MEDICINE

193.

X.206.c.

X.206.b

B
L.2

Spolini. was covered with a thick inflammatory crust. In one of these patients the urine yielded an ounce and a half, and in the other an ounce, of saccharine matter from each pound. It had, however, an urinous smell, and a saline taste mixed with the sweet one; and the urine of one fermented with yeast, we are told, into "tolerable small-beer." Both these patients had a voracious appetite, and perpetual gnawing sense of hunger; as had also Dr Dobson's patient. The insipid urine of those affected with diabetes has not been examined by physicians with sufficient accuracy to enable us to speak with confidence of its contents.

Causes. These are exceedingly obscure and uncertain; spasms of the nervous system, debility, and every thing inducing it, but especially strong diuretics and immoderate venery, have been accused as bringing on the diabetes. It has, however, occurred in persons where none of these causes could be suspected; nor have the best physicians been able to determine it.—Dissections have only shown that the kidneys were in an enlarged and lax state. In one of Dr Home's patients who died, they smelled sour; which showed that the urine peculiar to diabetes came from the kidneys, and was not sent directly from the intestines by a retrograde motion of the lymphatics, as some imagine.

Prognosis. The diabetes is rarely cured, unless when taken at the very beginning, which is seldom done; and in a confirmed diabetes the prognosis must therefore be unfavourable.

Cure. As there is reason to believe that in this affection the morbid secretion of urine, which is both preternatural in point of quantity and of quality, arises from a morbid diminution of tone in the kidney, the great object in the cure must be the restoration of due tone to the secreting vessels of the kidney. But as even this diminished tone would not give rise to the peculiar vitiated secretion without a morbid sensibility of that organ, it is necessarily a second object to remove this morbid sensibility. But besides this, the morbid secretion of urine may also be counteracted both by a diminution of the determination of fluids to the kidney, and by preventing the occurrence of superfluous water in the general mass of blood.

On these grounds the principal hopes of a cure in this distemper are from astringent and strengthening medicines. Dr Dobson's patient was relieved by the following remedies; which, however, were frequently varied, as none of them produced their good effects for any length of time: Cinchona in substance, with small doses of rhubarb; decoction of the bark, with the acid elixir of vitriol; the cold infusion of the bark, of which he drank from a quart to two quarts daily; Dover's powder; alum-whey; lime-water; antimonials combined with tinctura thebaica. The warm bath was used occasionally when the skin was remarkably hot and dry, and the patient complained of restlessness and anxiety. The tincture of cantharides was likewise tried; but he could never take more than 25 drops for a dose, without exciting great uneasiness in his bowels. The body was kept constantly open, either with rhubarb or the infusion of senna joined with rhubarb. His common drinks were rice water, barley-water, lime-water, and milk; lime-water alone; sage, balm, or mint tea; small-beer, simple water, and water acidulated with

VOL. XIII. Part II.

the sulphuric acid. In seven months, these remedies, in whatever manner varied, made no further progress in removing the disease. In Dr Home's patients, all these medicines, and many others, were tried without the least good effect; inasmuch that he uses this remarkable expression: "Thus, these two patients have exhausted all that experience had ever recommended, and almost all that theory could suggest; yet in both cases, the disease has resisted all the means of cure used." It is remarkable, that though septics were given to both, in such quantity as evidently to produce a putrefaction in the prime via, the urine remained unaltered both in quantity and quality.

But although this disease be frequently in its nature so obstinate as to resist every mode of cure, yet there can be no doubt that particular remedies have succeeded in different cases. Dr Brisbane relates several cases cured by the use of tincture of cantharides: and Dr McCormick has related some in the 9th volume of the Edinburgh Medical Commentaries, which yielded to Dover's powder after a variety of other remedies had been tried in vain.

But of all the modes of cure lately proposed, that which has been most celebrated, is the treatment recommended by Dr Rollo of the Royal Artillery. In a valuable work lately published, entitled Cases of the Diabetes Mellitus, he has recorded two remarkable examples of the good effects of a peculiar regimen in this disease. He considers diabetes as being a disease not of the kidney but of the alimentary canal, and as arising from the formation of an uncommon quantity of sugar. He therefore strictly forbids the use of every article of diet which can furnish sugar, even of bread; and by a diet consisting entirely of animal and alkaline food his patients were much benefited. The experience of some other practitioners has to a certain degree confirmed the observations of Dr Rollo. But we are sorry to add, that we have met with many other instances of diabetes mellitus, in which a diet consisting solely of animal food, had a fair trial, without producing any material benefit. And we may conclude with observing, that the cure of diabetes still remains to be discovered. As allaying the excessive thirst, and producing a temporary restoration of urinous smell, or the urea which it ought naturally to contain, we have found nothing equal in efficacy to a large proportion of fat meat, such as pork steaks or butter.

GENUS LXIII. HYSTERIA.
HYSTERICUS.

Hysteria, Savio. gen. 135. Lin. 126. Vog. 219. Sag. gen. 242.

Malum hystericum, Hoffm. III. 50. Junck. 36.

Affectio hysterica, Willis de Morb. Convulsiv. cap. 5. 10. 11. Sydenham Diss. Epist. ad G. Cole, Whitt on Nervous Disorders.

Description. The hysteria is a convulsive disease, which comes on at uncertain intervals, sometimes longer and sometimes shorter, but at no stated time. The paroxysms commonly begin with a languor and debility of the whole body; yawning, stretching, and restlessness. A sense of coldness also in the extremities, almost always precedes, and for the most part remains during the whole time of the paroxysm. To this some-

times succeeds a sense of heat; and the two sensations alternate with each other in different parts of the body. The face is sometimes flushed and sometimes pale; and sometimes the paleness and flushing come alternately. There is a violent pain in the head; the eyes become dim, and pour out tears; there is a rumbling and inflation of the intestines; a sensation is felt like that of a globe ascending from the lower part of the abdomen or hypogastrium, which sometimes seems to roll along the whole alimentary canal. It ascends to the stomach, sometimes suddenly, sometimes slowly; and there produces a sense of inflation and weight, together with anxiety, nausea, and vomiting. At last it comes up to the throat, where it produces a sense of suffocation, and difficulty of breathing or swallowing. During this time there are the most violent pains both in the external and internal parts of the abdomen; the muscles are convulsed; the umbilicus is drawn inwards; and there are frequently such spasms of the intestines, that neither clysters can be injected, nor even flatus pass downwards. Sometimes the paroxysm remits after these symptoms have continued for a certain time, but more frequently the patients fall into fainting fits; sometimes they lie without motion, as if they were in a deep sleep; sometimes they beat their breasts violently and continually with their hands, and sometimes they are seized with general convulsions, and the disease puts on the appearance of an epilepsy. In some patients the extremities become cold and stiff, and the body has the appearance of one in a catalepsy. Sometimes a most violent beating pain takes place in some part of the head, as if a nail was driven into it, and all visible objects seem to turn round; grievous pains attack the loins, back, and bladder, and the patients discharge a surprising quantity of urine as limpid as water; which last is one of the surest signs of the disease. The mind is very much affected as well as the body. Sometimes the patients are tormented with vain fears; sometimes they will laugh, at other times cry immoderately; and sometimes their temper becomes so peevish and fretful, that they cannot enjoy a moment's quiet. The appearances which take place in this affection are indeed so much varied, that they can hardly be enumerated: they may, however, with propriety, be divided into hysterical fits, which very much resemble those of epilepsy, excepting that they are not attended with an abolition of the internal senses; and hysterical symptoms, such as the globus hystericus, clavus hystericus, and the like, which are chiefly known to constitute a part of this disease from being observed to alternate with fits.

Causes, &c. The general cause of hysteria is thought by the best physicians to consist in a too great mobility and irritability of the nervous system, and of consequence the disease may be brought on by whatever debilitates and renders the body irritable. Hence it most frequently attacks females of a weak and lax habit of body, though there are some instances of men also attacked by it. It generally comes on between the time of puberty and the age of 35, and makes its attacks during the time of menstruation more frequently than at any other. It also more frequently seizes barren women and young widows, than such as are bearing children.

Prognosis. Though the appearance of this disease be

so very terrible, it seldom proves mortal unless by wrong treatment: but notwithstanding this, it is extremely difficult of cure, and rarely admits of any thing else than being palliated; for though it should seem to be conquered by medicine for a time, it very quickly returns, and that from the slightest causes.

Cure. The ends principally to be aimed at in the cure of this disease are, in the first place, the removal of particular convulsive or spasmodic affections immediately producing various appearances in the disease, whether under the form of proper hysterical fits, or merely of what may be called hysterical symptoms; and in the second place, the prevention of the return of symptoms after they have been removed, by the employment of proper remedies during those intervals from complaints which patients often have when labouring under this affection.

The most powerful remedy hitherto discovered in hysterical cases is opium, or the tincture of it. By this commonly the most violent paroxysms are stopped, though it be insufficient to accomplish a radical cure. In Dr. Home's Clinical Experiments we find an instance of a cure performed by venesection, though this remedy has been generally condemned in hysterical cases. Asafetida seems to stand next in virtue to opium; though with some it disagrees, and occasions pains in the stomach and vomiting. Salphuric ether will also frequently remove an hysterical fit: but its effects are of short duration; and if it do not effect a cure soon after its exhibition, no service is to be expected either by perseverance in the use of it or by increasing the dose; and with some constitutions it disagrees to such a degree as to occasion convulsions. If the patient be seized with a violent fit, so that she can swallow nothing, which is frequently the case, it will be proper to apply some strong volatile alkali to her nose; or if that be not at hand, the vapour of burning feathers is sometimes very efficacious. In some instances benefit is derived from the sudden application of cold water to the face or hands; but still more frequently the application of water in a tepid state, particularly the warm pediluvium, is found to be of very great service in bringing about a favourable termination of different violent hysterical symptoms. A plaster of galbanum and asafetida will also prove serviceable: but it must be remembered, that none of these things will prevent the return of the disease; and therefore a radical cure is to be attempted by exercise, cinchona, chalybeates, mineral waters, and other tonics; but particularly, where the state of the patient is such as to be able to bear it, by the use of the cold bath, which, where it does not disagree with the constitution, is often of the greatest service in preventing returns of this affection.

In hysteria as well as in chorea Dr. Hamilton has found, that in some instances very great benefit has been obtained from copious evacuations of the alimentary canal, by cathartics frequently repeated.

Hydrophobia, Sauv. gen. 231. Lin. 86. Veg. 30. Sag. gen. 343. Boerh. 1138. Junck. 124. Mead on poisons. Deffault sur la rage. Sauv. diss. sue

la rage. James on canine madness. Dalby, Virtues of cinnamon and musk against the bite of a mad dog. Nugent on the hydrophobia. Choisell, Nouvelle methode pour le traitement de la rage. Journal de Medicine, passim. Medical Obs. and Inquiries, vol. iii. art. 34. vol. v. art. 20. 26. and 15. App. Med. Transact. vol. ii. art. 5. 12. and 15. Heysham, Diss. inaug. de rab. canin. Edinb. 1777. Parry, Diss. inaug. de rab. contagios. five canin. Edinb. 1778. Andry, Recherches sur la rage, 1778. Vaughan, Cases of hydrophobia, second edit. 1778. Arnold, Case of hydrophobia, 1795.

of water. And when that dread commences, it is with Hydrophobia. an evident mental affection. Dr James, in his Treatise on Canine Madness, mentions a boy sent out to fill two bottles with water, who was so terrified by the noise of the liquid running into them, that he fled into the house crying out that he was bewitched. He mentions also the case of a farmer, who, going to draw some ale from a cask, was terrified to such a degree at its running into the vessel, that he ran out in a great haste with the spigot in his hand. But in whatever manner this symptom comes on, it is certain that the most painful sensations accompany every attempt to swallow liquids. Nay, the bare sight of water, of a looking-glass, of any thing clear or pellucid, will give the utmost uneasiness, or even throws the patient into convulsions.

With regard to the affection of the mind itself in this disease, it does not appear that the patients are deprived of reason. Some have, merely by the dint of resolution, conquered the dread of water, though they never could conquer the convulsive motions which the contact of liquids occasioned: while this resolution has been of no avail; for the convulsions and other symptoms increasing, have almost always destroyed the unhappy patients.

In this disease there seems to be an extreme sensibility and irritability of the nervous system. The eyes cannot bear the light, or the sight of any thing white; the least touch or motion offends them, and they want to be kept as quiet and in as dark a place as possible. Some complain of the coldness of the air, frequently when it is really warm. Others complain of violent heat; and have a great desire for cold air, which yet never fails to increase the symptoms. In all there is a great flow of viscid saliva into the mouth; which is exceedingly troublesome to the patients, as it has the same effect upon their fauces that other liquids have. This therefore they perpetually blow off with violence, which in a patient of Dr Fothergill's occasioned a noise not unlike the hollow barking of a dog, and which he conjectures might have given rise to the common notion that hydrophobous patients bark like dogs. They have an insatiable thirst; but are unable to get down any drink, except with the utmost difficulty; though sometimes they can swallow bread soaked in liquids, slices of oranges, or other fruits. There is a pain under the serobicus cordis, as in the tetanus; and the patients mournfully point to that place as the seat of the disease. Dr Vaughan is of opinion that it is this pain, rather than any difficulty in swallowing, which distresses the patient on every attempt to drink. The voice is commonly plaintive and mournful; but Dr Vaughan tells us there is a mixture of fierceness and timidity in the countenance which he cannot describe, but by which he could know a hydrophobous person without asking any questions.

In this distemper, indeed, the symptoms are so various, that they cannot be enumerated; for we will seldom read two cases of hydrophobia which do not differ very remarkably in this respect. Some seem to have at times a furious delirium, and an inclination to spit at or bite the bystanders; while others show no such inclination, but will even suffer people to wipe the inside of their mouths with the corner of a handkerchief in order to clear away the viscid saliva which

323 Sp. I. Hydrophonia Rabiosa, or Hydrophobia consequent on the Bite of a Mad Animal.

Hydrophobia vulgaris, Savo. sp. I.

It is the opinion of some, that Dr Cullen has done wrong in employing the term hydrophobia as a generic name, under which canine madness is included: and it must be allowed, that the dread of water, while it is not universal, is also a symptom occurring only late in the disease, at least in the greater part of cases. Perhaps his arrangement would have been less exceptionable, if, following Linnaeus, he had adopted rabies as a generic term, and had distinguished this particular species by the epithet of canina, contagiosa, or the like. Disputes, however, about names, are in general not very important; and it is sufficient to observe, that the affection now to be treated of is canine madness, or that disease which arises from the bite of a mad animal.

Description. This disease commonly does not make its attack till a considerable time after the bite. In some few instances it has commenced in seven or eight days from the accident; but generally the patient continues in health for 20, 30, or 40 days, or even much longer. The bite, if not prevented, will in general be healed long before that time, frequently with the greatest ease; though sometimes it resists all kinds of healing applications, and forms a running ulcer which discharges a quantity of matter for many days. It has been said, that the nearer the wounded place is to the salivary glands, the sooner the symptoms of hydrophobia appear. The approach of the disease is known by the cicatrix of the wound becoming high, hard, and elevated, and by a peculiar sense of prickling at the part; pains shoot from it towards the throat: sometimes it is surrounded with livid or red streaks, and seems to be in a state of inflammation; though frequently there is nothing remarkable to be observed about it. The patient becomes melancholy, loves solitude, and has sickness at stomach. Sometimes the peculiar symptom of the disease, the dread of water, comes on all at once. We have an instance of one who, having taken a vomit of ipecacuanha for the sickness he felt at his stomach, was seized with the hydrophobia in the time he was drinking the warm water. Sometimes the disease begins like a common sore throat; and the soreness daily increasing, the hydrophobic symptoms show themselves like a convulsive spasm of the muscles of the fauces. In others, the mind seems to be primarily affected, and they are subject to despondency and melancholy for some time prior to any dread

is ready to suffocate them. In some male patients there is an involuntary erection of the penis, and emission of the semen; and the urine is forced away by the frequent return of the spasms. In a letter from Dr Wolf of Warsaw to Henry Baker, F. R. S. dated Warsaw Sept. 26th, 1767, we have the following melancholy account of the cases of five persons who died of the hydrophobia: "None of them quite lost their right senses; but they were all talking without intermission, praying, lamenting, despairing, cursing, fighting, spitting a frothy saliva, screeching, sometimes belching, retching, but rarely vomiting. Every member is convulsed by fits, but most violently from the navel up to the breast and oesophagus. The fit comes on every quarter of an hour; the fauces are not red, nor the tongue dry. The pulse is not at all feverish; and when the fit is over nearly like a sound pulse. The face grows pale, then brown, and during the fit almost black; the lips livid; the head is drowsy, and the ears tingling; the urine limpid. At last they grow weary; the fits are less violent, and cease towards the end; the pulse becomes weak, intermittent, and not very quick; they sweat, and at last the whole body becomes cold. They compose themselves quietly as if to get sleep, and so they expire. The blood drawn a few hours before death appears good in every respect. A general observation was, that the lint and dressings of the wounds, even when dry, were always black, and that when the pus was very good in colour and appearance." In one of Dr Wolf's patients who recovered, the blood stunk intolerably as it was drawn from a vein; and one of Mr Vaughan's patients complained of an intolerable fetid smell proceeding from the wounded part, though nobody but himself could perceive it. In general, the violent convulsions cease a short time before death; and even the hydrophobia goes off, so that the patients can drink freely. But this does not always happen; for Mr Vaughan mentions the case of a patient, in whom, "when he had in appearance ceased to breathe, the spasmus cynicus was observable, with an odd convulsive motion in the muscles of the face; and the strange contrariety which took place in the action of these produced the most horrid assemblage of features that can well be conceived. Of this patient also it was remarkable, that in the last hours of his life he ceased to call for drink, which had been his constant request; but was perpetually asking for something to eat."

The hydrophobia seems to be a symptom peculiar to the human race; for the mad animals which communicate the infection, do not seem to have any dread of water. Dr Wolf, in the letter above quoted, says in general, that cattle bit at the same time and by the same animal (a mad wolf) which bit the persons whose cases he related, died nearly with the same frightful raging as the men; but says nothing of their having any hydrophobia: nay, Dr James and some others assert, that the hydrophobia is not always an attendant on rabies canina in the human race; and indeed it is certain that the disease has proved mortal after this terrible symptom has been removed. With regard to the symptoms of madness in dogs, they are very equivocal; and those particularly enumerated by some authors, are only such as might be expected in dogs much heated or agitated by being violently pur-

fued and struck. One symptom indeed, if it could be depended upon, would determine the matter; namely, that all other dogs avoid and run away from one that is mad; and even large dogs will not attack one of the smallest size who is infected with this disease. Upon this supposition they point out a method of discovering whether a dog who has been killed was really mad or not; namely, by rubbing a piece of meat along the inside of his mouth, and then offering it to a found dog. If the latter eats it, it is a sign the dog was not mad; but if the other rejects it with a kind of howling noise, it is certain that he was. Dr James tells us, that among dogs the disease is infectious by staying in the same place; and that after a kennel has been once infected, the dogs put into it will be for a considerable time afterwards in danger of going mad also. A remedy for this, he says, is, to keep geese for some time in the kennel. He rejects as false the opinion that dogs when going mad will not bark; though he owns that there is a very considerable change in their bark, which becomes hoarse and hollow.

Of all the accounts that have been published on the characteristics of rabies in dogs, the best is to be found in Dr Arnold's late treatise: the characteristics there mentioned are given on the authority of Mr Meynell, a gentleman who has paid particular attention to this subject. From Mr Meynell's observations it appears, that most of the characteristics which have been commonly mentioned, are mere vulgar errors; and, according to him, the best marks are from their peculiar dull look, and the peculiar sound which they utter. "Mad dogs (says Mr Meynell) never bark, but occasionally utter a most dismal and plaintive howl, expressive of extreme distress, and which, they who have once heard it, can never forget; so that dogs may be known to be going mad without being seen, when only this dismal howl is heard."

Causes, &c. In no disease whatever are we more at a loss to discover the causes than in the hydrophobia. In dogs, foxes, and wolves, it seems to come on spontaneously; though this is contested by some authors. It is said, that the causes commonly assigned, viz. heat, feeding upon putrid flesh, want of water, &c. are not sufficient for producing the distemper. It does not appear that madness is more frequent among dogs in the warm than in the cold climates; nay, in the island of Antigua, where the climate is very hot, and the water very scarce, this distemper has never, it is said, been observed. As to putrid aliment, it seems natural for dogs to prefer this to any other, and they have been known to subsist upon it for a long time without any detriment. For these reasons, they think the disease arises from a specific contagion, like the smallpox and measles among the human race, which, being once produced by causes unknown, continues to be propagated by the intercourse which dogs have with each other, as the diseases just mentioned continue to be propagated among the human race.

With regard to the immediate cause among mankind, there is not the least doubt that the hydrophobia is occasioned by the saliva of the mad animal being mixed with the blood. It does not appear that this can operate through the cuticula; but, when that is rubbed off, the smallest quantity is sufficient to communicate

Spasm. communicate the disease, and a slight scratch with the teeth of a mad animal has been found as pernicious as a large wound. It is certain also, that the infection has been communicated by the bites of dogs, cats, wolves, foxes, weasels, swine, and even cocks and hens, when in a state of madness. But it does not appear that the distemper is communicable from one hydrophobic person to another, by means of the bite, or any other way. Dr Vaughan inoculated a dog with the saliva of a hydrophobic child, but the animal continued free from disease for two months; and though the doctor promised to inform the public if it should happen to occur afterwards, nothing has hitherto appeared on that subject. A nurse also frequently killed the child during this time of his disorder, but no bad consequence ensued.

When we attempt to investigate the nature of the cause of the hydrophobia by dissections, our inquiries are commonly disappointed. In two bodies opened by Dr Vaughan, there was not the least morbid appearance; in the very fauces, where we might have expected that the disease would have shown itself most evidently, there was not the least appearance even of inflammation. The stomach, intestines, diaphragm, œsophagus, &c. were all in a natural state: neither do we find in authors of credit any certain accounts of morbid appearances in the bodies of hydrophobic persons after death. Dr Vaughan therefore concludes, that the poison acts upon the nervous system; and is so wholly confined to it, that it may be doubted whether the qualities of the blood are altered by it or not; and that it acts upon the nerves by impairing and disturbing their functions to such a degree as speedily to end in a total extinction of the vital principle. As to the difficulty in swallowing generally believed to accompany dread of the water, he treats it as a misrepresentation, as well as that the œsophagus with the muscles subservient to deglutition are especially concerned in this disease. The principal foundation of the evil, he thinks, rests on a morbid sensibility both of the external and internal fauces. For the sight of a liquid, or the application of any substance to the internal fauces, but more especially of a fluid, instantly excites the most painful feelings. Nay, the same symptoms are produced by touching the external fauces with a fluid, or by the contact of cold air with these parts; and nearly in as great a degree. But a solid or fluid substance being conveyed into the œsophagus, the transit into the stomach is accomplished with little or no impediment; so that in fact the difficulty is surmounted before the patient is engaged in the action of swallowing. Nor is the excruciating pain, which never fails to be the companion of every attempt to drink, felt in the fauces and throat: it is, he says, at the serobiculum cordis; to which the sufferer applies his hand. From this last circumstance, therefore, from the presence of the rifus sardonicus, from the muscles of the abdomen being forcibly contracted, and from the sense of suffocation which seems to threaten the patient with immediate death, Dr Vaughan has been led to think that in the hydrophobia a new sympathy was established between the fauces, the diaphragm, and the abdominal muscles.

Prognosis. When a person is bit, the prognosis with regard to the ensuing hydrophobia is very uncertain.

All those who are bit do not fall into the disease; Hydrophobia, Dr Vaughan relates, that out of 30 bit by a mad dog, only one was seized with the hydrophobia. During the interval betwixt the bite and the time the disease comes on, there are no symptoms by which we can judge whether it will appear or not. When once it has made its appearance, the prognosis is exceedingly fatal, though there are certainly some well authenticated cases of complete recovery, particularly one recorded by Dr Arnold.

Prevention and Cure. It has been generally allowed by practitioners, that though the hydrophobia may be prevented, yet it can seldom if ever be cured after it has made its appearance. The most essential part of the treatment therefore depends on the proper use of means of prevention. The great objects to be aimed at in prevention, are, in the first place, the complete removal of the contagious matter as soon as possible; or, secondly, means of destroying it at the part, where there is even the slightest reason to believe that it has not been completely removed. Of all the means of removal, the complete cutting out the part to which the tooth has been applied, is unquestionably the most to be depended upon. This practice, therefore, should be had recourse to as soon as possible. The sooner it can be accomplished, the better. But it has been observed, that as a peculiar sensation at the part affected always precedes the accession of the disease, even when it takes place at a late period after the bite, there is good ground for believing that the removal of the part may be of advantage even after a considerable interval. But besides removal of the contagious matter, by cutting away the part to which it is attached, this should also be attempted by careful and long-continued washing. This may be done, in most instances, before a proper opportunity can be had of having recourse to the knife. Cold water should particularly be poured upon the wound from a considerable height, that the matter may be washed away with some force. Even after removal by the knife, careful washing is still a necessary and proper precaution. And after both these, to prevent as far as can be the possibility of any contagious matter lurking about the wounded part, it should not be allowed to heal, but a discharge of matter should be supported for the space of several weeks, by ointment with cantharides, or similar applications. By these means there is at least the best chance of removing the matter at a sufficiently early period. And this mode of prevention seems to be of more consequence than all others put together which have hitherto been discovered. But besides removal, prevention may also be obtained by the destruction of the contagious matter at the part; and where there is the least reason to think that a complete removal has not been obtained, this should always be had recourse to. With this intention the actual cauterizing and burning with gun-powder have been employed. And the action of fire is probably one of the most powerful agents that can be used for this purpose. But recourse has also been had to washing both with acids and with alkalies. Of the former kind, vinegar has been chiefly used, but more may probably be expected from the latter; and particularly from the caustic alkali, so far dilated that it can be applied with safety: for from its influence as a solvent of animal mucus, it gives the

the best chance of a complete removal of the matter, independent of any influence in changing its nature. It has been thought also, that oil applied to the part may be of service. But if recourse be had to it, more active measures should at least be previously employed; and even then, some are of opinion that it is of advantage to increase the activity of the unclues matter by combining it with mercury.

On these grounds, and by these means, we are inclined to think that the action of this contagion on the system, after it has been applied by the bite of a rabid animal, may be most effectually prevented. But after this action has once taken place, no remedy has yet been discovered on which much dependence can be put. A very great variety of articles indeed have at different periods been held forth as infallible, both in the prevention and cure of this affection; but their reputation has, perhaps, universally been founded on their being given to people, who, though really bit by a mad dog, were yet not infected with the contagion. And this happily, either from the tooth being cleaned in making the bite, or not being covered with contagious matter, is by no means an unfrequent occurrence. Mankind, however, even from the earliest ages, have never been without some boasted specific, which has been held forth as an infallible remedy for this affection till fatal experience demonstrated the contrary. Dr Boerhaave has given a pretty full catalogue of those specifics from the days of Galen to his own time; and concludes, that no dependence is to be put in any of them. It is now, therefore, altogether unnecessary to take notice of burnt crabs, the hyena's skin, mithridate with tin, liver of the rabid animal, or a variety of other pretended remedies for this disease, proved by experience to be totally inefficacious. But although no greater confidence is perhaps to be put in specifics of modern date, it will be proper that these should be mentioned.

Bathing in cold water, especially in the sea, and drinking sea-water for a certain time, have been prescribed, and by some accounted a certain preventive. When this was known to fail, a long course of antiphlogistic regimen, violent submersion in water, even to danger of drowning, and keeping the wounded place open with cauteries, were recommended.—To this extreme severity Dr Mead objected; and in his treatise on this subject endeavours to show, that in all ages the greatest success has been reaped from diuretics, for which reason he proposes the following powder: "Take ash-coloured ground-liverwort, half an ounce; black-pepper, two drams: reduce them separately to powder, then mix them together." This powder was first published in the Philosophical Transactions, by Mr Dampier, in whose family it had been kept as a secret for many years. But this medicine, which was inserted in former editions of the London and Edinburgh pharmacopoeias, under the name of Pulvis Antilyssus, has long lost its credit.

There is a famous East-India medicine, composed of 24 grains of native and as much facetious cinnabar, made into a powder with 16 grains of musk. This is called the Tonquin medicine, and must be taken in a tea cupful of arrac or brandy; and is said to secure the patient for 30 days, at the expiration of

which it is to be repeated; but if he has any symptoms of the disease, it must be repeated in three hours, which is said to be a sufficient for a cure. The first dose is to be taken as soon after the bite as possible.

Another celebrated remedy is Palmarius's powder, composed of the leaves of rue, vervain, sage, polypody, wormwood, mint, mugwort, balm, betony, St John's wort, and lesser centaury. These herbs must be gathered in their prime, dried separately in the shade, and then powdered. The dose is a dram, or a dram and an half, taken every day.

A remedy which might promise to be more efficacious than any of those hitherto mentioned is mercury. This has been recommended in frictions, and to be taken inwardly in the form of calomel and turbith mineral, in order if possible to raise a slight salivation, on which the efficacy was thought to depend. Besides this, venesection, opium, cinchona, and camphor, have been tried in very large quantities; the warm bath; and, in short, every thing which human invention could suggest; but with how little success, can be judged from many well authenticated cases.

Dr Wolf, after detailing a number of interesting cases, makes the following observations.—"Thus we see, that the mercury, the acids, the musk, the feeding on the most famous herbs, the sweating, the cura antiphlogistica, &c. are no specifics."

The following case by Dr Raymond of Marcellies shows the inefficacy of mercury even as a preventive.—On the 19th of July 1765, Mr Boyer, aged 25, of a bloated cachectic habit, was bit by a mad dog in the inferior part of the leg: the wound extended half way round, bled freely, and was like a great scratch. The patient's legs had been swelled for a considerable time before the accident; and there were also two ulcers in the other leg. Some hours after the accident, the actual cautery was applied to the wound. The doctor was not present at this operation; but the part around the bite was rubbed with mercurial ointment immediately after, and the eschar was dressed with the same ointment. The eschar was separated on the first day, but the dressing was continued till the wound was cicatrified. The second day a bolus of four grains of turbith and eight grains of camphor was exhibited. This procured a considerable evacuation both by vomit and stool, and a spitting also came on. The third day the bitten leg was rubbed with mercurial ointment: in the space of a month the frictions were repeated five times on both legs, three drams of mercurial ointment being used in each friction. During the same time the bolus was five times repeated; and this treatment kept up a slight salivation to the 42th day. The evening of the third day he took the Tonquin medicine, called also Sir George Cobb's powder, in a bolus; which vomited him briskly. This powder was repeated seven or eight times in the month, generally with the same effect. During the first seven or eight days he got four times, in the morning, a dram of the anagallis flore puniceo, fresh gathered and powdered. The 41st day, the turbith bolus was prescribed for the seventh time: he was bathed in the sea, and continued the bathing for two days more. On the 74th he was seized with the disemper; and died on the 76th, seemingly suffocated or strangled, his mouth covered with slaver, and

Spasm. his face bloated. He lost his senses not above half a quarter of an hour before his death. The pulse was quiet the whole time.

Another instance is mentioned by the same author, of a pregnant woman bit by the same dog and on the same day with Mr Boyer, who was never seized with the distemper. She was treated in much the same manner with him, and salivated a little more. But she was bit through a shamoy leather shoe, which must necessarily have cleaned the animal's teeth of the poisonous saliva before they reached her skin, and to this we are naturally led to ascribe her safety. One of Dr Wolf's patients also was a pregnant woman, and was not seized with the distemper. Perhaps women in a state of pregnancy may be less liable to this distemper than others: but it is more probable that the contagion was not communicated.

The same author tells us, "there are many examples of the inefficacy of mercurial frictions. A surgeon of Marcellus treated a girl about 12 years of age bit by a mad dog, with mercurial frictions; applying them as in the lues venerea: yet she died of the hydrophobia on the 55th day. Her wound was not cauterized."

In the following case all the most powerful remedies were tried.—In the afternoon of the 29th of Aug. 1777, Dr Vaughan was called to a boy of eight years of age labouring under a hydrophobia. He had been bit on the wrist by a cat about a month before; of which the marks remained, but without any ulcer, or even the smallest appearance of inflammation. About the middle of the day before Dr Vaughan saw him, he began to complain of a pain in the part bitten, which ascended up the arm, and affected the temple on that side; soon after which he swallowed liquids with reluctance and difficulty. He was put into the warm bath for three quarters of an hour, during which time he was easier: he had a clyster of five ounces of fresh broth, and 30 drops of laudanum, injected immediately after his coming out of it; a liniment consisting of three drams of strong mercurial ointment, with the same quantity of oil of amber, was rubbed upon the shoulders and back; two pills of a grain of flowers of zinc, and half a grain of cuprum ammoniacum, were taken every three or four hours: and a medicated atmosphere was prepared for him, by burning gum ammoniac in his room. As these remedies were not attended with any good effect, each dose of pills was ordered to contain two grains of cuprum ammoniacum, the same quantity of opium, three grains of flowers of zinc, and ten grains of astringent; whilst a solution of that fetid gum, with a dram of laudanum, was administered as a clyster. These pills, though repeated every four hours, afforded not the smallest relief, nor did they show the least action on the frame. At last the doctor resolved to put in practice the desperate remedy mentioned by Van Helmont, of throwing the patient into cold water, and keeping him there till he is almost drowned. With this view a large tub of cold water, well saturated with common salt, was prepared, into which the poor boy was plunged over head and ears, and there held until he ceased to struggle. He was then taken out again, and the same operation repeated until he became so quiet that the doctor was under apprehensions that a total extinction of life would take place. He was then wrapped up in a

blanket and put to bed, and he remained more quiet than he had formerly been; but all his former restlessness soon returned, his pulse sunk, and he died about two o'clock in the morning.

Another celebrated antidote against the poison of a mad dog has been known for some years by the name of the Ormskirk medicine. The true composition of this is kept a secret by the proprietors: however, it has been analysed, and the following composition published by Dr Heysham as perfectly similar to it in all respects.

"Take half an ounce of chalk, three drams of Armenian bole, 10 grains of alum, one dram of elemampene in powder; mix them all together, and add six drops of oil of anise."

They must certainly be very credulous who can put confidence in such an insignificant medicine as a preservative against the hydrophobia: however, there is a possibility that there may be some unknown ingredient in the genuine powder; for it is difficult to analyse powders after the ingredients are thoroughly mixed together. The efficacy of the medicine therefore must depend on the virtues of that unknown ingredient, if any such there be. The following cases, however, too well determine that it is not infallible, as was at first pretended. In all probability, as well as many others, its reputation also is solely rested on its being exhibited in many cases where no contagion was communicated to the person bit, and while of course no disease could take place.

On the 14th of February 1774, Mr Bellamy of Holborn, aged 40, was bit by a cat affected with rabies, which was killed the same morning. The following day he took the celebrated Ormskirk medicine, sold by Hill and Berry in Hill-Street, Berkeley-Square, and conformed in every respect to the directions given by the vender. A servant maid, who was bitten in the leg before her master was bitten, likewise took the same remedy. About the middle of April Mr Bellamy complained of a pain in his right knee, which he supposed to be rheumatic, and which continued and increased till the 7th of June, when he got some pills of calomel, ipecacuanha, and pil. sapon. from an apothecary, with Huxham's tincture of the bark in small doses. In six days more he had a titillation in the urethra, a contraction of the scrotum and penis to a degree of pain, and an emission of semen after making water, to which he had frequent calls. The medicines were discontinued; and on the 16th of that month the hydrophobia came on, and Dr Fothergill was called. Six ounces of blood were taken from his arm, and a bolus of a scruple of native cinnamon and half a scruple of musk was given every four hours. The distemper manifestly increased through the day. In the evening a clyster was injected, and several times repeated during the night; he had been put into the warm bath, and two drams of strong mercurial ointment rubbed into his legs and thighs by himself. He was greatly relieved by the warm bath while he continued in it, but the symptoms returned with increased violence in the night. The next day being greatly worse, he was blooded to as great a quantity as he could bear, had the warm bath and clysters repeated, and half an ounce of mercurial ointment rubbed into his thighs and legs. Pills of opium were prescribed, but he did not take them. He died the

^Spa... the same night, at half an hour after 12. This patient was a man of great resolution, and could in part conquer his aversion at water. He seemed to have totally forgot the accident of the bite; and casually said, that he thought this disorder resembled the hydrophobia, without supposing that he was afflicted with that distemper at the time.—The bite on the girl's leg refused to heal, baffled the art of a young surgeon who attempted to cure it, and continued a running ulcer for a long time. She did not fall into the hydrophobia. Hence Dr Fothergill thinks it probable, that keeping the wounds made by the teeth of mad animals open for a long time, would probably be of service as a preventive; but in some of Dr Wolf's patients, these artificial drains appear not to have been attended with success.

On the 16th of November 1773, Thomas Nourse, a strong healthy boy of 14, was admitted into the Leicester infirmary; having been that day mouth bitten by a mad fox-hound. The wound was a large lacerated one on the cheek, and bled very freely on being inflicted. The day after he was bit he went to the sea, where he was dipped with all the severity usually practised under so disagreeable an operation. The Ormshirk medicine was also administered with all due care. It was bought of the person in Leicester who is deputed by the proprietor to sell it for him. A common adhesive plaster was applied to the part after sea-bathing; and in the course of a month, without any further trouble, the wound was healed; excepting a small portion, somewhat more than an inch in length, and in breadth about one-tenth. This yielded no discharge, and was quite in a cicatrizing state. Five days before his admission into the infirmary, he began to complain of a tightness over his temples, and a pain in his head: in two days the hydrophobia began to appear; and at its commencement he complained of a boiling heat in his stomach, which was continually ascending to the fauces. The disease was pretty strong when he came to the infirmary. He got a bolus of a scruple of musk with two grains of opium; then a composition of 15 grains of musk, one of turbith mineral, and five grains of opium, was directed to be taken every third hour; an ounce of the stronger mercurial ointment was to be rubbed on the cervical vertebrae and shoulders, and an embrocation of two ounces of laudanum, and half an ounce of acetum saturninum, was directed to be applied to the throat. But by this last he was thrown into convulsions, and the same effect followed though his eyes were first covered with a napkin. The embrocation was therefore changed for a plaster of three drams of powdered camphor, half an ounce of opium, and six drams confectio Damocriti. By these medicines the disease seemed to be somewhat suspended, but the symptoms returned with violence in the evening. His medicine was repeated at seven; and at eight five grains of opium were exhibited without musk or turbith. At nine, another ounce of mercurial ointment was rubbed upon the shoulders, and half an ounce of laudanum with six ounces of mutton-broth was injected into the intestines, but to no purpose. A larger dose of opium was then given, but with as little effect as the former, and he died the same night.

In the month of September 1774, a farmer, aged

25, was bit by a mad dog, whose teeth made a slight ^Hydropho- wound in the fore finger of the left hand. He was dipped, as usual, in the sea; and drank the sea-water for some time on the spot, which operated briskly as a purge. He continued well till the 6th of June following, when he first felt a pain in that hand and arm; for which he bathed in a river that evening, supposing that it had been a rheumatic complaint. The next day he was sick; and in the evening was seized with a violent vomiting, which continued all that night and till the middle of the next day, when it was succeeded by the hydrophobia. He was treated with the warm bath; had a purgative clyster injected; and as soon as it had operated, a second was given, consisting of four ounces of oil, and half an ounce of laudanum: half an ounce of strong mercurial ointment was rubbed on the fauces, and the part was afterwards covered with the cataplasma cymino, to which was added an ounce of opium. An embrocation was applied to the region of the stomach with continued friction, consisting of half an ounce of spirit of sal ammoniac, ten drams of olive oil, six drams of oil of amber, and ten drams of laudanum. Two ounces of strong mercurial ointment were rubbed upon the shoulders and back; and as a further means of inducing a ptyalism speedily, he received the smoke of cinnabar into the mouth by throwing a dram of that substance now and then upon a hot iron: he was also directed to take every four hours a bolus of 15 grains of musk, three grains of turbith mineral, and four grains of opium. He was easier while in the warm bath, and during the application of the ointment; but died the same night about two o'clock.

Many other instances might be adduced of the inefficacy of this pretended specific: which will, it is hoped, create a due degree of caution in those to whom they who are so unfortunate as to be bit by a mad animal may commit themselves. Another remedy may also be mentioned as having had the reputation of being sometimes successful in this disease; which is chiefly employed in different parts of India, particularly in the territory of Tanjore. The medicine to which we now allude contains indeed several articles which are altogether unknown in our materia medica: but it contains at least one very powerful substance well known to us, viz. arsenic. This medicine, known by the name of the Snake Pills, as being principally employed against the bite of the most venomous snakes, is directed to be prepared in the following manner:

Take white arsenic, of the roots of nelli navi, of nevi visham, of the kernels of the ner vatum, of pepper, of quicksilver, each an equal quantity. The quicksilver is to be rubbed with the juice of the wild cotton till the globules are perfectly extinguished. The arsenic being first levigated, the other ingredients, reduced to a powder, are then to be added, and the whole beat together with the juice of the wild cotton to a consistency fit to be divided into pills.

Though these pills are principally used against the bite of the cobra de capello, yet they are said also to be successful in the cure of other venomous bites; and, for the prevention of rabies canina, one is taken every morning for some length of time. Of this remedy European practitioners have, we believe, as yet no experience; and if, in the accounts transmitted by

Spasms. by East India practitioners, it cannot be said that we have authentic evidence of its want of success, it can as little be pretended that there is indubitable evidence of its efficacy in any instance; and it is by no means improbable, that it will be found equally inefficacious with others at one time considered as infallible.

Of the great variety of remedies which have had their day of reputation, there is not one which has not possessed the credit, some time or other, of preventing the noxious effects arising from the bite of a mad dog. A more adequate experience has with all of them discovered the deception. It was above observed, that rabies is by no means the infallible consequence of being bit by a mad animal; and that of between 20 and 30 persons who were bit by the dog which gave the fatal wound to one of Dr Vaughan's patients, not one felt the least ill effect but himself. "In the above number (says the doctor) were some who took the Ormskirk medicine; others went to the salt water; and a part of them used no remedy, who yet fared equally well with the most attentive to their injury. The same thing has often happened before; and much merit, I doubt not, has been attributed to the medicine taken, from that celebrated one of Sir George Cobb down to the infallible one which my good Lady Bountiful's receipt-book furnishes."

