perfectly safe; the instances to the contrary being extremely rare. The disease excited by it is slight, and seldom prevents those under it from following their ordinary occupations. It has been communicated with safety to pregnant women, to children during dentition, and in their earliest infancy; in all which respects it possesses material advantages over inoculation for the smallpox; which, though productive of a disease generally mild, yet sometimes occasions alarming symptoms, and is in a few cases fatal.

The security derived from vaccination against the smallpox, if not absolutely perfect, is as nearly so as can perhaps be expected from any human discovery; for amongst several hundred thousand cases, with the results of which the college have been made acquainted, the number of alleged failures has been surprisingly small, so much so, as to form certainly no reasonable objection to the general adoption of vaccination; for it appears that there are not nearly so many failures, in a given number of vaccinated persons, as there are deaths in an equal number of persons inoculated for the smallpox. Nothing can more clearly demonstrate the superiority of vaccination over the inoculation of the smallpox, than this consideration; and it is a most important fact, which has been confirmed in the course of this inquiry, that in almost every case, where the smallpox has succeeded vaccination, whether by inoculation or by casual infection, the disease has varied much from its ordinary course; it has neither been the same in the violence, nor in the duration of its symptoms, but has,

with

Exanth-
emata. with very few exceptions, been remarkably mild, as if the smallpox had been deprived, by the previous vaccine disease, of all its usual malignity.

The testimonies before the college of physicians are very decided in declaring, that vaccination does less mischief to the constitution, and less frequently gives rise to other diseases, than the smallpox, either natural or inoculated.

The college feel themselves called upon to state this strongly, because it has been objected to vaccination, that it produces new, unheard-of, and monstrous diseases. Of such assertions no proofs have been produced, and, after diligent inquiry, the college believe them to have been either the inventions of designing, or the mistakes of ignorant men. In these respects then, in its mildness, its safety, and its consequences, the individual may look for the peculiar advantages of vaccination. The benefits which flow from it to society are infinitely more considerable, it spreads no infection, and can be communicated only by inoculation. It is from a consideration of the pernicious effects of the smallpox, that the real value of vaccination is to be estimated. The natural smallpox has been supposed to destroy a sixth part of all whom it attacks; and that even by inoculation, where that has been general in parishes and towns, about one in 300 has usually died. It is not sufficiently known, or not adverted to, that nearly one-tenth, some years more than one-tenth of the whole mortality in London, is occasioned by the smallpox; and however beneficial the inoculation of the smallpox may have been to individuals, it appears to have kept up a constant source of contagion, which has been the means of increasing the number of deaths by what is called the natural disease. It cannot be doubted that this mischief has been extended by the inconsiderate manner in which great numbers of persons, even since the introduction of vaccination, are still every year inoculated with the smallpox, and afterwards required to attend two or three times a-week at the places of inoculation, through every stage of their illness.

From this, then, the public are to expect the great and uncontroverted superiority of vaccination, that it communicates no casual infection, and, while it is a protection to the individual, it is not prejudicial to the public.

III. The college of physicians, in reporting their observations and opinions on the evidence adduced in support of vaccination, feel themselves authorised to state that a body of evidence so large, so temperate, and so consistent, was perhaps never before collected upon any medical question. A discovery so novel, and to which there was nothing analogous known in nature, though resting on the experimental observations of the inventor, was at first received with diffidence: it was not, however, difficult for others to repeat his experiments, by which the truth of his observations was confirmed, and the doubts of the cautious were gradually dispelled by extensive experience. At the commencement of the practice, almost all that were vaccinated were afterwards submitted to the inoculation of the smallpox; many underwent this operation a second, and even a third time, and the uniform success of these trials quickly bred confidence in the new discovery. But the evidence of the security derived from vaccination against

the smallpox does not rest alone upon those who afterwards underwent various inoculation, although amounting to many thousands; for it appears, from numerous observations communicated to the college, that those who have been vaccinated are equally secure against the contagion of epidemic smallpox. Towns, indeed, and districts of the country, in which vaccination had been general, have afterwards had the smallpox prevalent on all sides of them without suffering from the contagion. There are also in the evidence a few examples of epidemic smallpox having been subdued by a general vaccination. It will not, therefore, appear extraordinary that many who have communicated their observations should state, that though at first they thought unfavourably of the practice, experience had now removed all their doubts.

It has been already mentioned, that the evidence is not universally favourable, although it is in truth nearly so, for there are a few who entertain sentiments differing widely from those of the great majority of their brethren. The college, therefore, deemed it their duty, in a particular manner, to inquire upon what grounds and evidence the opposers of vaccination rested their opinions. From personal examination, as well as from their writings, they endeavoured to learn the full extent and weight of their objections. They found them without experience in vaccination, supporting their opinions by hearsay information and hypothetical reasoning; and, upon investigating the facts which they advanced, they found them to be either misapprehended or misrepresented; or that they fell under the description of cases of imperfect smallpox, before noticed, and which the college have endeavoured fairly to appreciate.

The practice of vaccination is but of eight years standing, and its promoters, as well as opponents, must keep in mind, that a period so short is too limited to ascertain every point, or to bring the art to that perfection of which it may be capable. The truth of this will readily be admitted by those acquainted with the history of inoculation for the smallpox. Vaccination is now, however, well understood, and its character accurately described. Some deviations from the usual course have occasionally occurred, which the author of the practice has called spurious cowpox, by which the public have been misled, as if there were a true and a false cowpox; but it appears, that nothing more was meant, than to express irregularity or difference from that common form and progress of the vaccine pustule from which its efficacy is inferred. Those who perform vaccination ought therefore to be well instructed, and should have watched with the greatest care the regular progress of the pustule, and learnt the most proper time for taking the matter. There is little doubt that some of the failures are to be imputed to the inexperience of the early vaccinators, and it is not unreasonable to expect that farther observation will yet suggest many improvements that will reduce the number of anomalous cases, and furnish the means of determining, with greater precision, when the vaccine disease has been effectually received.

Though the college of physicians have confined themselves in estimating the evidence to such facts as have occurred in their own country, because the accuracy of them could best be ascertained, they cannot be insensi-

ble to the confirmation these receive from the reports of the successful introduction of vaccination, not only into every part of Europe, but throughout the vast continents of Asia and America.

IV. Several causes have had a partial operation in retarding the general adoption of vaccination; some writers have greatly undervalued the security it affords, while others have considered it to be of a temporary nature only; but if any reliance is to be placed on the statements which have been laid before the college, its power of protecting the human body from the smallpox, though not perfect indeed, is abundantly sufficient to recommend it to the prudent and dispassionate, especially as the smallpox, in the few instances where it has subsequently occurred, has been generally mild and transient. The opinion that vaccination affords but a temporary security is supported by no analogy in nature, nor by the facts which have hitherto occurred. Although the experience of vaccine inoculation be only of a few years, yet the same disease, contracted by the milkers of cows, in some districts has been long enough known to ascertain that in them, at least the unsusceptibility of the smallpox contagion does not wear out by time.

Another cause, is the charge against vaccination of producing various new diseases of frightful and monstrous appearance. Representations of some of these have been exhibited in prints in a way to alarm the feelings of parents, and to infuse dread and apprehension into the minds of the uninformed. Publications with such representations have been widely circulated, and though they originate either in gross ignorance, or wilful misrepresentation, yet have they lessened the confidence of many, particularly of the lower classes, in vaccination; no permanent effects, however, in retarding the progress of vaccination, need be apprehended from such causes, for, as soon as the public shall view them coolly and without surprise, they will excite contempt, and not fear.

Though the college of physicians are of opinion that the progress of vaccination has been retarded in a few places by the above causes, yet they conceive that its general adoption has been prevented by causes far more powerful, and of a nature wholly different. The lower orders of society can hardly be induced to adopt precautions against evils which may be at a distance; nor can it be expected from them, if these precautions are attended with expence. Unless therefore, from the immediate dread of epidemic smallpox, neither vaccination nor inoculation appear at any time to have been general, and when the cause of terror has passed by, the public have relapsed again into a state of indifference and apathy, and the salutary practice has come to a stand. It is not easy to suggest a remedy for an evil so deeply imprinted in human nature. To inform and instruct the public mind may do much, and it will probably be found that the progress of vaccination in different parts of the united kingdom will be in proportion to that instruction. Were encouragement given to vaccination, by offering it to the poorer classes without expence, there is little doubt but it would in time supersede the inoculation for the smallpox, and thereby various sources of various infection would be cut off; but till vaccination becomes general, it will be impossible to prevent the constant recurrence of the natural smallpox by means of those who are inoculated, except

it should appear proper to the legislature to adopt, in its wisdom, some measure by which those who still, from terror or prejudice, prefer the smallpox to the vaccine disease, may, in thus consulting the gratification of their own feelings, be prevented from doing mischief to their neighbours.

From the whole of the above considerations, the college of physicians feel it their duty strongly to recommend the practice of vaccination. They have been led to this conclusion by no preconceived opinion, but by the most unbiased judgement, formed from an irrefragable weight of evidence which has been laid before them. For when the number, the respectability, the disinterestedness, and the extensive experience of its advocates, is compared with the feeble and imperfect testimonies of its few opposers; and when it is considered that many, who were once adverse to vaccination, have been convinced by further trials, and are now to be ranked among its warmest supporters, the truth seems to be established as firmly as the nature of such a question admits; so that the college of physicians conceive that the public may reasonably look forward with some degree of hope to the time when all opposition shall cease, and the general concurrence of mankind shall at length be able to put an end to the ravages at least, if not to the existence, of the smallpox.

LUCAS PEPYS, PRESIDENT.

Royal College of Physicians,
12th of April, 1807.

JA. HERVEY, Registrar.

APPENDIX.

NO. I.

To the Royal College of Physicians of London.

GENTLEMEN,

I am ordered by the King and Queen's College of Physicians, in Ireland, to thank the Royal College of Physicians of London for the communication they have had the honour to receive from them, of certain propositions relative to vaccination, wherein his majesty has been pleased to direct an inquiry to be instituted, and in the prosecution of which, the co-operation of the college in Ireland is requested.

And I am directed to acquaint you, that the said college having referred the investigations of these propositions to a committee, have received from them a report, of which the inclosed is a copy; and that they desire the same may be considered as containing their opinion upon the subject.

I have the honour to be,

Gentlemen,

Your most obedient humble servant,

By order of the King and
Queen's College of Phy-
sicians in Ireland.

HUGH FERGUSON,
Registrar.

Dublin, 21st Nov. 1806.

"The practice of vaccination was introduced into this

Ex-
this city about the beginning of the year 1801, and ap-
pears to have made inconsiderable progress at first. A
variety of causes operated to retard its general adoption,
amongst which the novelty of the practice, and the ex-
traordinary effects attributed to vaccination, would natu-
rally take the lead.

Variolous inoculation had been long, almost exclu-
sively, in the hands of a particular branch of the pro-
fession, whose prejudices and interests were strongly op-
posed to the new practice; and by their being the usual
medical attendants in families, and especially employed
in the diseases of children, their opinions had greater
effect upon the minds of parents. The smallpox is ren-
dered a much less formidable disease in this country by
the frequency of inoculation for it, than it is in other
parts of his majesty's dominions, where prejudices ag-
ainst inoculation have prevailed; hence parents, not
unnaturally, objected to the introduction of a new dis-
ease, rather than not recur to that, with the mildness
and safety of which they were well acquainted.

In the beginning of the year 1804, the cowpox
institution was established under the patronage of the
earl of Hardwicke, and it is from this period that we
may date the general introduction of vaccination into
this city, and throughout all parts of Ireland.

The success of the institution, in forwarding the
new practice, is to be attributed in a great measure to
the respectability of the gentlemen who superintend it,
and to the diligence, zeal, and attention of Dr Labatt,
their secretary and inoculator. In order to show the
progress which has been made in extending vaccination,
your committee refer to the reports of the Cowpox In-
stitution for the last two years, and to extracts from
their register for the present year.

In the above statement, the numbers are averaged
to the end of the present year, on the supposition of pa-
tients resorting to the institution as usual. The cor-
respondence of the institution appears to be very general
throughout every part of Ireland, and by the accounts
received, as well from medical practitioners as others,
the success of vaccination seems to be uniform and ef-
fectual. At the present period, in the opinion of your
committee, there are few individuals in any branch of
the profession, who oppose the practice of vaccination in
this part of his majesty's dominions.

It is the opinion of your committee, that the prac-
tice of cowpox inoculation is safe, and that it fully
answers all the purposes that have been intended by its
introduction. At the same time, your committee is
willing to allow that doubtful cases have been reported
to them as having occurred, of persons suffering from
smallpox, who had been previously vaccinated. Upon

minute investigation, however, it has been found, that
these supposed instances originated generally in error,
misrepresentation, or the difficulty of discriminating be-
tween smallpox and other eruptions, no case having
come to the knowledge of your committee, duly authen-
ticated by respectable and competent judges, of genuine
smallpox succeeding the regular vaccine disease.

The practice of vaccination becomes every day
more extended; and, when it is considered that the
period at which it came into general use in Ireland is to
be reckoned from so late a date, your committee is of op-
inion, that it has made already as rapid a progress as
could be expected.

(Signed) "JAMES CLEGHORN.
"DANIEL MILLS.
"HUGH FERGUSON."

Nº. II.

Physicians Hall, Edinburgh, 26th Nov. 1806.

GENTLEMEN,

THE Royal College of Physicians of Edinburgh
have but little opportunity themselves of making ob-
servations on vaccination, as that practice is entirely
conducted by surgeon apothecaries, and other medical
practitioners not of their college, and as the effects pro-
duced by it are so inconsiderable and slight, that the aid
of a physician is never required.

The College know that in Edinburgh it is univer-
sally approved of by the profession, and by the higher and
middle ranks of the community; and that it has been
much more generally adopted by the lower orders of
the people than ever the inoculation for smallpox
was, and they believe the same to obtain all over Scot-
land.

With regard to any causes which have hitherto pre-
vented its general adoption, they are acquainted with
none except the negligence or ignorance of parents
among the common people, or their mistaken ideas of
the impropriety or criminality of being accessory to the
production of any disease among their children, or the
difficulty or impossibility, in some of our country dis-
tricts, of procuring vaccine matter, or a proper person
to inoculate.

The evidence in favour of vaccination appeared to
the Royal College of Physicians of Edinburgh so strong
and decisive, that in May last, they spontaneously and
unanimously elected Dr Jenner an honorary fellow of
their college;—a mark of distinction which they very
rarely confer, and which they confine almost exclusively
to foreign physicians of the first eminence.

They did this with a view to publish their opinion
with regard to vaccination, and in testimony of their
conviction of the immense benefits which have been,
and which will in future be derived to the world, from
inoculation for the cowpox, and as a mark of their
sense of Dr Jenner's very great merits and ability in
introducing and promoting this invaluable practice.

I have the honour to be

Gentlemen,

Your most obedient humble servant,

TH. SPENS, G. R. M. Ed. Pr.

To the Royal College of
Physicians of London.

Nº. III.

At a special court of assistants of the Royal College of Surgeons, convened by order of the Master, and holden at the College on Tuesday the 17th day of March 1807;

Mr Governor LUCAS in the chair:

Mr Long, as chairman of the board of curators, reported, that the board are now ready to deliver their report on the subject of vaccination.

It was then moved, seconded, and resolved, that a report from the board of curators, on the subject of vaccination, which was referred to their consideration by the court of assistants, on the 21st day of November last, be now received.

Mr Long then delivered to Mr Governor Lucas (presiding in the absence of the master) a report from the board of curators.

It was then moved, seconded, and resolved, that the report, delivered by Mr Long, be now read; and it was read accordingly, and is as follows:

To the Court of Assistants of the Royal College of Surgeons in London.

THE report of the Board of Curators, on the subject of vaccination, referred to them by the court, on the 21st day of November 1806; made to the court on the 17th of March 1807.

THE court of assistants having received a letter from the Royal College of Physicians of London, addressed to this college, stating, that his majesty had been graciously pleased, in compliance with an address from the honourable House of Commons, to direct his Royal College of Physicians of London to enquire into the state of vaccination in the united kingdom, to report their observations and opinion upon that practice, upon the evidence adduced in its support, and upon the causes which have hitherto retarded its general adoption; that the college were then engaged in the investigation of the several propositions thus referred to them, and requesting this college to co-operate and communicate with them, in order that the report thereupon might be made as complete as possible.

And having, on the 21st day of November last, referred such letter to the consideration of the board of curators, with authority to take such steps respecting the contents thereof as they should judge proper, and report their proceedings thereon, from time to time, to the court; the board proceeded with all possible dispatch to the consideration of the subject.

The board being of opinion, that it would be proper to address circular letters to the members of this college, with a view of collecting evidence, they submitted to the consideration of the court, holden on the 15th day of December last, the drafts of such letter as appeared to them best calculated to answer that end; and the same having been approved by the court, they caused copies thereof to be sent to all the members of the college in the united kingdom, whose residence could be ascertained, in the following form; viz.

" Sir,

" The Royal College of Surgeons being desirous to co-operate with the Royal College of Physicians of London, in obtaining information respecting vaccination, submit to you the following questions, to which the favour of your answer is requested.

" By order of the Court of Assistants,

" OKEY BELFOUR, Secretary."

Lincoln's-Inn Fields,

Dec. 15. 1806.

" 1st. How many persons have you vaccinated?

" 2d. Have any of your patients had the smallpox after vaccination? In the case of every such occurrence, at what period was the vaccine matter taken from the vehicle? How was it preserved? How long before it was inserted? What was the appearance of the inflammation? And what the interval between vaccination and the various eruption?

" 3d. Have any bad effects occurred in your experience in consequence of vaccination? And if so, what were they?

" 4th. Is the practice of vaccination increasing or decreasing in your neighbourhood; if decreasing, to what cause do you impute it?"

To such letters the board have received 426 answers: and the following are the results of their investigation:

The number of persons, stated in such letters to have been vaccinated, is 164,381.

The number of cases in which smallpox had followed vaccination is 56.

The board think it proper to remark under this head, that, in the enumeration of cases in which smallpox has succeeded vaccination, they have included none but those in which the subject was vaccinated by the surgeon reporting the facts.

The bad consequences which have arisen from vaccination are, eruptions of the skin in 66 cases, and inflammation of the arm in 24 instances, of which three proved fatal.

Vaccination, in the greater number of counties from which reports have been received, appears to be increasing; it may be proper however to remark, that, in the metropolis, it is on the decrease.

The principal reasons assigned for the decrease are,

Imperfect vaccination,
Instances of smallpox after vaccination,
Supposed bad consequences,
Publications against the practice,
Popular prejudices.

And such report having been considered, it was moved, seconded, and

Resolved, That the report now read, be adopted by this court, as the answer of the court to the letter of the Royal College of Physicians, of the 23d day of October last, on the subject of vaccination.

Resolved, That a copy of these minutes and resolutions, signed by Mr Governor Lucas (presiding at this court in the presence of the master) be transmitted by the secretary to the register of the Royal College of Physicians.

(Signed) WM LUCAS.

I mentioned in my former letter, that I would take the earliest opportunity of laying before the Royal College of Surgeons of Edinburgh, the communication with which the Royal College of Physicians of London had honoured them, on the 23d of October last:

I am now directed by the Royal College to send the following answer on that important subject.

The practice of vaccine inoculation, both in private, and at the vaccine institution established here in 1801, is increasing so rapidly, that for two or three years past, the smallpox has been reckoned rather a rare occurrence, even among the lower orders of the inhabitants of this city, unless in some particular quarters about twelve months ago; and, among the higher ranks of the inhabitants, the disease is unknown.

The members of the Royal College of Surgeons have much pleasure in reporting, that, as far as their experience goes, they have no doubt of the permanent security against the smallpox which is produced by the constitutional affection of the cowpox; and that such has hitherto been their success in vaccination, as also to gain for it the confidence of the public, inasmuch that they have not been required, for some years past, to inoculate any person with smallpox who had not previously undergone the inoculation with the cowpox.

The members of the Royal College have met with no occurrence in their practice of cowpox inoculation which could operate in their minds to its disadvantage; and they beg leave particularly to notice, that they have seen no instance of oblique eruptions, or of new and dangerous diseases, which they could attribute to the introduction among mankind this of mild preventive of smallpox. The Royal College of Surgeons know of no causes which have hitherto retarded the adoption of vaccine inoculation here; on the contrary, the practice has become general within this city; and from many thousand packets of vaccine matter having been sent by the members of the Royal College, and the vaccine institution here, to all parts of the country, the Royal College have reason to believe that the practice has been as generally adopted throughout this part of the united kingdom as could have been expected from the distance of some parts of the country from proper medical assistance, and other circumstances of that nature.

President of the Royal College and Incorporation of Surgeons of Edinburgh.

Royal College of Surgeons in Ireland,
Dublin, February 4th, 1807.

I am directed to transmit to you the inclosed report of a committee of the College of Surgeons in Ireland, to whom was referred a letter from the Royal College

of Physicians in London, relative to the present state of vaccination in this part of the united kingdom; and to state, that the College of Surgeons will be highly gratified by more frequent opportunities of corresponding with the English College of Physicians on any subject which may conduce to the advancement of science, and the welfare of the public.

At a meeting of the Royal College of Surgeons in Ireland, holden at their Theatre, on Tuesday the 13th day of January 1807.

Mr Johnson reported from the committee, to whom was referred a letter from the College of Physicians, London, relative to the present state of vaccination in the united kingdom, &c. &c. that they met, and came to the following resolutions:

That it appears to this committee, That inoculation with vaccine infection is now very generally adopted by the surgical practitioners in this part of the united kingdom, as a preventive of smallpox.

That it appears to this committee, that from the 25th day of March 1800 to the 25th of November 1806, 11,504 persons have been inoculated with vaccine infection at the dispensary for infant poor, and 2831 at the cowpox institution, making a total of 14,335, exclusive of the number inoculated at hospitals and other places, where no registry is made and preserved.

That it is the opinion of this committee, that the cowpox has been found to be a mild disease, and rarely attended with danger, or any alarming symptom, and that the few cases of smallpox which have occurred in this country, after supposed vaccination, have been satisfactorily proved to have arisen from accidental circumstances, and cannot be attributed to the want of efficacy in the genuine vaccine infection as a preventive of smallpox.

That it is the opinion of this committee, that the causes which have hitherto retarded the more general adoption of vaccination in Ireland, have, in a great measure, proceeded from the prejudices of the lower classes of the people, and the interest of some irregular practitioners.

After this report, we cannot help thinking that the British legislature would be fully warranted for passing an act prohibiting the inoculation of smallpox under very severe penalties, and ordering all those who may be subjected to smallpox by accidental contagion to be confined to lazarettos, or at least to their own houses, under a proper guard, to prevent the communication of infection, till their complete recovery. By such an act, there is good ground to believe, that the loathsome and dangerous disease of smallpox would in a few years be exterminated in Britain.

But although providence has thus furnished mankind with an easy mode of preserving their offspring from the danger of smallpox, by the inoculation of the cowpox at an early period of life, yet not a few deaths from the natural smallpox have occurred in Britain even during the course of the present year.

When the preventive has not been duly employed, after the contagion of variola is introduced into the body, nothing yet known will prevent the disease from running its course, either under the mild or confluent form; and the endeavours of the medical practitioner are altogether to be employed in rendering that course as favourable as possible by mitigating symptoms.

In the mild or distinct smallpox, the strictest anti-phlogistic regimen is to be enjoined. Gentle refrigerant cathartics are often useful, and mild diuretics should be copiously employed. Under these remedies the disease will generally run its course without much inconvenience. But it will sometimes be necessary to employ remedies for obviating particular urgent symptoms, such as gargarisms or blisters for affections of the throat.

In the malignant smallpox, besides the same refrigerant plan of cure which is best accommodated to the mild, as the secondary fever shews evident marks of a putrid tendency, it is necessary to employ those remedies which are accommodated to typhus, and accordingly recourse is not only had to opiates and cardiacs, but to wine, cinchona, and the mineral acids.

Genus XXIX. VARICELLA.

CHICKENPOX.

Varicella, Vog. 42.

Variola lymphatica, Saut. sp. 1.

Anglis, The Chickenpox, Edin. Med. Essays, vol. ii.

art. 2. near the end. Heberden, Med. Transact.

art. 17. The Watery-Pox.

This is in general a very slight disease; and is attended with so little danger, that it would not merit any notice, if it were not apt to be confounded with the smallpox, and thus give occasion to an opinion that a person might have the smallpox twice in his life; or they are apt to deceive into a false security those who have never had the smallpox, and make them believe that they are safe when in reality they are not. This eruption breaks out in many, according to Dr Heberden, without any illness or previous sign; in others it is preceded by a slight degree of chills, lassitude, cough, broken sleep, wandering pains, loss of appetite, and feverish state for three days.

In some patients the chickenpox make their first appearance on the back; but this perhaps is not constant. Most of them are of the common size of the smallpox, but some are less. Dr Heberden never saw them confluent, nor very numerous. The greatest number was about 12 on the face, and 200 over the rest of the body.