From all that has been said, the reader will judge how far the hydrophobia is capable of being subdued by any of the medicinal powers which have yet been tried. Some eminent physicians assert that it is totally incurable; and allege that the instances recorded by different authors of its cure have not been the genuine kind, but that which comes on spontaneously, and which is by no means so dangerous. Indeed two of Dr Wolf's patients recovered, where the disease seems to have been perfectly genuine; but in these the poison seemed to vent itself partly on some other place besides the nervous system. In one the blood was evidently infected, as it had an abominable savor; and the other had a violent pain and swelling in the belly. In all the others, it seemed to have attacked only the nervous system; which perhaps has not the same ability to throw off any offending matter as the vascular system.

There is, however, a possibility that the prodigious affections of the nerves may arise only from a vitiated state of the gastric juices; for it is well known, that the most terrible convulsions, nay the hydrophobia itself, will arise from an affection of the stomach, without any bite of a mad animal. This seems to be somewhat confirmed from one of Dr Wolf's patients, who, though he vomited more than 50 times, yet still threw up a frothy matter, which was therefore evidently secreted into the stomach, just as a continual vomiting of bilious matter shows a continual and extraordinary secretion of bile. Dr Wolf himself adopts this hypothesis so far as to say, that perhaps the serum may become frothy; but in blood drawn from a vein not the least fault appears either in the serum or crassamentum. He affirms, however, that the duodenum appears to be one of the parts first and principally affected; and as it is not inflamed, it would seem that the affection it sustains must arise from the vitiated state of its juices.

Be this as it will, however, in the hydrophobia, the
VOL. XIII. Part II.

stomach seems totally, or in a great measure, to lose the power which at other times it possesses. Two grains of cuprum ammoniacum were repeatedly given to a child of eight years of age without effect; but this dose would occasion violent vomiting in a strong healthy man. Something or other therefore must have prevented this substance from acting on the nervous coat of the stomach; and this we can only suppose to have been the exceedingly disordered state of the gastric juice, which occasioned such violent irritation through the whole body, that the weaker stimulus of the medicine was entirely lost. It would seem proper therefore to consider the stomach in hydrophobic cases as really containing a poisonous matter, which could not be expelled by vomiting, because it is renewed as fast as evacuated. The indication therefore must be, to change its nature by such medicines as are certainly more powerful than the poison; and this indication will naturally lead us to think of large doses of alkaline salts. These, it is certain, will destroy any animal substance with which they come in contact, and render even the poison of serpents inactive. By exhibiting a few doses of them, larger no doubt than what could be safely done on other occasions, we would be certain to change the state of the stomachic juices; and thus might free the patient from those intolerable spasms which always occasion death in such a short time. Dr Wolf seems inclined to think that volatile alkalies were of service; but the above hypothesis would incline us to use rather the fixed kind. At any rate, it seems vain for physicians to trust much to the power of opium, mercury, musk, or cinnabar, either singly or combined in any possible way. Cinchona has also failed, and the most celebrated specifics have been found ineffectual. Alkalies are the next most powerful remedies which the materia medica affords, and they cannot be more unsuccessful than the others have generally been.

Another remedy which seems adapted to change the nature of the gastric juices is ardent spirits. In one of Dr Wolf's patients two bottles of brandy seem to have effected a cure. The oil mixed with it was of no efficacy in other cases, and the opium and turbithe seem not to have been exhibited till the worst was past. In this case the disease seems to have attacked the vascular as well as the nervous system.

In all the patients the warm bath seems to have been a palliative, and a very powerful one, and as such it ought never to be omitted, though we can by no means trust to it as a radical cure; and the above histories abundantly show, that though the warm bath and opium may palliate for a short time, the cause on which the spasms depend is still going on and increasing, till at last the symptoms become too strong to be palliated even for a moment by any medicine however powerful. At any rate, the above-mentioned hypothesis suggests a new indication, which, if attended to, may perhaps lead to useful discoveries. In cases where putrescent bile is abundantly secreted, columbo root and vegetable acids are recommended to change the nature of the poison which the body is perpetually producing in itself. Where corrosive mercury has been swallowed, alkaline salt is recommended to destroy the poison which nature cannot expel by vomiting; and why

why should not something be attempted to destroy the poison which the stomach seems to secrete in the hydrophobia, and which nature attempts to expel, though in vain, by violent efforts to vomit?

But whatever plan may be pursued in the hopes of curing this dreadful malady after any of the symptoms have made their appearance, we ought, in every instance, to direct our immediate care to prevention, as being perhaps the only real ground of hope: And the most certain and efficacious way of preventing the ill consequences, is instantly (if it can be done) to cut out the piece that happens to be bitten. Dr James, indeed, says, that he would have little opinion of cutting or cauterizing, if ten minutes were suffered to elapse from the receiving of the bite before the operation was performed. But in an inaugural dissertation lately published at Edinburgh by Dr Parry, the author is of opinion that excision will be of use a considerable time after the bite is received. He adopts this opinion from what happens in the smallpox, where the blood does not seem to receive the infection till some days after inoculation has been performed. A second inflammation, he tells us, then takes place, and the infection is conveyed into the blood. In like manner, when the hydrophobic infection is about to be conveyed into the blood, according to him, the wound, or its cicatrix, begins again to be inflamed; and it is this second inflammation which does all the mischief. Excision, or the cautery, will therefore be effectual any time between the bite and the second inflammation of the wound. Without implicitly trusting to this doctrine, however, or considering it as in any degree ascertained in what manner the poison diffuses itself, by what marks its progress may be known, or how soon the system may be irredeemably tainted with its malignity, it is undoubtedly safest not to lose unnecessarily a moment's time in applying the knife. This, or a dilation of the wound if it be small, Dr Vaughan considers as the only prophylactics that can be depended upon. In the latter case, he directs to fill the wound with gunpowder, and set fire to it; which would produce a laceration of the part, and possibly the action of ignited powder upon the poison may have its use. In all cases, likewise, after these practices have been employed, the wound should be prevented from healing for some length of time.

This disease very much resembles the former, so that it has undoubtedly been often mistaken for it. It has been known to come on from an inflammation of the stomach, where it was cured by repeated and large bloodletting; in hysteria, where it was cured by opium, musk, or other antispasmodics; and in putrid fevers, where it was cured by evacuating the intestinal canal of the putrid matters by repeated clysters. A very good method of distinguishing the two is, that in the spontaneous hydrophobia the patient is much more delirious than in the genuine species. In the instance mentioned in the Medical Essays of this symptom attending the inflammation of the stomach, the patient raved in the most extraordinary manner. Dr Raymond says he remembers a spontaneous hydrophobia attended with madness;

and in almost all the cases of hydrophobia which are said to have been cured, the patient was very delirious. Dr Nugent's patient was very frequently delirious, and dreaded dogs as well as water. In the Medical Transactions a case is communicated by W. Wrightson surgeon in Sedgefield, Durham, of canine madness successfully treated. This madness indeed came on after the bite of a dog said to be mad: but it appeared only four days after the accident happened, and was attended with symptoms very unlike any of those above mentioned; for he suddenly started up in a fit of delirium, and ran out of the house, and after being brought in, caught hold of the hot bars of the grate which held the fire: Whereas, in the true hydrophobia, the patients dread the fire, light, or any thing which makes a strong impression on the senses. It is probable, therefore, that this was only a spontaneous hydrophobia, especially as it readily yielded to venesection, 30 drops of laudanum, and pills of a grain and an half of opium given every three hours, some boluses of musk and cinnabar, &c. while in some of the former cases as much opium was given to a boy as would have deprived of life the strongest healthy man had he swallowed it; and yet this amazing quantity produced scarcely any effect. This patient also dreaded the sight of a dog.

Although these dissemblers may be considered as distinct genera, yet they are so nearly allied, and so readily change into each other, that it sufficiently justifies the treating all of them together.

The distinguishing characteristic of madness, according to Dr Battie, is a false perception; and under this general character may be comprehended all kinds of what is called madness, from the most silly stupidity and idiocy to the most furious lunacy. Frequently the different kinds of madness are changed into each other by the casual excitement of some passion: thus, an idiot may become furiously mad, by being put in a violent passion; though this does not so often happen as the change of melancholy into the raving madness, and vice versa.

It is a very surprising circumstance, that mad people are not only less liable to be seized with infectious disorders than those who are in perfect health; but even when labouring under other diseases, if the patients chance to be seized with madness, they are sometimes freed from their former complaints. Of this kind Dr Mead relates two very remarkable instances.

On the other hand, it has been known, that an intermittent fever, supervening upon madness of long standing, has proved a cure for the madness; the senses having returned when the fever terminated. Dr Monro saw two instances of this himself; and mentions it as an observation made also by his predecessor in the care of Bethlehem hospital.

Another remarkable circumstance is, that immoderate joy, long continued, as effectually disorders the mind as anxiety and grief. For it was observable in the famous South Sea year, when so many immense fortunes were suddenly gained, and as suddenly lost, that more people had their heads turned, from the prodigious flow of unexpected riches, than from the entire loss of their whole substance.

Mad people, especially of the melancholic kind, sometimes obstinately persevere in doing things which must excite great pain; whence it should seem as if their minds were troubled with some distracting notions, which make them patiently bear the present distress, lest more severe tortures should be inflicted; or possibly they may think, that, by thus tormenting the body, they render themselves more acceptable to the divine Being, and expiate the heinous sins of which they may imagine themselves to have been guilty.

It is, however, also highly probable, that their feelings differ exceedingly from what they are in a natural state; at least they are every day observed to endure, apparently without the smallest uneasiness, watching, hunger, and cold, to an extent which in a state of health would not only be highly distressing, but to the greater part of individuals would even prove fatal. And this resistance of hunger, cold, and sleep, affords perhaps the best test for distinguishing cases of real insanity, from cases where the disease is only feigned, and appearances of it put on, to answer particular purposes; at least where this power of resistance is present, we have good reason to conclude that the affection is not feigned.

Cure. Although we be well acquainted with many

of the remote causes of this disease, some of the principal of which have already been mentioned, yet we are still so ignorant of the influence of these upon the system, as giving a derangement of the mental faculties, that no general principles on which the cure may be conducted, can with any confidence be pointed out.

It may, however, be observed, that while some remedies seem to operate by producing an artificial termination of this complaint, many others have effect only as aiding a natural termination. And where a recovery from this disease does take place, it most frequently happens in consequence of a natural convalescence. All the species and degrees of madness which are hereditary, or that grow up with people from their early youth, are out of the power of physic; and so, for the most part, are all maniacal cases of more than one year's standing, from whatever source they may arise. Very often mere debility, the dregs of some particular disease, such as an ague, the small-pox, or a nervous fever, shall occasion different degrees of foolishness or madness. In these cases, the cure must not be attempted by evacuations; but, on the contrary, by nourishing diet, clear air, moderate exercise, and the use of wine: whereas, in almost all the other maniacal cases, which arise from different sources, and which come on in consequence of intemperate living, violent passions, or intense thinking, it is generally held, that evacuations of every kind are necessary, unless the constitution of the patient be such as absolutely forbids them.

Blood is most conveniently drawn either from the arm or jugulars; and if the weakness be such as renders it improper to take away much blood, we may apply cupping glasses to the occiput.

Vomiting, in weakly people, must be excited by the vinum ipecacuanhae; but in the more robust by emetic tartar or antimonial wine: the most efficacious cathartics are the infusion or tincture of black hellebore, or infusion of senna quickened with tincture of jalap; but if there be suppression of the menses, or of an habitual haemorrhoidal discharge, then aloetic purges will be more proper; and in some instances cooling saline purgatives, such as lixiviated tartar, are of great service. In general, mad people require very large doses, both of the emetics and cathartics, before any considerable operation ensues.

Dr Monro assures us, that the evacuation by vomiting is infinitely preferable to any other: the prodigious quantity of phlegm with which the patients in this disease abound, he says, is not to be overcome but by repeated emetics; and he observes, that the purges have not their right effect, or do not operate to so good purpose, until the phlegm be broken and attenuated by frequent emetics. He mentions the case of a gentleman who had laboured under a melancholy for three years, from which he was relieved entirely by the use of vomits and a proper regimen. Increasing the discharge by urine, is also of the greatest moment, especially when any degree of fever is present. The cutaneous discharges are also to be promoted; for which purpose the hot bath is of the highest service in maniacal cases. Hoffman asserts, that he has seen numerous instances, both of inveterate melancholy and raging madness, happily cured by means of warm bathing; bleeding

bleeding and nitrous medicines having been premised. Camphor has also been highly commended; but, if we can believe Dr Locker of Vienna, not very deservedly. Having found very good effects from a solution of this medicine in vinegar, he took it for granted that all the success was owing to the camphor; therefore, in order to give it a fair trial, he selected seven patients, and gave it in large doses of half a dram twice a-day. This was continued for two months, and the doctor was surprised to find that only one of his patients received any benefit. He then returned the other six back to the camphorated julep made with vinegar, and in a few weeks four of them recovered the use of their reason. This inclined him to think that the virtue depended solely on the vinegar, and accordingly he began to make the trial. Common vinegar was first given: but after a little while he fixed on that which had been distilled, and gave about an ounce and a half of it every day; the patients having been previously prepared by bleeding and purging, which was repeated according as it was found necessary. He gives a list of eight patients who were cured by this method; some in six weeks, others in two months, and none of them took up more than three months in perfecting the cure. He does not indeed give the ages of the patients, nor mention the circumstances of the cases; he only mentions the day on which the use of the vinegar was begun and the day on which they were discharged; and he adds, that they all continued well at the time of his writing.

Dr Locker informs us, that this medicine acts chiefly as a sudorific; and he observed, that the more the patients sweated, the sooner they were cured: it was also found to promote the menstrual discharge in such as had been obstructed, or had too little of this salutary evacuation.

Both reason and experience show the necessity of confining such as are deprived of their senses; and no small share of the management consists in preventing them from hurting either themselves or others. It has sometimes been usual to chain and to beat them: but this is both cruel and absurd; since the contrivance called the strait waistcoat answers every purpose of restraining the patients without hurting them.

These waistcoats are made of ticken, or some such strong stuff; are open at the back, and laced on like a pair of slays; the sleeves are made tight, and long enough to cover the ends of the fingers, where they are drawn close with a string like a purse mouth, by which contrivance the patient has no power of his fingers; and when laid on his back in bed, and the arms brought across the chest, and fastened in that position by tying the sleeve-strings round the waist, he has no use of his hands. A broad strap of girth-web is then carried across the breast, and fastened to the bedstead, by which means the patient is confined on his back; and if he should be so outrageous as to require further restraint, the legs are secured by ligatures to the foot of the bed; or they may be secured by being both put into one bag not very wide, which may be more easily fixed than the feet themselves, at least without giving pain.

It is of great use in practice to bear in mind, that all mad people are cowardly, and can be awed even by the menacing look of a very expressive countenance;

and when those who have charge of them once impress them with the notion of fear, they easily submit to any thing that is required. The physician, however, should never deceive them in any thing, but more especially with regard to their dissembler: for as they are generally conscious of it themselves, they acquire a kind of reverence for those who know it; and by letting them see that he is thoroughly acquainted with their complaint, he may very often gain such an ascendant over them that they will readily follow his directions.

It is a more difficult matter to manage those whose madness is accompanied either with excessive joy or with great dejection and despondency, than those who are agitated with rage: and all that can be done is to endeavour to excite contrary ideas, by repressing the immoderate fits of laughter in the one kind by chiding or threatening (taking care, however, not absolutely to terrify them, which can never be done without danger, and has often added to the misery of the unhappy sufferer); and dispelling the gloomy thoughts in the other, by introducing pleasing concerts of music, or any other species of entertainment which the patients have been known to delight in while they had the use of their reason. Upon the whole, in the cure of insanity, more is perhaps to be effected by moral than by medical treatment. And this moral treatment should be as gentle as is consistent with safety. Chains, bolts, and severity of every kind are to be avoided as much as possible. But while great benefit is often derived from company and amusement, so also on the other hand, solitary confinement is in not a few cases productive of the best effects.

Though blistering the head has generally been directed, Dr Mead says he has oftener found it to do harm than service: but he recommends issues in the back; and advises to keep the head always close shaved, and to wash it from time to time with warm vinegar. Opium has by many been forbidden in maniacal cases, from a supposition that it always increases the disturbance; but there are instances where large doses of this medicine have been found to prove a cure, and perhaps if it were tried oftener we should find powerful effects from it: there certainly cannot much harm ensue from a few doses, which may be immediately disused if they should be found to exasperate the disease.

The diet of maniacal patients ought to be perfectly light and thin: their meals should be moderate; but they should never be suffered to live too low, especially while they are under a course of physic: they should be obliged to observe great regularity in their hours: even their amusements should be such as are best suited to their disposition. After the disease appears to be subdued, chalybeate waters and the cold bath will be highly proper to strengthen their whole frame and secure them against a relapse.

Marces. Noctambulatio, Junc. 124.
Ephialtes, Savv. gen. 138. Lin. 163. Sag. 245.
Incubus, Vog. 221. Junc. 50.

The greatest uneasiness which people feel in sleep is that commonly called the incubus or night-mare. Those seized with it seem to have a weight on their breasts and about their pro-cordia. Sometimes they imagine they see spectres of various kinds which oppress or threaten them with suffocation. Neither does this uneasiness continue only while they are asleep; for it is some time after they awake before they can turn themselves in their beds or speak; nay, sometimes, though rarely, the distemper has proved mortal.—The incubus rarely seizes people except when the stomach is oppressed with aliments of hard digestion, and the patient lies on his back. It is to be cured by eating light suppers, and raising the head high; or, if it become very troublesome, antispasmodic medicines are to be administered, and the body strengthened by chalybeates. The same method is to be followed by those who are subject to walking in their sleep; a practice which must necessarily be attended with the greatest danger: and somnambulism may justly be considered as merely a different modification of this disease. Accordingly Dr Cullen has distinguished the one by the title of oneirodynia activa, and the other by that of oneirodynia grava.

339 CLASS III. CACHEXIE.

Cachexie, Savv. Cls. X. and Cls. VIII. Sag. Cls. III.
Deformes, Lin. Cls. X.

334 ORDER I. MARCORES.

Macies, Savv. Cls. X. Order I. Sag. Cls. III.
Order I.
Emaciantes, Lin. Cls. X. Order I.

332 GENUS LXIX. TABES.

WASTING of the Body.

Tabes, Savv. gen. 275. Lin. 209. Vog. 306. Sag. 100.

This disorder is occasioned by the absorption of pus from some ulcer, external or internal, which produces an hectic fever. The primary indication therefore must be to heal the ulcer, and thus take away the cause of the disease. If the ulcer cannot be healed, the patient will certainly die in an emaciated state. But the proper treatment of the tabes proceeding from this cause, falls to be considered under the head of Ulcer in SURGERY, and likewise under the genera SYPHILIS, SCORFULA, SCORBUTICS, &c. diseases in which ulcers are at least a very common symptom.

333 GENUS LXX. ATROPHIA.

NERVOUS CONSUMPTION.

Description. This affection consists principally in a wasting of the body, without any remarkable fever, cough, or difficulty of breathing; but attended with want of appetite and a bad digestion, whence the

whole body grows languid, and wastes by degrees.— Atropia. Dr Cullen, however, asserts, that some degree of fever, or at least of increased quickness of the pulse, always attends this disease.

Causes. Sometimes this distemper will come on without any evident cause. Sometimes it will arise from passions of the mind; from an abuse of spirituous liquors; from excessive evacuations, especially of the semen, in which case the distemper has got the name of tabes dorsalis. It may arise from mere old age, or from famine.

Prognosis. This distemper, from whatever cause it may arise, is very difficult to cure, and often terminates in a fatal dropsy.

Cure. The general principles on which the treatment of this disease is to be regulated, very much depend on the cause by which it is induced; and it is unnecessary to add, that this must be removed as far as possible. Next to this, the disease is most effectually combated by the introduction of nutritious aliment into the system, and by obtaining the proper assimilation and digestion of this. With the first of these intentions, recourse must be had to the diet which is most nutritious, and at the same time of easiest digestion. But from the condition of the stomach commonly attending this disease, it is necessary that small quantities only should be taken at a time, and that it should be frequently repeated. With the second intention, stomachic and nervous medicines are the articles chiefly at least to be depended upon in this case. The Peruvian bark, sulphuric acid, and chalybeates, are excellent; and these should be conjoined with gentle exercise, as far as the strength and other circumstances of the patient will admit. In that species of the distemper occasioned by venereal excesses, it is so essentially necessary to abstain from them, that without it the best remedies will prove altogether useless.

ORDER II. INTUMESCENTIE.

Intumescentie, Savv. Cls. X. Ord. II. Sag. Cls. III. Ord. II.
Tumidosi, Lin. Cls. X. Ord. II.

GENUS LXXI. POLYSARCIA.

CORPULENCY.

Polysarcia, Savv. gen. 279. Lin. 213. Vog. 540. Sag. 160. Steatites, Vog. 390.

In a natural and healthy state, the fat, or animal oil, is not allowed to diffuse itself throughout the cellular interstices at large, but is confined to the places where such an oily fluid is necessary, by a particular apparatus of distinct vesicles. But in some constitutions the oily part of the blood appears to exceed the requisite proportion, and easily separates from the other constituent parts; or there is an uncommon tendency to the separation of oily matter. In these cases it is apt to accumulate in such quantities, that we may suppose it to burst those vesicles which were originally destined to hinder it from spreading too far; or almost every cell of the membrana adiposa, many of which are in ordinary cases altogether empty, may be completely filled and distended with fat.

The increase of the omentum particularly, and the accumulation

accumulation of fat about the kidneys and mesentery, swell the abdomen, and obstruct the motions of the diaphragm; whence one reason of the difficulty of breathing which is peculiar to corpulent people; while the heart, and the large vessels connected with it, are in like manner so encumbered, that neither the systolic nor substatory motion can be performed with sufficient freedom, whence weakness and slowness of the pulse: but when the whole habit is in a manner overwhelmed with an oily fluid, the enlargement of the cellular interstices will necessarily interrupt the general distribution and circulation throughout the nervous and vascular systems; impeding the action of the muscular fibres, and producing insensibility, somnolency, and death.

These cases are the more deplorable, as there is but little prospect of a cure. For the animal oil is of too gross a nature to be easily taken up by absorption; and we know, that when fluids are accumulated in the cellular system, there are only two ways in which they can be carried off or escape; namely, by the absorbents, which take their rise from the cellular interstices, and through the pores of the skin by transudation.

Another misfortune is, that the disease steals on so imperceptibly, that it becomes inveterate before people begin to think of pursuing the proper means of relief.

In this disease the cure must turn upon two points: First, on preventing the farther deposition of fat, by avoiding the introduction of superfluous aliment, particularly of fatty matters, into the system; and, secondly, on promoting and forwarding the absorption of fat. On these grounds, besides what may be done by proper regimen, a variety of articles have been recommended in the way of medicine.

Soap has been proposed as a remedy to melt down and facilitate the absorption of the fat in corpulent people; and Dr Fleming some years ago published a little treatise, wherein he recommends this medicine, and relates the case of a gentleman who is said to have received considerable benefit from it. But perhaps the soap-leys would be more powerful, and might be more easily taken sheathed, in the manner directed when used as a dissolvent of the stone.

Lieutaud advises to take acetum scilliticum in small doses, with frequent purging and brisk exercise. But it will seldom happen that the patients will be found sufficiently steady to persist in any of these courses, it being the nature of the disorder to render them irresolute and inattentive to their condition. Therefore the principal use of rules must be with a view to prevention; and persons who are disposed to corpulency should take care in time to prevent it from becoming an absolute disease, by using a great deal of exercise, not indulging in sleep, and abridging their meals, especially that of supper. Salted meats are less fattening than such as are fresh; and drinking freely of coffee is recommended to corpulent people.

But Dr Fothergill observes, that a strict adherence to vegetable diet reduces exuberant fat more certainly than any other means that he knows; and gives two cases in which this regimen succeeded remarkably well. The famous Dr Cheyne brought himself down in this way, from a most unwieldy bulk to a reasonable degree of weight; as he himself informs us. It deserves,

however, to be remarked, that every practice for the removal or prevention of fatness must be used with great caution and prudence: for not a few, anxious to prevent this affection, have had recourse to a regimen and to medicine which have proved fatal. This has particularly arisen from the excessive use of acids, probably operating by entirely destroying the action of the chylopoietic viscera.

Pneumatosis, Sauv. gen. 280. Veg. 391. Sag. 107.
Emphysema, Sauv. gen. 13. Lin. 288. Veg. 392.
Leucophlegmatia, Lin. 214.

The emphysema sometimes comes on spontaneously; but more frequently is occasioned by wounds of the lungs, which, giving vent to the air, that fluid infiltrates itself into the cellular texture, and often blows it up to a surprising degree. It must be observed, however, that it is only in cases of laceration of the lungs where this disease can take place; for in a simple wound, the effusion of blood always prevents the air from getting out. The cure is to be accomplished by scarifications and compresses; but in some cases only by the paracentesis of the thorax. When air introduced from the lungs is collected in a considerable quantity in the cavity of the thorax, the operation of the paracentesis is perhaps the only means of cure. Upon an opening being thus made, the air sometimes rushes out with incredible violence; and the patient receives at least immediate relief from circumstances the most distressing imaginable. In some instances it is followed even by a complete cure.

Tympanites, Sauv. gen. 291. Lin. 219. Veg. 316.
Sag. 118. Boerh. 226. Junck. 87.
Affectio tympanitica, Hoffm. III. 339.
Meteorismus, Sauv. gen. 292.

This is an inflation of the abdomen, and is of two kinds: 1. That in which the flatus is contained in the intestines, in which the patient has frequent explosions of wind, with a swelling of the belly commonly unequal. 2. When the flatus is contained in the cavity of the abdomen; in which case the swelling is more equal, and the belly sounds when struck, without any considerable emission of flatus. Of these two, however, the former disease is by much the most common; inasmuch, that many, even extensively engaged in practice, have never met with an instance of true abdominal tympanites. In both cases the rest of the body falls away.

Causes, &c. The tympany sometimes takes place in those who have been long troubled with flatulencies in the stomach and intestines. It happens frequently to women after abortion; to both sexes after the suppression of the hemorrhoids; and sometimes from tedious febrile disorders injudiciously treated.

Prognosis. This disease is generally very obstinate, and for the most part proves fatal by degenerating in-

Intumescence. to an ascites. Sometimes, if the patient be healthy and strong, the disease may terminate favourably, and that the more readily if it has followed from some disorder. A hectic consumption, dry cough, and emaciated countenance in a tympany, with a swelling of the feet, denote approaching death in a very short time.

Cure. With a view to the prevention of this affection, it is necessary, in the first place, to avoid, as far as it can be done, causes giving rise to an uncommon extrication of air, by preserving the proper tone of the alimentary canal. After the affection has taken place, the indications are, first, to expel the air already extricated and confined in different cavities; and, secondly, to prevent further accumulation. On these grounds different remedies are employed. The cure, however, is principally attempted by carminative, resolvent, and stomachic medicines, gentle laxatives, and at last tonics, especially chalybeates. In the Edinburgh Medical Essays, vol. i. we have a very remarkable history of a tympany by Dr Monro senior. The patient was a young woman of 22 years of age, who fell into the distemper after a tertian ague, in which she was badly treated. She became a patient in the Edinburgh Infirmary the 24th of March 1730; took several purgatives, and some doses of calomel; used the warm bath; and had an antihysterical plaster applied over the whole belly, but with very little effect. She was monstrously distended, inasmuch that the skin seemed to be in danger of bursting: her breathing was much straitened; but the swelling sometimes gradually decreased without any evacuation. The returns and degree of this swelling were very uncertain; and when the belly was most detumefied, several unequal and protuberant balls could be felt over the whole abdomen, but especially at its sides. Her stomach was good, she had no thirst, and her urine was in proportion to the quantity she drank. She was very colicky, had her menses at irregular periods, but no cedematous swellings appeared in the feet or any where else. In this situation she continued from the time of her admission till the 21st of June, during which interval she had only menstruated twice. Throughout this space of time, the following circumstances were observed, 1. Several times, upon the falling of the swelling, she complained of a headache; once of pains throughout all her body, once of a giddiness, twice of a nausea and vomiting, and the last time threw up green bile; and once her stomach swelled greatly, whilst the rest of the abdomen subsided. 2. During the flowing of the menses she did not swell, but became very big upon their stopping. 3. Blood-letting and emetics, which were made use of for some accidental urgent symptoms, had no very sensible effect in making the tympany either better or worse. 4. She never had passage of wind either way, except a little belching some days before the monthly evacuation.

Some time before the last eruption of the menses, the purgatives were given more sparingly; and antihysterics of the strongest kinds, such as asafoetida, oleum corn. cerv. &c. mixed with soap, were given in large doses, accompanied with the hotter antiscorbutics as they are called, as horseradish and ginger-root infused in strong ale with steel. The patient was ordered to use frequent and strong frictions to all the trunk of her body and extremities, and to use moderate exer-

cise. Immediately before the menses began to flow, clysters of the same kind of medicines were injected. The menses were in sufficient quantity; but as soon as they ceased, her belly increased in its circumference four inches and a half, but soon subsided. She then complained of pains, which a gentle sweat carried off. Borborygmi were for the first time observed on the same day, June 25th; and having taken some infusa sacra at night, she passed a small quantity of blood next day by stool. This was the first appearance of the return of the haemorrhoids, to which she had been formerly subject.

The two following days her saponaceous, antihysterical, and antiscorbutic medicines being still continued, she had such explosions of wind upwards and downwards, that none of the other patients would remain in the same room, nay scarce on the same floor with her. Her belly became less and softer than it had been from the first attack of the disease; her medicines, with a dose of syrup of buckthorn at proper intervals, still were continued, only the proportion of steel was increased; her flatulent discharge went on successfully, and she gradually recovered her former health.

Phyometra, Sauv. gen. 290. Sag. 119.
Hysterophyse, Vog. 317.

The treatment of this is not different from that of the tympany. It is however, upon the whole, a very rare disease; and when it takes place, very seldom if ever admits of a cure.

Anasarca, Sauv. gen. 281. Lin. 215. Vog. 313.
Sag. 108. Boerh. 1225. Hoffm. III. 322. Junck. 87. Monro on the Dropsy. Millman Animadversions de hydrope 1779.
Phlegmatia, Sauv. gen. 282.
Angina aquosa, Boerh. 791.

In this disease the feet first begin to swell, especially in the evening, after exercise, and when the patient has stood or sat long; this swelling rises frequently to the thighs. By lying in bed, the swelling becomes less, or even almost disappears. In the progress of the disease, the swelling often rises to the hips, loins, and belly, and at last covers the whole body. This disease, besides the other symptoms afterwards mentioned under ASCITES, is attended with a remarkable difficulty of breathing. In the cure of this, as well as other species of dropsy, the general intentions are, first, the evacuation of the water already effused either by natural or artificial outlets; and, secondly, the prevention of fresh accumulation, which is chiefly to be expected from supporting a due action of the absorbents, and from keeping up a proper discharge by the serous excretories.

The remedies employed with these intentions are much the same with what are employed against the more

more important genus of ascites. Only it may be here noticed, that in anasarca it has by many been recommended to scarify the feet and legs. By this means the water is often discharged: but the operator must be cautious not to make the incisions too deep; they ought barely to penetrate through the skin; and especial care must be taken, by spirituous fomentations and proper digessives, to prevent a gangrene. Dr Fothergill observes, that the safest and most efficacious way of making these drains is by the instrument used for cupping, called a scarificator; and he always orders it to be so applied as to make the little wounds transversely; as they not only discharge better, but are also longer in healing, than when made longitudinally.

Notwithstanding every precaution, however, gangrene will often ensue; and it is upon the whole a much safer practice to evacuate the water by the natural outlets, the valvular lymphatic absorbents; and with this intention emetics and cathartics, but particularly diuretics, are often employed with success.

Hydrocephalus, Sauv. gen. 285. Lin. 216. Boerh.

Hydrocephalum, Veg. 384.

This differs from the hydrocephalus formerly treated of at some length under the title of Apoplexia Hydrocephalica, chiefly in the water being collected in the external parts of the head, whereas the former is entirely within the skull. In the fifth volume of the Medical Observations we have an account of a very extraordinary case of this kind. The patient was a child only of a few days old, and had a tumor on his head about the size of a common tea-cup, which had the appearance of a bladder distended with water; near the apex was a small opening, through which a bloody serum was discharged. In other respects the child was healthy. No application was used but a piece of linen dipt in brandy. The tumor continued to increase for many months; at the end of which time the membrane containing the water appeared equally thick with the other part of the scalp, except at one place about the size of a shilling, which continued thin, and at times appeared as if it would burst. He remained in this situation for about 17 months, when the circumference of the head was 20 inches, the base 16$\backslash frac\{1\}\{2\}$, the middle 18$\backslash frac\{1\}\{2\}$, and from the base to the apex near 8$\backslash frac\{1\}\{2\}$. The water was then drawn off, and the child died in two days. Almost all other cases of this distemper have proved fatal; the sutures of the skull generally give way, and the whole external part of the head is equally enlarged: but in the instance just now given there was a deficiency of part of the bones. Although, however, in some instances where the head is thus enlarged to an enormous size, the water is exterior to the brain, and therefore entitled to the appellation of hydrocephalus exterior, yet much more frequently in those instances where there is a manifest separation of the bones of the cranium at the sutures, the water is still contained within the ventricles; and accordingly the disease may be much more properly distinguished

into the acute and chronic hydrocephalus, than as is commonly done into the internal and external. Although the latter be much slower in its progress, sometimes subsisting even for years, yet it is equally difficult of cure with the former, and very often it proves fatal in a few days if the water be drawn off by an artificial opening, which may be very easily performed by a mere puncture with a common lancet, without either pain or any immediate hazard from the operation itself, although the water be lodged in the ventricles; for these are distended to an enormous size, and the substance of the brain almost totally destroyed, so that hardly any thing is to be punctured but membrane.

Hydrorachitis, Sauv. gen. 287. Morgagn. de scd.

XII. 9. et seq.

Spinola, Lin. 289.

Spina bifida, Veg. 386.

This disease, which consists in a soft tumor on the lumbar vertebrae, attended with a separation of the vertebrae themselves, though generally considered as approaching to the nature of rachitis, is commonly referred to the article SURGERY, which may be consulted with regard to this affection.

Hydrothorax, Sauv. gen. 150. Veg. 311. Boerh.

This affection, particularly with respect to its causes, is in many circumstances similar to other kinds of dropsy, particularly to ascites. But from the situation of the water, which is here deposited in the cavity of the thorax, it may naturally be supposed that some peculiar symptoms will occur. Besides the common symptoms of dropsy, paleness of the countenance, scarcity of urine, and the like, this disease is, in some instances, attended with a fluctuation of water within the breast; which when it does occur may be considered as a certain distinguishing mark of this affection. But besides this, it is also distinguished by the remarkable affections of circulation and respiration with which it is attended.

The breathing is peculiarly difficult, especially in a recumbent posture; and in many instances patients cannot breathe with tolerable ease, unless when sitting erect, or even stooping somewhat forwards. The pulse is very irregular, and has often remarkable intermissions. But the disease has been thought to be principally characterized by a sudden starting from sleep, in consequence of an almost inexpressible uneasy sensation referred to the breast, and attended with strong palpitation, which may probably arise from an affection either of circulation or of respiration.

That these symptoms are common attendants of this disease, is undeniable; and they are certainly the best characteristics of this affection with which we are yet acquainted: but it must be allowed that they are present in some cases where there is no water in the breast; and

and that in other instances where the disease exists, they are either altogether wanting, or occur only to a very slight degree. Certain diagnostics, therefore, of this disease still remain to be discovered.

When hydrothorax is present, from the affection of the vital functions with which it is attended, it may readily be concluded that it is a dangerous disease, and in many instances it proves fatal. The cure, as far as it can be accomplished, is obtained very much on the same principles as in other dropsies. Here, however, probably from the uncertainty of the diagnostics, the artificial abstraction of water, by paracentesis of the thorax, is less frequently had recourse to than in ascites; though in some instances, after other means have failed, it has been said not only to give relief of symptoms highly urgent, particularly dyspnoea, but even to produce a complete cure. Benefit is often obtained from an artificial discharge of water by the application of blisters to the breast: but in this, as well as other dropsies, a discharge is chiefly effected by the natural outlets, particularly from the use of cathartics and diuretics. In this species of dropsy, more perhaps than in any other, recourse has been had to the use of the digitalis purpurea, or foxglove, so strongly recommended as a diuretic by Dr Withering in his treatise respecting the use of it. There can be no doubt that this article, though sometimes productive of inconvenience from the distressing sickness and severe vomiting which it not unfrequently excites, though used even but in small doses, often operates as a powerful diuretic, and produces a complete evacuation of water, after other articles have failed. From the effects mentioned above, however, as well as from its influence on the pulse, which it renders much slower, it is necessary that it should be employed with great caution, and in small doses. A dram of the dried leaves of the digitalis, macerated for four hours in half a pint of warm water, forms an infusion which may be given in doses of an ounce, and the dried powder of the leaves in doses of one or two grains: these doses may be gradually increased, and repeated twice or oftener in the day; but this requires to be done with great caution, lest severe vomiting, or other distressing symptoms, should take place.

Ascites, Sauv. gen. 288. Lin. 217. Veg. 314.
Sag. gen. 115. Boerh. 1226. Hoffm. III. 322.
Junc. 87. Dr Monro on the Dropsy, 1765.
Milman, Animadversiones de Hydrope, 1779.

Description. This disease assumes three different forms: 1. When the water immediately washes the intestines. 2. When it is interposed between the abdominal muscles and peritoneum; or, 3. When it is contained in sacs and hollow vesicles; in which case it is called the encysted dropsy. Some physicians of great reputation have asserted, that the water was often placed within the duplicature of the peritoneum: but this is alleged by Dr Milman to be a mistake, as that membrane is looked upon by the best anatomists to be single; and he thinks that the above-mentioned physicians have been led into this error from observing the

water collected in the cellular substance of the peritoneum.

In the beginning of an ascites the patient becomes languid, breathless, and has an aversion to motion: his belly swells; and, when struck, the sound of fluctuating water is perceptible; there is a difficulty of breathing when the belly is pressed. There is an almost continual thirst, which in the progress of the disease becomes very urgent; the urine is thick, in small quantity, and high coloured. The pulse is small and frequent; and as the belly swells, the other parts waste away. A fever at last arises, which, constantly increasing, in the end carries off the patient. These symptoms are most urgent where the waters are in immediate contact with the intestines: in the other kinds the rest of the body is less wasted; nor is there so great thirst or difficulty of breathing.

Causes, &c. The immediate cause of dropsy is a greater effusion of serum by the exhalant arteries than the absorbents take up. This may be occasioned either by too great a quantity of liquid thrown out by the former, or by an inability of the latter to perform their office. This commonly happens in people whose bodies are of a weak and lax texture, and hence women are more subject to this malady than men; chlorotic girls especially are very apt to become dropseal.

Sometimes, however, this disease is occasioned by a debility of the vital powers, by great evacuations of blood, or by acute diseases accidentally protracted beyond their usual period; and although this cause seems very different from a laxity of fibres, yet the dropsy seems to be produced in a similar manner by both. For the vital powers being debilitated by either of these causes, naturally bring on a certain debility and laxity of the solids; and, on the other hand, a debility of the solids always brings on a debility of the vital powers; and from this debility of the vital powers in both cases it happens, that those humours which ought to be expelled from the body are not discharged, but accumulate by degrees in its cavities. There is, however, this difference between the two kinds of dropsy arising from these two different causes: That in the one which arises from laxity the solid parts are more injured than in that which arises from a debility of the vital powers. In the former, therefore, the water seems to flow out from every quarter, and the body swells all over. But when the disease is occasioned by a debility of the vital powers, though the solids be less diseased, yet the power of the heart being much diminished, and the humours scarce propelled through the extreme vessels, the thin liquids, by which in a healthy state the body is daily recruited, are carried by their own weight either into the cavities or into the cellular texture. Hence those aqueous effusions which follow great evacuations of blood, or violent loosenesses, begin in the more depending parts of the body, gradually ascending, till they arrive at the cavity of the abdomen, or even the thorax.

But another and much more sufficient cause for the production of dropsy is an obstruction of the circulation; and this may take place from polypi in the heart or large vessels, and hard swellings in the abdomen. Instances have been observed of a dropsy arising from fleatomatous tumors in the omentum, and many more from a scirrhus liver or spleen, and from an infarction

tion and obstruction of the mesenteric glands, by which means the lymph coming from the extremities is prevented from arriving at the heart. Scirrhosity of the liver, the most common cause of ascites, probably operates by augmenting effusion, in consequence of its preventing the return of the venous blood, the greater part of the veins from the abdomen going to the formation of the vena portarum.

Lastly, Whatever, either within or without the vessels, contracts or shuts up their cavities, produces a more copious and easy transmission of the thin humours through the exhalant arteries, at the same time that it prevents their return by the absorbent veins. This has been established by experiment: For Lower having perforated the right side of the thorax in a dog, tied the vena cava, and sewed up the wound. The animal languished for a few hours, and then died. On dissection, a great quantity of serum was found in the abdomen, as if he had long laboured under an ascites. In like manner, having tied the jugular veins of another dog, a surprising swelling took place in those parts above the ligatures, and in two days the animal died. On dissection, all the muscles and glands were vastly distended, and quite pellucid, with limpid serum. From these experiments, and some cases of the disease mentioned by different authors, it appears, that when the veins are obstructed so that they cannot receive the arterial blood, the serum is separated as by a filter into the more open cavities and laxer parts of the body, while the thicker part stagnates and is collected in the proper blood vessels.