On the first day of the eruption they are reddish. On the second day there is at the top of most of them a very small bladder, about the size of a millet seed. This is sometimes full of a watery and colourless, some-

times of a yellowish liquor, contained between the cuticle and skin. On the second, or, at the farthest, on the third day from the beginning of the eruption, as many of these pocks as are not broken seem arrived at their full maturity; and those which are fullest of that yellow liquor very much resemble what the genuine smallpox are on the fifth or sixth day, especially where there happens to be a larger space than ordinary occupied by the extravasated serum. It happens to most of them, either on the first day that this little bladder arises, or on the day after, that its tender cuticle is burst by the accidental rubbing of the clothes, or by the patient's hands to allay the itching which attends this eruption. A thin scab is then formed at the top of the pock, and the swelling of the other part abates, without its ever being turned into pus, as it is in the smallpox. Some few escape being burst; and the little drop of liquor contained in the vesicle at the top of them, grows yellow and thick, and dries into a scab. On the fifth day of the eruption they are almost all dried and covered with a slight crust. The inflammation of these pocks is very small, and the contents of them do not seem to be owing to suppuration, as in the smallpox, but rather to what is extravasated under the cuticle by the serous vessels of the skin, as in a common blister. It is not wonderful, therefore, that this liquor appears so soon as on the second day; and that, upon the cuticle being broken, it is presently succeeded by a slight scab: hence too, as the true skin is so little affected, no mark or scar is likely to be left, unless in one or two pocks, where, either by being accidentally much fretted, or by some extraordinary sharpness of the contents, a little ulcer is formed in the skin.

The patients scarce suffer any thing throughout the whole progress of this illness, except some languidness of strength, spirits, and appetite; all which is probably owing to the confining of themselves to their chamber.

Remedies are not likely to be much wanted in a disease attended with hardly any inconvenience, and which in so short a time is certainly cured of itself.

The principal marks by which the chickenpox may be distinguished from the smallpox are,

1. The appearance, on the second or third day from the eruption, of that vesicle full of serum upon the top of the pock.

2. The crust, which covers the pocks on the fifth day; at which time those of the smallpox are not at the height of their suppuration.

Foreign medical writers hardly ever mention the name of this distemper: and the writers of our own country scarce mention any thing more of it than its name. Morton speaks of it as if he supposed it to be a very mild genuine smallpox. But these two distempers are certainly totally different from one another, not only on account of their different appearances above mentioned, but because those who have had the smallpox are capable of being infected with the chickenpox; but those who have once had the chickenpox are not capable of having it again, though to such as have never had this distemper, it seems as infectious as the smallpox. Dr Heberden wetted a thread in the most concocted pus-like liquor of the chickenpox which he could find; and after making a slight incision,

tion, it was confined upon the arm of one who had formerly had it; the little wound healed up immediately, and showed no signs of any infection.

From the great similitude between the two distempers, it is probable, that instead of the smallpox, some persons have been inoculated from the chickenpox; and that the distemper which has succeeded, has been mistaken for the smallpox by hasty or unexperienced observers.

There is sometimes seen an eruption, concerning which Dr Heberden is in doubt whether it be one of the many unnoticed cutaneous diseases, or only a more malignant sort of chickenpox.

This disorder is preceded for three or four days by all the symptoms which forerun the chickenpox; but in a much higher degree. On the fourth or fifth day the eruption appears, with a very little abatement of the fever: the pains likewise of the limbs and back still continue, to which are joined pains of the gums. The pox are redder than the chickenpox, and spread wider; and hardly rise so high, at least not in proportion to their size. Instead of one little head or vesicle of a ferous matter, these have from four to ten or twelve. They go off just like the chickenpox, and are distinguishable from the smallpox by the same marks; besides which, the continuance of the pains and fever after the eruption, and the degree of both these, though there be not above 20 pox, are circumstances never happening in the smallpox.

Rubeola, Sauv. gen. 94. Lin. 4. Sag. 293.
Febris morbillosa, Veg. 36. Hoffm. II. 62.
Morbilli, Junck. 76.

Rubeola vulgaris, Sauv. sp. 1.
Morbilli regulares, Sydenh. lect. iv. cap. 5.

Rubeola anomala, Sauv. sp. 2.
Morbilli anomali, Sydenh. lect. v. cap. 3.

In Scotland commonly called the Nirles.

Rubeola variolodes, Sauv. sp. 3.

Description. This disease begins with a cold stage, which is soon followed by a hot, with the ordinary symptoms of thirst, anorexia, anxiety, sickness, and vomiting; and these are more or less considerable in different cases. Sometimes from the beginning the fever is sharp and violent: often, for the first two days, it is obscure and inconsiderable; but always becomes violent before the eruption, which commonly happens on the fourth day. This eruptive fever, from the beginning of it, is always attended with hoarseness, a frequent hoarse dry cough, and often with some difficulty of breathing. At the same time, the eyelids

VOL. XIII. Part I.

are somewhat swelled; the eyes are a little inflamed, and pour out tears; and with this there is a coryza, and frequent sneezing. For the most part, a constant drowsiness attends the beginning of this disease. The eruption, as we have said, commonly appears upon the fourth day, first on the face, and successively on the lower parts of the body. It appears first in small red points; but, soon after, a number of these appear in clusters, which do not arise in visible pimples, but, by the touch, are found to be a little prominent. This is the case on the face; but, in other parts of the body, the prominence, or roughness, is hardly to be perceived. On the face, the eruption retains its redness, or has it increased for two days; but on the third, the vivid redness is changed to a brownish red; and in a day or two more the eruption entirely disappears, while a mealy desquamation takes place. During the whole time of the eruption, the face is somewhat turgid, but seldom considerably swelled. Sometimes, after the eruption has appeared, the fever ceases entirely: but this is seldom the case; and more commonly the fever continues or is increased after the eruption, and does not cease till after the desquamation. Even then the fever does not always cease, but continues with various duration and effect. Though the fever happen to cease upon the eruption's taking place, it is common for the cough to continue till after the desquamation, and sometimes much longer. In all cases, while the fever continues, the cough also continues, generally with an increase of the difficulty of breathing; and both of these symptoms sometimes arise to a degree which denotes a pneumonic affection. This may happen at any period of the disease; but very often it does not come on till after the desquamation of the eruption.

After the same period, also, a diarrhoea frequently comes on, and continues for some time.

It is common for measles, even when they have not been of a violent kind, to be followed by inflammatory affections, particularly ophthalmia and phthisis. If blood be drawn from a vein in the measles, with circumstances necessary to favour the separation of the fibrine, this always appears separated, and lying on the surface of the crassamentum, as in inflammatory diseases. For the most part, the measles, even when violent, are without any putrid tendency; but in some cases, such a tendency appears both in the course of the disease, and especially after the ordinary course of it is finished.

Causes. The measles are occasioned by a peculiar kind of contagion, the nature of which is not understood; and which, like that of the smallpox, affects a person only once in his life.

Prognosis. From the description of this distemper already given, it appears that the measles are attended with a catarrhal affection, and with an inflammatory diathesis to a considerable degree; and therefore the danger of them is to be apprehended chiefly from the coming on of a pneumonic inflammation.

Cure. In measles, as well as in smallpox, the disease from its nature must necessarily run a determined course; and therefore the sole aim of a practitioner is to conduct this course in the easiest manner, by preventing and obviating urgent symptoms.

From the consideration mentioned in the prognosis,

U u

8

it will be obvious, that the remedies especially necessary are those which may obviate and diminish the inflammatory diathesis; and therefore, in a particular manner, blood-letting. This remedy may be employed at any time in the course of the disease, or after the ordinary course of it is finished. It is to be employed more or less, according to the urgency of the symptoms of fever, cough, and dyspnea; and generally may be employed very freely. But as the symptoms of pneumonic inflammation seldom come on during the eruptive fever, and as this is sometimes violent immediately before the eruption, though a sufficiently mild disease be to follow; bleeding is seldom very necessary during the eruptive fever, and may often be reserved for the times of greater danger which are perhaps to follow.

In all cases of measles, where there are no marks of putrescency, and where there is no reason, from the known nature of the epidemic, to apprehend putrescency, bleeding is the remedy most to be depended upon: but assistance may also be drawn from cooling purgatives; and from blistering on the sides or between the shoulders. The dry cough may be alleviated by the large use of demulcent pectorals, mucilaginous, oily, or sweet. It may, however, be observed, with respect to these demulcents, that they are not so powerful in involving and correcting the acrimony of the mass of blood as has been imagined; and that their chief operation is by lubricating the fauces, and thereby defending them from the irritation of acrids, either arising from the lungs or distilling from the head. For moderating and quieting the cough in this disease, opiates certainly prove the most effectual means, whenever they can be safely employed. In the measles, in which an inflammatory state prevails in a considerable degree, opiates have indeed by some been supposed to be inadmissible: but experience abundantly demonstrates, that the objection made to their use is merely hypothetical: and even in cases where, from a high degree of pyrexia and of dyspnea, there is reason to fear the presence, or at least the danger, of pneumonic inflammation, opiates are highly useful, after bleeding, to obviate or abate the inflammatory state, has been duly employed: in such cases, while the cough and watchfulness are the urgent symptoms, opiates may be safely exhibited, and with great advantage. In all the exanthemata, there is an acrimony diffused over the system, which gives a considerable irritation; and, for obviating the effects of this, opiates are useful, and always proper, when no particular contraindication prevails.

When the desquamation of the measles is finished, though then there should be no disorder remaining, physicians have thought it necessary to purge the patient several times, with a view to draw off what have been called the dregs of this disease; that is, a portion of the morbid matter which is supposed to remain long in the body. Dr Cullen does not reject this supposition; but at the same time cannot believe that the remains of the morbid matter, diffused over the whole mass of blood, can be wholly drawn off by purging; and therefore thinks, that, to avoid the consequence of the measles, it is not the drawing off the morbid matter which we need to study, so much as to obviate and remove the inflammatory state of the system which had been induced by the disease. With this last view,

indeed, purging may still be a proper remedy; but bleeding, in proportion to the symptoms of inflammatory disposition, is still more so.

From our late experience of the use of cold air in the eruptive fever of the smallpox, some physicians have been of opinion that the practice may be transferred to the measles; but this point has not yet been determined by sufficiently extensive experience. We are certain, that external heat may be very hurtful in the measles, as in most other inflammatory diseases; and therefore, that the body ought to be kept in a moderate temperature during the whole course of the disease: but how far, at any period of the disease, cold air may be applied with safety, is still uncertain. Analogy, though so often the resource of physicians, is frequently fallacious; and further, though the analogy with the smallpox might lead to the application of cold air during the eruptive fever of the measles, the analogy with catarrh seems to be against the practice.

When the eruption is upon the skin, there are many instances of cold air making it disappear, and thereby producing much disorder in the system; and there are also frequent instances of these symptoms being removed by restoring the heat of the body, and thereby again bringing out the eruption.

Upwards of 20 years ago, inoculation for the measles was proposed, and practised in several instances with success, by Dr Home of Edinburgh. His method of communicating the infection was, by applying to an incision in each arm cotton moistened with the blood of a patient labouring under the measles; but with others who have made similar trials, the attempt has not yet succeeded. Attempts have been made to inoculate this disease by means of the fluid discharged under the form of tears, the squames falling from the surface, and the like; but there is reason to believe, that where it was imagined the infection had thus been communicated, the contagion was only carried about the person inoculating and communicated in the ordinary way.

From inoculation of the measles, it is imagined that several advantages may be obtained; and among others, it is thought the soreness of the eyes may be mitigated, the cough abated, and the fever rendered less severe. But the practice was never much employed, and now is scarce ever heard of.

Genus XXXI. MILIARIA.

The MILIARY FEVER.

Miliaria, Lib. 7.

Miliaris, Sawv. gen. 95. Sag. gen. 295.

Febris miliaris, Vog. 37.

Febris purpurata rubra et alba miliaris, Hoffm. II. 68.

Febris purpurea seu miliaris, Junck. 75.

Germanis der Friesel. God. Welsch. Hist. Med. de novo pauperarum morbo, qui der Friesel dicitur, Lips. 1655.

Hamilton, de febr. miliar. 1710. Fontanus, de febr. mil. 1747. Allioni de miliar. 1758. Fordyce, de febr. mil. 1748. Fischer, de febr. mil. 1767. De Haen, de divis. febr. 1760, et in Ration. med. passim. Matt. Collin ad Baldinger de miliar. 1764.

Miliaris

Miliaris benigna, Sauv. sp. 1.
Miliaris maligna, Sauv. sp. 2.
Miliaris recidivans, Sauv. sp. 3.
Miliaris Germanica, Sauv. sp. 5.
Miliaris Boia, Sauv. sp. a.
Miliaris Britannica, Sauv. sp. i.
Miliaris nova febris, Sydenh. Sched. monit. Sauv. sp. d.
Miliaris sudatoria, Sauv. sp. e.
Miliaris nautica, Sauv. sp. g.
Miliaris purpurata, Sauv. sp. h.
Miliaris lactea, Sauv. sp. c.
Miliaris puerperarum, Sauv. sp. k.
Miliaris scorbutica, Sauv. sp. l.
Miliaris critica, Sauv. sp. b.