The too great tenuity of the humours is very frequently accused as the cause of dropsy, and many authors have asserted that dropsy might arise merely from a superabundance of water in the blood. For this, some experiments are quoted, from which they would infer, that when a great quantity of aqueous fluid is introduced into the blood, the superfluous fluid ought by no means to pass through the extremities of the sanguiferous arteries into the veins in the common course of circulation, but by being effused into the cavities should produce a dropsy. But this can only happen when the vital powers are very much diminished; for, in a natural state, the superfluous quantity is immediately thrown out by the skin or the kidneys: and agreeable to this we have an experiment of Schultzius, who induced a dropsy in a dog by causing him drink a great quantity of water; but he had first bled him almost ad deliquium, so that the vital powers were in a manner oppressed by the deluge of water. In this manner do those become hydropic who are seized with the disease on drinking large quantities of water either when wearied with labour, or weakened by some kinds of diseases. Dr Fothergill relates an instance of a person who, being advised to drink plentifully of barley-water, in order to remove a fever, rashly drunk 12 pounds of that liquor every day for a month, and thus fell into an almost incurable dropsy. But if this quantity had been taken only during the prevalence of the fever, he would, in all probability, have suffered no inconvenience, as may be inferred from what has been related concerning the dieta aquosa used by the Italians.

It is moreover evident from experiments, that, in a healthy state, not only water is not deposited in the cavities, but that if it is injected into them it will be ab-

sorbed, unless some laxity of the solids has already taken place. Dr Muirgrave injected into the right side of the thorax of a dog four ounces of warm water; whence a difficulty of breathing and weakness immediately followed. But these symptoms continually lessened, and in the space of a week the animal seemed to be in as good health as before. Afterwards he injected 16 ounces of warm water into the left cavity of the thorax in the same dog; the same effects followed, together with great heat, and strong pulsation of the heart; but he again recovered in the space of a week. Lastly, He injected 18 ounces of water into one side of the thorax, and only six into the other: the same symptoms followed, but vanished in a much shorter time; for within five days the dog was restored to perfect health. During this time, however, he observed that the dog made a greater quantity of urine than usual.

The remote causes of dropsy are many and various. Whatever relaxes the solids in such a manner as to give an occasion of accumulation to the serous fluids, disposes to the dropsy. A lazy indolent life, rainy wet weather, a swampy or low soil, and every thing which conduces to vitiate the viscera, or insensibly to produce obstructions in them, paves the way for a dropsy. Hence those are ready to fall into the disease who use hard and viscous aliments, such as poor people in some countries who use coarse brown bread, and children who are fed with unwholesome aliments; and the same thing happens to those who drink immoderately of spirituous liquors.

Prognosis. When the dropsy arises from a scirrhus of the liver or spleen, or any of the other viscera, the prognosis must always be unfavourable, and also when it arises from disorders of the lungs. Neither is the case more favourable to those in whom the small vessels are ruptured, and pour out their liquids into the cavity of the abdomen. Those certainly die who have polypi in the vessels, or tumors compressing the veins and vessels of the abdomen. A dropsy arising from obstructions in the mesenteric glands is likewise difficult to cure, whether such obstructions arise from a bad habit of body, or from any other cause; if we can, however, by any means remove the disease of the glands, the dropsy soon ceases. But in those who fall into dropsy without any disease preceding, it is not quite so dangerous; and even though a disease has preceded, if the patient's strength be not greatly weakened, if the respiration be free, and the person be not affected with any particular pain, we may entertain great hopes of a cure. But where a great loss of blood is followed by a fever, and that by a dropsy, the patients almost always die, and that in a short time: those, however, are very frequently cured who fall into this disease without any preceding haemorrhage.

Cure. In the cure of this disease authors chiefly mention two indications: 1. To expel the effused water; and, 2. To prevent its being again collected. But before we proceed to speak of the remedies, it is necessary to take notice, that by the laws of the animal economy, if a great evacuation of a fluid takes place in any part of the body, all the other fluids in the body are directed towards that part, and those which lie, as it were, lurking in different parts will be immediately absorbed, and thrown out by the same passage. Hence the humours which in hydropic per-

fons are extravasated into the different cavities of the body will be thrown into the intestines, and evacuated by purgatives; or by diuretics will be thrown upon the kidneys, and evacuated by urine. It is, however, not only necessary to excite these evacuations in order to remove this malady, but they must be assiduously promoted and kept up till the abundant humour is totally expelled. For this reason Sydenham has advised purgatives to be administered every day, unless, either through the too great weakness of the body, or the violent operation of the purgative, it shall be necessary to interpose a day or two now and then; because if any considerable intervals be allowed to take place between the exhibition of the purgatives, an opportunity is given to the waters of collecting again. In this method, however, there is the following inconvenience, that, when the waters are totally evacuated, the strength is at the same time so much exhausted, that the distemper commonly returns in a very short time. Hence our chief hopes of curing a dropsy consist in gently evacuating the waters by means of diuretics. But the efficacy of these is generally very doubtful. Dr Freind has long ago observed, that this part of medicine is of all others the most lame and imperfect; but a French physician, Mr Bacher, lately discovered, as he alleges, a method of making the diuretics much more successful. His reputation became at last so great, that the French king thought proper to purchase his secret for a great sum of money. The basis of his medicine was the black hellebore root, the malignant qualities of which he pretended to correct in the following manner: A quantity of the dried roots of black hellebore were pounded, and then put into a glazed earthen vessel, and afterwards sprinkled with spirit of wine. They were suffered to stand for twelve hours, stirring them about twice or thrice during that space of time. They were then sprinkled again, and at last good Rhemish wine was poured on till it stood six fingers above the roots. The mixture was frequently agitated with a wooden spatula; and as the wine was imbibed by the roots, more was poured on, so as to keep it always at the same height for 48 hours. The whole was then put on the fire and boiled for half an hour, after which the decoction was violently pressed out; the same quantity of wine was added as at first, and the mixture boiled as before. After the second expression the woody residuum was thrown away as useless. Both the strained liquors were then mixed together with two parts of boiling water to one of the decoction. The whole is afterwards evaporated in a silver vessel to the consistence of a syrup. One part of the extract is again mixed with two parts of boiling water, and the whole inspissated as before.—By this means, says he, the volatile nauseous acrid particles are separated by evaporation, and the fixed ones remain corrected and prepared for medicinal uses; adding, towards the end, a ninth part of old brandy, and evaporating to the consistence of turpentine. Mr Bacher reasons a good deal on the way in which this process corrects the medicine; but tells us, that notwithstanding the improvement, his pills will not have the desired effect unless properly made up. For forming them, they ought to be mixed with matters both of an inviscating and indurating nature; yet so prepared that it will be readily soluble in the stomach, even of a person much debilitated. For answering these purpo-

ses, he chose myrrh and carduus benedictus, and he gives the following receipt for the formation of his pills:—

“Take of the extract of hellebore prepared as above directed, and of solution of myrrh, each one ounce; of powdered carduus benedictus, three drams and a scruple. Mix them together, and form into a mass, dividing it into pills of a grain and a half each.” To these pills Mr Bacher gives the name of the pilulae tonicae, from an idea, that while they evacuate the water, they at the same time act as tonics; and thus, from augmenting the action of the lymphatics, prevent the return of the disease. And if both these intentions could be effectually answered by the use of the same remedy, it would unquestionably be of great importance in practice.

The effects of these pills were, we are told, very surprising. Dr Daignan relates, that he gave them to 18 hydroptic patients at once; and these he divided into three classes, according to the degree of the disease with which they were affected. The first class contained those who laboured under an anasarca following intermittent fevers. The second class contained those who had an anasarca, together with some degree of ascites, arising from tedious febrile disorders. All these were cured; but these two classes consisted of such cases as are most easily removed. But the third contained six who were seized with a most violent anasarca and ascites, after being much weakened by tedious disorders, and of consequence in whom the disease was very difficult to be cured. Even of these, however, four were cured, and the other two died. The body of one of these being dissected, both sides of the cavity of the thorax were found to be full of a blackish-red water. The lungs were unsound; there was a polypous concretion in the right ventricle of the heart; the liver and spleen were hard, and of a preternatural bulk; and the glands of the mesentery were obstructed and infarcted. In the other, the liver and pancreas were scirrhus, and the spleen very hard.

The same medicines were given by De Horne to eight persons, six of whom had both an anasarca and ascites, but the other two only an ascites. Four of these recovered; three died without being freed from the dropsy; one in whom the dropsy was cured died in a short time after, having for some time before his death become speechless.

By these patients 10 of the pills were taken at once; and the same dose repeated to the third time, with an interval of an hour betwixt each dose. At first they proved purgative, and then diuretic: by which last evacuation they finally cured the disease. But though Mr Bacher was firmly of opinion that his pills cured the dropsy by reason of the above-related correction, yet it is certain that, in the hands of other practitioners, these very pills have failed, unless they also made use of the same regimen recommended by that physician; while, on the other hand, it is also certain, that different medicines will prove equally efficacious in dropical cases, provided this regimen is made use of.

For a great number of ages it has been recommended to dropical patients to abstain as much as possible from drink, and thus to the torments of their disease was added that of an intolerable thirst; and how great this torment was, we may understand from an example of a friend of King Antigonus, who, having

been closely watched both by order of the physicians and also of the king, was so unable to bear the raging thirst occasioned by his disease, that he swallowed his own excrements and urine, and thus speedily put an end to his life. Dr Milman shows at great length the pernicious tendency of this practice. He maintains that it is quite contrary to the sentiments of Hippocrates and the best ancient physicians. He asserts, that unless plenty of diluting drink be given, the best diuretics can have no effect. He condemns also in the strongest terms the practice of giving dropical patients only dry, hard, and indigestible aliments. These would oppress the stomach even of the most healthy; and how much more must they do so to those who are already debilitated by labouring under a tedious disorder! By what means also are these aliments to be dissolved in the stomach when drink is withheld? In this disease the saliva is viscid, and in small quantity; from whence it may be reasonably conjectured, that the rest of the fluids are of the same nature, and the gastric juices likewise depraved. Thus the aliments lie long in the stomach; and if the viscera were formerly free of obstructions, they are now generated; the strength fails; perspiration and other excretions are obstructed; the viscid and pituitous humours produced by these kinds of food float about the precordia, and increase the disease, while the surface of the body becomes quite dry. Nay, so much does this kind of diet conspire with the disease, that 100 pounds of fluid will sometimes be imbibed in a few days by hydropic persons who take no drink. Even in health, if the body from any cause becomes dry, or deprived of a considerable part of its juices, as by hunger, labour, &c. it will imbibe a considerable quantity of moisture from the air; so that we must impute the above-mentioned extraordinary inhalation, in part at least, to the denial of drink, and to the nature of the aliment given to the sick. The following is the account given by Sir Francis Milman of his practice in the Middlesex hospital.

If the patient be not very much debilitated, he is sometimes treated with the purging waters, and a dose of jalap and calomel alternately. On the intermediate days he gets a saline mixture, with 40 or 60 drops of acetum scilliticum every sixth hour; drinking with the purgatives oat-gruel and some thin broths. That he might the better ascertain what share the liquids given along with the medicines had in producing a copious flow of urine, he sometimes gave the medicines in the beginning of the dissemper without allowing the drink: but though the swellings were usually diminished a little by the purgatives, the urine still continued scanty, and the patients were greatly weakened. Fearing, therefore, lest, by following this course, the strength of the sick might be too much reduced, he then began his course of diuretic medicines, giving large quantities of barley water with a little sal diureticus; by which means, sometimes in the short space of 48 hours after the course was begun, the urine flowed out in very large quantity: but as saline drinks are very disagreeable to the taste, a drink was composed purposely for hydropic persons, of half an ounce of super-tartaric of potash, dissolved in two pounds of barley water, made agreeably sweet with syrup, adding one or two ounces of French brandy.

To this composition Sir Francis Milman was induced

by the great praises given to super-tartaric of potash by some physicians in hydropic cases. In the Acta Bononiensis, 15 cases of hydropic patients are related who were cured only by taking half an ounce of cream of tartar daily. But it is remarkable, that by these very patients the cream of tartar was taken for 20, 30, nay 40 days, often without any perceptible effect; yet when dissolved in a large quantity of water, it showed its salutary effects frequently within as many hours, by producing a plentiful flow of urine. This liquor is now the common drink of hydropic patients in the hospital above mentioned, of which they drink at pleasure along with their medicines.

Among purgative medicines Sir Francis Milman recommends the radix fenice; but says the decoction of it, according to the Edinburgh Pharmacopoeia is too strong, as he always found it excite vomiting when prepared as there directed, and thus greatly to distress the patients: but when only half an ounce or six drams of the root are used to a pound of decoction, instead of a whole ounce as directed by the Edinburgh college, he finds it an excellent remedy; and though it may sometimes induce a little vomiting, and frequently a nausea, yet it seldom failed to procure nine or ten stools a-day, and sometimes also proved diuretic. But we must take care not to be too free in the use of feneca, or any other purgative, if the patients be very weak; and therefore, after having used purgatives for some time, it will be proper to depend upon diuretics entirely for perfecting the cure; and of the success of this method our author gives some very remarkable instances. But he observes, that after the dropy is removed, the patients will sometimes die without any evident cause; and of this it is proper that the physicians should be aware. It is remarkable with what ease a flux of urine is induced in those who have a scirrhous liver; while, on the other hand, in one who had the mesenteric glands obstructed, along with a scirrhosity of the liver and vitiated state of the lungs, the most powerful diuretics proved ineffectual. In some cases Sir Francis Milman thinks the kidneys may be so pressed with the weight of the water, as to be unable to perform their office. With regard, however, to diuretics in general, it may be remarked, that the operation of none of them can be certainly depended upon. In particular constitutions, and at particular times, one will be observed to succeed, after another, though commonly much more powerful, has been tried in vain. Accordingly various articles of this kind are often used in succession. Recourse is particularly often had to the root of taraxacum, of colchicum, and of squills; the latter, especially when combined with calomel, is often found to be a very powerful diuretic. And indeed mercury in different forms, probably from acting as a deobstruent, is often of very great use in dropical complaints. Among other diuretics, the lactuca virosa has of late been highly extolled by Dr Collins of Vienna, and the nicotiana tabacum by Dr Fowler of York: but neither has been extensively introduced into practice, although we have known some instances in which the latter, in particular, has been used with great advantage.

The water having been drawn off, we are to put the patient on a course of strengtheners; such as cinchona, with some of the warm aromatics, and a due proportion

Intussusception. of rhubarb infused in wine and chalybeates. Gentle exercise, and frictions on the belly, with such a course of diet as shall be light and nourishing, are also to be enjoined: and it may be observed, that the use of tonic medicines is by no means to be delayed till a complete evacuation of the water can be obtained. On the contrary, by alternating, and even combining the use of evacuant and tonics, the influence of both is often very much promoted.

When the patient can by no other means be relieved, the operation of paracentesis must be had recourse to, which is described under the article SURGERY.

Hydrometra, Sauv. gen. 289. Sag. 116. Boerh. 1224.

Olcheocele, Sauv. gen. 41. Vog. 388.
Olcheophyma, Sag. 44.
Hydrops scroti, Vog. 389.
Hydrops testium, Boerh. 1227.

For the treatment of these two diseases, we may refer the reader to what has already been said of other species of dropsy, particularly Ascites. But both are chiefly to be combatted by surgical operation, especially the latter, in which it seldom fails to produce a complete cure.

Physconia, Sauv. gen. 283. Vog. 325. Sag. gen. 110.
Hypofarca, Lin. 218.

This disease may arise from a variety of causes, as from a swelling of the liver, spleen, kidneys, uterus, omentum, ovarium, mesentery, intestines, &c. and sometimes it arises merely from fat. In the former cases, as the viscera are generally scirrhous and indurated, the distemper is for the most part incurable; neither is the prospect much better where the disease is occasioned by a great quantity of fat.

Rachitis, Sauv. gen. 294. Lin. 212. Vog. 312. Sag. gen. 120. Boerh. 1480. Hoffm. III. 487. Zeviani della Rachitide. Giffon de Rachitide.

Description. This is one of the diseases peculiar to infancy. It seldom attacks children till they are nine months, nor after they are two years old; but it frequently happens in the intermediate space between these two periods. The disease shows itself by a flaccid tumor of the head and face, a loose flabby skin, a swelling of the abdomen, and falling away of the other parts, especially of the muscles. There are

protuberances of the epiphyses of the joints; the jugular veins swell, while the rest decrease; and the legs grow crooked. If the child has begun to walk before he be seized with this disease, there is a slowness, debility, and tottering in his motion, which soon brings on a constant desire of sitting, and afterwards of lying down; insomuch that nothing at last is moveable but the neck and head. As they grow older, the head is greatly enlarged, with ample sutures; the thorax is compressed on the sides, and the sternum rises up sharp, while the extremities of the ribs are knotty. The abdomen is protuberant, and the teeth black and carious. In such patients as have died of this disease, all the solids appear soft and flaccid, and the fluids dissolved and mucous.

Causes. The rickets may proceed from scrofulous or venereal taints in the parents, and may be increased by those of the nurse. It is likewise promoted by feeding the child with aqueous and mucous substances, crude summer fruits, fish, unleavened farinaceous aliment, and too great a quantity of sweet things.—Sometimes it follows intermittent fevers and chronic disorders; and in short, is caused by any thing which tends to debilitate the body, and induce a viscous and unhealthy state of the juices.

Prognosis. The rickets do not usually prove fatal by themselves, but if not cured in time, they make the person throughout life deformed in various ways; and often produce very pernicious disorders, such as carious bones in different parts of the body.

Cure. This is to be effected by mild cathartics, alteratives, and tonics, such as are used in other diseases attended with a debility of the system and a vitiated state of the blood and juices. In the Western islands of Scotland, the medicine used for the cure of the rickets is an oil extracted from the liver of the skate-fish. The method of application is as follows: First, the wrists and ankles are rubbed with the oil in the evening: this immediately raises a fever of several hours duration. When the fever from the first rubbing subsides, the same parts are rubbed again the night following; and repeatedly as long as the rubbing of these parts continues to excite the fever.—When no fever can be excited by rubbing the wrists and ankles alone, they are rubbed again along with the knees and elbows. This increased friction brings on the fever again; and is practised as before, till it no longer has that effect. Then the vertebrae and sides are rubbed, along with the former parts; and this friction, which again brings on the fever, is repeated as the former. When no fever can be any longer excited by this friction, a flannel shirt dipped in the oil is put upon the body of the patient: this brings on a more violent and sensible fever than any of the former frictions; and is continued till the cure be completed, which it commonly is in a short time.

A German physician, Dr Strack, has lately published a paper, in which he recommends the filings of iron as a certain remedy in the rickets. This disease, he observes, in general begins with children when they are about 16 months old. It is seldom observed with children before they be one year old, and seldom attacks them after they pass two; and it is very generally worse where it begins early than where it begins late.

For effecting a cure, it is, he affirms, a matter of the utmost consequence to be able to distinguish, very early, whether a child will be afflicted with rickets or not. And this, he assures us, may be determined by the following symptoms: Paleness and swelling of the countenance; and in that part of the cheeks which should naturally be red, a yellow colour approaching to that of sulphur. When that is the case, he directs that a medicine should be immediately had recourse to which will retard the further progress of the disease, and remove what has already taken place. For this purpose, he advises that five grains of the filings of iron, and as much rhubarb, should be rubbed up with ten grains of sugar, and given for a dose every morning fasting, and every evening an hour before supper. But if considerable looseness should be produced, it will be necessary, at first, to persist in the use of one dose only every day.

After a month's continuance in this course, according to Dr Strack, there in general ensues a keen appetite for food, quick digestion, and a copious flow of urine; by means of which the fulness of the face and yellowness of the complexion are by degrees removed, while the natural colour of the countenance and firmness of the body in general are gradually restored. This practice, he assures us, has never failed of success in any one instance; not even in those children born of parents greatly afflicted with the rickets.

In addition to the use of chalybeates, great benefit is often also obtained in this disease from the use of the cold bath; which under prudent administration, is perhaps one of the most effectual remedies for this complaint with which we are yet acquainted.

Mr Bonhome of Paris, in a late treatise on the subject of rachitis, has endeavoured to prove, that the disease arises from a peculiar acid, and in the cure he particularly recommends phosphate of soda, phosphate and muriate of lime; but above all other articles alkaline lotions. The efficacy of these remedies, however, is not yet confirmed by experience. And we may conclude with observing, that both in the prevention and cure nothing has been found so successful as cold bathing.

When the bones of rickety children begin to bend, they may sometimes be restored to their natural shape by compresses, bolsters, and proper supports. See the article SURGERY.

Impetigines, Sauv. Clafs X. Ord. V. Sag. Clafs III. Ord. V.

Scrophula, Sauv. gen. 285. Vog. 397. Sag. 121.
Struma, Lin. 284.

Description. This disease shows itself by hard, scirrhous, and often indolent tumors, which arise by degrees in the glands of the neck, under the chin, armpits, and different parts of the body, but most commonly in the neck, and behind the ears. In process of time, the cellular substance, ligaments of the joints, and even the

bones themselves, are affected. In scrophula the swellings are much more moveable than those of the scirrhous kind; they are generally softer, and seldom attended with much pain; they are tedious in coming to suppuration; are very apt to disappear suddenly, and again to rise in some other part of the body. We may likewise mention as characteristic circumstances of this disease, a remarkable softness of the skin, a kind of fulness of the face, generally with large eyes, and a very delicate complexion.

Causes. A variety of causes have been mentioned as tending to produce scrophula, viz. a crude indigestible food; bad water; living in damp, low situations; its being an hereditary disease, and in some countries endemic, &c. But whatever may in different circumstances be the exciting or predisposing causes of the scrophula, the disease itself either depends upon, or is at least much connected with, a debility of the constitution in general, and probably of the lymphatic system in particular, the complaint always showing itself by some affections of the latter. And that debility has at least a considerable influence in its production is probable, not only from the manifest nature of some of the causes said to be productive of scrophula, but likewise from such remedies as are found most serviceable in the cure, which are all of a tonic invigorating nature.

Prognosis. The scrophula is a distemper which often eludes the most powerful medicines, and therefore physicians cannot with any certainty promise a cure. It is seldom, however, that it proves mortal in a short time, unless it attacks the internal parts, such as the lungs, where it frequently produces tubercles that bring on a fatal consumption. When it attacks the joints, it frequently produces ulcers, which continue for a long time, and gradually waste the patient; while in the mean time the bones become foul and corroded, and death ensues after a long scene of misery. The prognosis in this respect must be regulated entirely by the nature of the symptoms.

Cure. It was long supposed that scrophula depended upon an acid acrimony of the fluids; and this, it is probable, gave rise to the use of burnt sponge, different kinds of soap, and other alkaline substitutes, as the best remedies for acidity. But although a fourness of the stomach and prime vie does no doubt frequently occur in these complaints, yet this symptom seems to be entirely the consequence of that general relaxation which in scrophula so universally prevails, and which does not render it in the least necessary to suppose a general acidity of the fluids to take place; as the one very frequently, it is well known, even in other complaints, occurs without the least suspicion of any acid acrimony existing in the other. This is also rendered very probable from the indolent nature of scrophulous tumors, which have been known to subsist for years without giving any uneasiness; which could not have been the case, if an acid, or any other acrimony, had prevailed in them.

In the treatment of scrophula, different morbid conditions, existing in different parts, require, according to circumstances, various means of cure: but, upon the whole, the remedies directed may be considered as used with a view either to the tumours, to the ulcerations, or to the general state of the system.

Impetigines. Gentle mercurials are sometimes of use as resolvents in scrofulous swellings; but nothing has such considerable influence as a frequent and copious use of cinchona. Cold bathing too, especially in the sea, together with frequent moderate exercise, is often of singular service here; as is likewise change of air, especially to a warm climate.

In the scrofulous inflammation of the eyes, or ophthalmia strumosa, the cinchona has also been given with extraordinary advantage: and we meet with an instance of its having cured the gutta rosacea in the face; a complaint which it is often difficult to remove, and which is extremely disagreeable to the fair sex.

From the various cases related of tumefied glands it appears, that when the habit is relaxed and the circulation weak, either from constitution or accident, cinchona is a most efficacious medicine, and that it acts as a resolvent and discutient. It will not, however, succeed in all cases; but there are few in which a trial can be attended with much detriment. Dr Fothergill observes, that he has never known it avail much where the bones were affected, nor where the scrofulous tumor was so situated as to be accompanied with much pain, as in the joints, or under the membranous coverings of the muscles; for when the disease attacks those parts, the periosteum seldom escapes without some injury, by which the bone will of course be likewise affected. Here cinchona is of no effect: instead of lessening, it rather increases the fever that accompanies those circumstances: and, if it do not really aggravate the complaint, it seems at least to accelerate the progress of the disease.

Various are the modes in which cinchona is administered: Dr Fothergill makes use of a decoction, with the addition of some aromatic ingredients and a small quantity of liquorice root, as a form in which a sufficient quantity may be given without exciting disgust. But where it is easily retained in the stomach in substance, perhaps the best form of exhibiting it is that of powder; and in this state it is often advantageously conjoined with powder of cicuta, an article possessing very great deobstruent powers.

The powder, however, soon becomes disagreeable to very young patients; and the extract seems not so much to be depended upon as may have been imagined. In making the extract, it is exposed to so much heat, as must have some effect upon its virtues, perhaps to their detriment. In administering it, likewise, if great care be not taken to mix it intimately with a proper vehicle, or some very soluble substance, in weak bowels it very often purges, and thereby not only disappoints the physician, but injures the patient. A small quantity of the cortex Winterianus added gives the medicine a grateful warmth; and a little liquorice, a few raisins, gum arabic or the like, added to the decoction before it be taken from the fire, by making the liquor viscid enables it to suspend more of the fine particles of the bark; by which process the medicine is not only improved in efficacy, but at the same time rendered less disagreeable.

In indolent swellings of the glands from viscid humours, sea water has been strongly recommended by Dr Ruffel.

Dr Fothergill also acquaints us, that the cicuta even by itself is not without a considerable share of efficacy

in removing scrofulous disorders. He mentions the case of a gentlewoman, about 28 years of age, afflicted from her infancy with scrofulous complaints, severe ophthalmies, glandular swellings, &c. cured by the extratum cicute taken constantly for the space of a year. He observes, however, that when given to children, even in very small doses, it is apt to produce spasmodic affections; for which reason he rarely exhibits it to them when very young, or even to adults of very irritable habits.

Dr Fothergill gives several other instances of the success of cicuta in scrofulous cases, and even in one which seemed to be not far removed from a confirmed phthisis; but owns that it seldom had such good effects afterwards: yet he is of opinion, that where there are symptoms of tubercles forming, a scrofulous habit, and a tendency to phthisis, the cicuta will often be serviceable. It is anodyne, corrects acrimony, and promotes the formation of good matter. With regard to the quality of the medicine, he observes, that the extract prepared from hemlock before the plant arrives at maturity, is much inferior to that which is made when the hemlock has acquired its full vigour, and is rather on the verge of decline: just when the flowers fade, the rudiments of the seeds become observable, and the habit of the plant inclines to yellow; this, he thinks, is the proper time to collect the hemlock. It has then had the full benefit of the summer heat; and the plants that grow in exposed places will generally be found more active than those that grow in the shade. The less heat it undergoes during the preparation, the better. Therefore, if a considerable quantity of the dry powder of the plant gathered at a proper season be added, less boiling will be necessary, and the medicine will be the more efficacious. But let the extract be prepared in what manner soever it may, provided it be made from the genuine plant, at a proper season, and be not destroyed by boiling, the chief difference observable in using it is, that a larger quantity of one kind is required to produce a certain effect than of another. Twenty grains of one sort of extract have been found equal in point of efficacy to thirty, nay near forty, of another; yet both of them made from the genuine plant, and most probably prepared with equal fidelity. To prevent the inconveniences arising from this uncertainty, it seems always expedient to begin with small doses, and proceed step by step till the extract produces certain effects, which seldom fail to arise from a full dose. These effects are different in different constitutions. But, for the most part, a giddiness affecting the head, and motions of the eyes, as if something pushed them outwards, are first felt; a slight sickness, and trembling agitation of the body; a laxative stool or two. One or all of these symptoms are the marks of a full dose, let the quantity in weight be what it will. Here we must stop till none of these effects be felt; and in three or four days advance a few grains more. For it has been supposed by most of those who have used this medicine to any good purpose, that the cicuta seldom procures any benefit, though given for a long time, unless in as large a dose as the patient can bear without suffering any of the inconveniences above mentioned. There is however reason to believe, that its effects, as a discutient, are in no degree dependent on its narcotic powers: and

and we are inclined to think, that recourse is often had to larger doses than are necessary; or at least that the same benefit might be derived from smaller ones continued for an equal length of time.

Patients commonly bear a greater quantity of the extract at night than at noon, and at noon than in the morning. Two drams may be divided into thirty pills. Adults begin with two in the morning, two at noon, and three or four at night, with directions to increase each dose, by the addition of a pill to each, as they can bear it.

But, after all, the best form under which the cicuta can, we think, be exhibited, is that of powder from the leaves. This, either under the form of powder or made into pills, may be given at first to the extent of four or five grains, and the dose gradually rising till it amount to 15 or 20 grains twice or thrice a-day. Given to this extent, particularly when conjoined with cinchona, it has often been found of great service in scrofulous cases. At the same time it must be allowed, that such patients, after resisting every mode of cure, will have in some instances a spontaneous recovery in the progress of life, probably from the system acquiring additional vigour.

Different mineral waters, particularly the sulphureous ones, as those of Harrowgate, Moffat, and Gillsland, have been much recommended in scrofula, and sometimes productive of benefit. Recourse has sometimes also been had with advantage to zinc, iron, and barytes, particularly muriate of barytes. But as well as in rachitis, no remedy has been found more efficacious in scrofula than cold bathing, especially sea-bathing.

Siphylis, Sauv. gen. 3086. Lin. 6. Veg. 319.
Seg. 126.

Lues venerea, Boerh. 1440. Hoffm. III. 413. Junck.
96. Astruc de Lue Venerea.

Dr Astruc, who writes a very accurate history of the lues venerea, is fully convinced that it is a new disease, which never appeared in Europe till some time between the years 1494 and 1496, having been imported from America by the companions of Christopher Columbus; though this opinion is not without its opponents. Dr Sanches in particular has contended with much learning and ability, that it appeared in Europe at an earlier period: But it is at least certain that it was altogether unknown to the medical practitioners of Greece and Rome, and that it was a very common disease in America when the Europeans first visited that country. But at whatever period it may have been introduced into Europe, or from whatever source it may have been obtained, there can be no doubt that, as well as smallpox or measles, syphilis depends on a peculiar specific contagion; on a matter sui generis, which is alone capable of inducing this disease.

The venereal infection, however, cannot, like the contagious miasmata of the smallpox and some other diseases, be carried through the air, and thus spread from place to place: for unless it is transmitted from the parents to the children, there is no other way of

contracting the disease but from actual contact with the infectious matter. Thus, when a nurse happens to labour under the disease, the infant that she suckles will receive the infection; as, on the other hand, when the child is infected, the nurse is liable to receive it: and there have even been instances known of lying-in women being infected very violently, from having employed a person to draw their breasts who happened to have venereal ulcers in the throat. It may be caught by touching venereal sores, if the cuticle be abraded or torn: and in this way accoucheurs and midwives have sometimes been infected severely. Dr Macbride says, the most inveterate pox he ever saw was caught by a midwife, who happened to have a whitelow on one of her fingers when she delivered a woman ill of the lues venerea.

But by far the most ready way of contracting this disease is by coition, the genital parts being much more bibulous than the rest of the body. When the disorder is communicated, the places where the morbid matter enters are generally those where it first makes its appearance; and as coition is the most usual way of contracting it, so the first symptoms commonly appear on or near the pudenda.

The patient's own account will, for the most part, help us to distinguish the disease: but there are sometimes cases wherein we cannot avail ourselves of this information, and where, instead of confessing, the parties shall conceal all circumstances; while, on the other hand, there are now and then people to be met with, who persuade themselves that symptoms are venereal, which in reality are owing to some other cause: and therefore it is of the utmost importance to inform ourselves thoroughly of the nature of those symptoms and appearances which may be considered as pathognomic signs of lues venerea.

In the first place, when we find that the local symptoms, such as chancres, buboes, phymosis, and the like, do not give way to the usual methods; or when these complaints, after having been cured, break out again without a fresh infection; we may justly suspect that the virus has entered the whole mass of fluids: but if at the same time ulcers break out in the throat, and the face is deformed by callous tubercles, covered with a brown or yellow scab, we may be assured that the case is now become a confirmed lues, which will require a mercurial course.

When eruptions of the furfuraceous and superficial kind are venereal, they are not attended with itching; and the scale being picked off, the skin appears of a reddish brown, or rather copper colour, underneath; whereas leprosy eruptions are itchy, throw off a greater quantity of scales, and rise in greater blisters, especially about the joints of the knees and elbows. Venereal tubercles or pustules are easily distinguished from carbuncles of the face, by not occupying the cheeks or the nose, nor as having a purulent apex, but are covered at top, either with a dry branny scurf like the superficial eruptions just now mentioned, or else with a hard dry scab of a tawney yellow hue; they particularly break out among the hair or near to it, on the forehead or on the temples.

Venereal ulcers affecting the mouth are distinguishable from those which are scrofulous, in the following manner: 1. Venereal ulcers first affect the tonsils, fau-

ces and uvula; then the gums, but these very rarely: on the contrary, scorbutic ulcers affect the gums first of all; then the fauces, tonsils, and uvula. 2. Venereal ulcers frequently spread to the nose; scorbutic ones almost never. 3. Venereal ulcers are callous in the edges; scorbutic ones are not so. 4. Venereal ulcers are circumscribed, and, for the most part, are circular, at least they are confined to certain places; scorbutic ones are of a more irregular form, spread wider, and frequently affect the whole mouth. 5. Venereal ulcers are for the most part hollow, and generally covered at bottom with a white or yellow slough; but scorbutic ones are more apt to grow up into loose fungi. 6. Venereal ulcers are red in their circumference, but scorbutic ones are always livid. 7. Venereal ulcers frequently rot the subjacent bones, the scorbutic ones seldom or never. 8. And lastly, Venereal ulcers are generally combined with other symptoms which are known to be venereal; scorbutic ones with the distinguishing signs of the scurvy, such as difficult breathing, listlessness, swelling of the legs, rotten gums, &c.

Another strong sign of the confirmed lues is often afforded from certain deep-seated nocturnal pains, particularly of the thighs, arms, and head. As for any superficial wandering pains that have no fixed seat, and which affect the membranes of the muscles and ligaments of the joints, they, for the most part, will be found to belong to the gout or rheumatism, and can never be considered as venereal unless accompanied with some other evident signs; but with regard to the pains that are deeply seated, and always fixed to the same place, and which affect the middle and more solid part of the ulna, tibia, and bones of the cranium, and rage chiefly and with greatest violence in the fore-part of the night, so that the patient can get no rest till morning approaches, these may serve to convince us that the disease has spread itself throughout the whole habit, whether they be accompanied with other symptoms of the lues or not. Gummata in the fleshy parts, nodes in the periosseum, ganglia upon the tendons, tophi upon the ligaments, exoflores upon the bones, and feci at the verge of the anus, are all of them signs of the confirmed lues: these are hard indolent swellings; but as they sometimes arise independently of any venereal infection, and perhaps may proceed from a scrofulous taint, unless they be accompanied or have been preceded by some of the more certain and evident symptoms of the lues, we must be cautious about pronouncing them venereal. When these swellings are not owing to the siphilitic virus, they are very seldom painful, or tend to inflame and suppurate, whereas those that are venereal usually do, and if they lie upon a bone generally bring on a caries.

These carious ulcers are most commonly met with upon the ulna, tibia, and bones of the cranium; and when accompanied with nocturnal pains, we can never hesitate about declaring their genuine nature. Frequent abortions, or the exclusion of scabby, ulcerated, half-rotten, and dead foetuses, happening without any manifest cause to disturb the foetus before its time, or to destroy it in the womb, may be reckoned as a sign that at least one of the parents is infected.

These then are the principal and most evident signs of the confirmed lues. There are others which are more

equivocal, and which, unless we can fairly trace them back to some that are more certain, cannot be held as signs of the venereal disease: Such are, 1. Obstinate inflammations of the eyes, frequently returning with great heat, itching, and ulceration of the eyelids. 2. A singing and hissing noise in the ears, with ulcers or caries in the bones of the meatus auditorius. 3. Obstinate headaches. 4. Obstinate cutaneous eruptions, of the itchy or leprosy appearance, not yielding to the milder methods of treatment. 5. Swellings of the bones; and, 6. Wandering and obstinate pains. None of these symptoms, however, can be known to be venereal, except they happen to coincide with some one or other of the more certain signs.

It may, perhaps, be considered as a singularity in this disease, that the diagnosis is often more difficult in the advanced than in the early periods of the affection. That is, with those who have been certainly subjected to siphylis, it is often very difficult to say whether certain symptoms, remaining after the ordinary modes of cure have been employed, be siphilitic or not. Very frequently, as appears from the sequel, nocturnal pains, ulcerations, and the like, remaining after a long course of mercury has been employed, are in no degree of a venereal nature, but are in reality to be considered as consequences rather of the remedy than of the disease; and are accordingly best removed by nourishing diet, gentle exercise, and tonics. But as long as any symptoms of any kind remain, it is often impossible to convince some patients that they are cured; and it is often impossible for a physician with certainty to affirm that the disease is altogether overcome.

Upon the whole, we are first to distinguish and consider the several symptoms apart; and then, by comparing them with each other, a clear judgement may be formed upon the general review.

Prognosis. Being thoroughly convinced that the case is venereal, we are to consider, first of all, whether it be of a longer or shorter date; for the more recent it is, it will, ceteris paribus, be less difficult to remove. But there are other circumstances which will assist us in forming a prognostic as to the event. As,

1. The age of the patient. This disorder is more dangerous to infants and old people, than to such as are in the flower and vigour of life, in whom some part of the virus may be expelled by exercise, or may be subdued in some degree by the strength of the constitution.

2. The sex. Though women are for the most part weaker than men, and therefore should seem less able to resist the force of any disease, yet experience shows that this is easier borne by them than by men; perhaps owing to the menstrual and other uterine discharges, by which a good portion of the virus may be carried off immediately from the parts where it was first applied; for it is observable, that whenever these discharges are obstructed, or cease by the ordinary course of nature, all the symptoms of this disease grow worse.

3. The habit of body. Persons who have acrid juices will be liable to suffer more from the venereal poison than such as have their blood in a milder state; hence, when people of a scorbutic or scrofulous habit contract venereal disorders, the symptoms are always remarkably violent, and difficult to cure. And

for the same reasons, the confirmed lues is much more to be dreaded in a person already inclined to an asthma, phthisis, dropsy, gout, or any other chronic distemper, than in one of a sound and healthy constitution. For as the original disease is increased by the accession of the venereal poison, so the lues is aggravated by being joined to an old disorder. The more numerous the symptoms, and the more they affect the bones, the more difficult the cure. Of all combinations the union of syphilis with scrofula is perhaps the most difficult to overcome: but if the acrimony should seize on the nobler internal parts, such as the brain, the lungs or the liver, then the disease becomes incurable, and the patient will either go off suddenly in an apoplectic fit, or sink under a consumption.

Cure. Viewing this disease as depending on a peculiar contagious matter introduced into the system, and multiplied there, it is possible to conceive that a cure may be obtained on one of three principles; either by the evacuation of the matter from the system, by the destruction of its activity, or by counteracting its influence in the system. It is not impossible that articles exist in nature capable of removing this complaint on each of these grounds: but we may venture at least to assert, that few such are yet discovered. Notwithstanding numbers of pretended infallible remedies for syphilis, mercury is perhaps the only article on which dependence is placed among European practitioners; and with regard to its mode of operation, all the three different opinions pointed out have been adopted and supported by different theorists.—But although many ingenious arguments have been employed in support of each, we are, upon the whole, inclined to think it more probable that mercury operates by destroying the activity of the venereal virus, than that it has effect either by evacuating it, or by exciting a state of action by which its influence is counteracted. Some practitioners have affirmed, that the disease may be totally extirpated without the use of mercury; but, excepting in slight cases, it appears from the most accurate observations, that this grand specific is indispensable; whether it be introduced through the pores of the skin, in the form of ointments, plasters, washes, &c.; or given by the mouth, disguised in the different shapes of pills, troches, powders, or solutions.

Formerly it was held as a rule, that a salivation ought to be raised, and a great discharge excited. But this is now found to be unnecessary: for as mercury probably acts by some specific power in subduing and correcting the venereal virus, all that is required is to throw in a sufficient quantity of the medicine for this purpose; and if it can be diverted from the salivary glands so much the better, since the inconveniences attending a spitting are such as we should always wish to avoid.

Mercury, when combined with any saline substance, has its activity prodigiously increased; hence the great variety of chemical preparations which have been contrived to unite it with different acids.

Corrosive sublimate or the murias hydrargyri corrosivus is one of the most active of all the mercurial preparations, inasmuch as to become a poison even in very small doses. It therefore cannot safely be given in substance; but must be dissolved in order to render it ca-

pable of a more minute division. We may see, by looking into Wiseman, that this is an old medicine, though seldom given by regular practitioners. How it came to be introduced into so remote a part of the world as Siberia, is not easily found out; but Dr. Clerc, author of the Histoire Naturelle de l'Homme Malade, assures us, that the sublimate solution has been in use there time out of mind.

It appears to have been totally forgotten in other places, until of late years, when Baron Van Swieten brought it into vogue; so that at one period, if we may credit Dr. Locker, they used no other mercurial preparation at Vienna. The number of patients cured by this remedy alone in the hospital of St. Mark, which is under the care of this gentleman, from 1754 to 1761 inclusive, being 4880.

The method of preparing the solution is, to dissolve as much sublimate in any kind of ardent spirit (at Vienna they use only corn brandy) as will give half a grain to an ounce of solution. The dose to a grown person is one spoonful mixed with a pint of any light pilsan or barley water, and this to be taken morning and evening: the patients should keep principally in a warm chamber, and lie in bed to sweat after taking the medicine; their diet should be light; and they ought to drink plentifully throughout the day, of whey, pilsan, or barley water. If the solution does not keep the belly open, a mild purge must be given from time to time; for Locker observes, that those whom it purges two or three times a-day, get well sooner than those whom it does not purge: he also says, that it very seldom affects the mouth, but that it promotes the urinary and cutaneous discharges. This course is not only to be continued till all the symptoms disappear, but for some weeks longer. The shortest time in which Locker used to let the patients out was six weeks; and they were continued on a course of decoction of the woods for some weeks after they left off the solution.

This method has been introduced both in Britain and Ireland, though by no means to the exclusion of others; but it appears, that the solution does not turn out so infallible a remedy, either in these kingdoms, or in France, as they say it has done in Germany. It was seldom if ever found to perform a radical cure, and the frequent use of it proved in many cases highly prejudicial. It has therefore been succeeded in practice, even at Vienna, by mercury exhibited in other forms; and, among these, by a remedy first recommended by Dr. Plenck, and since improved by Dr. Saunders; consisting of mercury united with mucilage of gum arabic, which is said to render its exhibition perfectly mild and safe. For particulars, we refer to Dr. Saunders's treatise.

But a late French writer, supposed to be Dr. Petit, in a small book, entitled, A parallel of the different methods of treating the venereal disease, insists, that there is neither certainty nor safety in any other method than the repeated frictions with mercurial ointment.

It, therefore, is determined to have recourse to the mercurial frictions, the patient may with advantage be prepared by going into the warm bath some days successively; having been previously blooded if of a plethoric habit, and taking a dose or two of some proper cathartic.

The patient being fitted with the necessary apparatus of flannels, is then to enter on the course.

If he be of a robust habit, and in the prime of life, we may begin with two drams of the unguentum hydrargyri fortius, (Ph. Lond.) which is to be rubbed in about the ankles by an assistant whose hands are covered with bladders: then having intermitted a day, we may expend two drams more of the ointment, and rest for two days; after which, if no soreness of the mouth comes on, use only one dram; and at every subsequent friction ascend till the ointment shall reach the trunk of the body; after which the rubbings are to be begun at the wrists, and from thence gradually extended to the shoulders. In order to prevent the mercury from laying too much hold of the mouth, it must be diverted to the skin, by keeping the patient in a constant perspiration from the warmth of the room, and by drinking plentifully of barley-water, whey, or pisan; but if, nevertheless, the mercury should tend to raise a spitting, then, from time to time, we are either to give some gentle cathartic, or order the patient into a vapour or warm bath; and thus we are to go on, rubbing in a dram of the ointment every second, third, or fourth night, according as it may be found to operate; and on the intermediate days either purging or bathing, unless we should choose to let the salivation come on; which, however, it is much better to avoid, as we shall thus be able to throw in a larger quantity of mercury.

It is impossible to ascertain the quantity of mercury that may be necessary to be rubbed in, as this will vary according to circumstances: but we are always to continue the frictions, for a fortnight at least, after all symptoms of the disease shall have totally disappeared; and when we have done with the mercury, warm bathing, and sudorific decoctions of the woods, are to be continued for some time longer.

This is a general sketch of the methods of treatment for the confirmed lues; but for a complete history of the disease, and for ample directions in every situation, we refer to Astruc, and his abridger Dr Chapman.—We have to add, however, that a method of curing this disease by mercurial fumigation has been lately recommended in France, but it seems not to meet with great encouragement. One of the most recent proposals for the cure of the venereal disease is that of Mr Clare, and consists in rubbing a small quantity of mercury under the form of the submuriatis hydrargyri, or calomel as it is commonly called, on the inside of the cheek; by which means it has been supposed that we will not only avoid the inconveniences ofunction, but also the purgative effects that are often produced by this medicine when taken into the stomach. But after all, the introduction of mercury under the form ofunction, as recommended by the latest and best writers in Britain on the venereal disease, Dr Swediaur, Mr John Hunter, and others, is still very generally preferred to any mode that has yet been proposed.

Where, after a long trial of mercury, distressing symptoms still remain, particularly obstinate ulcerations and severe pains, benefit has often been derived from the use of opium: but there is little reason to believe, as has been held by some, that of itself it af-

fords an infallible cure of this disease; at least we are inclined to think, that all the facts hitherto brought in support of the cure of syphilis by opium are at the utmost very doubtful.

The same observation may perhaps be made with regard to another remedy which has of late been highly extolled in syphilis, viz. the nitric acid. This article seems to have been first introduced both against affections of the liver and venereal complaints by Dr Scott of Bombay. It has since been highly extolled by Dr Beddoes and other writers in Britain. And there are many well authenticated cases on record in which it has produced a cure. But it is very rarely preferable to mercury; and it is chiefly useful when, from some peculiarity of constitution, mercury cannot be exhibited.

In obstinate ulcerations, remaining probably after the venereal virus has been overcome, and resisting the use of mercury, a complete cure has in many instances been obtained from the use of the root of the mezereon, the daphne mezereum of Linnaeus. This article has been chiefly employed under the form of decoction; and it now appears that it is the basis of an article at one time highly celebrated in venereal complaints, under the title of Lisbon diet drink. But, upon the whole, these sequelae of this disease are perhaps more readily overcome by country air, gentle exercise, and nourishing diet, particularly a milk diet, than by the use of any medicine whatever. It must indeed be allowed, that for combating different sequelae, various practices accommodated to the nature of these will on particular occasions be requisite. But into the consideration of these we cannot here propose to enter.

Scorbutus, Sauv. gen. 391. Lin. 223. Veg. 318. Seg. 127. Boerh. 1148. Hoffm. III. 369. Junck. 91. Lind on the Scurvy. Hulme de Scorbuto. Rousse de Morbis Navigantium.

Description. The first indication of the scorbutic diathesis is generally a change of colour in the face, from the natural and healthy look to a pale and bloated complexion, with a listlessness, and aversion from every sort of exercise; the gums soon after become itchy, swell, and are apt to bleed on the slightest touch; the breath grows offensive; and the gums, swelling daily more and more, turn livid, and at length become extremely fungous and putrid, as being continually in contact with the external air; which in every case favours the putrefaction of substances disposed to run into that state, and is indeed in some respects absolutely requisite for the production of actual putridity.

The symptoms of the scurvy, like those of every other disease, are somewhat different in different subjects, according to the various circumstances of constitution; and they do not always proceed in the same regular course in every patient. But what is very remarkable in this disease, notwithstanding the various and immense load of distress under which the patients labour, there is no sickness at the stomach, the appetite keeps up, and the senses remain entire almost to the very last: when lying at rest, scorbutic patients make no complaints, and feel little distress or pain; but

the moment they attempt to rise or stir themselves, then the breathing becomes difficult, with a kind of straitness or catching, and great oppression, and sometimes they have been known to fall into a syncope. This catching of the breath upon motion, with the loss of strength, dejection of spirit, and rotten gums, are held as the essential or distinguishing symptoms of the disease. The skin is generally dry, except in the very last stage, when the patients become exceedingly subject to faintings, and then it grows clammy and moist: in some it has an anserine appearance: but much oftener it is smooth and shining; and, when examined, is found to be spread over with spots not rising above the surface, of a reddish, bluish, livid or purple colour, with a sort of yellow rim round them. At first these spots are for the most part small, but in time they increase to large blotches. The legs and thighs are the places where they are principally seen: more rarely on the head and face. Many have a swelling of the legs, which is harder, and retains the impression of the finger longer than the common dropical or truly cedematous swellings. The slightest wounds and bruises, in scorbutic habits, degenerate into foul and unallowable ulcers; and the appearance of these ulcers is so singular and uniform, that they are easily distinguished from all others. Scorbutic ulcers afford no good digestion, but give out a thin and fetid ichor mixed with blood, which at length has the appearance of coagulated gore lying caked on the surface of the sore, not to be separated or wiped off without some difficulty. The flesh underneath these sloughs feels to the probe soft and spongy, and is very putrid. Neither detergents nor escharotics are here of any service; for though such sloughs be with great pains taken away, they are found again at the next dressing, where the same sanguineous putrid appearance always presents itself. Their edges are generally of a livid colour, and pushed up with excrescences of proud flesh arising from below the skin. As the violence of the disease increases, the ulcers shoot out a soft bloody fungus, which often rises in a night's time to a monstrous size; and although destroyed by cauteries, actual or potential, or cut away with the knife, is found at next dressing as large as ever. It is a considerable time, however, before these ulcers, bad as they are, come to affect the bones with rottenness. These appearances will always serve to assure us that an ulcer is scorbutic; and should put us on our guard with respect to the giving mercurials, which are very generally pernicious in these cases.

Scorbutic people, as the disease advances, are seldom free from pains; though they have not the same seat in all, and often in the same person shift their place. Some complain of universal pain in all their bones; but most violent in the limbs, and especially the joints: the most frequent seat of their pain, however, is some part of the breast. The pains of this disease seem to arise from the distraction of the sensible fibres by the extravasated blood being forced into the interstices of the periosteum and of the tendinous and ligamentous parts; whose texture being so firm, the fibres are liable to higher degrees of tension, and consequently of pain.

The states of the bowels are various: in some there is an obstinate costiveness; in others a tendency to a flux, with extremely fetid stools: the urine is also rank

and fetid, generally high coloured; and, when it has stood for some hours, throws up an oily scum on the surface. The pulse is variable; but most commonly slower and more feeble than in the time of perfect health. A stiffness in the tendons, and weakness in the joints of the knees, appear early in the disease: but as it grows more inveterate, the patients generally lose the use of their limbs altogether; having a contraction of the flexor tendons in the ham, with a swelling and pain in the joint of the knee. Some have their legs monstrously swelled, and covered over with livid spots or ecchymoses; others have had tumours there; some, though without swelling, have the calves of the legs and the flesh of the thighs quite indurated. As persons far gone in the scurvy are apt to faint, and even expire, on being moved and brought out into the fresh air, the utmost care and circumspection are requisite when it is necessary to stir or remove them.

Scorbutic patients are at all times, but more especially as the disease advances, extremely subject to profuse bleedings from different parts of the body; as from the nose, gums, intestines, lungs, &c. and likewise from their ulcers, which generally bleed plentifully if the fungus be cut away. It is not easy to conceive a more dismal and diversified scene of misery than what is beheld in the third and last stage of this distemper; it being then that the anomalous and more extraordinary symptoms appear, such as the bursting out of old wounds, and the dissolution of old fractures that have been long united.

Causes. The term scurvy has been indiscriminately applied, even by physicians, to almost all the different kinds of cutaneous foulness; owing to some writers of the last century, who comprehended such a variety of symptoms under this denomination, that there are few chronic distempers which may not be so called, according to their scheme: but the disease here meant is the true putrid scurvy, so often fatal to seamen, that with many it has got the name of seascurvy, though it be a disease frequently occurring on shore, as was experienced by the British garrisons of Boston, Minorca, and many other places. Indeed no disease is perhaps more frequent or more destructive to people sent up in garrisons without sufficient supplies of sound animal food and fresh vegetables. It is sometimes known to be endemic in certain countries, where the nature of the soil, the general state of the atmosphere, and the common course of diet, all combine in producing that singular species of corruption in the mass of blood which constitutes the scorbutic diathesis; for the appearances, on dissecting scorbutic subjects, sufficiently show that the scurvy may, with great propriety, be termed a disease of the blood.

Dr Lind has, in a postscript to the third edition of his treatise on the scurvy, given the result of his observations drawn from the dissection of a considerable number of victims to this fatal malady; from which it appears that the true scorbutic state, in an advanced stage of the distemper, consists in numerous effusions of blood into the cellular interstices of most parts of the body, superficial as well as internal; particularly the gums and the legs; the texture of the former being almost entirely cellular, and the generally dependent state of the latter rendering these parts, of all others in the whole body, the most apt to receive

and retain the stagnant blood, when its crisis comes to be destroyed; and when it loses that glutinous quality which, during health, hinders it from escaping through the pores in the coats of the blood-vessels or through exhalant extremities.

A dropsical indisposition, especially in the legs and breast, was frequently, but not always, observed in the subjects that were opened, and the pericardium was sometimes found distended with water: the water thus collected was often so sharp as to shrivel the hands of the dissection; and in some instances, where the skin happened to be broken, it irritated and festered the wound.

The fleshy fibres were found so extremely lax and tender, and the bellies of the muscles in the legs and thighs so stuffed with the effused stagnating blood, that it was always difficult, and sometimes impossible, to raise or separate one muscle from another. He says that the quantity of this effused blood was amazing; in some bodies it seemed that almost a fourth part of the whole mass had escaped from the vessels; and it often lay in large concretions on the periosteum, and in some few instances under this membrane immediately on the bone. Notwithstanding this dissolved and depraved state of the external fleshy parts, the brain always appeared perfectly sound, and the viscera of the abdomen, as well as those in the thorax, were in general found quite uncorrupted. There were spots indeed, from extravasated blood, observed on the mesentery, intestines, stomach, and omentum; but these spots were firm, and free from any mortified taint; and, more than once, an effusion of blood, as large as a hand's breadth, has been seen on the surface of the stomach; and what was remarkable, that very subject was not known while living to have made any complaint of sickness, pain, or other disorder, in either stomach or bowels.

These circumstances and appearances, with many others that are not here enumerated, all prove to a demonstration a putrescent, or at least a highly depraved state of the blood: and yet Dr Lind takes no small pains to combat the idea of the scurvy's proceeding from animal putrefaction; a notion which, according to him, "may, and hath misled physicians to propose and administer remedies for it altogether ineffectual."

He also, in the preface to his third edition, talks of the mischief done by an attachment to delusive theories. He says, "it is not probable that a remedy for the scurvy will ever be discovered from a preconceived hypothesis, or by speculative men in the closet, who have never seen the disease, or who have seen at most only a few cases of it;" and adds, "that though a few partial facts and observations may, for a little, flatter with hopes of greater success, yet more enlarged experience must ever evince the fallacy of all positive assertions in the healing art."

Sir John Pringle, however, is of a very different opinion. He "is persuaded, after long reflection, and the opportunities he has had of conversing with those who to much sagacity had joined no small experience in nautical practice, that upon an examination of the several articles which have either been of old approved, or have of late been introduced into the navy, it will appear, that though these means may vary in form

and in mode of operating, yet they all some way contribute towards preventing putrefaction; whether of the air in the clover parts of a ship, of the meats, of the water, of the clothes and bedding, or of the body itself."

What Dr Lind has above advanced is the more remarkable, as, in the two former editions of his book, he embraced the hypothesis of animal putrefaction being the cause of the scurvy; and if these effusions of blood, from a destruction of its crisis and the dissolved state of the muscular fibres, together with the rotten condition of the mouth and gums, do not betray putrefaction, it is hard to say what does, or what other name we shall bestow on this peculiar species of deprivation which constitutes the scurvy.

The blood, no doubt, derives its healthy properties, and maintains them, from the due supplies of wholesome food; while the insoluble, superfluous, effete, and acrid parts, are carried off by the several discharges of stool, urine, and perspiration.

Our senses of taste and smell are sufficient to inform us when our food is in a state of soundness and sweetness, and consequently wholesome; but it is from chemistry that we must learn the principles on which these qualities chiefly depend.

Experiments of various kinds have proved, that the soundness of animal and vegetable substances depends very much, if not entirely, on the presence of their aerial principle. Rottenness is never observed to take place without an emission of fixed air from the putrefying substance: and even when putrefaction has made a considerable progress, if aerial acid can be transferred, in sufficient quantity, from some other substance in a state of effervescence or fermentation, into the putrid body, the offensive smell of this will be destroyed. If it be a bit of rotten flesh with which the experiment is made, the firmness of its fibres will be found in some measure restored.

The experiments of Dr Hales, as well as many others made since his time, show that an aerial principle is greatly connected with, and remarkably abundant in, the gelatinous parts of animal bodies, and in the mucilage or farina of vegetables. But these are the parts of our food which are most particularly nutritive; and Dr Cullen, whose opinion on this as on every other medical subject must be allowed of the greatest weight, affirms, in his Lectures on the Materia Medica, that the substances on which we feed are nutritious only in proportion to the quantities of oil and sugar which they respectively contain. This oil and sugar are blended together in the gelatinous part of our animal food, and in the mucilaginous and farinaceous part of esculent vegetables; and, while thus intimately combined, are not perceivable by our taste, though very capable of being developed and rendered distinct by the power of the digestive organs; for in consequence of the changes produced during digestion, the oily and the saccharine matter become manifest to our senses, as we may see and taste in the milk of animals, which is chiefly chyle a little advanced in its progress toward sanguification; the oil is observed to separate spontaneously, and from which a quantity of actual sugar may be obtained by a very simple process.

Thus much being premised, we can now readily comprehend

comprehend how the blood may come to lose those qualities of smoothness, mildness, and tenacity which are natural to it. For if, in the first place, the fluids, and organs subservient to digestion, should be so far dissempered or debilitated that the nutritious parts of the food cannot be properly developed, the blood must be defrauded of its due supplies; which will also be the case if the aliment should not originally contain enough of oily and saccharine matter, or should be so circumstanced, from being dried or salted, as to hinder the ready extrication of the nutritious parts; or, lastly, if the natural discharges should be interrupted or suspended, so that the superfluous, acrid, and effete fluids are retained in the general mass; in all these instances the blood must of necessity run into proportionate degrees of depravation.

And hence we may understand how it may possibly happen, that when persons are greatly weakened by some preceding disorder, and at the same time debarred the use of proper bodily exercise, the scorbutic diathesis should take place, even though they enjoy the advantages of pure air and wholesome diet. But these are solitary cases, and very rarely seen; for whenever the scurvy seizes numbers, and can be considered as an epidemic disease, it will be found to depend on a combination of the major part, or perhaps all, of the following circumstances:

1. A moist atmosphere, and more especially if cold be joined to this moisture. 2. Too long cessation from bodily exercise, whether it be from constraint, or a lazy slothful disposition. 3. Dejection of mind. 4. Neglect of cleanliness, and want of sufficient clothing. 5. Want of wholesome drink, either of pure water or fermented liquors. And, 6. Above all, the being obliged to live continually on salted meats, perhaps not well cured, without a due proportion of the vegetables sufficient to correct the pernicious tendency of the salt, by supplying the bland oil and saccharine matter requisite for the purposes of nutrition.

These general principles respecting the causes and nature of scurvy, seem to afford a better explanation of the phenomena of the disease than any conjectures respecting it that have hitherto been proposed. It must, however, be allowed, that Dr Lind is by no means the only writer who is disposed to consider this disease as not referable to the condition of the circulating fluids. In a late ingenious treatise on this subject by Sir F. Milman, he strenuously contends, that the primary morbid affection in this complaint is a debilitated state of the solids arising principally from want of aliment. But his arguments on this subject, as well as those of Dr Lind, are very ably answered by a still later writer on this subject, Dr Trotter, who has drawn his observations respecting it from very extensive experience, and who considers it as clearly established, by incontrovertible facts, that the proximate cause of scurvy depends on some peculiar state of the blood.— That this disease does not depend on a debilitated state of the solids, is demonstratively proved from numerous cases where every possible degree of debility occurs in the solids without the slightest appearance of scurvy. Dr Trotter, in the second edition of his Observations on the Scurvy, from the result of further observation and later discoveries in chemistry, has attempted, with much ingenuity, to prove that the morbid condition

of the blood, which takes place in scurvy, arises from the abstraction of vital air, or, as it is now generally called, oxygen; and this opinion, though still, perhaps, in some particulars requiring further confirmation, is, it must be allowed, supported by many plausible arguments.

Prevention and Cure. The scurvy may be prevented, by obviating and correcting those circumstances in respect of the non-naturals which were mentioned as contributing to the disease, and laid down as causes. It is therefore a duty highly incumbent on officers commanding at sea, or in garrisons, to use every possible precaution; and, in the first place, to correct the coldness and moisture of the atmosphere by sufficient fires: in the next, to see that their men be lodged in dry, clean, and well ventilated births or apartments; thirdly, to promote cheerfulness, and enjoin frequent exercise, which alone is of infinite use in preventing the scurvy: fourthly, to take care that the clothing be proper, and cleanliness of person strictly observed; fifthly, to supply them with wholesome drink, either pure water or sound fermented liquors; and if spirits be allowed, to have them properly diluted with water and sweetened with mellasses or cane sugar: and lastly, to order the salted meats to be sparingly used, or sometimes entirely abstained from; and in their place, let the people live on different compositions of the dried vegetables; fresh meat and recent vegetables being introduced as often as they can possibly be procured.

A close attention to these matters will, in general, prevent the scurvy from making its appearance at all, and will always hinder it from spreading its influence far. But when these precautions have been neglected, or the circumstances such that they cannot be put in practice, and the disease has actually taken place, our whole endeavour must be to restore the blood to its original state of soundness: and happily, such is the nature of this disease, that if a sufficiency of new matter, of the truly mild nutritious sort, and particularly such as abounds with vital air, such as recent vegetables, or different acid fruits, can be thrown into the circulation while the fleshy fibres retain any tolerable degree of firmness, the patient will recover; and that in a surprisingly short space of time, provided a pure air, comfortable lodgings, sufficient clothing, cleanliness, and exercise, lend their necessary aid.

This being the case, the plan of treatment is to be conducted almost entirely in the dietetic way; as the change in the mass of blood, which it is necessary to produce, must be brought about by things that can be received into the stomach by pints or pounds, and not by those which are administered in drops or grains, drams or ounces. For here, as there is no disorder of the nervous system, we have no need of those active drugs which are indispensably necessary in febrile or nervous diseases; the scorbutic diathesis being quite opposite to that which tends to produce a fever or any species of spasmodic disorders; nay, Dr Lind says, he has repeatedly found, that even the infection of an hospital fever is long resisted by a scorbutic habit.

It will now naturally occur to the reader, what those alimentary substances must be which bid the fairest

Impeti-
giosa.
fairess to restore the blood to its healthy state; and he needs scarcely to be told, that they are of those kinds which the stomach can bear with pleasure though taken in large quantities, which abound in jelly or mucilage, and which allow those nutritious parts to be easily developed; for though the viscera in scorbutic patients may be all perfectly sound, yet we cannot expect that either the digestive fluids or organs should possess the same degrees of power, which enable them, during health, to convert the crude dry farinacea, and the hard salted flesh of animals, into nourishment. We must therefore search for the antiscorbutic virtue in the tender sweet flesh of herbivorous animals; in new milk; and in the mucilaginous acid juices of recent vegetables, whether they be fruits, leaves, or roots.

The four juices of lemons, oranges, and limes, have been generally held as antiscorbutics in an eminent degree, and their power ascribed to their acid; from an idea that acids of all kinds are the only correctors of putrefaction. But the general current of practical observations shows, and our experiments confirm it, that the virtue of these juices depends on their aerial principle; accordingly, while perfectly recent and in the mucilaginous state, and especially if mixed with wine and sugar, the juices of any one of these fruits will be found a most grateful and powerful antiscorbutic.

Dr Lind observing, "that the lemon juice, when given by itself undiluted, was apt, especially if overdosed, to have too violent an operation, by occasioning pain and sickness at the stomach, and sometimes a vomiting; found it necessary to add to it wine and sugar. A pint of Madeira wine, and two ounces of sugar, were put to four ounces and a half of juice, and this quantity was found sufficient for weak patients to use in 24 hours: such as were very weak sipped a little of this frequently according as their strength would permit; others who were stronger took about two ounces of it every two hours; and when the patients grew still stronger, they were allowed eight ounces of lemon juice in 24 hours."

While this very pleasant mixture, which is both a cordial and an antiseptic, may be had, it would be needless to think of prescribing any other; but when the fresh juice cannot be procured, we must have recourse to such other things as may be obtained. But the various modes of combining and administering these, so as to render them perfectly agreeable to the stomach, must always be regulated by circumstances, and therefore it will be in vain to lay down particular directions; since all that we have to do is, to fix on such fruits and other fresh vegetables as can be most conveniently had and taken, and contrive to give them in those forms, either alone or boiled up with flesh meat into soups, which will allow the patients to consume the greatest quantities.

The first promising alteration from such a course is usually a gentle diarrhoea; and if, in a few days, the skin becomes soft and moist, it is an infallible sign of recovery; especially if the patient gain strength, and can bear being stirred or carried into the open air without fainting.

But if the belly should not be loosened by the use of the fresh vegetables, nor the skin become soft and moist,

then they must be assisted by stewed prunes, or a decoction of tamarinds with super-tartrate of potash, in order to abate the colliqueness; and by drinking a light decoction of the woods, and warm bathing, in order to relax the pores of the skin; for nothing contributes more to the recovery of scorbutic patients than moderate sweating.

With regard to particular symptoms, antiseptic mouth waters composed of a decoction of cinchona and infusion of roots, with a solution of myrrh, must be used occasionally, in order to cleanse the mouth, and give firmness to the spongy gums. Swelled and indurated limbs, and stiffened joints, must be bathed with warm vinegar, and relaxed by the steam of warm water, repeatedly conveyed to them, and confined to the parts by means of close blankets: ulcers on the legs must never be treated with unctuous applications nor sharp escharotics; but the dressing should consist of lint or soft rags, dipp'd in a strong decoction of cinchona.

This disease at no time requires, or indeed bears, large evacuations, either by bleeding or purging; and as has been already mentioned, the belly must only be kept open by the fresh vegetables or the mildest laxatives. But we are always to be careful that scorbutic persons, after a long abstinence from greens and fruits, be not permitted to eat voraciously at first, lest they fall into a fatal dysentery.

All, however, that has now been laid down as necessary towards the cure, supposes the patients to be in situations where they can be plentifully furnished with all the requisites; but unhappily these things are not to be procured at sea, and often deficient in garisons: in order therefore, that a remedy for the scurvy might never be wanting, Dr Macbride, in the year 1762, first conceived the notion, that the infusion of malt, commonly called wort, might be substituted for the common antiscorbutics; and it was accordingly tried.

More than three years elapsed before any account arrived of the experiments having been made: at length, ten histories of cases were received, wherein the wort had been tried, with very remarkable success; and this being judged a matter of great importance to the seafaring part of mankind, these were immediately communicated to the public in a pamphlet, under the title of An historical account of a new method of treating the scurvy at sea.

This was in 1767; but after that time a considerable number of letters and medical journals, sufficient to make up a small volume, were transmitted to Dr Macbride, particularly by the surgeons of his Majesty's ships who had been employed of late years for making discoveries in the southern hemisphere. Certain it is, that in many instances it has succeeded beyond expectation. In others it has fallen short: but whether this was owing to the untoward situation of the patients, or inattention on the part of the persons who were charged with the administration of the wort, not preparing it properly, or not giving it in sufficient quantity, or to its own want of power, must be collected from the cases and journals themselves.

During Captain Cook's third voyage, the most remarkable, in respect of the healthiness of the crew, that ever was performed, the wort is acknowledged to have been of singular use.

Isopet-
gine.

In a letter which this very celebrated and successful circumnavigator wrote to Sir John Pringle, he gives an account of the methods pursued for preserving the health of his people; and which were productive of such happy effects, that he performed "a voyage of three years and 18 days, through all the climates from 52° north to 71° south, with the loss of one man only by disease, and who died of a complicated and lingering illness, without any mixture of scurvy. Two others were unfortunately drowned, and one killed by a fall; so that out of the whole number 118 with which he set out from England, he lost only four."

He says, that much was owing to the extraordinary attention of the admiralty, in causing such articles to be put on board as either by experience or conjecture were judged to tend most to preserve the health of seamen: and with respect to the wort, he expresses himself as follows:

"We had on board a large quantity of malt, of which was made sweet wort, and given (not only to those men who had manifest symptoms of the scurvy, but to such also as were, from circumstances, judged to be most liable to that disorder) from one or two to three pints in the day to each man, or in such proportion as the surgeon thought necessary, which sometimes amounted to three quarts in the 24 hours: this is without doubt one of the best sea antiscorbutic medicines yet found out; and if given in time, will, with proper attention to other things, I am persuaded, prevent the scurvy from making any great progress for a considerable time: but I am not altogether of opinion that it will cure it, in an advanced state, at sea."

On this last point, however, the captain and his surgeon differ; for this gentleman positively asserts, and his journal (in Dr Macbride's possession) confirms it, that the infusion of malt did effect a cure in a confirmed case, and at sea.

The malt being thoroughly dried, and packed up in small casks, is carried to sea, where it will keep sound, in every variety of climate, for at least two years: when wanted for use, it is to be ground in a hand mill, and the infusion prepared from day to day, by pouring three measures of boiling water on one of the ground malt; the mixture being well matted, is left to infuse for 10 or 12 hours, and the clear infusion then strained off. The patients are to drink it in such quantities as may be deemed necessary, from one to three quarts in the course of the 24 hours: a panada is also to be made of it, by adding biscuit, and currants or raisins; and this palatable mess is used by way of solid food. This course of diet, like that of the recent vegetables, generally keeps the bowels sufficiently open; but in cases where costiveness nevertheless prevails, gentle laxatives must be interposed from time to time, together with diaphoretics, and the topical assistants, fomentations and gargles, as in the common way of management.

Captain Cook was also provided with a large flock of sour krouk; (cabbage leaves cut small, fermented and stopped in the second stage of fermentation, and afterwards preserved by a due quantity of salt.) A pound of this was served to each man, twice a-week, while they were at sea. Sour krouk, since the trial

made of it on board Captain Cook's ships, has been extensively used by direction of the British government in many other situations, where scurbutus has prevailed; and it has been found to be highly serviceable both in preventing and in curing the disease. It was particularly found, during the late American war, to be highly beneficial to the British troops besieged in Boston, who were at that time entirely fed on salt provisions sent from England, and among whom true scurbutus was very fatal till the sour krouk arrived. The scurvy at one period broke out among them with very alarming appearances; but by the seasonable arrival of a quantity of sour krouk, it was effectually overcome. Care, however, must be bestowed, that this article be properly prepared and properly kept. When due attention is paid to these particulars, it may be preserved in good condition for many months; and is considered both by sailors and soldiers as a very acceptable addition to their salt provisions. But when served out to them in a putrid state, it is not only highly disagreeable to the taste, but probably also pernicious in its effects.

Among other means of preventing scurvy, Captain Cook had also a liberal supply of portable soup; of which the men had generally an ounce, three days in the week, boiled up with their pease; and sometimes it was served to them oftener; and when they could get fresh greens, it was boiled up with them, and made such an agreeable mess, that it was the means of making the people eat a greater quantity of greens than they would otherwise have done. And what was still of further advantage, they were furnished with sugar in lieu of butter or oil, which is seldom of the sweetest sort; so that the crew were undoubtedly great gainers by the exchange.

In addition to all these advantages of being so well provided with every necessary, either in the way of diet or medicine, Captain Cook was remarkably attentive to all the circumstances respecting cleanliness, exercise, sufficient clothing, provision of pure water, and purification of the air in the closer parts of the ship.

From the effect of these different means, as employed by Captain Cook, there can be little doubt that they will with due attention be sufficient for the prevention and cure of the disease, at least in most situations: but besides these, there are also some other articles which may be employed with great advantage.

Newly brewed spruce beer made from a decoction of the tops of the spruce fir and melasses, is an excellent antiscorbutic; it acts in the same way that the wort does, and will be found of equal efficacy, and therefore may be substituted. Where the tops of the spruce fir are not to be had, this beer may be prepared from the essence of spruce as it has been called, an article which keeps easily for a great length of time. But in situations where neither the one nor the other can be had, a most salutary mess may be prepared from oatmeal, by infusing it in water, in a wooden vessel, till it ferments, and begins to turn fourth; which generally happens, in moderately warm weather, in the space of two days.—The liquor is then strained off from the grounds, and

Impetigones and boiled down to the consistence of a jelly, which is to be eaten with wine and sugar, or with butter and sugar.

Nothing is more commonly talked of than a land scurvy, as a distinct species of disease from that which has been now described; but no writer has yet given a description so clear as to enable us to distinguish it from the various kinds of cutaneous foulness and eruption, which indeed are vulgarly termed scorbutic, but which are akin to the itch or leprosy, and for the most part require mercurials. These, however, are very different diseases from the true scorbutus, which, it is well known, may prevail in certain situations on land as well as at sea, and is in no degree to be attributed to sea air.

ulcerated; at other times affected with tubercles without ulceration. The muscular flesh between the thumb and forefinger is generally extenuated.

The whole skin, particularly that of the face, has a remarkably shining appearance, as if it was varnished or finely polished. The sensation in the parts affected is very obtuse, or totally abolished; so that pinching, or puncturing the part, gives little or no uneasiness; and in some patients, the motion of the fingers and toes is quite destroyed. The breath is very offensive; the pulse in general weak and slow.

The disease often attacks the patient in a different manner from that above described, beginning almost insensibly; a few indolent tubercles appearing on various parts of the body or limbs, generally on the legs or arms, sometimes on the face, neck, or breast, and sometimes in the lobes of the ears, increasing by very slow degrees, without any disorder, previous or concomitant, in respect of pain or uneasiness.

To distinguish the dislemp from its manner of attacking the patient, Dr Heberden styles the first by fluxion and the other by congestion. That by fluxion is often the attendant of a crapula, or surfeit from gross foods; whereby, perhaps, the latent seeds of the disorder yet dormant in the mass of blood are excited; and probably from frequent observations of this kind (the last meal being always blamed), it is, that, according to the received opinion, either fish, (the tunny, mackerel, and shell-fish, in particular), melons, cucumbers, young garden-beans, or mulberries, eaten at the same meal with butter, cheese, or any preparation of milk, are supposed to produce the dislemp, and are accordingly religiously avoided.

Violent commotions of the mind, as anger, fear, and grief, have more than once been observed to have given rise to the disorder; and more frequently, in the female sex, a sudden suppression of an accustomed evacuation, by bathing the legs and feet in cold water at an improper season.

The disorder by fluxion is what is the oftener endeavoured to be remedied by timely application; that by congestion, not being so conspicuous, is generally either neglected or attempted to be concealed, until perhaps it be too late to be cured, at least unless the patients would submit to a longer course of medicine and stricter regimen of diet than they are commonly inclined to do.

Several incipient disorders by fluxion have been known to yield to an antiphlogistic method, as bleeding, refrigerant salts in the saline draughts, and a solution of crystals of tartar in water, for common drink, (by this means endeavouring to precipitate part of the peccant matter, perhaps too gross to pass the pores by the kidneys); and when once the fever is overcome, cinchona, combined with sassafras, is the remedy principally to be relied on. The only topical medicine prescribed by Dr Heberden, was an attenuating embrocation of brandy and alkaline spirit. By the same method some confirmed cases have been palliated. But, excepting in one patient, Dr Heberden never saw or heard of a confirmed elephantiasis radically cured. He adds, however, that he never met with another patient possessed of prudence and perseverance enough to prosecute the cure as he ought.

GENUS LXXXVII. ELEPHANTIASIS.

Elephantiasis, Sauv. gen. 302. Vog. 321. Seg. gen. 128.
Elephantia Arabum, Vog. 322.

The best account of this disease is that by Dr Heberden, published in the first volume of the Medical Transactions. According to him, frequently the first symptom is a sudden eruption of tubercles, or bumps of different sizes, of a red colour, more or less intense (attended with great heat and itching), on the body, legs, arms, and face; sometimes in the face and neck alone, at other times occupying the limbs only; the patient is feverish; the fever ceasing, the tubercles remain indolent, and in some degree scirrhous, of a livid or copper colour, but sometimes of the natural colour of the skin, or at least very little altered; and after some months they not unfrequently ulcerate, discharging a fetid ichorous humour in small quantity, but never laudable pus.

The features of the face swell and enlarge greatly; the part above the eyebrows seems inflated; the hair of the eyebrows falls off, as does the hair of the beard; but Dr Heberden has never seen any one whose hair has not remained on his head. The ala nasi are swelled and scabrous; the nostrils patulous, and sometimes affected with ulcers, which, corroding the cartilage and septum nasi, occasion the nose to fall. The lips are tumid; the voice is hoarse; which symptom has been observed when no ulcers have appeared in the throat, although sometimes both the throat and gums are ulcerated. The ears, particularly the lobes, are thickened, and occupied by tubercles. The nails grow scabrous and rugose, appearing something like the rough bark of a tree; and the dislemp advancing, corrodes the parts gradually with a dry fordid scab or gangrenous ulcer; so that the fingers and toes rot and separate joint after joint. In some patients the legs seem rather poss than legs, being no longer of the natural shape, but swelled to an enormous size, and indurated, not yielding to the pressure of the fingers; and the superficies is covered with very thin scales, of a dull whitish colour, seemingly much finer, but not so white as those observed in the lepra Graecorum. The whole limb is overspread with tubercles, interspersed with deep fissures; sometimes the limb is covered with a thick moist scabby crust, and not unfrequently the tubercles ulcerate. In others the legs are emaciated, and sometimes

Lepra, Sauv. gen. 303. Lin. 262. Seg. 129.
Lepra Gracorum, Vog. 320.

This distemper is but little known to physicians in the western parts of Europe. Wallis tells us, that it first begins with red pimples, or pustules, breaking out in various parts of the body. Sometimes they appear single; sometimes a great number arise together, especially on the arms and legs; as the disease increases, fresh pimples appear, which, joining the former, make a sort of clusters: all which enlarge their borders, and spread in an orbicular form. The superficies of these pustules are rough, whitish, and scaly; when they are scratched the scales fall off, upon which a thin ichor oozes out, which soon dries and hardens into a scaly crust. These clusters of pustules are at first small and few; perhaps only three or four in an arm or leg, and of the size of a silver penny. But if the disease be suffered to go on, they become more numerous, and the clusters increase to the size of a crown-piece, but not exactly round. Afterwards the affection increases to such a degree, that the whole body is covered with a leprosy scurf. The cure of this distemper is very much the same with that of the ELEPHANTIASIS. Here, however, recourse is frequently had to antimonial and mercurial medicines, continued for a considerable length of time. In conjunction with these, warm bathing, particularly the vapour bath, has often been employed with advantage.

Although what can strictly be called lepra is now, at least, a very rare disease in this country, yet to this general head may be referred a variety of cutaneous affections which are here very common, and which in many instances prove very obstinate. These appear under a variety of different forms; sometimes under that of red pustules; sometimes of white scurfs; sometimes of ulcerations; and not unfrequently a transition takes place from one form to another, so that they cannot be divided into different genera from the external appearance. These affections will often yield to the remedies already mentioned; but where antimonials and mercurials either fail, or from different circumstances are considered as unadvisable, a cure may sometimes be effected by others. In particular cases, purging mineral waters, the decoction of cinchona, the infusion of the cantharides crocata, and various others, have been employed with success. Different external applications also have sometimes been employed with advantage. An article used in this way, known under the name of Gowland's lotion, with the composition of which we are unacquainted, has been much celebrated, and has been said to be employed with great success, particularly against eruptions on the face and nose.

Framboesia, Sauv. gen. 125. Seg. 125.

Description. The description which is given of this

distemper by the anonymous author of a paper in the Framboesia. 6th volume of the Edinburgh Medical Essays, (art. 76.) differs, in some circumstances, from one that Sauvages received from M. Virgile, an eminent surgeon of Montpellier, who practised twelve years in the island of St Domingo; and therefore he distinguishes the frambosia into two species, Guineensis and Americana.

The frambosia Guineensis is said by the first-mentioned writer to be so common on the coast of Guinea and other parts of Africa, that it seldom fails to attack each individual of both sexes, one time or other, in the course of their lives; but most commonly during childhood or youth. "It makes its appearance in little spots on the cuticle, level with the skin, at first no larger than a pin's head, which increase daily, and become protuberant like pimples: soon after the cuticle frets off, and then, instead of finding pus or ichor, in this small tumor, only white sloughs or sores appear, under which is a small red fungus, growing out of the cutis, increasing gradually to very different magnitudes, some less than the smallest wood strawberry, some as big as a raspberry, and others exceeding in size even the largest mulberries; which berries they very much resemble, being knobbed as these are." These protuberances, which give the name to the disease, appear on all parts of the body: but the greatest numbers, and the largest sized, are generally found in the groins, and about the pudenda or anus, in the armpits, and on the face: when the yaws are very large, they are few in number; and when remarkably numerous, they are less in size. The patients, in all other respects, enjoy good health, do not lose their appetite, and seem to have little other uneasiness than what the sores occasion.

M. Virgile describes the species of yaws that is common among the negroes of St Domingo, and which Sauvages has termed frambosia Americana, as beginning from an ulcer that breaks out indiscriminately in different parts of the body, though most commonly on the legs; at first superficial, and not different from a common ulcer in any other circumstance having its not healing by the usual applications; sooner or later, numerous fungous excrescences break out on the surface of the body, as before described, like little berries, moist, with a reddish mucus. Besides these, the soles of the feet and palms of the hands become raw, the skin fretting off, so as to leave the muscles bare; these excoriations are sometimes moist with ichor and sometimes dry, but always painful, and consequently very distressing. They are mentioned also by the author of the article in the Medical Essays; and both he and M. Virgile observe, that there is always one excrescence, or yaw, of an uncommon size, which is longer in falling off than the others, and which is considered as the master-yaw, and so termed. An ingenious inaugural dissertation on the subject of the yaws was lately published at Edinburgh by Dr Jonathan Anderson Ludford, now physician in Jamaica. The author of that dissertation considers Dr Cullen as improperly referring frambosia to the class of cachexies. He thinks that this disease ought rather to be referred to the exanthemata; for, like the smallpox, he tells us, it has its accession, height, and decline. It begins with some degree of fever, either more or less violent; it may be propagated by inoculation; and it attacks the

Impetigines. the same individual only once in the course of a lifetime, those who recover from the disease being never afterwards affected with it. These particulars respecting frambosia are rested not merely on the authority of Dr Ludford, but are supported also by the testimony of Dr William Wright, a physician of distinguished eminence, who, while he resided in Jamaica, had, in the course of extensive practice, many opportunities of observing this disease, and to whom Dr Ludford acknowledges great obligations for having communicated to him many important facts respecting it.