History and Description. This disease is said to have been unknown to the ancients, and that it appeared for the first time in Saxony about the middle of the last century. It is said to have since spread from thence into all the other countries of Europe; and since the period mentioned, to have appeared in many countries in which it had never appeared before.

From the time of its having been first taken notice of, it has been described and treated of by many different writers; and by all of them, till very lately, has been considered as a peculiar idiopathic disease. It is said to have been constantly attended with peculiar symptoms. It comes on with a cold stage, which is often considerable. The hot stage, which follows, is attended with great anxiety, and frequent sighing. The heat of the body becomes great, and soon produces profuse sweating, preceded, however, with a sense of pricking, as of pin points in the skin; and the sweat is of a peculiar rank and disagreeable odour. The eruption appears sooner or later in different persons, but at no determined period of the disease. It seldom or never appears upon the face; but appears first upon the neck and breast, and from thence often spreads over the whole body.

The eruption named miliary, is said to be of two kinds; the one named the red, the other the white miliary. The former, which in English is strictly named a rust, is commonly allowed to be a symptomatic affection; and as the latter is the only one that has any pretensions to be considered as an idiopathic disease, it is this only that we shall more particularly describe and treat of under this genus.

What is then called the white miliary eruption, appears at first like the red, in very small red pimples, for the most part distinct, but sometimes clustered together. Their little prominence is better distinguished by the finger than by the eye. Soon after the appearance of this eruption, and, at least, on the second day, a small vesicle is visible upon the top of the pimples. At first the vesicle is whey-coloured: but soon becomes white, and stands out like a little globule. In two or three days, these globules break, or are rubbed off; and are succeeded by small crusts, which soon after fall off in small scales. While one set of pimples takes this course, another set arises to run the same; so that the disease often continues upon the skin for many days together. Sometimes when one crop of this eruption has disappeared, another, after some interval, is

produced. And it has been further observed, that in some persons there is such a disposition to this disease, that they have been affected with it several times in the course of their lives.

This disease is said to affect both sexes, and persons of all ages and constitutions: but it has been observed at all times, to affect especially, and most frequently, lying-in women.

It is often accompanied with violent symptoms, and has frequently proved fatal. The symptoms, however, attending it are very various; but no symptom, or concurrence of symptoms, are steadily the same in different persons, so as to give any specific character to the disease. When the disease is violent, the most common symptoms are phrenetic, comatose, and convulsive affections, which are also symptoms of all fevers treated by a very warm regimen.

While there is such a variety of symptoms appearing in this disease, it is not to be expected that any one particular method of cure can be proposed; and, accordingly, we find in different writers different methods and remedies prescribed; frequent disputes about the most proper; and those received and recommended by some opposed and deserted by others.

It appears, however, to Dr Cullen, very improbable, that this was really a new disease, when it was first considered as such. There are very clear traces of it in authors who wrote long before that period; and though there were not, we know that ancient descriptions were often inaccurate and imperfect, particularly with respect to cutaneous affections; and we know also that those affections which commonly appeared as symptomatic only, were often neglected, or confounded together under a general appellation.

The antecedent symptoms of anxiety, sighing, and pricking of the skin, which have been spoken of as peculiar to this disease, are, however, common to many others; and perhaps to all those in which sweatings are forced out by a warm regimen. Of the symptoms said to be concomitant of this eruption, there are none which can be affirmed to be constant and peculiar but that of sweating. This, indeed, always precedes and accompanies the eruption: and, while the miliary eruption attends many different diseases, it never, however, appears in any of these but after sweating; and in persons labouring under the same disease it does not appear, if in such persons sweating be avoided. It is therefore probable, that the eruption is the effect of sweating: and that it is the effect of a matter not before prevailing in the mass of blood, but generated under particular circumstances in the skin itself. That it depends upon particular circumstances of the skin, is also probable from its being observed that the eruption seldom or never appears upon the face, although it affects the whole of the body besides; and that it comes upon those places especially which are more closely covered; and that it can be brought out upon particular places by external applications.

It is to be observed, that this eruptive disease differs from the other exanthemata in many circumstances, especially the following; that it is not contagious, and therefore never epidemic; that the eruption appears at no determined period of the disease; that the eruption has no determined duration; that successive eruptions frequently appear in the course of the same fever,

fever, and that such eruptions frequently recur in the course of the same person's life. All this renders it very probable, that, in the miliary fever, the morbid matter is not a subsisting contagion communicated to the blood, and thence, in consequence of fever and assimilation, thrown out upon the surface of the body, but a matter occasionally produced in the skin itself by sweating.

This conclusion is further rendered probable from hence, that, while the miliary eruption has no symptoms or concurrence of symptoms peculiar to itself, it, upon occasions, accompanies almost every febrile disease, whether inflammatory or putrid, if these happen to be attended with sweating; and from thence it may be presumed, that the miliary eruption is a symptomatic affection only, produced in the manner we have said.

But as this symptomatic affection does not always accompany every instance of sweating, it may be proper to inquire, what are the circumstances which especially determine this eruption to appear? And to this Dr Cullen gives no full and proper answer. He cannot say that there is any one circumstance which in all cases gives occasion to this eruption; nor can he say what different causes, in different cases, may give occasion to it. There is only one observation that can be made to the purpose; and it is, that these persons, sweating under febrile diseases, are especially liable to the miliary eruption, who have been previously weakened by large evacuations, particularly of blood. This will explain why it happens to lying-in women more frequently than to any other persons; and to confirm this explanation, he has observed, that the eruption has happened to other women, though not in childbirth, but who had been much subjected to a frequent and copious menstruation, and to an almost constant fluor albus. He has also observed it to have happened to men in fevers, after wounds from which they had suffered a great loss of blood.

Further, That this eruption is produced by a certain state of debility, is, he thinks, probable, from its so often attending fevers of the putrid kind, which are always accompanied with great debility. It is true, that it also sometimes attends inflammatory diseases, when it cannot be accounted for in the same manner; but he believes it may be observed, that it especially attends those inflammatory diseases in which the sweats have been long protracted, or frequently repeated, and which have thereby produced a debility, and perhaps a debilitating putrid diathesis.

That, however, the miliary eruption is not necessarily or even generally connected with a certain state of debility, is abundantly evident from its being entirely wanting in by much the greater number of instances of typhoid fever, and in a variety of other diseases where every possible degree of debility occurs: And that it is not connected with any certain state of debility, still farther appears, both from the condition of those affected with it in different instances, which in point of strength is very various; and likewise from the continuance of fresh eruptions with the same individual, although during that time in very different states with respect to debility. It appears, therefore, much more probable, that it depends on some peculiar state of the surface, induced by the concurring influence of certain predisposing and occasional causes.

It appears so clearly that this eruption is always a symptomatic and facultitious affection, that Dr Cullen is persuaded it may be, in most cases, prevented merely by avoiding sweats. Spontaneous sweatings, in the beginning of diseases, are very rarely critical; and all sweatings not evidently critical should be prevented, or at least moderated; and the promoting them, by increasing external heat, is commonly very pernicious. Even critical sweats should hardly be encouraged by such means. If, therefore, spontaneous sweats arise, they are to be checked by the coolness of the chamber; by the lightness and looseness of the bedclothes; by the persons laying out their arms and hands; and by their taking cold drink: and in this way Dr Cullen thinks he has frequently prevented miliary eruptions, which were otherwise likely to have appeared, particularly in puerperal women.

But it may happen, when these precautions have been neglected, or from other circumstances, that a miliary eruption does actually appear; and the question will then be put, how the case is to be treated? This is a question of consequence; as there is reason to believe that the matter here generated is often of a virulent kind; it is often the offspring of putrefaction; and, when treated by increasing the external heat of the body, it seems to acquire a virulence which produces those symptoms mentioned above, and proves certainly fatal.

It has been an unhappy opinion with most physicians, that eruptive diseases were ready to be hurt by cold; and that it was therefore necessary to cover up the body very closely, and thereby increase the external heat. We now know that this is a mistaken opinion; that increasing the external heat of the body is very generally mischievous; and that several eruptions not only admit, but require the application of cold air. Dr Cullen is persuaded, therefore, that the practice which formerly prevailed in the case of miliary eruptions, of covering up the body closely, and both by external means and internal remedies encouraging the sweatings which accompany this eruption, was highly pernicious, and commonly fatal. He is therefore of opinion, that even when a miliary eruption has appeared, in all cases in which the sweating is not manifestly critical, we should employ all the means of stopping the sweating that are mentioned above; and he has sometimes had occasion to observe, that even the admission of cool air was safe and useful.

This is, in general, the treatment of miliary eruptions: but at the same time, the remedies suited to the primary disease are to be employed; and therefore when the eruption happens to accompany inflammatory affections, and the fulness and hardness of the pulse or other symptoms show an inflammatory state present, the case is to be treated by blood-letting, purging, and other antiphlogistic remedies.

On the other hand, when the miliary eruption attends diseases, in which debility and putrefaction prevail, it will be proper to avoid all evacuations, and to employ tonic and antiseptic remedies, particularly the cinchona, cold drink, and cold air.

The most distressing circumstance attending this affection, is the almost unsupportable sickness at stomach which frequently occurs, and which is often observed to precede fresh eruptions taking place during the

the course of the disease. With the view of counteracting and alleviating this symptom, recourse is had to wine and other cordial medicines. But with many patients nothing is found to have so much influence as the use of camphor, particularly when introduced gradually in small doses, under the form of the mistura camphorata of the London Pharmacopoeia, or of the emulſio camphorata of that of Edinburgh.

Scarlatina, Sauv. gen. 98. Vog. 39. Sag. 294. Junck. 75.

Scarlatina febris, Sauv. sp. 1. Sydenham, sect vi. cap. 2.

Scarlatina anginosa, Withering on the Scarlet Fever.

The mild scarlet fever is described by Sydenham, who tells us that he can scarce account it a disease; and indeed nothing more seems to be necessary in the treatment of it than an antiphlogistic regimen, avoiding the application of cold air and cold drink. The disease, however, often rages epidemically, and is attended with very alarming symptoms, in which case it is called scarlatina anginosa.—The best description of this distemper has been published by Dr. Withering in the year 1778. This disease made its appearance, we are told, at Birmingham and the neighbouring villages, about the middle of May 1778. It continued in all its force and frequency to the end of October; varying, however, in some of its symptoms, as the air grew colder. In the beginning of November it was rarely met with; but towards the middle of that month, when the air became warmer, it increased again, and in some measure resumed those appearances it possessed in the summer months, but which it had lost during the cold winds in October.

It affected children more than adults; but seldom occurred in the former under two years of age, or in the latter if they had passed their fiftieth year.

Description. With various general symptoms of fever, the patient at first complains of a dejection of spirits, a slight soreness or rather stiffness in the neck, with a sense of straitness in the muscles of the neck and shoulders, as if they were bound with cords. The second day of the fever this soreness in the throat increases, and the patients find a difficulty in swallowing: but the difficulty seems less occasioned by the pain excited in the attempt, or by the straitness of the passage, than by an inability to throw the necessary muscles into action. The skin feels hot and dry, but not hard; and the patients experience frequent, small, pungent pains, as if touched with the point of a needle. The breath is hot and burning to the lips, and thirst makes them wish to drink; but the tendency to sickness, and the exertions necessary in deglutition, are so unpleasant, that they seldom care to

drink much at a time. They have much uneasiness also from want of rest during the night. In the morning of the third day, the face, neck and breast, appear redder than usual: in a few hours this redness becomes universal; and increases to such a degree of intensity, that the face, body, and limbs, resemble a boiled lobster in colour, and are evidently swollen. Upon pressure the redness vanishes, but soon returns again. The skin is smooth to the touch, nor is there the least appearance of pimples or pustules. The eyes and nostrils partake more or less of the general redness; and in proportion to the intensity of this colour in the eyes, the tendency to delirium prevails.

Things continue in nearly this state for two or three days longer, when the intense scarlet gradually abates, a brown colour succeeds, and the skin becoming rough, peels off in small scales. The tumefaction subsides at the same time, and the patients gradually recover their strength and appetite.

During the whole course of the disease, the pulse is quick, small, and uncommonly feeble, the urine small in quantity; the sub-maxillary glands somewhat enlarged and painful to the touch. The velum pendulum palati, the uvula, the tonsils, and gullet, as far as the eye can reach, partake of the general redness and tumefaction; but although collections of thick mucus, greatly resembling the specks or sloughs in the putrid sore throat, sometimes occur, yet those are easily washed off; and real ulcerations of those parts were never observed.

These are the most usual appearances of this disorder; but it too frequently assumes a much more fatal form. In some children the delirium commences in a few hours after the first attack; the skin is intensely hot; the scarlet colour appears on the first or second day, and they die very early on the third. Others again, who survive this rapid termination, instead of recovering, as is usual, about the time the skin begins to get its natural colour, fall into a kind of lingering, and die at last in the course of six or eight weeks.