Dr Ludford considers the yaws as being in every instance the consequence of contagion, and as depending on a matter sui generis. He supposes no peculiar predisposition from diet, colour, or other circumstances, as being in any degree necessary. He views the disease as chiefly arising from contact with the matter, in consequence of sleeping in the same bed, washing in the same vessel with the infected, or the like. In short, the yaws may be communicated by any kind of contact; nay, it is even believed that flies often convey the infection, when, after having gorged themselves with the virulent matter by sucking the ulcers of those who are diseased, they make punctures in the skin of such as are found, and thus inoculate them; in consequence of which the disorder will soon appear.

Prognosis. The yaws are not dangerous, if the cure be skilfully managed at a proper time; but if the patient has been prematurely salivated, or has taken any quantity of mercury, and if his skin has been suddenly cleared, the cure will be very difficult, if not impracticable.

Cure. In attempting the cure of this disease, the four following indications are chiefly to be held in view:

1. 1. To support the strength of the patient.
2. 2. To promote excretion by the skin.
3. 3. To correct the vitiated fluids.
4. 4. To remove and counteract the injuries done either to the constitution in general, or to particular parts, by the disease.

With the first of these intentions, a liberal diet, consisting of a considerable quantity of animal food, with a considerable proportion of wine, and gentle exercise, are to be employed: but the cure is principally to be effected by mercurial salivation, after the virulent matter has been completely thrown out to the surface of the body by sudorifics. The following are the particular directions given on this head by the author of the article in the Medical Essays. The yaws being an infectious disease, as soon as they begin to appear on a negro, he must be removed to a house by himself; or, if it is not certain whether the eruption be the yaws or not, shut him up seven days, and look on him again, as the Jews were commanded to do with their lepers, and in that time you may in most cases be certain.

As soon as you are convinced that it is the yaws, give a bolus of flowers of sulphur, with camphor and theriac. Repeat this bolus every night for a fortnight or three weeks, or till the yaws come to the height; that is, when they neither increase in size or number: then throw your patient into a gentle salivation with

calomel given in small doses, without farther preparation; five grains repeated once, twice, or thrice a-day, is sufficient, as the patient can bear it. If he spits a quart in 24 hours, it is enough. Generally, when the salivation is at this height, all the yaws are covered with dry scaly crusts or scabs; which, if numerous, look terribly. These fall off daily in small white scales; and in ten or twelve days leave the skin smooth and clean. Then the calomel may be omitted, and the salivation permitted to go off spontaneously. A dram of corrosive sublimate dissolved in an ounce of rum or brandy, and the solution daubed on the yaws, will, it is said, in general clear the skin in two days time.

After the salivation, sweat the patient twice or thrice in a frame or chair with spirits of wine; and give an alternative electuary of rethiops and gum gunic. He may likewise use the decoction of guaiacum and fassfras fermented with melasses, for his constant drink while the electuary is taking, and a week or a fortnight after the electuary is finished.

The master-yaw must be consumed an eighth or a tenth part of an inch below the skin, with Mercur. corros. rub. et alum. uis. part. aequal. and digested with Ung. basil. flav. 3j. and mercur. corros. rub. 3j. and cauterized with lint pressed out of spirits of wine, and with the sulphate of copper.

After the yaws are cured, some patients are afflicted with carbuncles in their feet; which sometimes render them incapable of walking, unless with pain. The method of cure is, by bathing and paring to destroy the cuticle, and then proceed as in the master-yaw. The gentle escharotics are to be preferred; and all imaginable care is to be taken to avoid the tendons and periosteum.

To children under six or seven years old, at the proper time of salivating, when the yaws are come to their full growth, give a grain or two of calomel in white sugar, once a-day, once in two days, or once in three days, so as only to keep their mouths a little sore till the yaws dry, and, falling off in white scales, leave the skin clean. This succeeds always, but requires a longer time than in adults.

In St Domingo they are salivated by unction; but it does not appear that success always followed this practice. It is also usual in that island to give the solution of corrosive sublimate along with a decoction of farfaparilla. Twelve ounces of this root, and 12 pounds of the coarsest sugar, macerated for 15 days in 12 quarts of water, is mentioned as a specific, and said to be the prescription of an English physician; the dose is four ounces every sixth hour.

GENUS XC. TRICHOMA.

The PLICA POLONICA, or Plaited Hair.

Trichoma, Sauv. gen. 311. Sag. 137.

Plica, Lin. 313.

Plica five Rhopalosis, Veg. 323.

This disorder is only met with in Poland and Lithuania, and consists of several blood-vessels running from the head into the ends of the hairs; which cleave together, and hang from the head in broad flat pieces, generally about an ell in length, but sometimes they are

Impetiginous five or six yards long; one patient has more or less of these, up to 20, and sometimes 30. They are painful to the wearer, and odious to every spectator. At the approach of winter an eruptive fever happens to many in these countries: the eruptions principally infest the head, and when at the height an ichorous humour flows from them. In this state they are too tender to admit of being touched, and the matter running down the hairs mats them together; the skin by degrees, breaking, the ramifications of the capillary vessels following the course of the hair, or prolonged out of the skin, are increased to a vast length.

No method of relief is yet known; for if the discharge be checked, or the vessels cut off, the consequence is an increase of more miserable symptoms, and in the end death. Sennertus says, when all the morbid matter is thrown out of the body the plicae fall off spontaneously. He further observes, that the only safe practice in this case is, to solicit the peccant matter to the hairs, to which it naturally tends; and that this is best answered by lotions of bear's-breech. Some say that a decoction of the herb club-moss, and its seeds, with which the head is to be washed, is a specific.

356 GENUS XCI. ICTERUS.

The JAUNDICE.

Icterus, Lin. 224. Vog. 306. Boerh. 918. Junc.

90.

Aurigo, Savv. gen. 306. Sag. 132.

Cachexia ictérica, Hoffm. III. 301.

Description. The jaundice first shows itself by a listlessness and want of appetite, the patient becomes dull, oppressed, and generally costive. These symptoms have continued but a very short time, when a yellow colour begins to diffuse itself over the tunica albuginea, or white part of the eye, and the nails of the fingers; the urine becomes high coloured, with a yellowish sediment capable of giving a yellow tinct to linen; the stools are whitish or gray. In some there is a most violent pain in the epigastric region, which is considerably increased after meals. Sometimes the patient has a continual propensity to sleep; but in others there is too great watchfulness; and sometimes the pain is so great, that though the patient be sleepy he cannot compose himself to rest. The pains come by fits; and most women who have had the jaundice and born children, agree, that they are more violent than labour-pains. As the disease increases, the yellow colour becomes more and more deep; an itching is felt all over the skin; and even the internal membranes of the viscera, the bones, and the brain itself, become tinged, as hath been shown from dissections, where the bones have been found tinged sometimes for years after the jaundice has been cured.

In like manner, all the secretions are affected with the yellow colour of the bile, which in this disease is diffused throughout the whole mass of fluids. The saliva becomes yellowish and bitter; the urine excessively high coloured, in such a manner as to appear almost black; nay, the blood itself is sometimes said to appear of a yellow colour when drawn from a vein; yet Dr Heberden says, that he never saw the milk altered in its colour, even in cases of very deep jaundice. In

proceeds of time the blood begins to acquire a tendency to dissolution and putrefaction; which is known by the patient's colour changing from a deep yellow to a black or dark yellow. Hemorrhages ensue from various parts of the body, and the patients frequently die of an apoplexy; though in some the disease degenerates into an incurable dropsy; and there have not been wanting instances of some who have died of the dropsy after the jaundice itself had been totally removed.

Causes. As the jaundice consists in a diffusion of the bile throughout the whole system, it thence follows, that whatever may favour the diffusion is also to be reckoned among the causes of jaundice. Many disputes have arisen concerning the manner in which the bile is introduced into the blood; but it is now generally agreed that it is taken up by the lymphatics of the gall-bladder and biliary ducts. Hence, a jaundice may arise from any thing obstructing the passage of the bile into the duodenum, or from any thing which alters the state of the lymphatics in such a manner as to make them capable of absorbing the bile in its natural state. Hence the jaundice may arise from scirrh of the liver or other viscera pressing upon the biliary ducts, and obstructing the passage of the bile; from flatus distending the duodenum, and shutting up the entrance of the ductus communis choledochus into it; from the same orifice being plugged up by viscid bile, or other sordes; but by far the most frequent cause of jaundice is the formation of calculi, or more properly biliary concretions: for although they were long considered as being of a calcareous nature, yet more accurate experiments have now demonstrated, that they consist principally of a sebaceous matter; accordingly, while they are so light as to swim in water, they are also highly inflammable. These are found of almost all sizes, from that of a small pea to that of a walnut, or bigger: they are of different colours; and sometimes appear as if formed in the inward part by crystallization, but of lamellae on the outer part; though sometimes the outward part is covered with rough and shining crystals, while the inward part is lamellated. These enter into the biliary ducts, and obstruct them, causing a jaundice, with violent pain for some time; and which can be cured by no means till the concretion is either passed entirely through the ductus communis or returned into the gall-bladder. Sometimes, in the opinion of many celebrated physicians, the jaundice is occasioned by spasmodic contractions of the biliary ducts; but this is denied by others, and it is not yet ascertained whether these ducts are capable of being affected by spasm or not, as the existence of muscular fibres in them has not with certainty been discovered. It cannot, however, be denied, that violent fits of passion have often produced jaundice, sometimes temporary, but frequently permanent. This has been by some deemed a sufficient proof of the spasmodic contraction of the ducts; but their opponents supposed, that the agitation occasioned by the passion might push forward some biliary concretion into a narrow part of the duct, by which means a jaundice would certainly be produced, till the concretion was either driven backward or forward into the duodenum altogether. But even supposing the ducts themselves to be incapable of spasm, yet there can be no doubt that by a spasm of the intestines biliary concretions may be retained in the ducts; and

Impetiginis and indeed it is principally where the duct entering obliquely into the intestine forms as it were a species of valve that these concretions are retained.

In a very relaxed state of the body there is also an absorption of the bile, as in the yellow fever; and indeed in all putrid disorders there is a kind of yellowish tint over the skin, though much less than in the true jaundice. The reason of this is, that in these disorders there is usually an increased secretion of bile, commonly of a thinner consistency than in a healthy state, while the orifices of the lymphatics are probably enlarged, and thus ready to absorb a fluid somewhat thicker than what they ought to take up in a healthy state; but these disorders are of short duration in comparison with the real jaundice, which sometimes lasts for many years. These affections, however, cannot with propriety in any case be considered as real instances of jaundice; for, to constitute that disease bile must not only be present in the blood, but wanting in the alimentary canal.

It is observable, that women are more subject to jaundice than men, which probably arises from their more sedentary life; for this, together with some of the depressing passions of the mind, is found to promote the accession of the disease, if not absolutely to produce it. Pregnant women also are frequently attacked by the jaundice, which goes off after their delivery.

Prognosis. As jaundice may arise from many different causes, some of which cannot be discovered during the patient's life, the prognosis must on this account be very uncertain. The only cases which admit of a cure are those depending upon biliary concretions, or obstructions of the biliary ducts by viscid bile; for the concretions are seldom of such a size that the ducts will not let them pass through, though frequently not without extreme pain. Indeed this pain, though so violent, and almost intolerable to the sick person, affords the best prognosis; as the physician may readily assure his patient that there is great hope of his being relieved from it. The coming on of a gentle diarrhoea, attended with bilious stools, together with the cessation of pain, are signs of the disease being cured. We are not, however, always to conclude, because the disease is not attended with acute pain, that it is therefore incurable; for frequently the passage of a concretion through the biliary ducts is accompanied only with a sensation of slight uneasiness.

Cure. The great object to be aimed at in the cure of jaundice is unquestionably the removal of the cause which obstructs the passage of bile into the intestines: But before this can be accomplished, practices are often necessary for alleviating urgent symptoms; which may be done sometimes by supplying the want of bile in the alimentary canal, sometimes by affording an exit for bilious matter from the general mass of blood, but most frequently by obviating the effects of distention and obstruction to the circulation in the system of the liver.

The measures to be employed for the removal of the obstruction must depend very much on the nature of the obstructing cause.

When the jaundice arises from indurated swellings or scirrh of the viscera, it is absolutely incurable; ne-

vertheless, as these cannot always be discovered, the physician ought to proceed in every case of jaundice as if it arose from calculi. The indications here are, 1. To dissolve the concretions; and, 2. To prevent their formation a second time. But unhappily the medical art has not yet afforded a solvent for biliary concretions. They cannot even be dissolved when tried out of the body either by acids or alkalies, or any thing but a mixture of oil of turpentine and spirit of wine; and these substances are by far too irritating to be given in sufficient quantity to affect a concretion in the biliary ducts. Boerhaave observes, that diseases of the liver are much more difficult to cure than those in any other part of the body; because of the difficulty there is in getting at the part affected, and the tedious and round-about passage the blood has to it. The juice of common grs has indeed been recommended as a specific in the jaundice, but on no good foundation. Glisson observes, that black cattle are subject to biliary concretions when fed with hay or dried straw in winter, but are cured by the succulent grass in the spring; and Van Swieten tells a strange story of a man who cured himself of the jaundice by living almost entirely on grass, of which he devoured such quantities, that the farmers were wont to drive him out of their fields; but other practitioners have by no means found this in any degree effectual. The only method of cure now attempted in the jaundice is to expel the concretion into the intestines; for which vomits and exercise are the principal medicines. The former are justly reckoned the most efficacious medicines, as they powerfully shake all the abdominal and thoracic viscera; and thus tend to dislodge any obstructing matter that may be contained in them. But if there be a tendency to inflammation, vomits must not be exhibited till bleeding has been premised. We must also proceed with caution if the pain be very sharp; for in all cases where the disease is attended with violent pain, it will be necessary to allay it by opiates before the exhibition of an emetic. There is also danger, that, by a continued use of vomits, a concretion which is too large to pass, may be so impacted in the ducts, that it cannot even be returned into the gall-bladder, which would otherwise have happened. In all cases, therefore, if no relief follows the exhibition of the second or third emetic, it will be prudent to forbear their farther use for some time.

Of all kinds of exercise, that of riding on horseback is most to be depended upon in this disease. It operates in the same manner with vomits, namely, by the concussion it gives to the viscera; and therefore the cautions necessary to be observed in the use of vomits are also necessary to be observed in the use of riding. Cathartics also may be of service, by cleansing the primæ viæ, and soliciting a discharge of the bile into the intestines; but they must not be of too drastic a nature, else they may produce incurable obstructions, by bringing forward concretions that are too large to pass. Anodynes and the warm bath are serviceable by their relaxing quality; and there can be no doubt, that, from acting as powerful antispasmodics, they often give an opportunity for the discharge of concretions by very slight causes, when they would otherwise be firmly retained. Soap has been supposed to do service

Dysæsthesie as a solvent; but this is now found to be a mistake, and it acts in no other way than as a relaxant or as a gentle purgative.

But when all means of relief fail, as in cases of scirrhus, we can then only attempt to palliate the symptoms, and preserve the patient's life as long as possible. This is best accomplished by diuretics; for thus a great quantity of bilious matter is evacuated, and the system is freed from the bad consequences which ensue on its stagnation in the habit. But even this is by no means equal to the common evacuation by stool; nor can all the attempts to supply the want of bile in the intestines by bitters and other stomachics restore the patient to his wonted appetite and vigour. If the pain be very violent, we must on all occasions have recourse to opiates; or if the blood has acquired a tendency to dissolution, it must be counteracted by proper antiseptics.

If the disease goes off, its return must be prevented by a course of tonic medicines, particularly the cinchona and antiseptics: but we can by no means be certain that the jaundice will not return, and that at any interval; for there may be a number of concretions in the gall-bladder, and though one has passed, another may very quickly follow, and produce a new fit of jaundice; and thus some people have continued to be affected with the distemper, at short intervals, during life.

In the East Indies, mercury has been lately recommended as exceedingly efficacious in disorders of the liver, especially those which follow intermitting and remitting fevers. Dr Monro, in his Observations on the means of preserving the health of soldiers, acquaints us, that he has seen some icteric cases which, he thought, received benefit from taking a few grains of the submuriæ hydrargyri at night, and a purge next morning; and this repeated two or three times a-week.

Infants are subject to a temporary jaundice, commonly called the gum, soon after birth; the cause of which is not well understood. It differs remarkably from the common jaundice; as, in the latter, the disease is first discoverable in the white of the eyes; but though the skin of infants in the gum is all over yellow, their eyes always remain clear. The disorder goes off spontaneously, or by the use of a gentle purgative or two.

CLASS IV. LOCALES.

357
Vitia, Sauv. Cls. I. Lin. Cls. XI. Vog. Cls. X. Sag. Cls. I.
Plagæ, Sag. Cls. II.
Morbi organici Auctorum.

ORDER I. DYSÆSTHESIE.

358
Dysæsthesie, Sauv. Cls. VI. Ord. I. Sag. Cls. IX. Ord. I.

GENUS XCII. CALIGO.

The CATARACT.

359
Caligo, Sauv. gen. 153. Vog. 288. Sag. gen. 259. Cataracta, Lin. 109.

A cataract is an obstruction of the pupil, by the interposition of some opaque substance which either diminishes or totally extinguishes the sight. It is generally an opacity in the crystalline humour. In a recent or beginning cataract, the same medicines are to be used as in the gutta serena; and they will sometimes succeed. But when this does not happen, and the cataract becomes firm, it must be counced, or rather extracted; for which operation, see SURGERY.—Dr Buchanan says he has resolved a recent cataract by giving the patient some purges with calomel, keeping a poultice of fresh hemlock constantly upon the eye, and a perpetual blister on the neck.

There is, however, but little reason to suppose that these practices will frequently succeed. A resolution can only be effected here by an absorption of the opaque matter; and where this is possible, there is perhaps a better chance of its being effected by the agency of the electric fluid than by any other means. For this purpose electricity is chiefly applied under the form of the electric aura, as it has been called; but even this is very rarely successful.

GENUS XCIII. AMAUROSI.

The GUTTA SERENA.

360
Amaurosis, Sauv. gen. 155. Lin. 110. Vog. 238. Sag. 261.
Amblyopia, Lin. 108. Vog. 236.

A gutta serena is an abolition of the sight without any apparent cause or fault in the eyes. In every case it depends on an affection of some part of the optic nerve. But the affections which may produce this disease are of different kinds. When it is owing to a decay or wasting of the optic nerve, it does not admit of a cure; but when it proceeds from a compression of the nerves by redundant humours, these may be in some measure drained off, and the patient relieved. For this purpose, the body must be kept open with the laxative mercurial pills. If the patient be young, and of a sanguine habit, he may be bled. Cupping with scarifications on the back part of the head will likewise be of use. A running at the nose may be promoted by volatile salts, stimulating powders, &c. But the most likely means of relieving the patient, are issues or blisters kept open for a long time on the back part of the head, behind the ears, or on the neck; which have been known to restore sight even after it had been for a considerable time lost.—Should these fail, recourse must be had to a mercurial salivation; or, what will perhaps answer the purpose better, 12 grains of the corrosive sublimate mercury may be dissolved in an English pint and a half of brandy, and a table spoonful of it taken twice a-day, drinking half a pint of the decoction of farsaparilla after it.—Of late electricity has been much celebrated as efficacious, when no other thing could do service; and here it has in some degree the same chance of success as in other cases of insensibility, depending on an affection of the nerves, in some of which it has certainly in particular cases been of use.

In the amaurosis, Dr Porterfield observes, that it is of the utmost consequence to know of how long standing the disease has been; which is not always easily done if one eye only be affected. This is a very essential

Dyslethe-
sac. tial point; because an amaurosis of long standing is al-
together incurable. Mr Boyle mentions the case of a
man who had a cataract for several years without know-
ing it himself, though others did. He discovered it
at last by happening to rub his found eye, and was sur-
prised to find himself in the dark. When a person
therefore has a gutta serena only in one of the eyes, he
may think that the eye has but lately lost the power of
sight; though this perhaps has been the case for several
years. On the other hand, he may imagine that a re-
cent disease of this kind is really of long standing. But
by inquiring at what time he first became subject to
mistakes in all actions that require the distance to be
exactly distinguished, as in pouring liquor into a glass,
snuffing a candle, or threading a needle, we may discover
the age of the disease, and thence be assisted to form
a more just prognostic with respect to its cure. Dr
Porterfield gives an instance of his conjecturing in this
manner concerning the case of a young lady who had
discovered a loss of sight in one of her eyes only the
day before. The disease was thought to be of long
standing; but as the doctor found that she had only
been subject to mistakes of the kind above mentioned
for about a month, he drew a favourable prognostic,
and the disease was cured.

There are several species referred to this genus by
Dr Cullen, viz.

1. Dysopia TENEBRARUM; 2. Dysopia LUMINIS.—
The former of these is properly the nyctalopia, or night-
blindness, of ancient authors. But amongst both the
Greek and Latin writers, there is a direct opposition
in the use of this word nyctalopia; some saying it sig-
nifies "those who cannot see by night," and others ex-
press by it "those who cannot see during the day, but
during the night."—The difference in the account of
this disorder, as to its appearing in the night or in
the day, is reconciled by considering it as of the in-
termitting kind: the difference then will consist in the
different times of its approach; so it may be called pe-
riodical blindness. Intermittents appearing in a variety
of modes, and the success of cinchona in some instances
of this sort of blindness, both favour the opinion of its
being an intermittent disease of the eyes; and this
view has accordingly been taken of it by some late
writers, particularly in some papers in the London Me-
dical Observations, and Medical Transactions.

3. Dysopia PROXIMORUM (Presbyopia), or the defect
of those who see only at too great distance. 4. Dys-
opia DISSITORUM (Myopia), or the defect of those who
are shortsighted.—These are disorders which depend on
the original structure or figure of the eye, therefore
admit of no cure. The inconveniences arising from
them may, however, be in some measure remedied by
the help of proper glasses. The former requires the
aid of a convex, and the latter of a concave glass.

5. Dysopia LATERALIS; a defect by which objects
cannot be viewed distinctly but in an oblique position.
—Thus, in viewing an object placed on the left, they
turn their face and eyes to the right, and vice versa.—

This disorder may proceed from various causes both
natural and accidental, some of which admit of no re-
medy. If it be occasioned by a partial adhesion of the
eyelids, the hand of the surgeon is required: if by a
transverse position of the pupil, some mechanical con-
trivance is necessary. If it be owing to an albugo co-
vering part of the pupil, or to a film rendering a por-
tion of the cornea opaque, the remedies for these af-
fections are to be here applied.

Suffusio, Sauv. gen. 217. Sag. 329.
Phantasma, Lin. 73. Sag. 289.

This very often takes place when the body is dis-
eased, and then the patient is said to be delirious.
Sometimes, however, in these cases, it does not amount
to delirium; but the person imagines he sees gnats or
other insects flying before his eyes; or sometimes, that
every thing he looks at has black spots in it, which
last is a very dangerous sign. Sometimes also sparks
of fire appear before the eyes; which appearances are
not to be disregarded, as they frequently precede apo-
plexy or epilepsy. Sometimes, however, people have
been affected in this manner during life without feeling
any other inconvenience. Such a disorder can rarely if
ever be cured.

Paracusis, Sauv. gen. 159. Sag. 265.
Syrgmus, Sauv. gen. 219. Sag. 231.

The functions of the ear may be injured by wounds,
ulcers, or any thing that hurts its fabric. The hear-
ing may likewise be hurt by excessive noise; violent
colds in the head; fevers; hard wax, or other sub-
stances sticking in the cavity of the ear; too great a
degree of moisture or dryness of the ear. Deafness is
very often the effect of old age, and is incident to
most people in the decline of life. Sometimes it is ow-
ing to an original fault in the structure or formation of
the ear itself. When this is the case it admits of no
cure; and the unhappy person not only continues deaf,
but generally likewise dumb, for life.

When deafness is the effect of wounds or ulcers of
the ears, or of old age, it is not easily removed.
When it proceeds from cold applied to the head, the
patient must be careful to keep his head warm, espe-
cially in the night; he should likewise take some gen-
tle purges, and keep his feet warm, and bathe them
frequently in lukewarm water at bedtime. When
deafness is the effect of a fever, it generally goes off
after the patient recovers. If it proceed from dry
wax sticking in the ears, it may be softened by drop-
ping oil into them; afterwards they must be syringed
with warm milk and water.

If deafness proceeds from dryness of the ears, which
may

Dysenthe-
sis. may be known by looking into them, half an ounce of the oil of sweet almonds, and the same quantity of camphorated spirit of wine, or tincture of asafetida, may be mixed together, and a few drops of it put into the ear every night at bedtime, stopping them afterwards with a little wool or cotton. Some, instead of oil, put a small slice of the fat of bacon into each ear, which is said to answer the purpose very well.—When the ears abound with moisture, it may be drained off by an issue or seton, which should be made as near the affected parts as possible.

Some, for the cure of deafness, recommend the gall of an eel mixed with spirit of wine, to be dropped into the ear; others, equal parts of Hungary water and spirit of lavender. Et Muller extols amber and musk; and Brookes says, he has often known hardness of hearing cured by putting a grain or two of musk into the ear with cotton wool. Where, however, an application with considerable stimulant power is necessary, camphorated oil, with the addition of a few drops of volatile alkaline spirit, may be considered as one of the best. It is proper, however, to begin with a small quantity of the alkali, increasing it as the ear is found to bear it. In some instances, where deafness depends on a state of insensibility in the nerves, electricity, particularly under the form either of sparks or of the electric aura, has been employed with great success. Great benefit has also in some cases been derived from galvanism. But these and other applications must be varied according to the cause of the disorder.

Though such applications may sometimes be of service, yet they much oftener fail, and frequently they do hurt. Neither the eyes nor ears ought to be tampered with; they are tender organs, and require a very delicate touch. For this reason, what we would chiefly recommend in deafness, is to keep the head warm. From whatever cause this disorder proceeds, this is always proper; and more benefit has often been derived from it alone, in the most obstinate cases of deafness, than from any medicines whatever.

GENUS XCVIII. ANOSMIA.

Defect of SMELLING.

Anosmia, Sauv. gen. 156. Lin. 113. Voz. 248. Sag. 262.

Causes. Morbid affections in the sense of smelling, may be considered with respect to their causes, as arising from one of two sources; either from some organic affection of the parts here principally concerned, or from a mere atonic state of the parts without any obvious affection. The sense of smelling may be diminished or destroyed by various diseases of the parts; as, the moisture, dryness, inflammation or suppuration of that membrane which lines the inside of the nose commonly called the olfactory membrane; the compression of the nerves which supply this membrane, or some fault in the brain itself at their origin. A defect, or too great a degree of solidity, of the small spongy bones of the upper jaw, the caverns of the forehead, &c. may likewise impair the sense of smelling. It may also be injured by a collection of fetid matter in those caverns, which keeps constantly exhaling from

them. Few things are more hurtful to the sense of smelling than taking great quantities of snuff.

Cure. When the nose abounds with moisture, after gentle evacuations, such things as tend to take off irritation and coagulate the thin sharp serum may be applied; as the oil of anise mixed with fine flour, camphire dissolved in oil of almonds, &c. The vapours of amber, frankincense, gum mastic, and benzoin, may likewise be received into the nose and mouth. For moistening the mucus when it is too dry, some recommend snuff made of the leaves of marjoram, mixed with oil of amber, and aniseed; or a stimulatory of calcined sulphate of zinc, 12 grains of which may be mixed with two ounces of marjoram-water and filtrated. The steam or vapour of vinegar thrown upon hot iron received up the nostrils is likewise of use for softening the mucus, opening obstructions, &c.

If there be an ulcer in the nose, it ought to be dressed with some emollient ointment, to which, if the pain be very great, a little laudanum may be added. If it be a venereal ulcer, it is not to be cured without mercury. In that case, the solution of the corrosive sublimate in brandy may be taken, as directed in the gutta ferena. The ulcer ought likewise to be washed with it; and the fumes of cinnamon may be received up the nostrils.

If there be reason to suspect that the nerves which supply the organs of smelling are inert or want stimulating, volatile salts, strong snuffs, and other things which occasion sneezing, may be applied to the nose. The forehead may likewise be anointed with balsam of Peru, to which may be added a little of the oil of amber.

GENUS XCIX. AGEUSTIA.

Defect of TASTING.

Ageusia, Sauv. gen. 157. Sag. 263.
Ageusia, Lin. 114.
Apogeusia, Voz. 449.

Cause. This disease also may arise either from an organic affection, or an atonic state of the parts. The taste may be diminished by crusts, filth, mucus, aphthæ, pellicles, warts, &c. covering the tongue; it may be depraved by a fault of the saliva, which, being discharged into the mouth, gives the same sensation as if the food which the person takes had really a bad taste; or it may be entirely destroyed by injuries done to the nerves of the tongue and palate. Few things prove more hurtful either to the sense of tasting or smelling than obstinate colds, especially those which affect the head.

Cure. When the taste is diminished by filth, mucus, &c. the tongue ought to be scraped, and frequently washed with a mixture of water, vinegar, and honey, or some other detergent. When the saliva is vitiated, which seldom happens unless in fevers or other diseases, the curing of the disorder is the cure of this symptom. To relieve it, however, in the mean time, the following practices may be of use: if there be a bitter taste, it may be taken away by vomits, purges, and other things which evacuate bile: what is called a nidorous taste, arising from putrid humours,

Dyspepsia is corrected by the juice of citrons, oranges, and other acids: a salt taste is cured by plentiful dilution with watery liquors: an acid taste is destroyed by absorbents and alkaline salts, as powder of oyster-shells, salt of wormwood, &c.

When the sensibility of the nerves which supply the organs of taste is diminished, the chewing of horseradish, and other stimulating substances, will help to recover it.

Defect of the Sense of Feeling.

Sauv. gen. 161. Lin. 218. Vog. 267.

Causes, &c. This sense may be hurt by any thing that obstructs the nervous influence, or prevents its being regularly conveyed to the organs of touching, as pressure, extreme cold, &c. It may likewise be hurt by too great a degree of sensibility, when the nerve is not sufficiently covered by the cuticle or scarf-skin, or where there is too great a tension of it, or it is too delicate. Whatever disorders the functions of the brain and nerves, hurts the sense of touching. Hence it appears to proceed from the same general causes as palsy and apoplexy, and requires nearly the same method of treatment.

In a stupor, or defect of touching, which arises from an obstruction of the cutaneous nerves, the patient must first be purged; afterwards such medicines as excite the action of the nerves, or stimulate the system, may be used. For this purpose, the spirit of hartshorn, either by itself or combined with essential oils, horseradish, &c. may be taken inwardly; the disordered parts, at the same time, may be frequently rubbed with fresh nettles or spirit of sal ammoniac. Blisters and sinapisms applied to the parts will likewise be of use; and also warm bathing, especially in the natural hot baths.

Morositates, Sauv. Cl. VIII. Order II. Sag. Cl. XIII. Order II.

Pathetici, Lin. Cl. V. Order II.

Hyperesthesis, Vog. Cl. VII.

INSATIABLE HUNGER, or Canine Appetite.

Bulimia, Sauv. gen. 223. Lin. 79. Sag. gen. 335.

Bulimus, Vog. 296.

Addephagia, Vog. 297.

Cynorexia, Vog. 298.

This disease is commonly owing to some fault in the stomach, by which the aliments are thrown out too soon; and unless the person be indulged in his desire for eating, he frequently falls into fainting fits. Sometimes it is attended with such a state of the stomach, that the aliment is rejected by vomit almost immediately after being swallowed; after which the appetite for food returns as violent as ever. But there

VOL. XIII. Part II.

are many circumstances which seem to render it probable that it more frequently arises from a morbid condition of the secreted fluid poured into the stomach, by means of which the aliment is dissolved. When the activity of this fluid is morbidly increased, it will both produce too sudden a solution of the solid aliment, and likewise operate as a powerful and peculiar stimulus to the stomach, giving an uneasy sensation, similar to that which takes place in natural hunger. Such things are proper for the cure as may enable the stomach to perform its office: chalybeates and other tonics will generally be proper. In some, brandy drunk in a morning has been useful; and frequent smoking tobacco has relieved others. Oil, fat meat, pork, opiates, and in short every thing which in a sound person would be most apt to pall the appetite, may also be used as temporary expedients, but cannot be expected to perform a cure. In some, the pylorus has been found too large; in which case the disease must have been incurable.

EXCESSIVE THIRST.

Polydipsia, Sauv. gen. 224. Lin. 80. Vog. 275. Sag. 336.

This is almost always symptomatic; and occurs in fever, dropsy, fluxes, &c. The cure is very generally obtained only by the removal of the primary disease; and it is best palliated by the gradual introduction of diluents: But when these are contraindicated, it may often be successfully obviated by such articles taken into the mouth as have effect in augmenting the flow of saliva.

LONGING, or Falsse Appetite.

Pica, Sauv. gen. 222. Sag. 334.

Citta, Lin. 78.

Allotriophagia, Vog. 299.

Malacia, Vog. 300.

The pica is also very generally symptomatic of other diseases, as of worms, chlorosis, pregnancy, &c.; and is therefore chiefly to be combatted by the removal of the primary affection. It may, however, be observed, that peculiar longings occurring in certain diseases, as for example in fevers, often point out a natural cure. The indulgence of such appetites to a moderate degree is seldom productive of any inconvenience, and often followed by the best consequences. —Hence there are some practitioners who think that such craving should very generally be indulged; particularly when the patient can assign no reason whatever for such particular longings, but is merely prompted by an uncommon and inexplicable desire.

Satyriasis, Sauv. gen. 228. Lin. 81. Sag. 340.

Satyriasis is a violent desire of venery in men, even so that reason is depraved by it. The pulse is quick, and the breathing short; the patient is sleepless, thirsty,

Dyspepsia and loathes his food; the urine is evacuated with difficulty, and a fever soon comes on. These symptoms, however, are probably not so much the consequence of satyriasis, as merely concomitant effects resulting from the same cause. And indeed this affection is most frequently the concomitant of a certain modification of infancy. The nature and cause of this affection are in most instances very little ascertained; but as far as we are acquainted with the treatment, it agrees very much with the affection next to be mentioned, which, of the two, is the most common occurrence.

Nymphomania, Sauv. 229. Sag. 341.
Satyriasis, Lin. 81.

The furor uterinus is in most instances either a species of madness or a high degree of hysteria. Its immediate cause is a preternatural irritability of the uterus and pudenda of women (to whom the disorder is proper), or an unusual acrimony of the fluids in these parts.—Its presence is known by the wanton behaviour of the patient: she speaks and acts with unrestrained obscenity; and as the disorder increases, she scolds, cries, and laughs, by turns. While reason is retained, she is silent, and seems melancholy, but her eyes discover an unusual wantonness. The symptoms are better and worse until the greatest degree of the disorder approaches, and then by every word and action her condition is too manifest.—In the beginning a cure may be hoped for; but if it continue, it degenerates into a mania.—In order to the cure, blood-letting is commonly recommended in proportion to the patient's strength. Camphor in doses of 15 or 20 grains, with nitre, and small doses of the tincture of opium, should be repeated at proper intervals. Some venture to give cerusa acetata in doses from three to five grains. Besides bleeding, cooling purges should also be repeated in proportion to the violence of symptoms, &c. What is useful in maniacal and hypochondriac disorders, is also useful here, regard being had to sanguine or phlegmatic habits, &c. When the delirium is at the height, give opiates to compose; and use the same method as in a phrenitis or a mania. Injections of barley-water, with a small quantity of hemlock-juice, according to Rivierus, may be frequently thrown up into the uterus: this is called specific; but matrimony, if possible, should be preferred. For although this cannot be represented as a cure for the disease when in an advanced state, yet there is reason to believe that it has not unfrequently prevented it where it would otherwise have taken place.

Nostalgia, Sauv. gen. 226. Lin. 83. Sag. 338.

This is to be reckoned a species of melancholy; and unless it be indulged, it very commonly proves not only incurable but even fatal. Although it cannot be considered as altogether peculiar to any nation, yet it is observed to be much more frequent with

some than with others; and it has particularly been remarked among Swiss soldiers in the service of foreign states. Nostalgia.

Anepithymie, Sauv. Cl. VI. Ord. II. Sag. IX.
Ord. II.
Privativi, Lin. Cl. VI. Order III.
Adynamie, Vog. Cl. VI.

Anorexia, Sauv. gen. 162. Lin. 116. Vog. 279.
Sag. 268.

The anorexia is symptomatic of many diseases, but seldom appears as a primary affection; and it is very generally overcome only by the removal of the affection on which it depends.

Adipsia, Sauv. gen. 163. Lin. 117. Vog. 281. Sag. 269.

This by Dr Cullen is reckoned to be always symptomatic of some distemper affecting the senforum commune.

Anaphrodisia, Sauv. gen. 164. Sag. 270.
Atecnia, Lin. 119.
Agenesia, Vog. 283.

For this, see the article IMPOTENCE in the alphabetical order.

Aphonia, Sauv. gen. 166. Lin. 115. Vog. 253.
Sag. 272.

The loss of voice may proceed from various causes. If one of the recurrent nerves, which are formed by the par vagum and the nervus accessorius, and reach the larynx, be cut, the person is capable of only as it were a half-pronunciation; but if both be cut, the speech and voice are both lost. The loss of speech happening in hysteric patients is also called aphonia; but more properly that loss of speech is thus named which depends on some fault of the tongue.

Since the motion of any part is destroyed, or lessened at least, by the interception of the nervous fluid in its passage thither, and since the nerves destined for the motion of the tongue arise principally from the fifth pair, it appears that the seat of this disorder is in the fifth pair of nerves, and that the immediate cause

Dysphonia is a diminution or total destruction of the nervous power in them. Hence a palsy of the tongue, which is either antecedent or subsequent to hemiplegia or apoplectic disorders, demand our utmost attention.

If an aphonia appears alone, it generally bespeaks an approaching hemiplegia or apoplexy; but if it succeeds these disorders, and is complicated with a weak memory and a sluggishness of the mental powers, it threatens their return. That aphony usually terminates the best which proceeds from a stagnation of serous humours compressing the branches of the fifth pair of nerves, which run to the tongue; but it is no less afflictive to the patient, and is very obnoxious to cure.

Other causes of this disorder are, the striking in of eruptions on the skin, a congestion of blood in the fauces and tongue, obstructed periodical evacuations in plethoric habits, spasmodic affections, worms, a crumb of bread falling into the larynx, fear, too free an use of spirituous liquors; also whatever destroys the ligaments which go from the arytenoid to the thyroid cartilages, will destroy the voice.

The prognostics vary according to the cause. That species which is owing immediately to spasms, soon gives way on the removal of them. If a palsy of the tongue be the cause, it is very apt to return, though relieved, but often continues incurable.

In order to the cure, we must endeavour first to remove whatever obstructs the influx of the nervous fluid into the tongue, and secondly to strengthen the weak parts. These general intentions, in all cases, being regarded, the particular causes must be removed by remedies accommodated to each.

If worms be the cause, antispasmodics may give present relief; but the cure depends on the destruction or expulsion of the animals themselves. In case of a congestion of blood about the head, bleeding and nitrous medicines are to be used.—That species of aphony which remains after the shock of an hemiplegia or apoplexy, requires blisters to be applied to the nape of the neck; if spasmodic contractions about the fauces and tongue be the cause, external paregorics are of the greatest service, anodyne antispasmodics may be laid under the tongue, and the feet bathed in warm water; carminative clysters also are useful.—When a palsy of the tongue produces this complaint, evacuations, according to the patient's habit, must be made, and warm nervous medicines must be externally applied, and internally administered; blisters also should be placed between the shoulders.—In case of repelled cuticular eruptions, sudorifics should be given, and the patient's drink should be warm. The spiritus ammoniæ succinatus, or vinum antimonii, may be employed either in combination with other articles, or by themselves, and given at proper distances of time, in the patient's drink, or on a bit of sugar.—Sometimes the serum flows so rapidly to the fauces and adjacent parts, in a salivation, as to deprive the patient of all power to speak; in this case diaphoretics and laxatives, with a forbearance of all mercurials, are the speediest remedies.

Mutitas, Sauv. gen. 165. Vog. 257. Seg. 271.

Dumb people are generally born deaf; in which case the distemper is incurable by medicine: though even such people may be taught not only to read and write, but also to speak and to understand what others say to them. For some observations on the method in which this has been accomplished, we may refer the reader to the article DUMBNESS, in the alphabetical order. But in these cases, admitting of cure in the manner above alluded to, the dumbness proceeds principally, if not solely, from the deafness. For when it proceeds from a defect of any of the organs necessary for speech, the tongue for instance, it is always incurable; but if it arise from a palsy, the medicines applicable in that case will sometimes restore the speech.

Paraphonia, Sauv. gen. 168.

Cacophonia, Seg. 274.

Rauccedo, Lin. 146.

Raucitas, Vog. 252.

Alaphia, &c. Vog. 250, 251, 254, 255, 256.

The voice may be changed from various causes. In males it becomes much more hard about the time of puberty; but this can by no means be reckoned a disease. In others it proceeds from a catarrh, or what we call a cold; it arises also from affections of the nose and palate, as polypi, ulcers, &c. in which case the cure belongs properly to SURGERY. In some it arises from a laxity of the velum pendulum palati and glottis which makes a kind of snoring noise during inspiration. The cure of this last case is to be attempted by tonics and such other medicines as are of service in diseases attended with laxity.

Psellismus, Sauv. gen. 167. Lin. 139. Seg. 273.

Traulotis, &c. Vog. 258, 259, 260, 261.

Of this disease (if such it may be called), there are many different kinds. Some cannot pronounce the letter S; others labour under the same difficulty with R, L, M, K: &c.; while some who can with sufficient ease pronounce all the letters, yet repeat their words, or the first syllables of them, in such a strange manner, that they can scarce be understood. Very frequently these defects arise entirely from habit, and may then be got the better of by those who have the resolution to attempt it; as we are told that Demosthenes the celebrated orator got the better of a habit of stammering by declaiming with pebbles in his mouth. Sometimes, however, pronunciation may be impeded by a wrong conformation of the tongue or organs of speech; and then it cannot by any pains whatever be totally removed.

Strabismus, Sauv. gen. 116. Lin. 304. Vog. 514. Seg. 222.

Description. This disease shows itself by an uncommon contraction of the muscles of the eye; whereby the axis of the pupil is drawn towards the nose, temples, forehead, or cheeks, so that the person cannot behold an object directly.