In adults, circular livid spots were frequently observed about the breast, knees, and elbows; also large blotches of red, and others of white intermixed, and often changing places.

In the month of October, when the air became colder, the scarlet colour of the skin was both less frequent and less permanent. Many patients had no appearance of it at all; while others, especially adults, had a few minute red pimples, crowned with white pellucid heads. The inside of the throat was considerably tumefied, its colour a dull red, sometimes tending to a livid. The pulse beat in general 130 or 140 strokes in a minute; was small, but hard, and sometimes sufficiently so to justify the opening of a vein; and the blood thus taken away, in every instance, when cool, appeared fizy, and the whole crassamentum firm.

Happy would it be, Dr. Withering observes, if the baneful influence of this disorder terminated with the febrile symptoms. But in ten or fifteen days from the cessation of the fever, and when a complete recovery might be expected, another train of symptoms occurs, which at last frequently terminate fatally. The patients, after a few days amendment, feel a something that prevents their farther approach to health;

health; an unaccountable languor and debility prevails, a stiffness in the limbs, an accelerated pulse, disturbed sleep, distaste to food, and a scarcity of urine. These symptoms, we are told, are soon succeeded by swellings of a real dropical nature, forming sometimes an anasarca, and on other occasions an ascites; and not unfrequently scarlatina has proved fatal, from supervening hydrothorax in consequence of the effusion of water into the chest. It is unnecessary to remark, that when this happens, a fatal termination is more sudden than from any other modification of dropy.

Dr Withering, after examining the accounts given of this disease by different authors, proceeds to the diagnosis. It may be distinguished, he observes, from the petechial fever, by the eruption in the latter appearing seldom before the fourth day, by the regularity and distinctness of the spots, and by its principally occupying the neck, the back, and the loins. On the other hand, in the scarlet fever, the eruption generally appears about the third day; and consists either of broad blotches, or else one continued redness, which spreads over the face and the whole body.

In the fever called purpura, the pustules are prominent, keep their colour under pressure, and never appear early in the disease; whereas in the scarlet fever, the eruption appears more early, is not prominent, but perfectly smooth to the touch, and becomes quite white under pressure.

Although the purple fever and scarlatina may be connected by some general cause, yet our author takes occasion to observe, that they cannot be mere modifications of the same eruption: for examples occur, he says, of the same person being first seized with one of these disorders, and afterwards with the other; but he never met with an instance of the same person having the scarlet fever twice; and he believes it to be as great an improbability as a repetition of the smallpox.

This disorder is particularly distinguished from the measles, we are told, by the want of that cough, watery eye, and running at the nose, which are known to be the predominant symptoms in the early state of the measles, but are never known to exist in the scarlatina.

From the erysipelas this disease is distinguishable, by the limited seat of the former, together with its not being contagious.

The cyanche maligna, however, is according to Dr Withering more difficult to distinguish from this disease than any other; and yet the distinction is, he thinks, a matter of the greatest importance, as the method of treatment, according to him, ought to be extremely different.—Although, in a number of circumstances, these two diseases bear a very great resemblance, yet, with a little attention, the one may in general, he thinks, be distinguished from the other. From Dr Fothergill's account of the sore throat attended with ulcers, our author has made out the following characteristic circumstances of the two diseases, contrasted to one another.

Scarlatina Anginosa.
Season. Summer. Autumn.

Angina Gangrenosa.
Season. Spring. Winter.

Scarlatina Anginosa.
Air. Hot. Dry.
Places. High. Dry. Gravelly.

Subjects. Vigorous. Both sexes alike. Robust in most danger. . . .

Skin. Full scarlet. . . . smooth. . . . If pimply, the pimples white at the top. . . . Always dry and hot.

Eyes. Shining, equable, intense redness, rarely watery.

Throat. In summer, tonsils, &c. little tumefied; no slough. . . . In autumn, more swelled. Integuments separating. . . . Sloughs white.

Breath. Very hot, but not fetid.

Voice. In summer, natural.

Bowels. Regular at the accession.

Blood. Buffy. Firm.

Termination. The 3d, 5th, 8th, or 11th day.

Nature. Inflammatory.

Angina Gangrenosa.
Air. Warm. Moist.
Places. Close. Low. Damp. Marshy.

Subjects. Delicate. Women and female children. Robust adults not in danger.

Skin. Red tinct. . . . pimply. . . . The pimples redder than the interstices. . . . Bedewed with sweat towards morning.

Eyes. Inflamed and watery, or sunk and dead.

Throat. Tonsils, &c. considerably swelled and ulcerated. . . . Sloughs dark brown.

Breath. Offensive to the patients and assistants.

Voice. Flat and rattling.

Bowels. Purging at the accession.

Blood. Florid. Tender.

Termination. No stated period.

Nature. Putrid.

It is not pretended, Dr Withering remarks, that all the above-contrasted symptoms will be met with in every case. It is enough, he observes, that some of them appear; and that if, conjoined with the consideration of the prevailing constitution, they enable us to direct that mode of treatment which will most contribute to the relief of the sick.

But notwithstanding the attention which Dr Withering has bestowed upon this subject, we are still decidedly of opinion, that the disease which he has so accurately described under the title of scarlatina anginosa, is in reality the same affection with the malignant ulcerous sore throat of Huxham and Fothergill. During different epidemics, this disease, like smallpox and measles in different seasons, is considerably varied in its appearance. But still there occurs such a similarity as clearly marks the sameness of the affection. And indeed this, as in the case of the smallpox, is abundantly demonstrated by infection from one contagion giving protection against succeeding ones, although the appearances be much varied. This has particularly appeared at Edinburgh, where the disease has of late prevailed as an epidemic on five different years, viz. 1774-75, 1782-83, 1789-90, 1797-98, and 1804-5. During the first of these occasions, in the greater part of patients, the sore throats were of a very gangrenous and malignant nature: during the second, the disease more commonly appeared under the form of what might be called simple scarlatina: and during the other epidemics, the contagion was, if we may be allowed the expression, of an intermediate nature. But it is farther to be remarked, that during every one of those epidemics, when several children of a family were at the same time subjected

Exanthematic—subjected to the infection, in one the disease would have been attended with almost all the symptoms mentioned in the column of scarlatina anginosa, with respect to skin, eyes, throat, breath, bowels, termination of the affections, &c. In another, would have occurred all the symptoms with respect to those particulars which he has mentioned under the column of angina gangrenosa. While at the same time, in numberless instances, even in the same patient, the disease at its commencement has shown evident marks of an inflammatory, and at its termination of a putrid tendency. And there cannot be a doubt, that both the scarlatina anginosa of Withering, and the cynanche maligna, as described by Fothergill and Huxham, have occurred in every season and situation, and have affected persons of every age and constitution not before subjected to either disease.

Causes. Dr Withering affirms, that the immediate cause of this disease is a poison of a peculiar kind communicable by contagion.

2. That this poison first takes possession of the mucous membrane lining the fauces and the nose; and either by its action upon the secretory glands, or upon the mucus itself, assimilates that mucus to its own nature.

3. That it is from this beginning, and from this only, that it spreads to the stomach, &c. and at length acts upon the system at large.

4. That its first action upon the nerves is of a sedative or debilitating nature.

5. That in consequence of certain laws of the nervous system, when the debilitating effects operate upon the sensorium commune, a reaction takes place; and that this reaction is, cateris paribus, proportioned to the debilitating power.

6. That, in consequence of this reaction of the nervous system, the vibratory motion of the capillary blood-vessels dependant thereon is greatly increased; an unusually large quantity of blood is accumulated in those vessels; the heart and large blood-vessels are deprived of their customary proportion; and hence, though stimulated to more frequent contraction, the pulse must necessarily be feeble.

7. That as violent exertions are followed by debility, upon the cessation of the fever, the capillary vessels, which had acted with such unusual violence, are left in a state of extreme debility, and are long in recovering their tone; hence it is that so many patients afterwards become dropical.

Dr Withering next proceeds to the consideration of the different remedies, which either are at present in common use, or have been recommended as proper in this disease.

Cure. Blood-letting has been recommended by authors; but such was the state of the pulse in this disorder, at least during the summer months, that it was not in any instance thought advisable to take away blood. In some cases, indeed, where the fiery redness of the eyes seemed to demand the use of leeches, they were had recourse to, but never with any advantage. In the harvest months, when the pulse was more firm, and when suffocation seemed to be threatened from the swelling in the fauces, blood-letting was sometimes advised; but still with less advantage than

one would have expected in almost any other situation. Scarlatina.

Vomiting.] This, Dr Withering observes, seems to be the remedy of nature; and he is surprised how it should have been omitted by several authors who have gone before him. Vomiting, he says, most amply fulfils the indications arising both from a consideration of the cause and of the effects; and a liberal use of the remedy he holds forth as the true foundation for successful practice in scarlet fever and sore throat. His common form of emetic is a combination of tartar emetic and ipecacuanha, given in pretty smart doses; and these are to be repeated at least once in 48 hours, and in the worst cases so often as twice in 24 hours.

Purging.] The action of purgatives is considered by Dr Withering as altogether repugnant to the curative indications in this disease: for the poisons, as formerly remarked, being received into the system by the fauces, the operation of a purge, instead of discharging it, can only promote its diffusion along the alimentary canal; and in fact, we are told, that when even a spontaneous purging supervenes in this disease, the patients sink so amazingly fast, that it is not within the reach of art to support them. When, however, a considerable quantity of acrid matter passing from the fauces into the stomach, makes its way to the rectum, a considerable degree of looseness often takes place. And although evacuations from the system in general by means of cathartics may be hurtful, yet patients often obtain great relief from a free discharge of this matter; and by discharging it, purgatives have the effect even of preventing an evacuation from the system, which would otherwise take place.

Sudorifics. Cordials. Alexipharmics.] None of these remedies were found beneficial. With respect to cordials, Dr Withering observes, that although they seem to be indicated by the great loss of strength and feeble pulse, yet the certain consequence of their use always was, an increase of restlessness, of the delirium, and of the heat.

Diuretics.] These were found very beneficial. The vegetable fixed alkali is recommended as the most proper article of this kind: a dram or two may be easily swallowed every 24 hours, by giving a small quantity in every thing the patient drinks. Diuretics, however, have been found principally serviceable, by practitioners in general, in those cases where the urine is observed to be scanty, and where dropical symptoms have taken place.

Cinchona.] No medicine, we are told, ever had a fairer trial in any disease than the Peruvian bark had in this epidemic; for the feeble pulse, great prostration of strength, with here and there a livid spot, were thought to be such undeniable evidences of a putrid tendency, that cinchona was poured down not with a sparing hand. But this was only at first; for these livid spots and the sloughs in the throat being found to be the effects of inflammation instead of putrefaction, and the bark instead of diminishing, rather increasing these symptoms, it was at last entirely laid aside by Dr Withering in his practice. But although cinchona may not have been successful with a particular epidemic at a particular place; yet from the concurring testimony of many practitioners, it is very commonly

mostly found to be productive of good effects: And there is perhaps no remedy on which greater dependence is in general put, particularly in the advanced periods of the disease, where the factor is considerable.

Upon the same principles that cinchona was prescribed, fixable air was at first likewise advised, but with no evident effects either one way or another. Dulcified acids were also had recourse to, but with no advantage.

Opiates.] These, although recommended by some authors for the removal of inquietude and watchfulness, yet in this epidemic, instead of effecting these purposes, always increased the distress of the patient.

Blisters.] In the summer appearance of the disease, blisters were universally detrimental; they never failed to hasten the delirium; and if the case was of the worst kind, they too often confirmed its fatal tendency. But although this may have been the case during the epidemic which Dr Withering describes, it has by no means been generally observed. On the contrary, by the early application of blisters to the external fauces, both the glandular swellings and likewise the discharge from the mouth and fauces have been much diminished; and practitioners have believed, not without probable reason, that the after-affections of the throat were less considerable than would otherwise have been the case.

Injected gargles of contrayerva decoction, sweetened with oxymel of squills, &c. were found very beneficial in bringing always large quantities of viscid ropy stuff from the fauces.

The immersion of the feet and legs in warm water, although it did no harm, yet did not either procure sleep or abate the delirium, as it frequently does in other kinds of fever.

As in summer it was found difficult to keep the patients sufficiently cool, they were ordered to lie upon a mattress instead of a feather-bed; a free circulation of air was kept up; and where the patients strength would admit of it, they were ordered frequently out of doors. Animal food and fermented liquors were denied them, and nothing allowed but tea, coffee, chocolate, milk and water, gruel, barley-water, and such articles.

With respect to the dropical disorder which so frequently succeeds to this complaint, it was never observed, Dr Withering remarks, when the preceding symptoms had been properly treated.

When called upon to patients in the dropical state, he began his practice by a dose of calomel at night, and a purgative in the morning. When a febrile pulse attended the other symptoms, emetics were useful, as well as the saline draughts and other neutral salts. When great debility, comatose or peripneumonic symptoms occurred, blisters were found very serviceable: but when dropical symptoms were the principal cause of complaint, small doses of rhubarb and calomel were advised; recourse was also had to diluted solutions of fixed alkalies, squills, Seltzer waters, and other diuretics.

When the urine flows freely, steel and other tonics are recommended; together with gentle exercise, high-seasoned food, wine, and the wearing of flannel in contact with the skin.

Dr Withering concludes his essay with an enumera-

tion of several cases, treated according to the principles above laid down. The successful termination of these cases demonstrates the propriety of the practice which he has recommended; at least for the epidemic under the form in which it then appeared.

Since Dr Withering's publication, two other practices have obtained considerable celebrity in this disease. The one is dashing cold water on the surface of the body in the manner recommended by Dr Currie in proper fevers. It is, however, very certain that although this may obviate symptoms, and particularly diminish the heat when very urgent, yet it never produces an artificial termination of the disease as some have alleged. When the contagion of scarlatina is introduced into a human body, never before subjected to the disease, it must, like smallpox and measles, run a certain course, and the attention of the practitioner must merely be employed in endeavouring to render that course as mild as he can, principally by obviating urgent symptoms.

The other remedy, lately introduced, and highly commended in scarlatina anginosa, is the oxygenated muriatic acid. This has been particularly extolled by Mr John Ayre Braithwaite, surgeon at Lancaster. One dram of the oxygenated muriatic acid is mixed with eight ounces of distilled water. This quantity he directs to be taken by a patient at the age of puberty every day. But the quantity must be regulated by the age and situation of the patient. This remedy also is only useful as obviating symptoms, particularly the affection of the throat. But with this intention we have often employed it with great advantage.

Febris urticata, Vog. 40.
Uredo, Lin. 8.
Purpura urticata, Junck. 75.
Scarlatina urticata, Sauv. sp. 2.
Erysipelatis species altera, Sydenham, sect. vi. cap. 6.
Febris scarlatina, et febris urticata, Meyferey, Mal. des armées, 291 et seq.

Description. This disease has its English name of nettle-rash from the resemblance of its eruption to that made by the stinging of nettles. These little elevations upon the skin in the nettle-rash often appear instantaneously, especially if the skin be rubbed or scratched, and seldom stay many hours in the same place, and sometimes not many minutes. No part of the body is exempt from them; and where many of them rise together, and continue an hour or two, the parts are often considerably swelled; which particularly happens in the face, arms, and hands. These eruptions will continue to infect the skin, sometimes in one place and sometimes in another, for one or two hours at a time, two or three times every day, or perhaps for the greatest part of the 24 hours.—In some persons they last only a few days, in others many months; nay, sometimes the disease has lasted for years with very short intervals.

But though the eruption of the urticaria resembles, as already observed, that produced by the stinging of nettles,

nettles, it is sometimes accompanied with long weals, as if the part had been struck with a whip. Whatever be the shape of these eminences, they always appear solid, without having any cavity or head containing either water or any other liquor: and this affords an easy mark whereby this disease may be distinguished from the itch. For it often happens, that the insufferable itching with which this eruption is attended, provokes the patient to scratch the parts so violently, that a small part of the cuticle on the top of these little tumors is rubbed off; a little scab succeeds; and, when the swelling is gone down, there is left an appearance hardly to be distinguished from the itch, but by the circumstance just now mentioned. The nettle-rash also further differs from the itch, in not being infectious.

Causes, &c. Dr Heberden is inclined to ascribe this disorder to some mechanical cause outwardly applied to the skin. He observes, that most people suffer in a similar manner from the real stinging of nettles. Cowhage, or, as it is corruptly called, cow-itch, a sort of phaseolus, or French bean, the pod of which is covered over with a kind of down or hair, and the effect of which upon the skin is much the same as that of nettles; and almost any hairs cut equally short, and sprinkled upon the skin, whenever they happen to stick in it, will make the part itch or smart in such a manner as to give great uneasiness; it is also a considerable time before the skin can be cleared of the finer ones, when once they are strewed upon it.

Reaumur, in the fourth memoir of his History of Insects, describes a species of caterpillars to which belong a sort of hairs almost invisible to the naked eye, which are easily detached, and frequently float in the air round their nest, though it have not been at all disturbed. The touch of these hairs has a similar effect with the cow-itch; that is, they occasion intolerable itching, with little bumps and redness, arising sometimes to a slight inflammation. These he found would continue four or five days, if the animal or the nest had been much handled; and though they had not been touched at all, yet, by only walking near their nests, the same effects would be brought on, but for a shorter time. These hairs affect the skin in this manner by sticking in it, as he could perceive with a glass of a great magnifying power; for with one of a small power they were not visible. The uneasy sensations caused by these small wounds, not only, as he says, last several days, but move from one part of the body to another; so that they will cease upon one wrist, and immediately begin on the other; from the wrist they will go to the fingers or the face, or even to the parts of the body which are covered. He supposes, that the motions of the body, when much of this fine down lies near or upon the skin, may drive it from one part to another, or change what was lying there insensitively to a situation fit to make it penetrate into the skin. Neither cold water, nor oil, nor spirit of wine, with which the parts affected were bathed, had any effect in removing the itching. He thinks the most efficacious remedy which he tried for this complaint was, to rub the parts strongly with parsley, which instantly lessened the sensations, and after two or three hours, entirely freed the patient from them. It is also well known, that many species of caterpillars, by only walking over the hands,

will produce something like this effect on the parts which they touch, and undoubtedly from the same cause.

Dr Heberden asks, Is it impossible that the nettle-rash should arise from the same causes, or from others similar, which we miss by looking too deeply for them in the blood and humours? Such, says he, may have been its origin in some instances, where it has lasted only a few days; but where this affection has continued for some years, in persons who change their linen every day, and who bathe frequently all the time, it can hardly be ascribed to such an external cause. He has observed it frequently to arise from cantharides: but though it has continued many weeks after the removal of the blister, yet it might be suspected that this arose from the fine spicule of the cantharides sticking all this time about the skin; it being customary to strew much of the dry powder of the cantharides over the blister-plaster, whence it may readily be carried to other parts of the body. But it is certain that similar effects will sometimes follow the internal use of wild valerian root, or the eating of fish not sufficiently dressed; mussels, shrimps, and even honey, and the kernels of fruits, will also sometimes produce symptoms of a similar kind. But whatever be its cause, Dr Heberden never saw any reason to suppose that the nettle-rash had in any way vitiated the humours to such a degree as to require the use of internal remedies; and if the itching could be certainly and expeditiously allayed, there would be no occasion for any farther cure. He concludes this history of the disorder with a case communicated to him by Dr Monsey, physician of Chelsea College, and in which the disease appeared with uncommon violence.

W. A. aged near 30, of a thin spare habit, was seized with a disorder attended with symptoms of a very uncommon kind. Whenever he went into the air, if the sun shined bright, he was seized with a tickling of his flesh on those parts exposed to the sun: this tickling, by his continuing in the air, increased to a violent itching, attended with great heat and pain: the skin would then be almost as red as vermilion, and thicken like leather; and this remained till he went out of the open air, and then abated in about 15 or 20 minutes. This happened only when the sun was above the horizon; at other times he was what he called quite well.—But it was not owing to the heat of the sun; for the sun in winter affected him full as much, if not more, and the heat of the fire had no such effect. Thus he was confined to the house for 10 years. He tried several hospitals, and had advices from many physicians, without the least abatement of his complaints. At last it was agreed by a consultation of physicians, that he should try dipping in salt water; which he did at Yarmouth for 13 weeks, without any visible amendment. One hot day, having pulled off his clothes and gone into the sea in the middle of the day, the heat diffused itself so violently all over his body, that, by the time he had put on his clothes, his eyesight began to fail, and he was compelled to lie down upon the ground to save himself from falling. The moment he lay down, the faintness went off: upon this he got up again; but had no sooner arisen, than he found himself in the former condition: he therefore lay down

down again, and immediately recovered. He continued alternately getting up and lying down, till the disorder began to be exhausted, which was in about half an hour; and he was frequently obliged to have recourse to the same expedient.

Having at last accidentally met with Dr Monsey, this physician questioned him concerning the cause of the disorder; but nothing could be guessed at, excepting that the patient owned he had one winter lived entirely upon bullock's liver and porter, from inability to purchase better victuals. A comrade lived with him at that time, on the same provisions; and he also was affected in a similar manner, though in a less degree, and had recovered. This patient was then first put upon a course of Dover's sweating powder without any effect, and afterwards tried a course of nitrous ones with the same bad success. At last Dr Monsey determined to try the effect of mercury, which happily proved effectual in removing this obstinate and uncommon distemper. The patient began with taking five grains of calomel for three nights running, and a cathartic next morning. In this course he went on for near a fortnight, at the end of which he found himself very sensibly relieved. This encouraged him to go on rather too boldly, by which means a slight salivation ensued; however, that went off soon, and in about six weeks he was quite well.—Some time after, he was threatened with a return of his disorder; but this was effectually relieved by a dose of calomel, which he had afterwards occasion to repeat for the same reason, and with the same success; but at last the disorder seemed to be radically cured, by his having no further symptoms of a relapse.

Pemphigus, Sauv. gen. 93. Sag. 291.

Morta, Lin. 1.

Febris bullosa, Pog. 41.

Pemphigus major, Sauv. sp. 1.

Exanthemata serosa, C. Pison. Obs. 150.

Febris pemphygodes, Ephem. Germ. D. I. A. viii.
Obs. 56.

Pemphigus castrensis, Sauv. sp. 2.

Febres synoches, cum vesiculis per pectus et col-
lum sparsis, Morton. App. ad Exere. II.

Pemphigus Helveticus, Sauv. sp. 3. Langhans in
Act. Helvet. vol. ii. p. 260. et in Beschreibung
des Siementhals, Zurich 1753.

This is a very rare disease, inasmuch that Dr Cul-
ten declares he never saw it. He declines taking the
descriptions of foreign physicians: we shall therefore
content ourselves with giving an instance of this very
uncommon distemper, as it was observed in the Infir-
mary at Aberdeen, and was treated by the late Dr
David Stuart, then physician to that hospital, who
soon after published an account of it in the Edinburgh
Medical Commentaries. A private soldier of the 73d
regiment, aged eighteen years, formerly a pedlar, and
naturally of a healthy constitution, was received into
the hospital at Aberdeen on the 25th of April. About
twenty days before that, he had been seized with the
measles when in the country; and, in marching to
town, on the second day of their eruption, he was ex-
posed to cold; upon which they suddenly disappeared.

Having arrived at Aberdeen, he was quartered in a ^Pemphigus
damp, ill-aired, under-ground apartment. He then
complained of sickness at stomach, great oppression
about the precordia, headache, lassitude, and wear-
iness, on the least exertion; with stiffness and rigidity
of his knees and other joints. The surgeon of the re-
giment visited him: he was purged, but with little
benefit. About ten days before, he observed on the
inside of his thighs a number of very small, distinct,
red spots, a little elevated above the surface of the
skin, and much resembling the first appearance of small-
pox. This eruption gradually spread itself over his
whole body, and the pustules continued every day to in-
crease in size.

Upon being received into the hospital, he complained
of headache, sickness at stomach, oppression about
the precordia, thirst, sore throat, with difficulty of
swallowing; his tongue was foul, his skin felt hot and
feverish; pulse from 110 to 120, rather depressed;
belly costive; eyes dull and languid, but without deli-
rium. The whole surface of his skin was interspersed
with vesicles, or phlyctæanæ, of the size of an ordinary
walnut; many of them were larger, especially on the
arms and breast. In the interstices, between the ves-
icles, the appearance of the skin was natural, nor was
there any redness round their base; the distance from
one to another was from half an inch to a hand-
breadth or more. In some places two or three were
joined together, like the pustules in the confluent small-
pox. A few vesicles had burst of themselves, and formed
a whitish scab or crust. These were chiefly on the
neck and face; others showed a tolerably laudable pus.
However, by far the greatest number were perfectly
entire, turgid, and of a bluish colour. Upon opening
them, it was evident that the cuticle elevated above
the cutis, and distended with a thin, yellowish, semi-
pellucid serum, formed this appearance. Nor was the
surface of the cutis ulcerated or livid; but of a red
florid colour, as when the cuticle is separated by a
blister, or superficial burning. No other person lab-
oured under a similar disease, either in the part of the
country from which he came, or when he resided in
Aberdeen.

This case was treated in the following manner. The
largest of the vesicles were snipped, and dressed with
unguent. de lap. calaminari. In the evening he was vo-
mited with a solution of tartar emetic, given in small
quantities and at intervals. This also procured two
loose stools. And he was ordered for drink, water-
gruel acidulated with lemon juice.