Causes, Prognosis, &c. 1. This disease may proceed from custom and habit; while in the eye itself, or in its muscles, nothing is preternatural or defective.

Thus children by imitating those that squint, and infants by having many agreeable objects presented to them at once, which invite them to turn one eye to one and the other eye to another, do frequently contract a habit of moving their eyes differently, which afterwards they cannot so easily correct. Infants likewise get a custom of squinting by being placed obliquely towards a candle, window, or any other agreeable object capable of attracting their sight: for though, to see the object, they may at first turn both eyes towards it; yet, because such an oblique situation is painful and laborious, especially to the most distant eye, they soon relax one of the eyes, and content themselves with examining it with the eye that is next it; whence arises a diversity of situation and a habit of moving the eyes differently.

In this case, which may admit of a cure if not too much confirmed, it is evident, that objects will be seen in the same place by both eyes, and therefore must appear single as to other men; but because, in the eye that squints, the image of the object to which the other eye is directed falls not on the most sensible and delicate part of the retina, which is naturally in the axis of the eye, it is easy to see that it must be but faintly perceived by this eye. Hence it is, that while they are attentive in viewing any object, if the hand be brought before the other eye, this object will be but obscurely seen, till the eye change its situation and have its axis directed to it; which change of situation is indeed very easy for them, because it depends on the muscles of the eyes, whose functions are entire; but, by reason of the habit they have contracted of moving their eyes differently, the other eye is at the same time frequently turned aside, so that only one at a time is directed to this object.

II. The strabismus may proceed from a fault in the first conformation, by which the most delicate and sensible part of the retina is removed from its natural situation, which is directly opposite to the pupil, and is placed a little to a side of the axis of the eye; which obliges such people to turn away the eye from the object they would view, that its picture may fall on this most sensible part of the organ.

When this is the case, the disease is altogether incurable, and the phenomena that arise therefrom differ in nothing from the phenomena of the former case, excepting only that here, 1. The object to which the eye is not directed will be best seen; which is the reverse of what happens when this disease arises barely from habit and custom. 2. No object will appear altogether clear and distinct: for all objects to which the eye is directed, by having their image painted in the retina at the axis of the eye, where it is not very sensible, will be but obscurely seen; and objects that are placed so far to a side of the optic axis as is necessary for making their image fall on the most sensible and delicate part of the retina, must appear a little

confused, because the several pencils of rays that come therefrom fall too obliquely on the crystalline to be accurately collected in so many distinct points of the retina; though it must be acknowledged, that this confusion will, for the most part, be so small as to escape unobserved.

III. This disease may proceed from an oblique position of the crystalline, where the rays that come directly to the eye from an object, and that ought to converge to the point of the retina, which is in the axis of the eye, are, by reason of the obliquity of the crystalline, made to converge to another point on that side of the visual axis where the crystalline is most elevated; and therefore the object is but obscurely seen, because its image falls not on the retina at the axis of the eye, where it is most sensible: But the rays that fall obliquely on the eye, will after refraction, converge to this most sensible part of the retina; and, by converging there, must impress the mind with a clear idea of the object from whence they came. It is for this reason that the eye never moves uniformly with the other, but turns away from the object it would view, being attentive to the object to which it is not directed. When this is the case, it is in vain to expect any good from medicine.

The symptoms which naturally arise from it are, 1. The object to which the eye is directed will be but faintly seen, because its image falls on the retina where it is not very sensible. 2. The object to which the eye is not directed, by having its image painted on the retina at the axis of the eye, will be clearly perceived. But, 3. This same object must appear somewhat indistinct, because the pencils of rays that flow from it are not accurately collected in so many distinct points in the retina, by reason of their oblique incidence on the crystalline. 4. It must be seen, not in its proper place, but thence translated to some other place situated in the axis of vision. And, 5. Being thus translated from its true place, where it is seen by the other eye that does not squint, it must necessarily appear double; and the distance between the places of its appearance will be still greater, if the crystalline of the other eye incline to the contrary side.

IV. This disease may arise from an oblique position of the cornea; which, in this case, is generally more arched and prominent than what it is naturally.

When the eye has this conformation, no object to which it is directed can be clearly seen, because its image falls not on the retina at the axis of the eye; and therefore the eye turns aside from the object it would view, that its image may fall on the most sensible part of the retina.

When the strabismus proceeds from this cause, the prognostic and the phenomena that attend it will be much the same as in the case immediately preceding; from which nevertheless it may be distinguished by the obliquity of the cornea, which is manifest to the senses and if the cornea be also more arched and prominent than what it is naturally, which is commonly the case, the eye will also be short-sighted.

V. This want of uniformity in the motions of our eyes, may arise from a defect, or any great weakness

Dysmetrie or imperfection, in the sight of both or either of the eyes; and this, according to Dr Porterfield, is the most common cause of this disease. The prognostic in this case is the same with that of the disease from which it proceeds.

VI. Another cause from which the strabismus may proceed, lies in the muscles that move the eye. When any of those muscles are too short or too long, too tense or too lax, or are seized with a spasm or paralysis, their equilibrium will be destroyed, and the eye will be turned towards or from that side where the muscles are faulty.

In this case, the disease frequently yields to medicine, and therefore admits of favourable prognostic; excepting only when, by a fault in the first conformation, any of the muscles are longer or shorter than their antagonists; in which case, if ever it should happen, no medicine can be of any use.

As to what concerns the optical phenomena, they are the same here as in case first: only when the disease commences not till, by custom and habit, the uniform motion of the eyes has been rendered necessary, all objects do for some time appear double; but in time they appear single.

Lastly, This want of uniformity in the motions of our eyes may proceed from a preternatural adhesion or attachment to the eyelids: of this we have an instance in Langius. And that the same thing may also be occasioned by a tumor of any kind within the orbit, pressing the eye aside, and restraining it from following the motions of the other, is so evident, that instances need not be brought to prove it. Here also the case may admit of a favourable prognostic; and as for what concerns the optical phenomena, they must be the same as in the case immediately preceding.

The cure, in confirmed cases, is to be effected by mechanical contrivances, by which the person may be obliged to look straight upon objects, or not see them at all; or at least that he may see with uneasiness and confusedly when he squints. In the 68th volume of the Philosophical Transactions we have an account of a confirmed case of squinting of a very uncommon kind. The patient was a boy of five years old, and viewed every object which was presented to him with but one eye at a time. If the object was presented on his right side, he viewed it with his left eye; and if it was presented on his left side, he viewed it with his right eye. He turned the pupil of that eye which was on the same side with the object in such a direction that the image of the object might fall on that part of the bottom of the eye where the optic nerve enters it. When an object was held directly before him, he turned his head a little to one side, and observed it with but one eye, viz. that most distant from the object, turning away the other in the manner above described; and when he became tired of observing it with that eye, he turned his head the contrary way, and observed it with the other eye alone, with equal facility; but never turned the axis of both eyes on it at the same time. He saw letters which were written on bits of paper, so as to name them with equal ease, and at equal distances, with one eye as with the other. There was no perceptible difference in the diameters of the irises, nor in the con-

tractility of them after having covered his eyes from Strabismus. the light. These observations were carefully made by writing single letters on sheets of paper, and laying wagers with the child that he could not read them when they were presented at certain distances and in certain directions.

As from these circumstances it appeared that there was no defect in either eye, which is frequently the case with persons who squint, and hence that the disease was simply a depraved habit of moving his eyes, the disease seemed capable of a cure. A paper gnomon was made for this purpose, and fixed to a cap; and when this artificial nose was placed over his real nose, so as to project an inch between his eyes, the child, rather than turn his head so far to look at oblique objects, immediately began to view them with that eye which was next to them. But having the misfortune to lose his father soon after this method was begun to be followed, the child was neglected for six years, during which time the habit was confirmed in such a manner as seemed to leave little room to hope for a cure. The same physician, however, being again called, attempted a second time to remove the deformity by a similar contrivance. A gnomon of thin brass was made to stand over his nose, with a half circle of the same metal to go round his temples: these were covered with black silk, and by means of a buckle behind his head, and a cross-piece over the crown of his head, this gnomon was worn without any inconvenience, and projected before his nose about two inches and an half. By the use of this machine he soon found it less inconvenient to view all oblique objects with the eye next to them than the eye opposite to them.

After this habit was weakened by a week's use of the gnomon, two bits of wood, about the size of a goose-quill, were blackened all but a quarter of an inch at their summits; these were frequently presented to him to look at, one being held on one side the extremity of his black gnomon, and the other on the other side of it. As he viewed these, they were gradually brought forwards beyond the gnomon, and then one was concealed behind the other: by these means, in another week, he could bend both his eyes on the same object for half a minute together; and by continuing the use of the same machine, he was in a fair way of being cured when the paper was written.

Dr Darwin, who writes the history of the above case, adds, that all the other squinting people he had occasion to attend, had one eye much less perfect than the other: these patients, says he, are certainly curable by covering the best eye many hours in a day; as by a more frequent use of the weak eye, it not only acquires a habit of turning to the objects which the patient wishes to see, but gains at the same time a more distinct vision; and the better eye at the same time seems to lose somewhat in both these respects, which also facilitates the cure.

GENUS CXV. CONTRACTURA.

Contractions of the LIMBS.

Contractura, Sauv. gen. 119. Lin. 299. Sag. 225.
Ostipitias, Sauv. gen. 11.

Apocenosos. Caput oblitum, Vog. 513.
Digitum, Vog. 221.

The contraction of various muscles of the body is generally the consequence of some other disease, as the rheumatism, gout, scurvy, or palsy, especially that species of the latter which follows the colica Pictonum. It is exceedingly difficult of cure; though the warm medicinal waters are much recommended, and have sometimes done great service. Of late electricity has been found to perform surprising cures in this way.

Apocenosos, Vog. Clafs II. Ord. II.
Fluxus, Sauv. Clafs IX. Sag. Clafs V.
Morbi evacuatorii, Lin. Clafs IX.

Profusio, Lin. 259.
Hæmorrhagia, Vog. 81. Boerh. 218.

The disease commonly known by the name of bloody flux, is the putrid or contagious dysentery, a disease which has already been treated of. But independent of the discharge of blood which then takes place, hæmorrhagy may take place from the alimentary canal as well as from other parts of the system. In such instances, however, if we except the place from which the discharge occurs, the phenomena are very much the same as in menorrhagia, hæmoptysis, and other hæmorrhagies already treated of; while the disease is to be combatted on the same principles and by the same remedies.

Ephidrosis, Sauv. gen. 258. Sag. gen. 194.
Sudor, Lin. 208.
Hydropedesis, Vog. 121.

This is generally symptomatic; and occurs in almost all fevers, but especially in the latter stages of the hectic. Sometimes it is a primary disease, arising merely from weakness; and then easily admits of a cure by the use of the cinchona, the cold bath, and other tonics.

Epiphora, Sauv. gen. 259. Lin. 172. Vog. 99.
Sag. 195.

This by Sauvages is described as an involuntary effusion of tears without any remarkable itching, heat, or pain. It follows long continued ophthalmias; or it may be occasioned by moderate fluidity, or any thing that weakens the eyes: hence it comes on about the age of 50 years, when the eyesight naturally becomes weak. It in general grows worse in the winter-time, and is very hard to cure. Some authors re-

commend purgatives, and blisters on the nape of the neck, in order to draw off the abundant humours; but as the disease evidently proceeds from weakness, it would rather seem proper to pursue a contrary method. Sauvages recommends to the patients to abstain from study, wine, and salted meats; and also to avoid smoke or wind, and at night to foment the eyes with an infusion of four cloves in two ounces of proof-spirit. Hungary water, rose water with sulphate of zinc dissolved in it, &c. have also been recommended.

Ptyalismus, Sauv. gen. 261. Lin. 176. Vog. 103.
Sag. 197.

A salivation is often symptomatic, but rarely a primary disease. Dr Cullen is of opinion, that when the latter happens to be the case, it arises from laxity; and then is to be cured by astringents and tonics. In the Medical Transactions we have the following account of a salivation brought on by a foreign substance irritating one of the parotid glands.

In the month of April 1751, a young lady about the age of 16 years, of a delicate habit, but subject to no particular complaints, perceived the beginning of a disease which afterwards proved most obstinate and loathsome, viz. an incessant spitting. The quantity of this discharge was different at different times, varying from one pint to two pints and an half in 24 hours. As to its quality, it seemed to be no other than the ordinary secretion of the salival glands. By so large and constant an evacuation, her strength became extremely impaired, and the most efficacious medicines had proved useless. She had taken large quantities of cinchona, both alone and combined with preparations of iron: and afterwards the fetid gums, opium, amber, alum, and the Neville-Holt water, had in succession been given her. In the mean time an exact regimen had been prescribed: she had been ordered to ride constantly; and to confine herself to a mucilaginous diet, such as veal, calves feet, &c. Likewise a gentle opening medicine had now and then been interposed. The disease still continuing unaltered, she had afterwards tried the tinctura saturnina; and had, at the same time, been encouraged to chew cinchona, and to swallow the saliva. But all these attempts had been vain; and after she had taken some or other of the medicines above mentioned until the end of September 1753, namely, above two years, it appeared to her physician, Sir George Baker, unreasonable to expect relief in such a case from any internal medicines whatever.

He now conceived a suspicion, that some extraneous body having accidentally found its way into the meatus auditorius, might possibly be the cause of this extraordinary secretion, by keeping up a continued irritation in the parotid glands. With this view he examined her ears, and extracted from them a quantity of fetid wool. How, or when, it came thither, no account could be given.

To this substance he attributed the beginning of the salivation, notwithstanding that the disease did not immediately abate on the removal of the wool; as it appeared to be no improbable supposition that the discharge

Apocynum charge might be continued by the force of habit, though the original cause no longer remained.

It seemed, therefore, expedient to introduce some other habit, in the place of the increased secretion of saliva; which habit might afterwards be gradually left off. With this intention, he prevailed on the patient to chew perpetually a little dry bread, and to swallow it with her spittle. In a few weeks, it became necessary for her to chew the bread only at certain hours in the day; and thus, after two months, she became entirely free from a most disgusting and tedious disorder.

It is worthy of observation, that, at first, the swallowing of so much saliva frequently occasioned a nausea; and that then, for a few hours, she was obliged to spit it out as usual; and that, during the greatest part of the time, when she chewed the bread, she had a stool or two every day more than common.

396 GENUS CXX. ENURESIS.

An involuntary Flux of URINE.

Enuresis, Sauv. gen. 264. Lin. 195. Veg. 113. Sag. 200.

This is a distemper which frequently affects children, otherwise healthy, when asleep; and is extremely disagreeable. Often it is merely the effect of laziness, and may be driven off by proper correction; but sometimes it proceeds from an atony or weakness of the sphincter of the bladder. Many ridiculous cures have been prescribed for it, and among the rest field-mice dried and powdered. Tonics are frequently of use; but sometimes the distemper proves obstinate, in spite of every thing we can use. In the London Medical Observations we find blisters much recommended in this disease, when applied to the region of the os sacrum. A girl of 13 years of age had been subject to an enuresis for four years. She could retain her water but a very little while in the day-time, but it flowed continually in the night. She had taken Peruvian bark and tincture of vitriol in considerable quantities; also valerian and the volatile julep, without effect. She was severely threatened, as the physician suspected it might arise from a bad habit; but this producing no effect, a blister was applied to the os sacrum, which in 24 hours totally removed the disease. A man aged 32, having been seized with an incontinence of urine and palsy of the lower extremities in consequence of taking a quack medicine, was cured of the incontinence of urine in 24 hours by one blister, and of the palsy itself by another. A woman of 50 having been seized with an enuresis and paralytic affection of the right thigh and leg in consequence of a sprain, was cured of both by a single blister. Several other cases are mentioned, by which the power of blisters in removing this distemper seems to exceed that of every other medicine whatever.

591 GENUS CXXI. GONORRHOEA.

Gonorrhœa, Sauv. gen. 208. Lin. 200. Veg. 118. Sag. 204.

The gonorrhœa is a flux of viscid matter of various colours, from the urethra in men and the vagina in wo-

men. It commonly proceeds from coition with a person infected with the venereal disease, and is one of the most common forms under which that disease shows itself.

Description. The first symptoms of the disease in men are commonly a sensation at the end of the penis not unlike a flea-bite, together with a fulness of the lips of the urethra, and some degree of tension in the penis, the urinary canal feeling as if tightened, and the urine flowing in a small and unequal stream: a little whitish mucus is to be seen about the orifice of the urethra, and oozing from it when slightly pressed, especially if the pressure be made on the spot where the soreness is most felt. The discharge soon increases in quantity, and varies in its colour according to the degree of inflammation. The patient feels a sensation of heat and pain in evacuating his urine, particularly at certain spots of the urethra, and above all towards its orifice; and the involuntary erections to which he is subjected from the stimulus, particularly when warm in bed, occasion a distortion or curvature of the penis, attended with exquisite pain. When the inflammation is violent, the glans appears tumid and transparent, the tension extends through the whole of the penis, the perineum is affected with swelling and redness, and even the loins, buttocks, and anus, sympathize and afford a very uneasy sensation. Sometimes the prepuce inflames about the end of the penis, and cannot be drawn back, occasioning what is called a phymosis; at other times, as in the paraphymosis, it remains in an inflamed state below the glans, so that it cannot be drawn forwards; and, if the stricture and inflammation be violent, may terminate in gangrene. Now and then, especially when there is a phymosis, we may perceive a hard chord extending along the back of the penis. This is an inflamed lymphatic, and may be considered as a prelude to a bubo. When, however, a bubo does appear, almost universally some ulceration is previously to be discovered about the preputium, or glans penis; which gives ground to presume that some other contagious matter besides that of gonorrhœa may have been applied to the urethra. For it is certain that matter capable of communicating the contagion of gonorrhœa to a female, is often copiously applied to the whole glans penis of a male for several days together, without giving either ulceration or bubo.

In mild cases, the seat of the disease is in the urethra, not far from its orifice; but it frequently happens that the virus infiltrates itself much higher up, so as to affect Cowper's glands, the prostate, and parts very near to the neck of the bladder.

In the generality of cases, the inflammation goes on increasing for several days, commonly for a week or a fortnight; after which the symptoms begin to abate; and the running, when left to itself, gradually lessens in quantity, and becomes whiter and thicker, till at length it totally stops. The colour of the mucus, however, is by no means a certain guide in these cases: for in many patients it is of a yellowish, and sometimes of a greenish hue to the very last; but in general it becomes more consistent towards the close of the disease.

In women, the external parts of generation being fewer and more simple, the disease is less complicated than

Appendices than in men. Sometimes the vagina only is affected; and when this happens, the symptoms are very trifling: but in general it comes on with an itching and sensation of heat as in the other sex; and is attended with inflammation of the nymphæ, inside of the labia, elitoris, caruncule myrtiformes, the orifice and sometimes the whole of the meatus urinarius. Very often the deep-seated glands of the vagina are affected, and it is sometimes difficult to distinguish the discharge of a gonorrhœa from that of the fluor albus.

Causes, &c. Many ingenious arguments have of late been advanced to prove, that the gonorrhœa and the lues venerea are different affections, originating from two distinct species of virus; and this controversy still, perhaps, remains to be decided by future facts. Certain it is, that in 19 of 20 cases of gonorrhœa, no symptom whatever of syphilis appears; and that the disease readily admits of cure without having recourse to those remedies which are universally requisite for combating the contagion of syphilis. It is by no means wonderful, that in some cases both contagious, supposing them different, should be communicated at the same time. Nay, cases are by no means rare, where the contagion of itch, though essentially different from both, has been communicated with either. But as undeniable proof that the contagion in both cases is precisely the same, it has been alleged by some, that the matter of a chancre introduced into the urethra will generate a gonorrhœa, and that the discharge from a gonorrhœa will produce chancre, bubo, and every other symptom of syphilis. On the other hand, however, it is contended, that when experiments of this nature are conducted with the greatest accuracy, the matter of syphilis uniformly produces syphilis, and that of gonorrhœa, gonorrhœa only. Without pretending to decide on which of these experiments the greatest dependence is to be put, we may only observe, that while an almost inconceivably small portion of syphilitic matter applied to the glans penis, from connection with an infected female, infallibly produces syphilis if it be not speedily removed, the matter of gonorrhœa, in every instance of that disease, is applied to the whole surface of the glans penis for many days together without producing almost any bad effect whatever. From this, therefore, there is ground for inferring, either that it is not capable of being absorbed, or that if absorbed it is innocent.

But while there have been disputes with regard to the peculiar nature of the matter in gonorrhœa, there have also been controversies with respect to the source from whence it is derived. While some suppose it to be principally purulent matter arising from ulcerations, others assert that no such ulceration is ever produced in the urethra by gonorrhœa. They contend that the increased secretion in these cases is exactly similar to what happens in the catarrh. But the comparison will by no means hold good in every particular: in the latter the whole membrane of the nose is equally irritated; whereas in the gonorrhœa, only particular parts of the urethra seem to be affected. The disease, in the generality of cases, seldom extends more than an inch and a half along that canal, and in many is confined (at least in the beginning) to a small spot about an inch from the extremity of the glans. The dis-

charge is produced from that part of the urethra where Gonorrhœa the pain is felt; and the patient, when he voids his urine, feels no smarting till it reaches the inflamed spot: but as the disorder increases, the inflammation affects a greater number of points, just in the same manner as chancres affect different parts of the glans. It might be supposed that dissection would at once clear up this matter, and put an end to the dispute; but this is far from being the case. Dr Simmons has seen several urethras opened in persons who had a gonorrhœa at the time of their death: in three of them the surface of the urethra, as in the cases related by Morgagni, appeared for some way down of a slight red colour, and in all of them was covered with mucus; but without any appearance of ulceration, except in two dissections at Paris, in which most of the gentlemen present were convinced that they saw evident marks of it: but Dr Simmons says that the appearances were to him not sufficiently satisfactory to enable him to decide with certainty on the subject. On the other hand, when we consider that the discharge in a gonorrhœa is sometimes tinged with blood, and that when this happens a little blood-vessel is no doubt ruptured, we can have no reason to doubt that an ulceration may, and sometimes does, happen in these cases; especially as we often observe an excoriation near the orifice of the urethra. It is certain, that wherever there is considerable inflammation, there will be danger of ulceration. Besides, from a neglected or badly-treated gonorrhœa, we often see filulas in perineo, and other ulcers of the urethra, penetrating through its substance, and affording a passage to the urine. And there can be no doubt that slight ulcerations of this canal often occur, and are afterwards perfectly obliterated, in a similar manner to what happens in the papillæ of the tongue, the tonsils, &c. Such an obliteration will the more readily take place in a part like the urethra, defended with mucus, and not exposed to the air, which is known to have no little effect in hardening a cicatrix.

But whether ulcers take place or not, whether the virus of gonorrhœa be precisely of the same kind with that which gives syphilis, or of a different kind, there is reason from the phenomena of the disease to conclude, that the matter first acts by mixing with the mucus at the extremity of the urethra; and that from thence it is propagated upwards, particularly where the excretories of mucus are most numerous; and that on the parts to which it is applied, it operates as a peculiar irritating cause. The consequences of this irritation will be inflammation and an increased secretion of mucus; and so far the complaint will be local. In ninety-nine cases of an hundred a local affection of this kind constitutes the whole of the disease; and of this inflammation, ulcerations within the urethra, strictures, and other local affections, may be the consequence. But whether a disease of the habit ever takes place, unless when the contagion of syphilis is communicated with that of gonorrhœa, still remains to be determined by future observations and experiments.

Nothing can be more variable than the period at which the disease makes its appearance after infection. Perhaps, at a medium, we may place it between the 4th and 14th day: but in some cases it happens within

Apocynoses. 24 hours; and in others, not before the end of five or even six weeks: neither of these extremes, however, are common.

From what has been said of the manner in which the contagious matter in gonorrhoea acts, and of the influence it exerts on those parts with which it comes in contact, it follows, that the prevention of gonorrhoea must depend on the removal of the contagious matter, as soon as that can be done; and where this is either altogether neglected or not properly accomplished, that the cure must depend on counteracting the inflammation which this contagious matter excites, and the consequences which result from it.

The first of these intentions may be most certainly and most easily accomplished by careful lotion of all the parts to which the contagious matter has any chance of being applied. These parts, at least on the first application of the matter, are readily accessible: for even in men there is no reason to believe that it at first penetrates to any extent in the urethra. This washing of the parts should be performed as soon as possible; because then the matter is both most accessible and least involved with mucus: but although washing cannot be accomplished at an early period, it should not be neglected afterwards; for from the disease uniformly commencing, even when it does not appear till a considerable time after the application of the contagious matter, with a peculiar sense of titillation at the external parts, particularly in men at the extremity of the urethra, there is reason to believe that the contagious matter attached to the mucus may remain latent there for a very considerable time. For the purpose of washing, with a view to the prevention of this disease, recourse may be had to almost any watery fluid, provided it be not so stimulant as to produce bad effects from injuring the parts. Pure water, properly applied, is perhaps one of the best lotions; but there can be no doubt that its power in removing the contagious matter may be somewhat increased by such additions as render it a more powerful solvent of mucus. With this intention, one of the most powerful additions is the vegetable alkali, either in its mild or caustic state. In the latter state it is the most active, but in the former it is most safe; and the carbonas potassie of the Edinburgh pharmacopoeia, to the extent of half a dram, dissolved in six or eight ounces of water, is one of the best lotions that can be employed. The purpose of removing the contagion may often also be effectually answered from washing with water impregnated with soap; for there the alkali, though in a caustic state, is prevented from exerting any disagreeable effects, in consequence of its being combined with oily matters.

With the view of preventing gonorrhoea, some have advised, that the alkali either in its mild or caustic state, properly diluted with water, should be injected into the urethra: and there can be no doubt, that by this means the contagious matter, when it has entered the urethra, may be removed. A removal may also be effected by the injection of a weak solution of corrosive sublimate, which seems to act not by dissolving the mucus but by producing an augmented secretion. But at a very early period of the disease, injections are probably unnecessary; and if it has made any considerable progress, they are dangerous: for from the aug-

mented sensibility of the part, even very gentle ones are apt to excite a high degree of inflammation.

There are practitioners who, supposing that the body possesses powers to expel the virus, and that the disease has a certain period to run through its several stages of progress, acme, and decline, are for leaving the cure to nature; or at least content themselves with assisting her by an antiphlogistic regimen, gentle evacuations, and the like.

That in many cases the disorder admits of a natural cure, there can be no doubt; the increased secretion of mucus carrying off the virus faster than it is formed, till at length the infection is wholly removed: But it is equally certain, that in every case, by the application of suitable remedies to the inflamed part, we may shorten the duration of the complaint, and abridge the sufferings of the patient, with the same certainty and safety as we are enabled to remove the effects of an ophthalmia or any other local inflammation, by proper topical applications. General remedies, such as occasional blood-letting, a cooling diet, the liberal use of diluting liquors, and mild purges, are by all allowed to be useful, and even necessary. Astruc was of opinion that in these cases blood-letting ought to be repeated five or six times; and there are still many practitioners who depend much on repeated evacuations of this sort for a removal of the inflammation. But there is, perhaps, not one case in ten in which it is at all requisite; and this small number of cases will consist only of the strong and plethoric: in such, when the chordee is frequent and painful, and the pulse hard and full, the loss of from eight to twelve ounces of blood will be beneficial, but it will be seldom necessary to repeat the operation. The inflammation in these cases is kept up by the local stimulus of the virus and the urine; and all that we can expect from venesection is to moderate the pain and the frequency of erection. In persons of a delicate habit, and of an irritable fibre, the evacuation will do no good; but if repeated will certainly be liable to do harm, by increasing irritability, and of course rendering the patient more susceptible of stimulus.

The utility, and even the necessity, of a cooling regimen, are sufficiently obvious; wine and spirituous liquors, spices, a fish-diet, much animal-food, and salted and high-seasoned dishes of every sort, will constantly add to the complaint. The patient should eat meat only once a-day, and that sparingly. He should abstain from hot suppers. Milk, mild vegetables, and fruit, should constitute the principal part of his diet while the inflammatory symptoms continue. Every thing that tends to excite the venereal imagination should be studiously avoided; for whatever promotes erections of the penis will increase the inflammation, and of course add fuel to the disease. For the same reasons much walking or riding on horseback will be hurtful, from the irritation kept up in the perineum by such means. Violent exercise of any kind, or any thing that is liable to increase the heat and the momentum of the blood, will of course be improper.

The drinking freely of mild, cooling, mucilaginous liquors, such as linseed-tea, orgeat, whey, milk and water, almond emulsion, and the like, will be extremely useful, by diluting the urine, and preventing its salts from stimulating the urethra. When the heat and pain in making water are very considerable, mucilaginous

Apocynoses. substances are found to have the best effect, particularly the gum tragacanth. It is a common practice to give equal quantities of this gum or gum-arabic and nitre, and to dissolve nitre in the patient's drink, with a view to lessen the inflammation. But in these cases nitre is always improper: it is known to be a powerful diuretic, its chief action being upon the urinary passages; so that the stimulus it occasions will only serve to increase the evil it is intended to alleviate. Supertartrite of potash, on account of its diuretic quality, will be equally improper. Our view here is not to promote a preternatural flow of urine; for the virus, being insoluble in water, cannot easily be washed away by such means; but our object ought to be, to render the urine that is secreted as mild and as little stimulating as possible.

Mild purges, which constitute another material part of the general remedies, are no doubt extremely useful when exhibited with prudence; but it is well known that the abuse of purgative medicines in this disease has been productive of numerous evils. Formerly it was a pretty general practice to give a large dose of calomel at bed-time, three or four times a-week; and to work it off the next morning with a strong dose of the pillula coeciae, or some other drastic purge. This method was persevered in for several weeks: in consequence of which the patient often found himself troubled with an obstinate gleet, and perhaps his constitution materially injured; the effect of such a method being (especially in irritable habits) to weaken the stomach and bowels, and lay the foundation of hypochondriacal complaints. Violent purging likewise often occasions strangury, and other troublesome symptoms.

The cathartics employed in these cases should be gentle; such as Rochelle salt, manna, tartarised alkali, and the like. They should be given only in a dose sufficient to procure two or three stools, and be repeated only every two or three days. The daily use of the purgative electuaries that are still given by some practitioners, serves only to keep up a continual irritation on the bladder, and of course to prolong the inflammation.

The topical remedies that are used consist chiefly of different sorts of injections, the ingredients of which are extremely various; but their modes of operation may in general be referred to their mucilaginous and sedative, or to their detergent, stimulating, and astringent qualities. In the hands of skillful practitioners, great advantages may doubtless be derived from the use of these remedies; but, on the other hand, the improper and unseasonable administration of them may prove a source of irreparable mischief to the patient.

We know that mucilaginous and oily injections will tend to allay the local inflammation; and that a sedative injection, such as a solution of opium, will lessen the irritability of the parts, and of course produce a similar effect; the utility of such applications is therefore sufficiently obvious.

A detergent injection, or one that will act upon the mucus of the urethra, increase the discharge of it, wash it away, and with it the venereal virus that is blended with it, can only be used as a prophylactic before the symptoms of infection have made their appearance. But great circumspection is necessary in the use of this kind of injection. If it be too weak, it can be of no efficacy; and if it be too strong, it may prove

dangerous to the patient. A suppression of urine has been brought on by the improper use of an injection of this kind. When the symptoms of inflammation have once made their appearance, the stimulus of such an injection must be extremely hazardous. Excoriation of the urethra has but too often been produced by remedies of this sort in the hands of adventurous and unskillful practitioners.

While the inflammation of the urethra continues, every thing that stimulates it must be hurtful. If the injection excites a painful sensation in the urethra, as is but too often the case, it will be liable to produce swelled testicles, difficulty in making water, excoriation, and other effects of increased inflammation: if, by its astringency, the running be checked before the virus that excited the discharge be properly subdued, the patient will be exposed to fresh dangers; and perhaps to a variety of local complaints, such as obstructions in the urethra, and abscesses in perineo, which are well known to be sometimes owing to applications of this sort improperly managed.

When the inflammation has subsided, gently stimulating and astringent injections may be used with safety, and with considerable advantage: for as the inflammation is at first excited by the stimulus of the venereal virus, so when the former begins to lessen, we may be assured that the activity of the latter has abated in proportion; and, in general, when the inflammatory symptoms are entirely removed, it will be found, that the mucus is no longer of an infectious nature, but is merely the effect of an increased secretion and of relaxation. Mild astringents will therefore serve to brace and strengthen the vessels secreting mucus, and in this way will lessen the discharge, and greatly promote the cure. It is certain, that in the greater number of cases, a gonorrhoea, which if treated by internal remedies alone, would continue for five or six weeks, or longer, may, when judiciously treated with injections, be cured in a fortnight, and very often in less time. The great aim, therefore, of the practitioner ought to be at first to make use of such injections only as will tend to lubricate the surface of the urethra, and to counteract and destroy the stimulus of the virus: as the inflammation abates, he may add some gently astringent preparation to a mucilaginous and sedative injection; taking care that its astringency be suited to the state of the disease, and to the irritability of the patient. Amongst a great variety of substances, mercury in different forms is one of those that is the most frequently employed in injections. All these mercurial injections have more or less of astringency; and, according to Dr Simmons, it is solely to this property that we are to ascribe their effects; for the idea of their correcting the venereal virus was originally introduced, and has, he thinks, been continued, upon mistaken principles.

Calomel, mixed with the mucus discharged in a gonorrhoea, has no more power in destroying the infectious properties of that mucus than cerusse or any other preparation would have. A diluted solution of sublimate injected into the urethra, will, like a solution of verdigris, or blue vitriol, or any other slyptic, constringe the mouths of the lacunæ; but this is all that it will do, for it will never lessen the infectious nature of the virus. The same thing may be observed of crude

Apocynoides. crude mercury extinguished by means of mucilage, or of mercurial ointment, blended with the yolk of an egg, and which, when thrown up into the urethra, will act nearly in the same manner as balsam of copaiva, or any other stimulating injection. The stimulus of mercury, however, has often been found of considerable efficacy; and in women, when the vagina only was affected, after washing the parts well, the cure has been accomplished by rubbing them repeatedly with mercurial ointment.

As the gonorrhoea is only a local affection, it may be inferred, that the internal use of mercury is unnecessary towards the cure. Very often indeed this complaint may be removed without having recourse to mercurials. Sometimes patients have been met with whose general health has been greatly impaired by a long continued use of mercury in such cases, while the original disease, the gonorrhoea, was rendered much worse by it. In some it has degenerated into a gleet, that was cured with extreme difficulty; in others it has brought on a variety of distressing symptoms. In cases of gonorrhoeas, therefore, whenever mercury is administered, it ought to be, not with a view to expedite the cure, but merely to obviate the dangers of syphilis. When the infection is apparently slight, and the inflammation and the symptoms trifling, we may proceed without the assistance of mercury, especially if the patient be of a weak, relaxed, and irritable habit, likely to be injured by mercurial medicines. On the other hand, when the discharge is violent, the inflammation considerable, or the seat of the disease high up in the urethra, it is perhaps the most prudent plan to give mercurials in small doses, and in such forms as seem the best adapted to the constitution of the patient.

The pilula hydrargyri, as prepared according to the receipts inserted in the last edition either of the London or Edinburgh Pharmacopoeias, in both of which the mercury is rendered active merely by triture, may perhaps be considered as one of the mildest and most efficacious forms under which mercury can be exhibited by the mouth. Its efficacy will depend on its not irritating the bowels, and thus passing off by stool; care must likewise be taken to prevent its affecting the mouth. Of the chemical preparations of mercury, the mildest and least irritating is calomel. It may be given from gr. iij. to gr. iii. at bed-time, occasionally interposing a mild purgative to prevent it from salivating; but in general the mercurial pill just mentioned is to be preferred.

When there is no chancre nor bubo, no appearance in short of syphilitic infection, it would be improper to administer corrosive sublimate, the mercurius calcinatus, or any other of the more acrid preparations of mercury.

After a gonorrhoea proceeding from venereal causes has been removed, another kind of running without pain, called the gonorrhoea mucosa, or gleet, sometimes remains. Sometimes it arises from a constriction and excoriation of the urethra, and frequently it is the effect of an enlargement and diseased state of the prostate. In each of these cases, as the gleet is the effect of irritation, the cure will depend on the removal of the local disease that occasions it. But there is another species of gleet that seems to depend chiefly on relaxation. It is in general free from infection, and

is most common in those who have had long and frequent gonorrhoeas. It is likewise often the effect of a debilitated habit, from severe purging, or a long continued use of mercurials. A discharge of this kind is more frequent in women than in men; or, at least, the fluor albus, after a gonorrhoea, will often be mistaken for a gleet.

When there is no reason to suspect remaining contagion, astringent injections will be of the greatest service. It will be necessary, at the same time, to attend to the health of the patient, by employing cinchona, chalybeate waters, cold bathing, and such other remedies as will tend to strengthen the system: and indeed by the use of these, particularly by the cinchona, such runnings are often successfully combated in those who from apprehension of dangerous consequences cannot be prevailed upon to employ injections. When there is no tendency to inflammation, the balsam of copaiva may be prescribed with advantage in large doses. Dr. Simmons says he once saw a complaint of this sort removed by applying a blister to the perineum, after it had resisted a variety of other remedies. In the Medical Observations also we have an account of a gleet and incontinence of urine removed at once by a blister to the os sacrum. In general, however, the other methods above mentioned will be sufficient to remove it, though sometimes it will continue for a long time in spite of all our endeavours to check it.—Other kinds of gonorrhoea, in which the semen itself is ejected, especially during sleep, may be cured by tonics and a mild cooling regimen.

Obstipatio, Lin. 166. Vog. 128. Sag. 221.

Costiveness is sometimes occasioned by debility in dyspeptic persons, sometimes it is the effect of rigidity, and sometimes it is symptomatic of the colic. It may proceed from an affection of the liver; drinking rough red wines, or other astringent liquors; too much exercise, especially on horseback: it may likewise proceed from a long use of cold insipid food, which does not sufficiently stimulate the intestines. Sometimes it is owing to the bile not descending to the intestines, as in the jaundice; and at other times it proceeds from diseases of the intestines themselves, as a palsy, spasms, tumors, &c.

Excessive costiveness is apt to occasion pains of the head, vomiting, colics, and other complaints of the bowels. It is peculiarly hurtful to hypochondriac and hysterical persons, as it generates wind and other distressing symptoms.

Persons who are generally costive should live upon a moistening and laxative diet; as roasted or boiled apples, pears, stewed prunes, raisins, gruels with currants, butter, honey, sugar, and such like. Broths with spinage, leeks, and other soft pot-herbs, are likewise proper. Rye-bread, or that which is made of a mixture of wheat and rye together, ought to be eaten. No person troubled with costiveness should eat white bread alone, especially that which is made of fine

Epithetes. flour. The best bread for keeping the belly soluble is what in some parts of England they call meffin. It is made of a mixture of wheat and rye, and is very agreeable to those who are accustomed to it.

Costiveness is increased by keeping the body too warm, and by every thing that promotes the perspiration; as wearing flannel, lying too long in bed, &c. Intense thought, and a sedentary life, are likewise hurtful. All the secretions and excretions are promoted by moderate exercise without doors, and by a gay, cheerful, sprightly temper of mind.

The drink should be of an opening quality. All ardent spirits, austere and astringent wines, as port, claret, &c. ought to be avoided. Malt liquor that is fine and of a moderate strength is very proper. Butter-milk, whey, and other watery liquors, are likewise proper, and may be drunk in turns, as the patient's inclination directs.

Those who are troubled with costiveness ought, if possible, to remedy it by diet, as the constant use of medicines for that purpose is attended with many inconveniences, and often with bad consequences. In time the custom becomes necessary, and generally ends in a total relaxation of the bowels, indigestion, loss of appetite, wasting of the strength, and death.

The learned Dr Arbuthnot advises those who are troubled with costiveness to use animal oils, as fresh-butter, cream, marrow, fat broths, &c. He likewise recommends the expressed oils of mild vegetables, as olives, almonds, pillaches, and the fruits themselves; all oily and mild fruits, as figs; decoctions of mealy vegetables; these lubricate the intestines; some saponaceous substances which stimulate gently, as honey, hydromel, or boiled honey and water, unrefined sugar, &c. are useful.

The doctor observes, that such lenitive substances are proper for persons of dry atrabilarian constitutions, who are subject to attrition of the belly and the piles, and will operate when stronger medicinal substances are sometimes ineffectual; but that such lenitive diet hurts those whose bowels are weak and lax. He likewise observes, that all watery substances are lenitive; and that even common water, whey, four milk, and butter-milk, have that effect:—That new milk, especially asses milk, stimulates still more when it sours on the stomach; and that whey, turned four, will purge strongly:—That most part of fruits are likewise laxative; and that some of them, as grapes, will throw such as take them immoderately, into a cholera morbus, or incurable diarrhoea.

When the body cannot be kept open without medicine, gentle doses of rhubarb may be taken twice or thrice a-week. This is not near so injurious to the stomach as aloes, jalap, or the other drastic purgatives so much in use. Infusions of fenna and manna may likewise be taken, or half an ounce of tartarified alkali dissolved in water gruel. About the size of a nutmeg of lenitive electuary taken twice or thrice a-day, generally answers the purpose very well.

GENUS CXXIII. ISCHURIA.

SUPPRESSION OF URINE.

Ischuria, Sauv. gen. 293. Lin. 167. Vor. 129. Sag. 212. Home's Clinical Experiments, lect. xv.

This disease is distinguished into various species, according as the seat of it is in the kidneys, the ureters, the bladder, or the urethra; and hence these species are named renalis, ureterica, vesicalis, and urethralis.