"April 16. He still complained of sickness, some
oppression about his breast, and sore throat; he had
slept little during the night; his tongue was foul and
blackish; his skin, however, was not so hot as the pre-
ceding day; his urine was high-coloured, but had the
appearance of separation; his pulse 90, and soft; most
of the sores on the trunk of the body looked clean.
Others, particularly where the vesicles were con fluent,
seemed beginning to ulcerate, and to have a bluish sub-
lived appearance. They were dressed afresh with ce-
rate, and he was ordered the following medicines:

R. Decoct. Cort. Peruvian. 3vj. Vini rubr. Lusitan.
3iij. M. Hujus mixture capiat 3ss. tertia qua-
que hora.

"His acidulated drink was continued; and on account of the very offensive smell on approaching near him, some vinegar was placed in a basin before the bed, and sprinkled on the floor; and the room was kept properly aired.

"April 17. His fores looked tolerably clean, unless on his arms and thighs; where they were livid, a little ulcerated, and discharged a bloody ichor.

"His headache, sickness, &c. were almost gone; his tongue was rather cleaner; pulse 68, and soft. As the decoction of the bark fat easily on his stomach, the following prescription was ordered:

R. Pulv. subtiliss. Cort. Peruv. 3s. Vini rubri Lusitan. Aque fontan. 3s. M. ft. Haust. tercia quaque hora repetend.

The acidulated drink was continued, and fresh dressings applied to the fores.

"April 18. The little ulcers in his arms and thighs still discharged a bloody ichor, and looked ill; his other complaints were better; pulse 82. The bark had not nauseated him, and it was continued as well as his former drink.

"April 19. His fores looked much cleaner and better; the fever was gone, his pulse natural, and he had no complaint but weakness and a troublesome itching of the skin: The Peruvian bark, &c. were continued.

"April 20. Some of the ulcers still poured forth a bloody ichor; most of them, however, looked well, and had begun to heal—fever gone—medicines continued.

"From the 21st of April, he went on gaining strength, and his fores appeared to heal fast; he was desired to take only four doses every day; and by the 27th his fores, &c. were totally dried up—he had no complaint, and was dismissed cured."

Since the publication of this case of pemphigus by Dr Stuart, observations on this disease have been published by Dr Stephen Dickson of Dublin, in the Transactions of the Royal Irish Academy. In these observations, an account is given of six different cases which Dr Dickson has had an opportunity of seeing. Judging from these, Dr Dickson thinks that Dr Cullen's definition of this disease requires correction; and that it ought to be defined, "a fever accompanied with the successive eruption, from different parts of the body, internal as well as external, of vesicles about the size of an almond, which become turgid with a faintly yellowish serum, and in three or four days subside."

From the cases which have fallen under Dr Dickson's observation, he concludes, that the disease varies considerably as to its mildness or malignity. In three of the cases which he has seen, the symptoms were extremely mild, but in the other three strong symptoms of putrefaction were manifested, and the life of the patient was in great danger. With respect to the method of cure, he is of opinion, that the general symptoms of weakness, and tendency to putrefaction, obviously point out the proper treatment. Nourishment must be supplied, and the Peruvian bark and wine carefully administered; and when vesicles appear on internal parts, irritation must be guarded against by opiates, demulcents, and gentle laxatives.

Some additional observations on the subject of pem-

phigus have lately been published in the London Medical Journal by Mr Thomas Christie. From a case which Mr Christie describes, he is disposed to agree with Dr Dickson in thinking that sometimes at least pemphigus is not contagious. He remarks, however, that the pemphigus described by some foreign writers was extremely infectious; which he thinks may lead to a division of the disease into two species, the pemphigus simplex and complicatus; both of which, but especially the last, seem to vary much with respect to mildness and malignity.

Aphtha, Sauv. gen. 100. Lin. 9. Sag. 298.
Boerh. 978. Hoffm. 11. 478. Junck. 137.
Febris aphthosa, Vog. 44.

The only idiopathic species is the thrush to which infants are subject; (Aphtha lactucinen, Sauv. sp. 1.)

The aphas are whitish or ash coloured pustules, invading the uvula, fauces, palate, tonsils, inside of the cheeks, gums, tongue, and lips. They for the most part begin at the uvula, sending forth a glutinous mucus, and the pustules covering all or the greatest number of the parts above mentioned, with a thick whitish crust adhering most tenaciously. This crust does not induce an eschar on the parts on which it lies by eating into them, but comes off in whole pieces after the pustules have arrived at maturity. This will often happen in a short time, so that the throat and internal parts of the mouth are frequently observed to be clean, which a few years before were wholly covered with white crusts. Neither is this disease confined to the throat and fauces, but is said to affect the oesophagus, stomach, and all parts of the alimentary canal. Of this indeed there is no other proof, than that, after a great difficulty of swallowing, there is sometimes an immense quantity of aphas evacuated by stool and vomiting, such as the mouth could not be thought capable of containing.

Causes, &c. The aphas fever seems to be produced by cold and moisture, as it is found only in the northern countries, and especially in marshy places; and in them the aphas often appear without any fever at all.

Prognosis. There is no symptom by which the coming out of aphas can be foretold, though they are common in many fevers; but they themselves are in general a bad symptom, and always signify a very tedious disorder: the danger denoted by them is in proportion to the difficulty of deglutition; and a diarrhoea accompanying them is likewise bad. This indeed generally carries off old people when they become affected with aphas. The dark-coloured aphas also are much more dangerous than such as are of a brown or ash colour; but it is a good sign when the appetite returns, and the dark-coloured ones are succeeded by others of a whiter colour. Neither are those which are unaccompanied with fever so dangerous as the other kind.

Cure. As the aphas are seldom a primary disease, we must generally endeavour to remove the disorder upon which they depend, after which they will fall off;

off; but in the mean time we are not to neglect applications to the aphis themselves, such as detergent and softening gargles made of the decoction of figs, with the addition of honey of roses, a little vinegar, and some tincture of myrrh.

Hæmorrhagia, Vog. Cls. II. Ord. I. Hoffm. II. 194. Junck. 5.
Sanguifluxus, Sauv. Cls. IX. Ord. I. Sag. Cls. V. Order I.

Hæmorrhagia, Sauv. gen. 239. Lin. 173. Sag. gen. 174.
Hæmorrhagia narium, Hoffm. II. 196. Junck. 6.
Hæmorrhagia plethorica, Sauv. sp. 22. Hoffm. II. 198.

The other species enumerated by authors are all symptomatic.

Description. The milder species of this hæmorrhage comes on more frequently in summer than in winter, and for the most part without giving any warning, or being attended with any inconvenience; but the less benign kind is preceded by several remarkable symptoms. These are, congestions of the blood sometimes in one part, and sometimes in another, and which are often very troublesome in the sides of the head: there is a redness of the cheeks; an inflation of the face, and of the vessels of the neck and temples; a tinnitus aurium; a heavy pain of the eyes, with a prominence, dryness, and sparks; there is a vertiginous affection of the head, with an itching of the nostrils, and a sense of weight, especially about the root of the nose. In some the sleep is disturbed with dreams about blood, fire, &c. Frequently the belly is colicky, there is a diminution of the quantity of urine, a suppression of sweat, coldness of the lower extremities, and tension of the hypochondria, especially the right one.

Causes, &c. This hæmorrhage may occur at any time of life; but most commonly happens to young persons, owing to the peculiar state of the system at that time. Sometimes, however, it happens after the æcus and during the state of manhood, at which time it is to be imputed to a plethoric state of the system; to a determination of the blood, by habit, to the vessels of the nose; or to the particular weakness of these vessels.

In all these cases the disease may be considered as an arterial hæmorrhage, and depending upon an arterial plethora; but it sometimes occurs in the decline of life, and may then be considered as the sign of a venous plethora in the vessels of the head. It often happens at any period of life in certain febrile diseases, which are altogether or partly of an inflammatory nature, and which show a particular determination of the blood to the vessels of the head. As by this evacuation, other diseases are often removed, it may on these

occasions be deemed truly critical. It happens to persons of every constitution and temperament; but most frequently to the plethoric and sanguine, and more commonly to men than women.

Prognosis. In young people, the bleeding at the nose may be considered as a slight disease, and scarce worth notice. But, even in young persons, when it recurs very frequently and in great quantity, it is alarming; and is to be considered as a mark of an arterial plethora, which in the decline of life may give the blood a determination to parts from which the hæmorrhage would be more dangerous; and this will require more particular attention, as the marks of plethora and congestion preceding the hæmorrhage are more considerable, and as the flowing of the blood is attended with a more considerable degree of febrile disorder. These consequences are more especially to be dreaded, when the epistaxis happens to persons after their æcus, returning frequently and violently. Even in the decline of life, however, it may be considered as in itself very salutary; but at the same time it is a mark of a dangerous state of the system, i. e. of a strong tendency to a venous plethora in the head, and it has accordingly been often followed by apoplexy, palsy, &c. When it happens in febrile diseases, and is in pretty large quantity, it may be generally considered as critical and salutary; but it is very apt to be too profuse, and thus becomes dangerous. It sometimes occurs during the eruptive fever of some exanthemata, and is in such cases sometimes salutary; but if these exanthemata be accompanied with any putrid disposition, this hæmorrhage, as well as artificial bloodlettings, may have a very bad tendency.

Cure. The treatment in cases of epistaxis may be referred to two heads. 1st, The treatment during the time of the discharge; and, 2dly, The treatment after the discharge is stopped, with the view of preventing the return of it. During the former of these periods, it is necessary in the first place to consider whether the discharge should be left to its natural course or stopped by artificial means. In determining this question, regard must be paid to the quantity of the discharge; the appearance of the blood; the constitution with which epistaxis occurs; the former habit of the patient; and the consequences which result from the discharge. When, from due consideration of these circumstances, there is reason to fear that further evacuation would be attended with bad consequences, though this disease has been generally thought very slight, it should seldom be left to the conduct of nature; and in all cases it should be moderated by keeping the patient in cool air, by giving cold drink, by keeping the body and head erect, by avoiding any blowing of the nose, speaking, or other irritation; and if the blood has flowed for some time without showing any tendency to stop, we are to attempt the suppression of the hæmorrhage, by pressing the nostril from which the blood flows, washing the face with cold water, or applying this to some other parts of the body. These measures Dr Cullen judges to be proper even on the first attacks, and even in young persons where the disease is in the least hazardous: but they will still be more requisite if the disease frequently recurs without any external violence; if the returns happen to persons not disposed

disposed to a plethoric habit; and more particularly if no signs of plethora appear in the symptoms preceding the discharge.

When the bleeding is so profuse that the pulse becomes weak and the face pale, every means must be used to put a stop to it, and that whether the patient be young or old. Besides those methods above mentioned, we must use astringents both internal and external; but the latter are the most powerful, and the choice of these may be left to the surgeon. The internal astringents are either vegetable or fossil; but the vegetable astringents are seldom powerful in the cure of any hæmorrhages except those of the alimentary canal. The fossil astringents are more active, but differ considerably in strength from one another.—The chalybeates appear to have little strength: the preparations of lead are more powerful; but cannot be employed, on account of their pernicious qualities, unless in cases of the utmost danger. The tinctura saturina, or antiphthifica, is a medicine of very little efficacy, either from the small quantity of lead it contains, or from the particular state in which it is. The safest, and at the same time the most powerful astringent, seems to be alum.

For suppressing this and other hæmorrhages, many superfluous remedies and charms have been used, and said to have been employed with success. This has probably been owing to the mistake of the by-standers, who have supposed that the spontaneous cessation of the hæmorrhage was owing to their remedy. At the same time Dr Cullen is of opinion, that such remedies have sometimes been useful, by impressing the mind with horror or dread. Opiates have sometimes proved successful in removing hæmorrhages; and when the fulness and inflammatory diathesis of the system have been previously taken off by bleeding, they may, in Dr Cullen's opinion, be used with safety and advantage. Ligatures have been applied upon the limbs, for retarding the return of the venous blood from the extremities; but their use seems to be ambiguous. In the case of profuse hæmorrhages, no care is to be taken to prevent the patient from fainting, as this is often the most certain means of stopping them.

Hæmoptysis catamenialis, Sauv. sp. 4.
Hæmoptysis periodica, Sauv. sp. 5.

Description. This hæmorrhage commonly begins with a sense of weight and anxiety in the chest, some uneasiness in breathing, pain of the breast or other parts of the thorax, and some sense of heat under the sternum: and very often it is preceded by a saltish taste in the mouth. Immediately before the appearance of blood, a degree of irritation is felt at the top of the larynx. The person attempts to relieve this by hawking, which brings up a little florid and somewhat frothy blood. The irritation returns; and in the same manner blood of a similar kind is brought up, with some noise in the windpipe, as of air passing through a fluid. Sometimes, however, at the very first, the blood comes up with coughing, or at least somewhat of coughing, and accompanies the hawking above mentioned.

The blood is often at first in very small quantity, and soon disappears; but in other cases, especially when it frequently recurs, it is in greater quantity, and often continues to appear at times for several days together. It is sometimes profuse, but rarely in such quantity as either by its excess or by a sudden suffocation to prove immediately mortal.

It is not always easy to discover whether the blood evacuated by the mouth proceeds from the internal surface of the mouth itself, from the fauces or adjoining cavities of the nose, from the stomach, or from the lungs. It is, however, very necessary to distinguish these different cases; and for this Dr Cullen offers the following considerations.

1. When the blood proceeds from some part of the internal surface of the mouth, it comes out without any hawking or coughing; and generally, upon inspection, the cause is evident.

2. When blood proceeds from the fauces, or adjoining cavities of the nose, it may be brought out by hawking, and sometimes by coughing. In this case, there may be a doubt concerning its real source, and the patient may be allowed to please himself with the thoughts that the blood does not come from the lungs. But the physician must remember that the lungs are much more frequently the source of a hæmorrhage than the fauces. The latter seldom happens but to persons who have before been liable to a hæmorrhage from the nose, or to some evident cause of erosion; and in most cases, by looking into the fauces, the distillation of the blood from thence will be perceived.

3. When blood proceeds from the lungs, the manner in which it is brought up will commonly show from whence it comes; but, independent of that, it may also be known from the causes of hæmoptysis from the lungs, to be afterwards mentioned, having preceded.

4. When vomiting accompanies the throwing out of blood from the mouth, we may generally know the source from whence it proceeds, by considering that blood does not proceed so frequently from the stomach as from the lungs: that blood proceeding from the stomach commonly appears in greater quantity than from the lungs. The pulmonary blood also is usually of a florid colour, and mixed with a little frothy mucus.

Hæmoptysis, Sauv. gen. 240. Lin. 179. Vog. 84.
Sag. gen. 175. Junck. 8.
Hæmoptoë, Boerh. 1198.
Sanguinis fluxus ex pulmonibus, Hoffm. II. 202.

Hæmoptysis accidentalis, Sauv. sp. 1.
Hæmoptysis habitualis, Sauv. sp. 2.
Hæmoptysis traumatica, Sauv. sp. 12.

Hæmoptysis phthisica, Sauv. sp. 9.
Hæmoptysis ex tuberculo pulmonum, Sauv. sp. 10.

Hæmoptysis calculosa, Sauv. sp. 14.

mous only; but the blood from the stomach is of a darker colour, more grumous, and mixed with the other contents of the stomach. The coughing or vomiting, as the one or the other happens first to arise, may sometimes point out the source of the blood; and this has also its peculiar antecedent signs and causes.

Causes, &c. A hæmoptysis may be produced at any time of life by external violence; and, in adult persons, while the arterial plethora prevails in the system, i. e. from the age of 16 to 35, a hæmoptysis may at any time be produced merely by a plethoric state of the lungs. More frequently, however, it arises from a faulty proportion between the capacity of the lungs and that of the rest of the body. Thus it is often an hereditary disease, which implies a peculiar and faulty conformation.

This disease especially happens to persons, who discover the smaller capacity of their lungs by the narrowness of their chest, and by the prominence of their shoulders; which last is a mark of their having been long liable to a difficulty of respiration. In such cases, too, the disease very frequently happens to persons of a sanguine temperament, in whom particularly the arterial plethora prevails. It happens also to persons of a slender delicate make, of which a long neck is a mark; to persons of much sensibility and irritability, and therefore of quick parts; to persons who have formerly been liable to hæmorrhages from the nose; to those who have suffered a suppression of any usual hæmorrhage, the most frequent instance of which is in females who have suffered a suppression of their menstrual flux; and, lastly, to persons who have suffered the amputation of a limb.

All this constitutes the predisposing cause of hæmoptysis; and the disease may happen merely from the predisposing cause arising to a considerable height. But in those who are already predisposed, it is often brought on by the concurrence of various occasional and exciting causes. One of these, and perhaps a frequent one, is external heat; which, even when in no great degree, brings on the disease in spring, and the beginning of summer, while the heat rarefies the blood more than it relaxes the solids, which had before been contracted by the cold of winter. Another exciting cause is a sudden diminution of the weight of the atmosphere, especially when concurring with any effort in bodily exercise. The effort alone, may often be the exciting cause in those who are already predisposed; and more particularly any violent exercise of respiration. In the predisposed, also, the disease may be occasioned by any degree of external violence.

Prognosis. Hæmoptysis may sometimes be no more dangerous than a hæmorrhage from the nose; as when it happens to females, in consequence of a suppression of their menses; when, without any marks of predisposition, it arises from external violence; or, from whatever cause it may proceed, when it leaves no cough, dyspnea, or other affection of the lungs, behind it. But, even in these cases, a danger may arise from too large a wound being made in the vessels of the lungs, from any quantity of red blood being led to stagnate in the cavity of the bronchus, and particularly from any determination of the blood being made into the vessels

of the lungs, which by renewing the hæmorrhage may have these consequences.

Cure. In the treatment of this disease, with a view of stopping the discharge, it is first necessary to have recourse to those measures which tend to diminish the impetus by which the blood is expelled. This is to be effected by a removal of plethora when it exists; by diminishing the general impetus of circulation; by diminishing local increased action when it takes place in the vessels of the lungs; and by producing a determination of blood to other parts of the system remote from the lungs. But besides practices diminishing impetus, it is often also necessary to employ such as augment the resistance to the passage of blood through the ruptured vessels of the lungs. With these views a variety of practices may be employed, particularly blood-letting, refrigerants, sedatives, astringents, and the like.

On this subject Dr Cullen differs from those who prescribe chalybeates and cinchona in the cure of hæmoptysis. Both of these, he observes, contribute to increase the phlogistic diathesis then prevailing in the system, and the hæmoptysis from predisposition is always accompanied with such a diathesis. Instead of these, therefore, he recommends blood-letting in greater or smaller quantity, and more or less frequently repeated as the symptoms shall direct. At the same time cooling purgatives are to be employed, and every part of the antiphlogistic regimen is to be strictly enjoined. In the London Medical Observations, the use of nitre is greatly recommended by Dr Dickson, to whom its efficacy was made known by Dr Letherland, physician to St Thomas's Hospital. The most commodious method of exhibiting it he found was in an electuary. Four ounces of conserve of roses were made into an electuary with half an ounce of nitre; of which the bulk of a large nutmeg was directed to be given, four, six, or eight times a day, according to the urgency of the case. The good effects of this, he tells us, have often astonished him; and when given early in the disease, he says he can depend as much upon it for the cure of an hæmoptysis, as on cinchona for the cure of an intermittent. He agrees with Dr Cullen, however, that in those cases where there is any hardness in the pulse, and which almost always happens, there is a necessity for venesection. A cool regimen, and quiet of body and mind, are certainly useful; but Dr Cullen observes that some kinds of gestation, such as sailing, and travelling in an easy carriage on smooth roads, have often proved a remedy. When the cough is very troublesome, it is absolutely necessary to exhibit frequently a small dose of an opiate. Dr Dickson also informs us, that the nitre joined with spermaceti, or pulv. & tragacanth. comp. has produced equally good effects with the electuary above mentioned; in the composition of which he at first considered the conserve only as a vehicle for the nitre, though he means not to insinuate that the former is totally destitute of efficacy.

When this hæmorrhage has resisted other modes of cure, and there is reason to apprehend, even from the mere quantity of blood evacuated, that the patient may sink under the discharge, blisters, particularly when applied to the breast, are often had recourse to with great advantage; and the sulphuric acid, properly diluted,

luted, both as an astringent and refrigerant, is often employed with very good effects.

Phthisis, Sauv. gen. 276. Lin. 208. Vog. 319. Seg. 101. Junck. 33.

Phthisis pulmonis, Boerh. 1196.

Affectio phthisica, ille tabes pulmonalis, Hoffm. II. 284.

337 Sp. I. The Incipient Phthisis, without expectoration of Pus.

Phthisis incipiens, Morton Physiolog. L. II. cap. 3.
Phthisis sicca, Sauv. sp. 1.

339 Sp. II. The Confirmed Phthisis, with an expectoration of Pus.

Phthisis confirmata anteriorum.

Phthisis humida, Sauv. sp. 2.

Sometimes, notwithstanding all the care that can be taken, the hæmoptysis will degenerate into a phthisis pulmonalis, or consumption of the lungs; and sometimes hæmoptysis will be the consequence of this dangerous disorder. It has indeed been supposed, that an ulceration of the lungs, or phthisis, was the natural and almost necessary consequence of hæmoptysis: but according to Dr Cullen, this is in general a mistake; for there are many instances of ja hæmoptysis from external violence without being followed by any ulceration. The same thing has often been observed where the hæmoptysis arose from an internal cause; and this not only in young persons, when the disease returned for several times, but when it has often recurred during the course of a long life; and it may easily be conceived, that a rupture of the vessels of the lungs, as well as of the vessels of the nose, may be sometimes healed. The causes of phthisis, therefore, Dr Cullen reduces to five heads. 1. A hæmoptysis. 2. A suppuration of the lungs in consequence of a pneumonia. 3. A catarrh. 4. An asthma; and 5. Tubercles.

1. When a phthisis arises from a hæmoptysis, it is probable that it is occasioned by particular circumstances; and what these circumstances are, may not always be easily known. It is possible, that merely the degree of rupture, or frequently repeated rupture, preventing the wound from healing, may occasion an ulcer; or it is possible, that red blood effused, and not brought up entirely by coughing, may, by stagnating in the bronchiae, become acrid, and erode the parts. But these hypotheses are not supported by any certain evidence; and from many observations we are led to think, that several other circumstances must concur in producing the disease from hæmoptysis.

2. The second cause of an ulceration of the lungs mentioned above is a suppuration formed in consequence of pneumonia. When a pneumonia, with symptoms neither very violent nor very slight, has continued for many days, it is to be feared it will end in a suppuration; but this is not to be determined by the number of days; for, not only after the fourth, but even after the tenth day, there have been examples of a pneumonia ending by a resolution; and if the dis-

case has suffered some intermission, and again recurred, there may be instances of a resolution happening at a much later period from the beginning of the disease than that now mentioned. But if a moderate disease, in spite of proper remedies employed, be protracted to the 14th day without any considerable remission, a suppuration is pretty certainly to be expected; and it will be more certain still, if no signs of resolution have appeared, or if an expectoration which had appeared shall have again ceased, and the difficulty of breathing has continued or increased, while the other symptoms have been rather abated.

That in a pneumonia, the effusion is made which may lay the foundation of a suppuration, may be concluded from the difficulty of breathing becoming greater when the patient is in a horizontal posture, or when the patient can lie more easily on the affected side. That, in such cases, a suppuration is actually begun, may be inferred from the patient's being frequently affected with slight cold shiverings, and with a sense of cold felt sometimes in one sometimes in another part of the body. We form the same conclusion also from the state of the pulse, which is commonly less frequent and softer, but sometimes quicker than before. That a suppuration is already formed, may be inferred from there being a considerable remission of the pain which had before subsisted; while with this the cough, and especially the dyspnoea, continue, and are rather increased. At the same time the frequency of the pulse is rather increased, the feverish state suffers considerable exacerbations every evening, and by degrees a hectic fever in all its circumstances comes to be formed.

In this state of symptoms, we conclude very confidently, that an abscess, or, as it is called, a comica, is formed in some part of the pleura, and most frequently in that portion of it investing the lungs. Here purulent matter frequently remains for some time, as if enclosed in a cyst; but commonly not long before it comes to be either absorbed and transferred to some other part of the body, or breaks through into the cavity of the lungs, or into that of the thorax. In the latter case it produces the disease called empyema; but it is when the matter is poured into the cavity of the bronchiae that it properly constitutes the phthisis pulmonalis. In the case of empyema, the chief circumstances of a phthisis are indeed also present: but we shall here consider only that case in which the abscess of the lungs gives occasion to purulent expectoration.

An abscess of the lungs, in consequence of pneumonia, is not always followed by a phthisis: for sometimes a hectic fever is not formed; the matter poured into the bronchiae is a proper and benign pus, which frequently is coughed up very readily, and spit out; and though this purulent expectoration should continue for some time, if it be without hectic fever, the ulcer soon heals, and every morbid symptom disappears. This has so frequently happened, that we may conclude, that neither the access of the air, nor the constant motion of the lungs, will prevent an ulcer of these parts from healing, if the matter of it be well-conditioned. An abscess of the lungs, therefore, does not necessarily produce phthisis pulmonalis; and if it be followed by such a disease, it must be in consequence of particular circumstances which corrupt the purulent