1. Ischuria renalis, or a suppression of urine from an affection of the kidneys, happens but rarely; however, Dr Home in his Clinical Experiments describes such a case. In the end of December 1774, a man of a full habit, aged 35, was seized with shivering, coldness, and severe cough. Three days after, his urine appeared high-coloured, was passed with pain, and in small quantity. About the 8th of January 1775, he was attacked with violent pains in the small of his back, over the whole abdomen, and in the ankles, with pain in the region of the liver when pressed. A general swelling was afterwards observed all over the body, but chiefly in the ankles and abdomen, which felt was tense and hard. These were attended with vomiting, bad appetite, and considerable thirst. When he entered the clinical ward (January 21st), the cough, sickness, and vomiting, had gone off, but the suppression of urine remained. The little which he made was passed with his stools, so that Dr Home saw it but once; and then it was pale, and had a white powder at bottom. The pains and swellings, which retained the impression of the finger, continued; he had a headache, and a very slow pulse, beating only 48 strokes in a minute. He had taken a great many diuretic medicines before his admission. The day after his reception, he was seized with a spontaneous diarrhoea, which continued during the remainder of his life. Crystals of tartar were exhibited in doses of half an ounce each morning; at bed-time he took 20 drops of tincture of opium with a scruple of nitre, and continued this course for eight days without any increase of urine. The stronger and heating diuretics were then tried, as an infusion of juniper berries and pills of garlic; but they were attended with no sensible advantage. Whenever the pulse became so strong that he could bear bleeding, eight ounces of blood were taken away, which was frizy. This was thrice repeated; he appeared easier after each bleeding, his pulse bore it well, and the swellings and other symptoms abated. The heating diuretics, in this state, were given up; and a mixture of vinegar and nitre was substituted in their place, in each dose of which, taken every two hours, there was a scruple of nitre. Emetications were applied to the region of the kidneys, and camphorated oil was afterwards rubbed on the part. He was ordered the semicupium, which from a deficiency of water in the hospital at that time he got only once; and which then seemed to have a good effect, as he passed a gill of urine when he was in it. Notwithstanding this, however, the disease continually gained ground; he became comatose, delirious, and died ten days after his admission. On dissection, the kidneys were found of an irregular form; some watery vesicles appeared on their surface, containing black gritty particles like fine sand; and the lower part of the right kidney was considerably inflamed. The pylorus, part of the duodenum, and a considerable part of the small intestines, were much inflamed. In the abdomen were found about five pounds of fluid, and in the cavities of the thorax about half a pound. The

Epithelites. The lungs were a little inflamed, and full of small tubercles on their surface and in their substance: the heart was large, and a polypus in each ventricle. About six ounces of fluid were found in the pericardium: in the brain nothing preternatural appeared, except about an ounce of water in each ventricle.

Dr Home seems to have been at a loss for the remote cause of this suppression of urine, which manifestly had its immediate origin from the kidneys having lost the power of performing their functions. He thinks the inflammation which appeared in the right kidney was scarce sufficient to have occasioned the distemper, as the other would have supplied its place: for which reason also he thinks that the ischuria was owing to a general affection of the system; and that it was of an arthritic nature, the patient having been troubled with complaints of that kind for a long time before.

2. The ischuria ureterica is also a rare disease, unless the obstruction proceeds from a stone or clot of blood stopping up the passage. Gravel or stones, indeed, are very frequently formed in the kidneys; and, by falling into the ureters, occasion an ischuria, with violent pain, and symptoms more or less urgent in proportion to the size and shape of the stones. Sometimes it is attended with coldness of the extremities, nausea, vomiting, and spastic constriction of the precordia, a difficulty of making water, constipation of the belly, difficulty of breathing, stupor of the thigh, retraction of the testicle, inquietude, loss of strength, syncope, and convulsion fits. When the violent pain has continued for several days and nights without intermission, and has brought the patient exceeding low, and the suppression of urine is complete, with coldness of the extremities and convulsions of the tendons, death is at hand. Nor is it a good sign when the stone continues long in the ureter; for then the appetite decays, a nausea and retching to vomit supervene, and the patient is consumed with a hectic heat. Sometimes the pain is attended with an inflammation of the stomach and intestines; and sometimes the disease ends in a dropsy of the breast, or lethargy, which soon carry off the patient.

The indications of cure are, to exclude the stone as easily as possible, and prevent the breeding of others. If the patient be of a sanguineous temperament, Sydenham recommends to take away ten ounces of blood from the affected side; and then to give the patient a gallon of posset-drink in which two ounces of marsh-mallow roots have been boiled, injecting at the same time an emollient glyster. After the posset drink has been vomited up, and the clyster returned, give a pretty large dose of an opiate. But if the patient be old or weak, or subject to nervous affections, bleeding may be omitted, especially if his urine at the beginning of the fit be coffee-coloured, and mixed with gravel; but as to other things, the cure is the same.—Huxham highly recommends an emollient bath prepared of a decoction of marsh-mallow root, lintseed, fenugreek seed, and flowers of chamomile, to which may be added a few white poppy seeds. By the use of this bath he says he has seen the most cruel fit of the gravel suddenly ended, when neither copious bleeding nor opiates had the least effect. Mild diuretics are also of service. Hoffman recommends dulcified spirit of

ni re as proper to relax the spastic fistula. It is to be taken with suitable distilled waters and syrup of poppies; or in broth, with a few spoonfuls of oil of sweet almonds. Turpentine glysters are also accounted very serviceable; and may be prepared with ten ounces of a decoction of chamomile, with half an ounce of turpentine dissolved in the yolk of an egg, and about as much honey. The sal diureticus, or aceti potassie, is much esteemed by some, when taken along with an opiate. But when the stone is too big to pass, Arbuthnot recommends a cool and diluent diet to hinder the further growth of it. Whey, infusion of lintseed, decoction of marshmallows, and gently resolving diuretics, are also proper. To put a stop to the vomiting, the compound tincture of benzoin, formerly named basanum traumaticum, has sometimes been used with success, when almost every other means have failed.

3. The ischuria vesicalis may arise from a stone in the bladder; and this indeed is the most common cause of it: but there are certain cases, in which, though the usual quantity of urine, or perhaps more, be passed, the patient dies from the retention of a still greater quantity in the bladder. Of this Dr Home gives the following instances. A man of 58 years of age, of a strong spare habit, and never subject to the gravel, had, during the winter of 1777, a cough with expectoration, which went off in the beginning of 1778. About the 17th of February 1778 he felt some difficulty in passing his urine, and much pain about the region of the bladder. He continued in this way for ten days, after which he became easier on application of some medicines. The abdomen then swelled, and he had pains in his loins and thighs. On the 3d of March he was admitted into the clinical ward: his abdomen was then swelled and tense; and an evident fluctuation was felt, which some that touched him thought was sonorous and produced by wind. A tumor was discovered between the navel and spine of the os ilium on the left side, which gave him much pain, especially when pressed. This tumor became more easily felt after the swelling of the abdomen decreased, seemed round, and very near as large as the head of a child. It appeared very much on the left side, even when the patient lay on the right, and it then became dependent. He passed urine frequently, and rather more than in health, as it was computed at four pints a-day. It was always clear, and of a light colour. His body had a strong disagreeable smell; his skin was dry, belly bound, and his appetite entirely gone, so that he had hardly taken any food for 12 days. His legs swelled slightly for some days in the evening. His pulse was generally regular, sometimes slower than natural, and sometimes a little quicker; being once felt at 64, and another time at 92. He was often seized, especially after eating or drinking, with hiccough; which increased and lasted till his death. On the 22th day of his disease, after some doses of squills, the general swelling of his abdomen fell, became much softer, and more distinctly discovered the swelling of the left side. The next day a vomiting came on; he became delirious, and died the day following. The body being opened, it appeared that the tumor which was so distinctly felt on the left side of the abdomen, was owing to a distension of the bladder with urine. Its fundus reached to about the division of the aorta into the

Epithelium the iliacs; it entirely filled the pelvis, and contained between five and six pounds of urine of a pale colour. On examining the external surface, its neck, and the beginning of the urethra, were found to be surrounded with a scirrhoty, which impeded the evacuation of the urine. The bladder itself was much thickened, but not more in one part than another. The ureters entered naturally; but were much thickened in their upper half near the kidney. The kidneys were somewhat enlarged; particularly the left, which had several watery vesicles on its external surface. These organs were not in their usual situation; but lay close on each side of the spine, and very near the aorta; so that the renal vessels were very short. What was very singular, the lower end of each arose over the spine, and they were united together by their membranes, the aorta passing beneath the union. The bladder had pressed considerably on this part; and the peritoneum covering them was considerably thicker than natural. The lungs adhered every where to the pleura, and in some places very firmly; they were of a loose texture and black colour; and the veins of the lower extremities were turgid with blood. It does not appear that this patient got any medicines farther than a few dried squills, which diminished the swellings and brought off much wind. He also got a mixture of musk, and afterwards of opium, for his hiccough; but without success. His disease was mistaken for an ascites; and the catheter was not tried: but in another case the use of this instrument was apparently of more service than any internal medicines. This last patient was about 90 years of age, and laboured under symptoms very similar to those already mentioned. When admitted into the clinical ward, he had the hypogastric region swelled, and difficulty of passing his water; but without pain, vomiting, or hiccough. He had lost all appetite; was thirsty, and colicky. His pulse was 110, and weak. In the evening about three English pints of pale clear urine were drawn off by means of the catheter: the next day all the symptoms were gone off or abated. After this he continued to pass some urine, sometimes voluntarily, sometimes involuntarily and insensibly; but so much always remained behind, that his bladder was constantly full, unless when the urine was drawn off, which was done twice every day. The urine was sometimes pale, sometimes of a deep red colour; and once there was some blood mixed with it, which perhaps might have been occasioned by the catheter. About the sixth day the urine was very putrid, with much purulent like matter at the bottom, and was passed with more pain. About the 11th, the putrid smell went off. The next day all the urine passed insensibly except what was drawn off; and an hiccough, though not very severe, had come on. In this way he continued without fever, though frequently troubled with the hiccough, especially during those nights in which the urine had not been drawn off. A month after admission, the bladder, with the assistance of the catheter, was almost entirely, though insensibly evacuated, and the hiccough had left him; he had no other complaint but that of voiding his urine insensibly, the natural effect of a scirrhotous bladder, and which was probably incurable. With this patient the hot bath and mercurials were tried, in order

to soften the scirrhoty of the bladder, but without Ischuria, effect.

4. The ischuria urethralis arises from some tumor obstructing the passage of the urethra, and thus hindering the flow of urine. It is no uncommon distemper, and often follows a gonorrhoea. Dr Home gives us an example of this also.—The patient was a man of 60 years of age, who had laboured under a gonorrhoea six months before, and which was stopped by some medicines in two or three days. He felt, soon afterwards, a difficulty in passing his urine, which gradually increased. About 10 days before his admission into the clinical ward, it was attended with pains in the glans, and ardor urinae; he had passed only about eight ounces the day before his admission, and that with very great difficulty; and the hypogastric region was swelled and pained. On introducing the catheter, three pounds of urine were drawn off, by which the pain and swelling were removed. The instrument required force to make it pass the neck of the bladder, and blood followed the operation; and the finger, introduced into the anus, felt a hard tumor about its neck. He was treated with mercurial pills and ointment, by which the swelling about the neck of the bladder soon began to decrease; but at the same time a swelling of the right testicle appeared. He was vomited with four grains of turbitil-mineral, the subsulphas hydrargyri flavus of the present pharmacopoeia, which operated gently; and here Dr Home observes, that though these vomits are little used, from a mistaken notion of their severity, he never saw them operate with more violence than other vomits, or than he could have wished. The swelling diminished in consequence of the emetic and some external applications; and the cure was completed by bleeding and a decoction of mezereon root.

Dysuria, Savv. gen. 265. Lin. 57. Vog. 164. Seg. 213.
Stranguria autorum.

A difficulty of making water may arise from many different causes; as from some acid matter in the blood, cantharides, for instance: and hence a strangury very often succeeds the application of blisters. In many cases it arises from a compression of some of the neighbouring parts; of the uterus, for instance, in a state of pregnancy. Or it may arise from a spasmodic affection of the bladder, or rather its sphincter; or from an inflammation of these parts, or others near them. Hence the disease is distinguished into so many species, the cure of which is to be attempted by remedies indicated by their different causes.

But the most common, as well as the most dangerous species is that arising from a calculous concretion, or

Dysuria calculosa, Savv. sp. 12.

The signs of a stone in the bladder are, pain, especially about the sphincter; and bloody urine, in consequence

Epistheses.—consequence of riding or being jolted in a carriage; a sense of weight in the perineum; an itchingness of the glans penis; slimy sediment in the urine; and frequent stoppages in making water; a tenesmus also comes on while the urine is discharged: but the most certain sign is, when the stone is felt by the finger introduced into the anus, or by sounding.

Causes, &c. It is not easy to say what the particular causes are which occasion the apparently earthy particles of the fluids to run together, and form those calculous concretions which are found in different parts of the body, and especially in the organs for secreting and discharging the urine.

The gout and stone are generally supposed to have some affinity, because gouty people are for the most part afflicted with the gravel. But perhaps this is in part owing to their long confinement, and to lying on the back, which people who labour under the gout are often obliged to submit to; since the want of exercise, and this posture, will naturally favour the stagnation of gross matters in the kidneys: besides, there are many instances of people severely afflicted with the stone for the greatest part of a long life, who have never had the least attack of the gout.

There is, however, good reason for believing, that some farther connection takes place between the two diseases; and when treating of the gout we have already given some account of the opinion of an ingenious anonymous author, who has endeavoured to prove, that both the one and the other depend on a peculiar acid, the concretizing, lithic, or uric acid, which is always present in blood; and which may be precipitated from thence by various causes, such as the introduction of other acids, or the like. When thus precipitated, he supposes it to produce the whole phenomena of both diseases. The objections we formerly stated to his theory of gout, do not equally militate against that of calculus; and it is at least certain, from the best chemical analysis, that what are commonly called urinary calculi, and have been considered as entirely an earthy matter, consist principally of acid in a solid state united only with a small proportion of earth or mucus. We may, therefore, whether this hypothesis be altogether well founded or not, justly view lithiasis as depending, in a great measure, on the separation of an acid from the blood.

Whatever may be the particular cause of the disposition to lithiasis, the kidneys appear to be the most likely places for particles to concretize or run together, because of the great quantity of blood which passes through the renal arteries, and which comes immediately from the heart, fraught with various newly-received matters, that have not undergone much of the action of the vessels, and therefore cannot as yet be supposed to be thoroughly assimilated.

Anatomists who have carefully examined the kidneys in the human subject, particularly M. Bertin, inform us, that there are two sets of tubuli uriniferi; the one continued directly from the extremities of the renal artery, and the other springing from that vesicular texture which is conspicuous in the kidneys.

It is in this vesicular part of the kidney that we presume the particles of the concretizing matter first stagnate and coalesce; for it is hardly to be supposed,

that such solid matters could be allowed to stop in the extremities of the renal arteries, since the blood, and the urine separated from it, must flow through these vessels with great degrees of force and velocity; but in the intermediate vesicles the particles may lie, and there attracting each other, soon come to acquire sensible degrees of magnitude, and thus become sand or gravel. As long as this sand or gravel formed in the vesicular part of the kidney lies quiet, there will be no pain or uneasiness, until the concretions become large enough to press either on the adjoining tubuli, or on the blood-vessels; then a sense of weight, and a kind of obtuse pain in the loins, will be felt. But when the small pieces of concretizing matter shall be dislodged and washed off by the force of the circulating fluids, or loosened by some spasmodic action of the moving fibres in these parts, they will in their passage create pain, raise different degrees of inflammation, or perhaps lacerate some blood-vessels, and cause bloody urine. When these little concretions happen to be detained in the pelvis of the kidney, or any other place where a flow of urine continually passes, they soon increase in size, and become calculi, from the constant accession of particles, which are attracted by the original bit of sand, which thus becomes the nucleus of a stone.

It is an opinion which Hippocrates first advanced, and which has been almost universally adopted by his followers, and has remained till lately uncontroverted, that the stone and gravel are generated by the use of hard water. From the quality, which the waters of certain springs possess, of depositing a large earthy sediment, either in the aqueducts through which they are conveyed, or in the vessels in which they are boiled or preserved, it was conjectured, that in passing through the kidneys, and especially whilst retained in the bladder, they would let fall their grosser particles, which by the continued apposition of fresh matter, connected by the animal gluten, and compacted by the muscular action of that organ, would in time form a calculus sufficiently large to produce a train of the most excruciating symptoms. And this reasoning a priori has been supposed to be confirmed by facts and experience; for not to mention the authority of Hippocrates, Dr Lister has observed, that the inhabitants of Paris are peculiarly subject to the stone in the bladder. Nicholas de Blegny has related the history of one who was dissected at Paris, in whom the pylorus, a great part of the duodenum, and the stomach itself, were found incrusted with a stony matter, to the thickness of a finger's breadth. And it is well known, that the water of the river Seine, with which that city is supplied, is so impregnated with calcareous matter, as to incrustate, and is a short time to choke up, the pipes through which it runs. But on the other hand it is objected, that the human calculus is of animal origin, and by chemical analysis appears to bear very little analogy to the stony concretions of water: and though it be allowed, that more persons are cut for the stone in the hospitals at Paris than in most other places; yet upon inquiry it is found, that many of those patients come from different provinces, and from towns and villages far distant from the Seine.

Dr Percival conjectures, that though this disease may chiefly depend upon a peculiar disposition to concretize in

Epithelium in the animal fluids, which in many instances is hereditary, and in no instance can with certainty be imputed to any particular cause; yet hard water is at least negatively favourable to this diathesis, by having no tendency to diminish it. The urine of the most healthy person is generally loaded with an apparently terreneous matter, capable in favourable circumstances of forming a calculus; as is evident from the thick crust which it deposits on the sides of the vessels in which it is contained. And it seems as if nature intended by this excretion to discharge all the superfluous salts of the blood, together with those earthy particles, which are either derived from our aliment, and fine enough to pass through the lacteals, though insuperable by the powers of circulation, or which arise from the abrasion of the solids, or from the dissolution of the red globular part of our fluids. Now water, whether used as nature presents us with it, or mixed with wine, or taken under the form of beer or ale, is the great diluter, vehicle, and menstruum, both of our food, and of the saline, earthy, and excrementitious parts of the animal juices. And it is more or less adapted to the performance of these offices, in proportion to its degree of purity. For it must appear evident to the most ordinary understanding, that a menstruum already loaded, and perhaps saturated with different contents, cannot act so powerfully as one which is free from all sensible impregnation. Nor is this reasoning founded upon theory alone; for it is observed, that Malvern water, which issues from a spring in Worcestershire remarkable for its uncommon purity, has the property of dissolving the little fabulous stones which are often voided in nephritic complaints. And the solution too, which is a proof of its being complete, is perfectly colourless. Hence this water is drunk with great advantage in disorders of the urinary passages. And during the use of it, the patient's urine is generally limpid, and seldom deposits any sandy sediment. Yet notwithstanding this appearance of transparency, it is certainly at such times loaded with impurities, which are so diluted and dissolved as not to be visible. For it is attended with a strong and fetid smell, exactly resembling that of asparagus. Hoffman mentions a pure, light, simple water in the principality of Henneberg, in Germany, which is remarkable for its efficacy in the stone and gravel; and a water of similar virtues was discovered not many years ago in the Black forest, near Osterod, which upon examination did not afford a single grain of mineral matter. Indeed it is worthy of observation, that most of the springs which were formerly held in great esteem, and were called holy wells, are very pure, and yield little or no sediment.

Dr Percival informs us that a gentleman of Manchester, who had been long subject to nephritic complaints, and often voided small stones, was advised to refrain from his own pump-water, which is uncommonly hard, and to drink constantly the soft water of a neighbouring spring; and that this change alone, without the use of any medicine, has rendered the returns of his disorder much less frequent and painful. A lady also, much affected with the gravel, was induced by the perusal of the first edition of Dr Percival's Essay, to try the effect of soft water; and by the constant use of it remained two years entirely free from her disorder.

In nephritic cases, distilled water would be an excellent substitute for Malvern water, as the following experiment evinces.

Two fragments of the same calculus, nearly of equal weight, were immersed, the one in three ounces of distilled water, the other in three ounces of hard pump-water. The phials were hung up close together in a kitchen-chimney, at a convenient distance from the fire. After 14 days maceration, the calculi were taken out, and carefully dried by a very gentle heat. The former, viz. that which had been immersed in distilled water, was diminished in its weight a grain and a half; the latter had lost only half a grain.

It is the passage of these calculi from the kidneys down into the bladder, which occasions the pain, vomiting, and other symptoms, that constitute what is usually termed a fit of the gravel or stone.

When an inflammation is actually raised, the disease is known by the name of nephritis, and has been already treated of.

As soon as the stone passes through the ureter, and falls into the bladder, the pain and other nephritic symptoms cease; and every thing will remain quiet, either till the stone be carried into the urethra, or until it has remained long enough in the bladder to acquire weight sufficient to create new distress.

If a stone happen to be smooth and of a roundish form, it may lie in the bladder and acquire considerable bulk before it can be perceived by the patient; but when it is angular, or has a rugged surface, even though it may be small in size, yet it seldom fails to raise pain, and occasion bloody urine, or the discharge of a slimy fluid, with tenesmus, and difficulty in making water.

There have been various attempts made to dissolve the stone; and there are certainly some articles which have this effect when applied to them out of the body; but the almost total impossibility of getting these conveyed to the kidneys, renders it extremely doubtful whether a solvent ever will be discovered. Of all the articles employed for this purpose, no one perhaps has had greater reputation than fixed alkaline salt in its caustic state, particularly under the form of the lixivium causticum, or aqua potassa, as it is now called: but this being of a very acrid nature, it requires to be well sheathed by means of some gelatinous or mucilaginous vehicle. Veal-broth is as convenient as any for this purpose; and accordingly it is used by those who make a secret of the caustic alkali as a solvent of calculus.

Mr Blackrie, who has taken much pains in this inquiry, has proved very satisfactorily, that Chittick's nostrum is no other than soap-lees given in veal-broth, which the patients send every day to the doctor, who returns it mixed up with the medicine, in a close vessel secured by a lock.

It is not every case, however, that either requires or will bear a course of the caustic alkali. Some calculi are of that soft and friable nature, that they will dissolve even in common water; and there are cases wherein it appears that the constant use of some very simple decoction or infusion of an insignificant vegetable, has brought away large quantities of earthy matter, in flakes which apparently have been united together in layers to form a stone. Dr Macbride assures

Epistheses. fures us, that a decoction of raw coffee, only 30 berries in a quart of water, boiled till it acquired a deep greenish colour, taken morning and evening to the quantity of eight or ten ounces, with ten drops of sweet spirit of nitre, had the powerful effect of bringing away, in the course of about two months, as much earthy matter in flakes as filled a large tea cup. The patient was far advanced in years; and, before he began this decoction, had been reduced to great extremities by the continuance of pain and other distressing symptoms: he was purged occasionally with oleum ricini.

Very lately the alkali in a mild state, and in a different form, has been much used by many calculous patients, and with great advantage, under the form of what is called alkaline aerated water, the aqua supercarbonatis potassæ of the present edition of the Edinburgh Pharmacopoeia. For the introduction of this medicine, or at least for its extensive use, we are chiefly indebted to that ingenious physician Dr William Falconer of Bath. He has lately published an account of the Aqua Mephitica Alkalina, or solution of fixed alkaline salt, saturated with fixable air, in calculous disorders; which contains a number of cases strongly supporting the benefit to be derived from it. But whether the good effects obtained in these instances are to be explained from its operating as a solvent of calculus, seems to be extremely doubtful. There are indeed cases in Dr Falconer's treatise, of patients in whom, after using it for a considerable time, no stone could be detected by sounding, although it had been discovered in that way before they began the employment of it. But in many instances, the relief has been so sudden, that it may be concluded, that, notwithstanding the case obtained, the calculus still remained. In such cases, it probably removed from the urine that quality by which it gives to the calculus fresh accretions, producing that roughness of its surface by which it is chiefly capable of acting as a stimulus. For the distressing symptoms resulting from stone are chiefly to be attributed to the inflammatory and spasmodic affections which it induces; and when its surface is least capable of operating as a stimulus, these of course will be least considerable. It is therefore not improbable, that this remedy produces relief, by preventing fresh additions being made to the calculus.

An infusion of the feeds of daucus sylvestris sweetened with honey, is another simple and much celebrated remedy; it has been found to give considerable ease in cases where the stomach could not bear any thing of an acrid nature. The leaves of the ura ursi were strongly recommended by the late celebrated Dr Haen; and this, whatever its way of operating may be, seems to have been productive of good effects in some instances. There is no reason to believe that it has any influence in dissolving calculus; and indeed it seems to be chiefly useful in these instances where ulcerations take place in the urinary passages.

In the Edinburgh Medical Commentaries, vol. iii., we have an account of a method used by the inhabitants of Arabia Petraea for curing the stone, to which they are very much subject, and which the author (an English gentleman of experience and candour) affirms he has seen frequently performed with success. By means of a catheter, they inject into the bladder a weak

ley of alkali with the purified fat of a sheep's tail, and a proper quantity of opium, all put together. Their catheters are made of gold; and in performing the operation they introduce them quite into the bladder; so that the composition is safely conveyed to the stone without hurting any other part. But when a stone is situated in the kidney, they have no method of cure.

If this method of curing by injection could be safely practised, it would no doubt have the advantage over that of taking alkalies by the mouth, where the medicine is not only much weakened, but the constitution of the patient runs the risk of being greatly injured. But from some experiments mentioned in the second volume of the Medical Transactions, and still more from the chemical analysis of urinary concretions, lately published by Fourcroy and other modern chemists, it appears that the human calculi are very different from one another in their natures. Some, for instance, will easily yield to an alkaline menstruum, and very little to an acid; while others are found to resist the alkali, and yield to the acid; and some are of such a compact nature, that they yield neither to acids nor alkalies. An attention, however, to the fragments, scales, or films, which the stone may cast off, and also to the contents and sediment of the urine, may lead to the discovery of what solvent is proper, or whether the stone can be dissolved by any. To use either alkalies or acids improperly may be hurtful; though there may be such kinds of calculi as demand the alternate use of acids and alkalies; nay, there may be found calculi of opposite kinds in the same subject.

In such cases as will not allow us to think of dissolving the stony concretions, and where the only object is to palliate and procure ease from time to time, little more can be done than to keep the bowels open occasionally by some gentle cathartic, and wash off as much of the loose gravelly matter and slime as can be removed by such mild diuretic infusions and decoctions as shall be found to pass freely and fit well on the stomach. Persons afflicted with the stone should be careful in respect of their diet, and studiously avoid all heavy and flatulent food, as well as high sauces that are apt to turn rancid. For the same reason, butter and acids are to be shunned; for these often create heart-burning, and every thing that offends the stomach raises the nephritic pain; such is the sympathy that obtains between the digestive and the uropoietic organs.

There have been surgeons bold enough to entertain an idea of cutting even into the kidney, in order to extract a stone: this, however, except in cases where an abscess has been formed, and nature points out the way, is both very uncertain and very hazardous. But cutting into the bladder for the same purpose, is an ancient and well-known operation, and often crowned with success. A description, however, of this operation belongs to the article SURGERY, to which we refer; and here shall only make this remark, that a surgeon should never begin his operation, until he and his assistants are perfectly satisfied, from actually feeling the stone, that there is one in the bladder; because it has sometimes happened, that when the incision has been made, no stone could be found: and the patient having died in consequence of the operation, and the

Epistheses. body being opened, it has appeared that the symptoms which occasioned the belief of a stone in the bladder arose from some other cause.

WHEN a dysuria proceeds from any acrimonious matter thrown into the blood, it may be readily cured by bleeding, emollient clysters, cooling and diluting drinks with gum arabic or gum tragacanth, linseed tea, or the warm bath. When it arises from inflammations of the bladder or parts adjoining to it, we are to regard it only as a symptomatic affection; and the remedies used to remove the primary disease will also remove the dysuria. Sometimes it may arise from an ulcer of the bladder; in which case it is generally incurable; a mild nutritious diet will, however, protract the patient's life; and even render that life tolerable, by alleviating symptoms.

Dyspermatismus, Savo. gen. 260.
Sterilitas, Lin. 171. Sag. 211.
Agenesia, Vog. 283.

This impediment proceeds generally from obstructions in the urethra, either by tumors in itself, or in the cavernous bodies of the penis; in which case the treatment is the same as in the ischuria urethralis; sometimes it is owing to a kind of epileptic fit which seizes the man in the venereal act; and sometimes the semen, when ejected from the proper receptacles, is again absorbed, or flows into the bladder, and is expelled along with the urine. The last case it is very difficult, or even impossible, to cure; as proceeding from scirrh, or other indissoluble tumors of the verumontanum, or the neighbouring parts. It is also, in general, incurable. In some it proceeds merely from too violent an erection; in which case emollient and relaxing medicines will be of service; and we have an example of a cure performed by means of these in the first volume of the Edinburgh Medical Essays.

Amenorrhœa, Vog. 130.
Dysmenorrhœa, Lin. 168. Sag. 218.

This obstruction, with many other symptoms, as dyspepsia, yellowish or greenish colour of the skin, unusual appetites, &c. constitutes the chlorosis already treated of, a disease which seldom or never appears without a suppression of the menses. In Dr Hume's Clinical Experiments we find the virtues of several emmenagogues set forth in the following manner. Chalybeates seldom or never succeeded: they were always found more useful in diminishing the evacuation when

too violent, than in restoring it when deficient. The tincture of black hellebore proved successful only in one of nine or ten cases, though given to the length of four tea-spoonfuls a-day, which is double the quantity recommended by Dr Mead. Compression of the crural artery, recommended by Dr Hamilton in the Physical and Literary Essays, vol. ii. proved successful only in one of six cases. From the effects produced by this compression, it has the strongest appearance of loading the uterus with blood; from the sensations of the patient it produces the same effects as the approach of the menses, and has every appearance in its favour; yet does not succeed. Dr Hume supposes that the uterus is most frequently in too plethoric and inflammatory state; in which case, this remedy will do more hurt than in a state of inanition; however, he owns, that in the case in which it did succeed, the patient was plethoric and inflammatory. Venesection is recommended as an excellent remedy; the doctor gives three instances of its success, and says he could give many more. It acts by removing the plethoric state of the uterus, relaxing the fibres, and giving the vessels full play; so that their action overcomes all resistance, and the evacuation takes place. It is of no great moment from whence the blood is taken: the saphœnic vein has been supposed to empty the uterus most; but it is difficult to get the proper quantity from it, and the quantity of the discharge cannot be so well measured. The powder of sylvine is a most powerful remedy; and proved successful in three cases out of four in which it was tried. It was given to the quantity of half a dram twice a-day. It is a strong topical stimulus, and seems improper in plethoric habits. Madder-root, according to Dr Hume, is a very powerful medicine in this disease; and proved successful in 14 out of 19 cases in which it was tried, being sometimes exhibited in the quantity of two scruples, or a dram, four times a-day. It has scarcely any sensible effects; never quickens the pulse, or excites inflammatory symptoms: on the contrary, the heat, thirst, and other complaints abate; and sometimes these symptoms are removed, though the disease be not cured; but when it succeeds, the menses appear from the third to the 12th day.

We have now considered all those diseases enumerated in Dr Cullen's Nosology, the cure of which is to be attempted chiefly by internal medicines. The other genera either require particular manual operations, or a very considerable use of external applications; and therefore more properly fall under the article SURGERY. To this, therefore, we shall refer the genera which fall under the three last orders of the class of locales, viz. the tumores, ectopie, and dialyses; and we shall add, by way of Appendix, a few observations on some important affections to which Dr Cullen has not given a place in his system, or which practitioners in general are not agreed in referring to any one particular genus which he has mentioned.

DR HEBERDEN was the first who described this disease, though it is an extremely dangerous, and, by his account, not very rare affection. It seizes those who are subject to it when they are walking, and particularly when they walk soon after eating, with a most disagreeable and painful sensation in the breast, which seems to threaten immediate destruction: but the moment they stand still, all the uneasiness vanishes. In all other respects the patients at the beginning of this disorder are well, and have no shortness of breath; from which the angina pectoris is totally different. After it has continued some months, the fits will not cease instantaneously on standing still; and it will come on not only when the patients are walking, but when they are lying down, and oblige them to rise up out of bed every night for many months together. In one or two very inveterate cases, it has been brought on by the motion of a horse or carriage, and even by swallowing, coughing, going to stool, speaking, or by any disturbance of mind. The persons affected were all men, almost all of whom were above 50 years of age, and most of them with a short neck and inclining to be fat. Something like it, however, was observed in one woman, who was paralytic; and one or two young men complained of it in a slight degree. Other practitioners have observed it in very young persons.

When a fit of this sort comes on by walking, its duration is very short, as it goes off almost immediately upon stopping. If it comes on in the night, it will last an hour or two. Dr Heberden met with one in whom it once continued for several days; during all which time the patient seemed to be in imminent danger of death. Most of those attacked with the distemper died suddenly: though this rule was not without exceptions; and Dr Heberden observed one who sunk under a lingering illness of a different nature.

The osterni is usually pointed to as the seat of this malady. It seems as if it was under the lower part of that bone, and at other times under the middle or upper part, but always inclining more to the left side; and in many cases there is joined with it a pain about the middle of the left arm, which appears to be seated in the biceps muscle.

The appearance of Dr Heberden's paper in the Medical Transactions very soon raised the attention of the faculty, and produced other observations from physicians of eminence; particularly Dr Fothergill, Dr Wall of Worcester, Dr Haygarth of Chester, and Dr Percival of Manchester. It also induced an unknown sufferer under the disease to write Dr Heberden a very sensible letter, describing his feelings in the most natural manner; which, unfortunately, in three weeks after the date of this anonymous epistle, terminated in a sudden death, as the writer himself had apprehended.

The youngest subject that Dr Fothergill ever saw afflicted with this disorder was about 30 years of age;

and this person was cured. The method that succeeded with him was a course of pills, composed of the mass of gum pill, soap, and native cinnabar; with a light chalybeate bitter: this was continued for some months, after which he went to Bath several successive seasons, and acquired his usual health: he was ordered to be very sparing in his diet; to keep the bowels open; and to use moderate exercise on horseback, but not to take long or fatiguing walks.

The only symptom in this patient that is mentioned, was a stricture about the chest, which came on if he was walking up hill or a little faster than ordinary, or if he was riding at a very brisk trot; for moderate exercise of any kind did not affect him: and this uneasy sensation always obliged him to stop, as he felt himself threatened with immediate death if he had been obliged to go forward.

It is the sharp constrictive pain across the chest, which (according to Dr Fothergill's observation) particularly marks this singular disease; and which is apt to supervene upon a certain degree of muscular motion, or whatever agitates the nervous system.

In such cases as fell under the inspection of Dr Fothergill, he very seldom met with one that was not attended with an irregular and intermitting pulse; not only during the exacerbations, but often when the patient was free from pain and at rest: but Dr Heberden observes, that the pulse is, at least sometimes, not disturbed; and mentions his having once had an opportunity of being convinced of this circumstance, by feeling the pulse during the paroxysm.

But no doubt these varieties, as well as many other little circumstances, will occur in this disease, as they do in every other, on account of the diversity of the human frame; and if those which in general are found to predominate and give the distinguishing character be present, they will always authorise us in giving the name to the disease: thus, when we find the constrictive pain across the chest, accompanied with a sense of strangling or suffocation; and still more, if this pain should strike across the breast into one or both arms; we should not hesitate to pronounce the case an angina pectoris.

As to the nature of this disease, it appears to be purely spasmodic: and this opinion will readily present itself to any one who considers the sudden manner of its coming on and going off; the long intervals of perfect ease; the relief afforded by wine, and spirituous cordials; the influence which passionate affections of the mind have over it; the ease which comes from varying the posture of the head and shoulders, or from remaining quite motionless; the number of years for which it will continue, without otherwise disordering health; its bearing so well the motion of a horse or carriage, which circumstance often distinguishes spasmodic pains from those which arise from ulcers; and, lastly, its coming on for the most part after a full meal, and in certain patients at night, just after the first sleep, at which time the insub, convulsive asthma, and other diseases, justly attributed to the disordered functions

tions of the nerves, are peculiarly apt to return or to be aggravated.

From all these circumstances taken together, there can be little doubt that this affection is of a spasmodic nature: but though it should be admitted, that the whole distress in these cases arise from spasm, it may not be so easy to ascertain the particular muscles which are thus affected.

The violent sense of strangling or choking, which shows the circulation through the lungs to be interrupted during the height of the paroxysm; and the peculiar constrictive pain under the sternum, always inclining (according to Dr Heberden's observation) to the left side; together with that most distressing and alarming sensation, which, if it were to increase or continue, threatens an immediate extinction of life; might authorize us to conclude that the heart itself is the muscle affected: the only objection to this idea is, that the pulse is not always interrupted during the paroxysm. The appearances in two of the dissections, favour the opinion that the spasm affects the heart; as in one subject the left ventricle was found as empty of blood as if it had been washed; and in another, the substance of the heart appeared whitish, not unlike a ligament; as it should seem, in both cases, from the force of the spasm squeezing the blood out from the vessels and cavities.

If this hypothesis be allowed, we must conclude that the spasm can only take place in an inferior degree, as long as the patient continues to survive the paroxysm; since an affection of this sort, and in this part, of any considerable duration or violence, must inevitably prove fatal: and accordingly, as far as could be traced, the persons who have been known to labour under this disease have in general died suddenly.

The dissections also show, that whatever may be the true seat of the spasm, it is not necessary for the bringing of it on, that the heart, or its immediate appendages, should be in a morbid state; for in three out of the six that have as yet been made public, these parts were found in a sound state.

On opening the body of the poor gentleman who wrote the letter to Dr Heberden, "upon the most careful examination, no manifest cause of his death could be discovered; the heart, in particular, with its vessels and valves, were all found in a natural condition."

In the case communicated by Dr Percival to the publishers of the Edinburgh Medical Commentaries, "the heart and aorta descendens were found in a sound state." And in Dr Haygarth's patient, "on opening the thorax, the lungs, pericardium, and heart, appeared perfectly sound." Not to mention Dr Fothergill's patient (R. M.), in whose body the only morbid appearance about the heart was a small white spot near the apex. Thus the cause, whatever its nature might have been, was at too great a distance, or of too subtle a nature, to come under the inspection of the anatomist. But there was a circumstance in two of the subjects that is worthy of remembrance; and which shows that the crisis of the blood, while they were living, must have been greatly injured, namely, its not coagulating, but remaining of a cream-like consistency, without any separation into serum and crassamentum.

From all that we have seen hitherto published, it does not appear that any considerable advances have been made towards the actual cure of this anomalous spasm.

The very judicious and attentive Dr Heberden (to whom the public are highly indebted for first making the disorder known) confesses, that bleedings, vomits, and other evacuations, have not appeared to do any good: wine and cordials taken at bed-time, will sometimes prevent or weaken the fits; but nothing does this so effectually as opiates: in short, the medicines usually called nervous or cordial, such as relieve and quiet convulsive motions, and invigorate the languishing principle of life, are what he recommends.

Dr Wall mentions one patient, out of the 12 or 13 that he had seen, who applied to him early in the disease, and was relieved considerably by the use of anti-monial medicines joined with the fetid gums: he was still living at the time the doctor wrote his paper, (November 1772), and going about with tolerable ease. Two were carried off by other disorders; all the rest died suddenly.

Dr Fothergill's directions are chiefly calculated with the view to prevent the disorder from gaining ground, and to alleviate present distress. Accordingly he enjoins such a kind of diet as may be most likely to prevent irritability: in particular, not to eat voraciously: to be very abstemious in respect to every thing heating; spices, spirits, wines, and all fermented liquors: to guard most scrupulously against passion, or any vehement emotions; and to make use of all the usual means of establishing and preserving general health: to mitigate excesses of irritability by anodynes; or pains, if they quicken the circulation: to disperse flatulencies when they distend the stomach, by moderate doses of carminatives; amongst which, perhaps, simple peppermint water may be reckoned one of the safest. But since obesity is justly considered as a principal predisposing cause, he insists strongly on the necessity of preventing an increase of fat, by a vegetable diet, and using every other practicable method of augmenting the thinner secretions.

These were the only means recommended by the practitioners mentioned above for opposing this formidable disease: but Dr Smyth of Ireland has, we are told, discovered that it may be certainly cured by issues, of which Dr Macbride gives the following instance.

"A. B. a tall well-made man; rather large than otherwise; of healthy parents, except that there had been a little gout in the family; temperate; being very attentive to the business of his trade (that of a watchmaker), led a life uncommonly sedentary; had, from his boyhood upwards, been remarkably subject to alarming inflammations of his throat, which seized him, at least, once in the course of the year; in all other respects well.

"In 1767, (then 48 years of age), he was taken, without any evident cause, with a sudden and very dispiriting throbbing under the sternum. It soon afterwards increased, and returned upon him every third or fourth week, accompanied with great anxiety, very laborious breathing, choking, a sensation of fulness and distension in the head, a bloated and flushed countenance, turgid and watery eyes, and a very irregular and unequal pulse. The paroxysm in-

vaded, almost constantly, while he was sitting after dinner; now and then he was seized with it in the morning, when walking a little faster than usual: and was then obliged to stop, and rest on any object at hand. Once or twice it came on in bed; but did not oblige him to sit up, as it was then attended with no great difficulty in breathing. In the afternoon fits, his greatest ease was from a supine posture; in which he used to continue motionless for some hours, until, quite spent and worn out with anguish, he dropt into a slumber. In the intervals between these attacks, which at length grew so frequent as to return every fourth or fifth day, he was, to appearance, in perfect health.

"Thus matters continued for more than two years; and various antispasmodics were ineffectually tried for his relief. In 1769, there supervened a very sharp constrictory pain at the upper part of the sternum, stretching equally on each side, attended with the former symptoms of anxiety, dyspnoea, choking, &c. and with an excruciating cramp, as he called it, that could be covered with a crown-piece, in each of his arms, between the elbow and the wrist, exactly at the insertion of the pronator teres; the rest of the limb was quite free. The fits were sometimes brought on, and always exasperated, by any agitation of mind or body. He once attempted to ride on horseback during the paroxysm; but the experiment was near proving fatal to him. The difference of season or weather made no impression upon him. Still, in the intervals, his health was perfectly good; except that his eyes, which before his illness were remarkably strong and clear, were now grown extremely tender: and that his sight was much impaired. He had no flatulency of stomach, and his bowels were regular.

"In this situation, February 22. 1770, he applied to me for assistance. I had seen, I believe, eight or ten of these frightful cases before. Two of the patients dropt dead suddenly. They were men between 40 and 50 years of age, and of a make somewhat fleshy. The fate of the others I was not informed of; or, at least cannot now recollect.

"Having found the total inefficacy of blisters and the whole class of nervous medicines in the treatment of this anomalous spasm, I thought it right to attempt the correcting or draining off of the irritating fluid in the case now before us. To this purpose, I ordered a mixture of lime-water with a little of the compound juniper-water, and an alternative proportion of Huxham's antimonial wine: I put the patient on a plain, light, perspirable diet; and restrained him from all viscid, flatulent, and acrimonious articles. By pursuing this course, he was soon apparently mended; but after he had persisted regularly in it for at least two months, he kept for some time at a stand. I then ordered a large issue to be opened on each of his thighs. Only one was made. However, as soon as it began to discharge, his amendment manifestly increased. The frequency and severity of the fits abated considerably: and he continued improving gradually, until, at the end of 18 months he was restored to perfect health: which he has enjoyed, without the least interruption, till now, except when he has been tempted (perhaps once in a twelvemonth) to transgress rules, by making a large meal on salted meat, or indulging himself in

ale or rum-punch, each of which never failed to disorder him from the beginning of his illness: and even on these occasions, he has felt no more than the slightest motion of his former sufferings; inasmuch as he would despise the attack, if it did not appear to be of the same stock with his old complaint. No other cause has had the least ill effect on him.

"Though rum was constantly hurtful, yet punch made with a maceration of black currants in our vulgar corn-spirit, is a liquor that agrees remarkably well with him.

"He never took any medicine after the issue began to discharge; and I have directed that it shall be kept open as long as he lives. The inflammations of his throat have disappeared for five years past; he has recovered the strength and clearness of his sight; and his health seems now to be entirely re-established."

Dr Macbride, in a letter to Dr Duncan, published in the Edinburgh Medical Commentaries, gives the following additional observations on this disease.

"Within these few weeks I have, at the desire of Dr Smyth, visited, three or four times, a very ingenious man who keeps an academy in this city, of about 34 years of age, who applied to the doctor for his advice in January last.

"I shall give you his symptoms as I had them from his own mouth, which appear to me to mark his case to be an angina pectoris, and as deplorable as any that I have read of. It was strongly distinguished by the exquisite constrictory pain of the sternum, extending to each of his arms as far as the insertion of the deltoid muscle, extreme anxiety, laborious breathing, strangling, and violent palpitation of the heart, with a most irregular pulse. The paroxysms were so frequent, that he scarcely ever escaped a day, for six or seven years, without one. They were usually excited by any agitation of mind or body, though slight. He had clear intervals of health between the fits. The distemper seems hereditary in him, as he says his father was affected in the same manner some years previous to his death. He has a strong gouty taint, which never showed itself in his limbs; and he has led a life of uncommon sedentariness, from intense application to mathematical studies, attention of mind, and passion, even from his boyish years. These circumstances may, perhaps, account for his having been taken with this disease at so early an age as 17.

"A large issue was immediately opened in each of his thighs. In a month afterwards he began to mend, and has gone on improving gradually. He can now run up stairs briskly, as I saw him do no later than yesterday, without hurt; can bear agitation of mind; and has no complaint, excepting a slight oppression of the breast, under the sternum, which he feels sometimes in a morning, immediately after dressing himself, and which he thinks is brought on by the motion used in putting on his clothes; though for a complete week preceding the day on which I saw him last, he told me that he had been entirely free from all uneasiness, and was exulting that he had not had such an interval of ease for these last seven years.

"Doctor Smyth also showed me, in his adversaria, the case of a gentleman who had been under his care in 1760, which he had forgotten when my book went

went to the press, and which he was reminded of the other day by a visit from his patient. It was a genuine angina pectoris, brought on by a very sedentary life, and great vexation of mind, clearly marked by the exquisite pain under the sternum, that extended acutely to the upper extremities, particularly along the left arm, together with the other symptoms of dyspnoea, anxiety, palpitation of the heart, &c. recited in the case above. The disorder went off in 1762, by large spontaneous discharges from the piles, but returned upon him severely in 1765. Issues in his thighs were then recommended to him, but not made. But, whether it was by the persuasion of some friend, or of his own accord, he went into a course of James's powder, in small alternative doses, combined with a little castor and asafoetida. This he persisted in for about six weeks; in the meanwhile, he had large acrimonious gleetings from the scrotum and a plentiful discharge of ichor from the anus.— From this time he began to find his complaints grow less and less distressing, and he has now been totally free from them for six years past."

The PUERPERAL, or CHILDBED FEVER.

This species of fever, as its name imports, is peculiar to women in childbed; and is usually the most fatal of all the disorders to which the sex is liable. But, notwithstanding the prevalence of it in all ages, its real nature has remained, to the present time, a subject of much dispute and uncertainty. The critical period of its invasion, when febrile commotions are apt to be excited by various accidents, and the equivocal symptoms which accompany it, have even afforded room for questioning whether it be a primary or a secondary disease. Some writers have considered it as proceeding entirely from an inflammation of the uterus; others have imagined it to be the consequence of an obstruction to the secretion of the milk; while the greater number has been inclined, for reasons equally if not more plausible, to impute it to a suppression of the lochia. If we examine this fever attentively, however, according to its natural course, and independently of all the accidental concomitant symptoms with which it is not essentially connected, we may safely pronounce it to be a primary disease of a particular nature, and perhaps not the necessary consequence of any of the causes above mentioned.

This fever is most generally incident to women within 48 hours after delivery, though it may supervene on the fourth or fifth day, and sometimes considerably later. It is preceded, like other fevers, by a rigor, which is commonly violent; and, when happening during the time of labour, may be confounded with the pains of parturition. In its earlier stage it is attended with the signs of inflammation. A great pain is felt in the back, hips, and the region of the uterus; which, in the part last mentioned, is accompanied with the sense of heat and throbbing. A sudden change in the quality or quantity of the lochia now also takes place; the patient is frequently troubled with a tenesmus; and the urine, which is very high-coloured, is discharged in small quantity and with pain. At the first attack of the fever, the woman is generally seized with a vomiting of porraceous matter, as in the cholera morbus,

to which disease it then bears a strong resemblance.— But instead of this symptom, there is sometimes only a nausea, or loathing at the stomach, with a disagreeable taste in the mouth. The belly swells to a considerable bulk, and becomes susceptible of painful sensations from the slightest impression. The tongue is generally dry, though sometimes moist, and covered with a thick brownish fur. When the fever has continued a few days, the symptoms of inflammation usually subside, and the disease acquires a more putrid form. At this period, if not at the very beginning of the disorder, a bilious or putrid diarrhoea, of a dangerous and obstinate nature, supervenes, and accompanies it through all its future progress; each motion to stool being preceded by a temporary increase, and followed by an alleviation of pain. The patient usually nauseates all kind of food and drink, except what is cold and acidulated. A brown or blackish sordes, the consequence of putrid exhalations, adheres to the edges of the teeth; a troublesome hiccough is at length produced, which greatly exasperates the pains of the abdomen; petechiae or vices also appear, with sometimes a milia erythema, but which produces no mitigation of the disease. Through the whole course of the fever, the patient is affected with great anxiety and dejection of spirits.

Such in general is the course of the puerperal fever; the symptoms of which, however, may be often varied, according to the constitution of the patient, the degree of the disease, and its earlier or later invasion. When the woman is naturally weak, or her strength has been greatly reduced by immoderate evacuations after delivery; when the disease is violent, and immediately follows that period; its progress and termination are proportionably rapid and fatal. In such unfortunate circumstances, many have been known to expire within 24 hours from the first attack of the disease; may, there are some instances where the rigor has concluded the scene. The catastrophe, however, is most generally suspended for some days; and the number of these is variable, though the 11th from the commencement of the fever may justly be fixed as the period which is usually decisive. In whatever stage of the disease an unfavourable termination may happen, it would seem as if the commencement of the patient's recovery were not marked by any critical revolution of the fever, as depending on an alteration of the humours; but that the cure is gradually effected, either by a spontaneous vomiting, or a long-continued discharge by stool of that porraceous matter, the existence of which in the stomach is usually evinced at the first attack of the disease. The most unfavourable prognostic, therefore, arises from such a weakness of the patient as renders her unable to support so tedious an evacuation as that by which the fever is overcome. When the lochia return to their former state, when the swelling and tenderness of the abdomen abate, and there is a moisture on the skin, we have reason to hope for a happy termination of the disease.

Though the puerperal fever may generally be ascertained from the description which has been given, and chiefly by that remarkable tenderness of the abdomen which particularly distinguishes it; yet, as some of its symptoms may be confounded with those arising from other diseases, and which require a different method of

Puerperal Fever. of cure, it will be proper to mention here the circumstances by which it may be known with greater certainty.

The pains of the abdomen, attending the childbed fever, may be distinguished from those called after-pains, by their uninterrupted continuance through the course of the disease, though sometimes they suffer exacerbations; whereas, in the latter, they often totally intermit. They are also distinguishable by the absence of fever with concomitant symptoms in the one, and their evident existence in the other.

Many circumstances evince a dissimilarity between the puerperal and miliary fevers, notwithstanding the symptoms of anxiety and oppression are common to both; inasmuch that the nature of the approaching disease may be ascertained at the very commencement of its attack. In the puerperal fever the rigor is more violent, of longer duration, and not interrupted, as it is in the other. The pulse is fuller and stronger; the skin is more hot; and the tongue, whether moist or dry, though generally the latter, is not of a white, but brownish appearance; and the urine is also higher coloured. Eruptions, which are critical in miliary fevers, procure no mitigation of the puerperal fever, and cordials generally increase it.

When the original attack of the puerperal fever happens to coincide with the febrile commotion which is excited in childbed women by the milk, the nature of it may at first be misapprehended; but the concomitant symptoms, and greater violence of the disease, must in a short time dissipate such an error.

From all the most accurate accounts of this disease, and from the period at which it generally commences, there seems reason to conclude, that it owes its rise more immediately to accidents after delivery. For it is allowed that it may follow a labour under the belt and most favourable circumstances, though endeavours to dilate the os internum are supposed frequently to produce it. The more immediate causes generally assigned by authors are a stoppage of perspiration, the too free use of spices, and the neglect of procuring stools after delivery; sudden frights, too hasty a separation of the placenta, and binding the abdomen too tight. The putrid appearance, however, which this disease so soon assumes, affords ground to suspect that the predisposing cause of it is a vitiated state of the humours; for it is generally observed to be most prevalent in an unhealthy season, and among women of a weakly and scorbutic constitution. But from its prevalence in some particular hospitals, while others in the same city are entirely free from it, there can be little doubt that it is often communicated by contagion from one female to another. This opinion is corroborated also by many other circumstances; particularly by the means by which it has been removed from hospitals. It would seem, however, that this contagion does not act on the female system without a certain predisposition, and that this predisposition is induced by those changes to which the female habit is subjected in consequence of delivery.

Within these few years this fever has been treated of by several writers, most of whom have differed from each other in their sentiments of the nature of the disease. The first in the order of publication is Dr Denman, who seems to be of opinion, that it may de-

rive its origin either from a redundancy or too great acidity of the bile, the secretion of which appears to be much interrupted in the time of gestation. In Dr Manning's treatise on this fever, he mentions its being highly probable that such a cause contributes greatly to produce the disease, especially where the putrid tendency of the humours is increased by unwholesome air and diet.

It has likewise been the fate of the puerperal fever, that no disease has more divided the sentiments of physicians in regard to the method of cure. The apparent indications and contra-indications of bleeding, and other remedies, arising from the complication of inflammatory and putrid symptoms; the equivocal appearance of the vomiting and purging, as whether they be critical or symptomatical; and the different causes whence symptoms similar to each other may arise in pregnant women; all these circumstances concur to involve the subject in great obscurity and indecision. If we carefully attend to the several characteristics of the disease, however, so as to be able to distinguish it from every other puerperal complaint, and observe at the same time the usual manner of its declension, our judgement may be guided in the method of cure by the salutary efforts of nature. But, in order to obtain a clearer view of the genuine indications, it will be proper to consider them under the several lights in which they have been generally agitated by authors.

One of the most essential points to be ascertained in the cure of the childbed fever, respects the propriety of bleeding. A free use of the lancet has been generally regarded as the most successful expedient in practice; and there are some instances of critical haemorrhagies which would seem to confirm its utility. But Dr Denman thinks we may safely affirm from experience, that for one who will be benefited by large bleeding, a much greater number will be injured, and that even almost irretrievably. Nor can this seem surprising, when we consider the situation of childbed women. In most, the evacuations consequent upon delivery are sufficient to diminish any undue superabundance of the fluids; and if, as frequently happens, the disease be produced by too hasty a separation of the placenta, the consequence of which is generally a very copious discharge of blood, we can never suppose that nature will be assisted in overcoming the febrile commotion, by the farther evacuation of the vital fluid, through the defect of which she is now rendered unequal even to the ordinary support of the animal economy. We may appeal to every practical physician, how much he has known the pulse to sink, and what a train of nervous symptoms he has observed to succeed an excess of the discharge above mentioned. Besides, it is an axiom in physic, that a remedy which cures any disorder, will always prove sufficient to prevent it; and therefore, if bleeding were the proper cure in the childbed fever, the disease ought to have been prevented by a large evacuation of blood, when that happened previous to its attack. Experience, however, in this, as in all other diseases, is the only unerring guide we can follow; and whoever regulates his practice by fact and observation, will be convinced that bleeding, especially in a larger quantity, is, in general, very far from being attended with success. Bleeding

is seldom proper, except in women of plethoric constitutions, and in whom the signs of inflammation rise high. Nor even in such patients ought it to be repeated without great caution, and the existence of strong indications. Bleeding, when used in proper circumstances, may unquestionably palliate the fever; but that it often shortens the duration of it, appears to be a matter of much doubt. On this account the practice becomes still more suspicious and exceptionable, when we consider that by venesection improperly used the patient's strength may be so far reduced as not to support the tedious looseness by which the disease is generally carried off. Though bleeding, however, ought in general to be used with great caution, there are certainly many cases in which it is both necessary and advantageous.

The genuine nature and effects of the looseness in this disease, is another controverted point of the highest importance, and which merits the most attentive inquiry. Physicians, observing that women who die of the puerperal fever are generally molested with that evacuation, have been induced to consider this symptom as of the most dangerous and fatal tendency; and what, therefore, we should endeavour by every means to restrain. In this opinion, however, they would seem to have been governed by too partial an observation of facts. For experience certainly authorises the assertion, that more women appear to have recovered of the childbed fever, through the intervention of a diarrhoea, than have been destroyed by that cause. If it also be considered, that purging is usually almost the only sensible evacuation in the more advanced state of the disease, and is that which accompanies it to its latest period, we shall have the strongest reason to think that it is critical rather than symptomatical, and ought therefore to be moderately supported, instead of being unwarily restrained. Nay, the advantage which is found to attend vomiting as well as purging, in the earlier stage of the disease, would seem to evince that the matter discharged by these evacuations is what chiefly foment the disease. Emetics and purgatives, therefore, in the opinion of Dr Manning, are the only medicines on which any rational dependence is to be placed in this fever; at least, they are certainly such as are found the most successful. It is an established rule in practice, to prescribe a vomit at the beginning of every fever attended with any nausea or loathing of the stomach, and where there is not any reason to apprehend an inflammation of that organ. Nor does the state of childbed women afford the smallest ground for prohibiting our recourse to the same expedient in answering a similar indication.

It is so seldom a physician is called during the rigor preceding the puerperal fever, that he has few opportunities of trying the effects of remedies in that early state of the disease. When such occur, however, we should endeavour as much as possible to abate and shorten that period, as the succeeding fever is generally found to bear a proportion to the violence and duration of it. For this purpose, warm diluting drinks should be plentifully used, with a small quantity of volatile spirits or brandy. When Dr Manning apprehended such an accident, he sometimes ordered the nurse to give immediately a dish or two of warm sack-whey; taking care that it was not too strong, which

is a caution that ought always to be remembered: for though a free use of the more cordial and spirituous kinds of liquors might perhaps soon abate the rigor, there is danger to be feared from their influence on the approaching fever, especially in women of a strong and healthy constitution. In all cases, warm applications to the extremities, such as heated bricks, towels, or toasted grains in a linen bag, may be used with perfect safety, and some advantage.

When the hot fit is advanced, the first thing Dr Manning orders is some emollient injection, as chicken-water, or water and milk, which ought to be frequently repeated through the course of the disease. These prove beneficial, not only by promoting the discharge from the intestines, which seems in fact to be the solution of the disease; but also by acting as a kindly fomentation to the uterus and adjacent parts. With this intention they are particularly serviceable when the lochia are suppressed. Great care, however, is requisite in administering them, on account of the tenderness and inflammatory disposition, which at that time render the parts in the pelvis extremely susceptible of pain.

The next step in the method of cure ought to be to promote the discharge of the morbid matter both by the stomach and intestines. This intention may be answered by a remedy prescribed by Dr Denman—Two grains of tartre of antimony rubbed up with a scruple of the powder of lapilli cancrorum.

Of a powder thus prepared, Dr Denman gives from two to six grains, and repeats it as circumstances require. If the first dose do not procure any sensible operation, he repeats it in an increased quantity at the end of two hours, and proceeds in that manner; not expecting any benefit but from its sensible evacuation.

Should the disease be abated, but not removed, (which sometimes happens), by the effect of the first dose, the same medicine must be repeated, but in a less quantity, till all danger be over. But if any alarming symptoms remain, he does not hesitate one moment to repeat the powder, in the same quantity as first given; though this be seldom necessary, if the first dose operates properly.

It is to be observed, says Dr Denman, that as the certainty of cure depends upon the proper repetition of the medicine, the method of giving it at stated hours does not appear eligible. If the first dose produce any considerable effect by vomiting, procuring stools, or plentifully sweating, a repetition of the medicine in a less quantity will seldom fail to answer our expectations; but great judgement is required in adapting the quantity first given to the strength of the patient and other circumstances. We are not to expect that a disease which from the first formation carries so evident marks of danger, should instantly cease, even though a great part of the cause be removed.

Frequent doses of the saline draughts ought also to be given, which not only promote the evacuation by the intestines, but likewise increase the salutary discharges of urine and perspiration. These medicines are particularly serviceable in subduing the remains of the fever, after its violence has been broken by the more efficacious remedies above mentioned; but when they are used even in the decline of the disease, gentle laxatives of rhubarb and magnesia, as advised by Dr Denman,

Puerperal Fever. Denman, ought to be frequently interposed, since, as he justly observes, without stools we can do little service.

Although the discharge by the intestines appears to have the most salutary effect in this disease; yet when the stomach has not been properly unloaded of offensive matter, though a great nausea and sickness had indicated the expediency of such an evacuation at the beginning of the fever, the continuance of the looseness is sometimes so long protracted as in the end to prove fatal. In this alarming state of the disease, when the stools are very frequent and involuntary, and all appearances threaten danger, Dr Denman says, that a clyster of chicken-water injected every one, two, or three hours, or as often as possible without fatiguing the patient too much, with a cordial diaphoretic draught taken every six hours, has produced better effects than could be expected.

While these medicines are employed, we should endeavour to mitigate the pains of the belly by relaxing applications. During the course of the disease, the patient ought to drink freely of diluting liquors, and abstain from every thing of a heating quality, unless great faintness should indicate the use of a small quantity of some cordial medicine.

Such is the practice recommended in this disease by Dr Denman. We shall now take a cursory view of the sentiments of succeeding writers on this subject.

According to Dr Hulme, the proximate cause of the puerperal fever is an inflammation of the intestines and omentum; for the confirmation of which opinion he appeals to dissections. He supposes the chief predisposing cause of the disease to be the pressure of the gravid uterus against the parts above mentioned. The omentum, says he, in the latter stage of pregnancy, must either be flat, which is its natural situation, or be rumpled or carried up by the gravid uterus in folds or doublings. When the latter is the case, which he observes is probably not seldom, the danger of a strangulated circulation will be greater.

Mr White, who has also written on this disease, judiciously remarks, that were Dr Hulme's hypothesis well founded, the disorder ought rather to take place before delivery, and be immediately removed at that period: That it would likewise most generally happen to women at their first labour, when the abdominal muscles are less yielding, and the pains more violent; the contrary of which is most frequently experienced to be the case.

It also deserves to be remarked, that, upon Dr Hulme's supposition, we cannot account for the disease being more common and fatal in large towns and in hospitals, than in the country and private practice, while other inflammatory disorders are more endemic among those who live in the latter than the former situation. Even admitting the friction of the intestines and omentum against the uterus to be as violent as Dr Hulme supposes, is it not highly improbable, that any inflammation could be occasioned by the pressure of such soft substances upon each other? Or, were this effect really produced, ought not the puerperal fever to be more common and fatal after the most laborious deliveries? But this observation is not supported by experience.

Dr Hulme, in favour of his own hypothesis, alleges Vol. XIII. Part II.

that it gives a satisfactory answer to the question, "Why all lying-in women have been, and ever will be, subject to this disease?" In this proposition, however, the doctor supposes such an universality of the disease as is not confirmed by observation. It is affirmed upon undoubted authority, that in many parts of Britain the puerperal fever is hardly known; whereas, were it really produced by the causes he assigns, it would be equally general and unavoidable.

But how peculiar soever this author's sentiments are in respect of the proximate cause of this disease, they have not led him to any method of cure different from the established practice. On this subject Dr Hulme divides his observations into two parts, comprehending under the former the more simple method of treatment, and under the latter the more complex. He sets out with remarking, that the patient being generally costive at the beginning of the disease, an emollient opening clyster will often give immediate relief; but if this should not prove effectual, recourse must be had to cathartics. Those which he found answer his purpose best, were the sal catharticus amarus, the oleum ricini, emetic tartar, and antimonial wine. When the bowels have been sufficiently cleared and the pain abates, he advises encouraging a gentle diaphoresis by medicines which neither bind the body nor are heating; such as small doses of ipecacuan, emetic tartar, and antimonial wine, combined with an opiate in a moderate dose, and given once or twice in the course of 24 hours; administering the saline draughts in the intermediate spaces. If, preceding or during this course, a sickness at stomach or vomiting attend, he advises assisting the efforts of nature, by drinking, plentifully of chamomile tea, warm water, or any other diluting liquor. He concludes with recommending a cooling regimen, rest of body, and tranquillity of mind; prohibiting all kinds of bandage upon the abdomen, and enjoining particular attention to the state of the bowels, which ought to be kept gently open for some time, even after the disorder seems to be gone off, till the patient be quite out of danger.

So much for the simple treatment: we now proceed to the second part, where he describes the method of practice when the disease is in its more irregular and complicated state.

When a diarrhoea accompanies the disease, he observes that it ought by no means to be checked, but supported, by ordering the patient to drink plentifully of mild aperient liquors. If the pain of the hypogastric region be attended with stitches in the sides or over the pit of the stomach, and a pulse that resists the finger pretty strongly, he remarks that bleeding would then be highly necessary: declaring, however, his opinion, that, in the puerperal fever, bleeding is to be considered only as a secondary means of relief, though the first in point of time; that it ought to be advised with great caution; and that the greatest dependence is always to be placed upon evacuations by stool.

Mr White imputes the puerperal fever to a putrescent disposition of the humours, contracted during pregnancy, and fomented by the hot regimen commonly used by women in childbirth. In conformity to this opinion, the chief means which he recommends for preventing the disease is a cool regimen and free circulation

tion of air, which he evinces to be of the greatest importance. In respect of bleeding, he informs us, that, upon the strictest inquiry, he cannot find that those who have bled the most copiously have had the greatest success, either in private or hospital practice. He even seems to question the propriety of this evacuation in any case; but approves of emetics, cathartics, and clysters, for cleansing the primæ viæ, and likewise of such medicines and diet as will correct the putrid humours: adding, that an upright posture and free ventilation are at all times useful, and absolutely necessary, both for the prevention and cure of the disease.

Another writer who treats of the childbed fever is Dr Leake, who has published the result of his observations on this disease from April 1768 to the autumn of the year 1770; but chiefly from December 1769 to May 1770, during which period the childbed fever prevailed much about London.

Dr Leake tells us that this fever generally commenced the evening of the second or morning of the third day after delivery, with a rigor or shivering fit. Sometimes it invaded soon after delivery; and at other times, though rarely, it has seized so late as the fifth or sixth day. Now and then it seemed to be occasioned by catching cold, or by errors in diet; but oftener by anxiety of mind. Sometimes the thirst was great; though the tongue had, in general, a better appearance at the beginning than is common in other fevers. It was seldom ever black or very foul; but, as the disease advanced, became white and dry, with an increase of thirst; and at last was of a brownish colour towards the root, where it was slightly covered with an inspissated mucus. The loss of strength was so great and sudden, that few of the patients could turn in bed without assistance, even so early as the first or second day after the attack. The lochia, from first to last, were not obstructed, nor deficient in quantity; neither did the quality of this discharge seem to be in the least altered from its natural state; a presumption, says the author, that the uterus was not at all affected. Of this he was convinced by making a considerable pressure above the pubes with the hand, which did not occasion pain; but when the same degree of pressure was applied higher, between the stomach and umbilical region, it became almost intolerable. A perfect crisis seldom if ever happened in this fever, which he imputes to the great oppression of the vital powers, whereby they were rendered unable to produce such an event. When the disease proved mortal, the patient generally died on the 10th or 11th day from the first attack. In those who died of the fever, the omentum was found suppurated; an inflammation of which part, or of the intestines, Dr Leake concludes to be the proximate cause of the disease.

In consequence of this idea of the cause of the disease, Dr Leake affirms that venesection is the only remedy which can give the patient a chance for life. But, though it be the principal resource to be depended upon at the beginning of the fever, he observes that it will seldom prove of service after the second or third day; and, if directed yet later, will only weaken and exhaust the patient; when, matter having begun to form in the omentum, the progress of the disease can no longer be prevented by that evacuation. At this period the blood begins to be tainted by the absorption

of the purulent fluid; and the fever, from being inflammatory, is changed into a putrid nature.

After bleeding in such a quantity as the symptoms require, he advises that the corrupted bile be evacuated and corrected as soon as possible; that the diarrhoea, when excessive, be restrained by emollient anodyne clysters and gentle sudorifics, or even by opiates and mild astringents, when the patient's strength begins to sink under the discharge; and, lastly, that where the signs of the putrefaction or intermission take place, antiseptics and the cinchona may be administered.

The great uniformity of the symptoms in all Dr Leake's patients might authorise an opinion, that the fever which he describes was in a great measure a disease sui generis, and depended much upon the constitution of the air preceding and during the period in which the fever prevailed.

Dr Kirkland has also made judicious observations on this subject. He rejects the opinion that the puerperal fever is a disease sui generis, and arises always from the same cause. The particular situation of childbed women, he acknowledges, occasions a similarity in the appearance of all the febrile symptoms: but he affirms that the same kind of fever may be produced by various causes; for instance, by an inflammation of the uterus or abdomen, by putrid blood or other matter, and putrid miasms. The symptoms, he observes, will vary according to the time of seizure. If the fever happen in three or four days after delivery, all the symptoms usual to the situation of the patient will make their appearance; but if it do not invade till the milk has been secreted, and the lochial discharge be nearly finished, the symptoms, if the breasts are properly drawn, will, for the most part, be those only which are common to that kind of disorder by which the fever has been produced.

With respect to the cure of puerperal fevers, Dr Kirkland advises the antiphlogistic method when they arise from inflammation; but when this method fails of success, and a diarrhoea supervenes, the disease has changed its nature, having become more or less putrid, and requires a very different treatment.

His observations relative to the management of the diarrhoea merit attention. No one, says he, would purge and bleed to cure the colliquative fever arising from the absorption of matter in large wounds; and yet the only difference is, that in the puerperal fever the matter absorbed from the uterus, &c. acts with more violence, because the blood is commonly thinner and the habit in a more irritable state. We see, continues he, that absorbed matter purges as effectually as if any purging medicine had been given by the mouth; and may we not therefore do harm by additional purging, when there has been a large evacuation, especially as purges in this case are incapable of entirely removing the formæ morbi?

He considers cinchona as the principal remedy, as soon as the pulse sinks, the heat is lessened, and the stomach will bear it. If this increase the diarrhoea beyond moderation, he joins with it small doses of laudanum; but if the diarrhoea should entirely stop without the fever going off, in place of laudanum he advises a proper quantity of rhubarb. Should the diarrhoea, notwithstanding the use of the medicines proposed, become

Puerperal fever. come so violent as to endanger the patient, he agrees with Mr White in recommending the columbo root, which is a warm cordial, and removes the irritability of the stomach and intestines more powerfully than any other bitter he knows.

Of this disease also, as it appeared in Derbyshire and some of the adjacent provinces, an account has been published by Dr Butter. Concerning the causes and nature of the disease, he observes, that pregnancy seems to add much to the natural sensibility of the female constitution; because at this period women are often subject to a train of nervous symptoms, which never molest them at other times. During gestation likewise, the appetite is for the most part keen, while the digestion appears to be impaired; and this weakness is increased not only by improper food, of which the woman is frequently desirous, but also by the inactivity attending her situation. To these circumstances, it is added, that the intestinal passage being interrupted by the uterine pressure, colicness generally prevails. From the several observations here enumerated, Dr Butter concludes, that the proximate cause of the puerperal fever is a spasmodic affection of the first passages, with a morbid accumulation in their cavity; and upon this supposition he endeavours to account for the various symptoms of the disease.

In treating of the method of cure, he lays down two indications; the former of which is to promote two, three, or four stools daily, in a manner suited to the strength of the patient, till such time as they resume a natural appearance. The second indication is to relieve all uneasy symptoms, such as heat, thirst, headache, &c.

With respect to the opinion entertained by Dr Butter of the cause of the puerperal fever, it nearly coincides with that of Mr White. But however plausible it may appear, we are not entirely satisfied that a disease attended with so peculiar symptoms as the puerperal fever can depend principally upon an irritability, which is not restricted either to the pregnant or puerperal state.

The late Dr Thomas Young professor of midwifery in the university of Edinburgh, although he published nothing on the subject of the puerperal fever, wrote a very ingenious dissertation respecting it, which was read in the Philosophical Society of Edinburgh. In that dissertation, after giving a very accurate account of the symptoms of the disease, which coincides very nearly with the account given by others, he endeavours to show, that the puerperal fever, strictly so called, is in every instance the consequence of contagion; but he contends, that the contagious matter of this disease is capable only of producing its effect, in consequence of a peculiar predisposition given by delivery and its consequences. In support of this doctrine, he remarks, that for many years the disease was altogether unknown in the lying-in ward of the Royal Infirmary at Edinburgh; but that after it was once accidentally introduced into the hospital, almost every woman was in a short time after delivery attacked with it; although prior to her delivery, she may have lain, even for weeks together, not only in the same ward with the infected, but even in the very next bed. He remarks, that it was only eradicated from the hospital in consequence of the wards being entirely emptied, thoroughly venti-

lated, and new painted. After these proceedings, puerperal females in the hospital remained as free from this disease as formerly. The puerperal fever, according to Dr Young, has very generally a strong tendency to the typhoid type; although he allows, that in the beginning it is not unfrequently attended with inflammatory symptoms, and even with topical inflammation, particularly in the intestinal canal. On this idea, he considers the puerperal fever as admitting of the same variety of treatment with other affections depending on contagion, in which sometimes an inflammatory, sometimes a putrescent tendency, prevails; such, for example, as smallpox or erysipelas. But from the prevailing putrescent tendency in this affection, he considers the free access of cool air, with the liberal use of antiseptics, as being very generally requisite.

It deserves to be remarked, that though the several writers who treat of this subject have conducted their method of cure conformably to their particular idea of the cause of the disease, respecting which their sentiments are very different, they seem to have been equally successful in the treatment of their patients. Indeed the several writers differ less from each other in their method of cure than might be expected, where so great an opposition of theoretical sentiment prevails. For after endeavouring to establish indications correspondent to their particular systems, those who contend for the expediency of promoting the intestinal discharge, dissuade not from having recourse to phlebotomy when the disease is attended with inflammatory symptoms; while, on the other hand, the most strenuous advocates for bleeding admit the utility of the former evacuation. It appears, therefore, that a due regulation of the alvine discharge is necessary through the whole course of the fever, but venesection only sometimes.

WORMS.

Those infesting the human body are chiefly of three kinds: the ascarides, or small round and short white worms; the teres, or round and long worm; and the tania, or tape worm.

The ascarides have usually their seat in the rectum.— The teretes or lumbri are about a span long, round and smooth: they are seated for the most part in the upper small intestines; but sometimes they are lodged also in the stomach, and in any part of the intestines, even to the rectum.— The tape-worms are from two to forty feet long, according to the testimony of Platerus; they generally possess the whole tract of the intestines, but especially the ileum: they very much resemble a tape in their appearance, whence the name of tape-worm; but another species of this genus, from the resemblance of each joint to a gourd seed, has the name of the gourd-worm.

In the Medical Transactions, vol. 1st. Dr Heberden gives a very accurate account of the symptoms produced by the ascarides, from an eminent physician who was troubled with them all his life. They brought on an uneasiness in the rectum, and an almost intolerable itching in the anus; which sensations most usually came on in the evening, and prevented sleep for several hours. They were attended with heat, sometimes so considerable as to produce a swelling in the rectum both

both internally and externally; and if these symptoms were not soon relieved, a tenesmus was brought on, with a mucous dejection. Sometimes there was a gripping pain in the lower part of the abdomen, a little above the or pubis. If this pain was very severe, a bloody mucus followed, in which were often found ascarides alive. They were also sometimes suspected of occasioning disturbed sleep, and some degree of headache.

On this case Dr Heberden observes, that the general health of the patient did not seem to have suffered from the long continuance of the disease, nor the immediate inconveniences of the disorder itself to have increased. "It is (says he) perhaps universally true, that this kind of worms, though as difficult to be cured as any, yet is the least dangerous of all. They have been known to accompany a person through the whole of a long life, without any reason to suspect that they had hastened its end. As in this case there was no remarkable sickness, indigestion, giddiness, pain of the stomach, nor itching of the nose, possibly these symptoms, where they have happened to be joined with the ascarides, did not properly belong to them, but arose from some other causes. There is indeed no one sign of these worms, but what in some patients will be wanting."

The above mentioned patient used purging and irritating clysters with very little success. One dram and an half of tobacco was infused in six ounces of boiling water; and the strained liquor being given as a clyster, occasioned a violent pain in the lower part of the abdomen, with faintness and a cold sweat: this injection, though retained only one minute, acted as a smart purge, but did little or no good. Lime-water was also used as a clyster; which brought on a costiveness, but had no good effect. Six grains of salt of steel were dissolved in six ounces of water, and injected. This clyster in a few minutes occasioned an aching in the rectum, gripped a little without purging, and excited a tenesmus. Some few ascarides were brought off with it; but all of them were alive. The uneasy sensation in the rectum did not abate till some warm milk was thrown up. Whenever the tenesmus or mucous stools were thought worth the taking notice of, warm milk and oil generally gave immediate relief. If purging was necessary, the lenient purges, such as manna with oil, were, in this particular case, made use of: rhubarb was found too stimulating. But, in general, the most useful purge, and which therefore was most usually taken, was cinnabar and rhubarb, of each half a drachm: this powder seldom failed to bring away a mucus as transparent as the white of an egg, and in this many ascarides were moving about. The cinnabar frequently adhered to this mucus, which did not come off in large quantities, when a purge was taken without cinnabar. Calomel did no more than any other purge which operates briskly would have done; that is, it brought away ascarides, with a great deal of mucus. Oil given as a clyster sometimes brought off these animalcules: the oil swam on the surface of the mucus, and the ascarides were alive and moving in the mucus itself, which probably hindered the oil from coming in contact with them and killing them.

Dr Heberden also observes, that mucus or slime is

the proper nest of the ascarides, in which they live, and is perhaps the food by which they are nourished; and it is this mucus which preserves them unhurt, though surrounded with many other liquors, the immediate touch of which would be fatal. It is hard to satisfy ourselves by what instinct they find it out in the human body, and by what means they get at it; but it is observable in many other parts of nature, as well as here, that where there is a fit soil for the hatching and growth of animals and vegetables, nature has taken sufficient care that their seeds should find the way thither. Worms are said to have been found in the intestines of still-born infants. Purges, by lessening this slime, never fail to relieve the patient: and it is not unlikely, that the worms which are not forced away by this quickened motion of the intestines, may, for want of a proper quantity of it, languish, and at last die; for if the ascarides are taken out of their mucus, and exposed to the open air, they become motionless, and apparently die in a very short time. Dr Heberden supposes that the kind of purge made use of is of some consequence in the cure of all other worms as well as ascarides; the animals being always defended by the mucus from the immediate action of medicines; and that therefore those purges are the best which act briskly, and of which a repetition can be most easily borne. Purging waters are of this sort, and jalap especially for children; two or more grains of which, mixed with sugar, are most easily taken, and may be repeated daily.

From Dr Heberden's observations, we may easily see why it is so difficult to destroy these animals; and why anthelmintics, greatly celebrated for some kinds, are yet so far from being specifics in the disease. As the worms which reside in the cavities of the human body are never exposed to the air, by which all living creatures are invigorated, it is evident, that in themselves they must be the most tender and easily destructible creatures imaginable, and much less will be requisite to kill them than any of our common insects. The most pernicious substances to any of the common insects are oil, caustic fixed alkali, lime, and lime-water. The oil operates upon them by shutting up the pores of their bodies; the lime-water, lime, and caustic alkali, by dissolving their very substance. In the case of intestinal worms, however, the oil can have very little effect upon them, as they are defended from it by the moisture and mucus of the intestines; the like happens with lime-water: and therefore it is necessary that the medicine should be of such a nature as to destroy both mucus and insects together; for which purpose the caustic fixed alkali is at once safe and efficacious; nor is it probable that any case of worms whatever could resist the proper use of this medicine. A very large dose of any salt indeed will also destroy the mucus and destroy the worms; but it is apt to inflame and excoriate the stomach and intestines, and thus to produce worse disorders than that which it was intended to cure. Dr Heberden gives the following remarkable case of a patient cured of worms by enormous doses of common salt, after trying many other remedies in vain. In February 1757, the patient was seized with uncommon pains in his stomach, attended with nausea, vomiting, and constipation of bowels, and an almost total loss of sleep and appetite:

He soon became much emaciated, and could neither stand nor walk upright; his belly grew small and hard, and closely retracted, inasmuch that the sternum covered the navel, and the latter could scarce be discovered or felt by the finger: his urine was always milky, and soon deposited a thick white sediment; his excrements were very hard and lumpy, resembling those of sheep, only of a brown colour; nor had he ever a stool without some medicine or other to procure it. In this situation he continued four years; during which time he had been in an infirmary, attended by eminent physicians, but was dismissed as incurable. At last he was advised by a neighbour to drink salt and water, as he said he knew one cured by it who had for many years been afflicted with the same kind of pains in the belly and stomach. As his distemper was now almost insupportable, he willingly tried the experiment. Two pounds of common salt were dissolved in as little water as possible, all which he drank in less than an hour. Soon afterwards he found himself greatly oppressed at the stomach, grew extremely sick, and vomited violently; on the fourth straining he brought up about half a pint of small worms, part ascarides, and the rest resembling those worms which are called the botts, and frequently met with in the stomach of horses, but much smaller, and about the size of a grain of wheat. The salt soon began to operate downwards, and he had five or six very copious fetid stools, tinged with blood; and in them discharged near an equal quantity of the same kind of worms he had vomited. Being greatly fatigued with the violence of the operations, he fell into a calm sleep, which lasted two hours, during which he sweated profusely, and awoke much refreshed. Instead of his usual pains, he now only complained of a rawness and soreness of his gullet, stomach, and bowels, with an almost unquenchable thirst; to allay which, he drank large quantities of cold water, whey, butter-milk, or whatever he could get. The urine he now passed was small in quantity, and rendered with very great difficulty, being highly saturated with the salt, from whence arose a most troublesome dysuria and strangury. However, these symptoms gradually abated by a free use of the liquors above-mentioned; and on the third morning he was so well recovered, that he took two pounds more of salt, dissolved in the like quantity of water. The effects were nearly similar to the former; only that most of the worms were now burst, and came away with a considerable quantity of slime and mucus. The drought, strangury, &c. returned with their former violence, but soon yielded to the old treatment. He sweated very copiously for three days, slept easily, and by that time could extend his body freely: on the fifth day he left his bed, and, though very weak, could walk upright; his strength and appetite soon returned, and he became robust and well.

The anthelmintic medicines which have been recommended by one person or other, are in a manner innumerable; but the principal are,

1. Quicksilver. This is very efficacious against all kinds of worms, either taken in the form of calomel or corrosive sublimate. Even the crude metal boiled in water, and the water drunk, has been recommended as an almost certain cure. But this, it is evident, can

receive no impregnation from the mercury. If, therefore, it have any effect, it must be from some foreign and accidental impregnation. In most instances there can be no objection to mercury, but only that it is not endowed with any attenuating quality whereby the mucus in which these insects reside can be dissolved. It therefore fails in many cases, though it will most certainly destroy worms where it can get at them.

2. Powder of tin. This was for some time celebrated as a specific, and indeed we may reasonably expect good effects from it; as by its weight and grittiness it rubs off the mucus and worms it contains from the coats of the intestinal canal, in which case they are easily evacuated by purgatives. In order to produce any considerable effects, it must be given in a large dose.

3. Gessnea inermis, or cabbage bark. This remedy is used by the inhabitants of Jamaica. The first account of it which appeared in this country was published in the Physical and Literary Essays, vol. ii. by Mr Duguid surgeon in that island. He acquaints us, that the inhabitants of Jamaica, young and old, white and black, are much infested with worms, especially the long round sort; the reason of which, he thinks, is the quantity of sweet viscid vegetables which they eat. On dissecting a child of seven months old, who died of vomiting and convulsions, twelve large worms were found; one of them filled the appendix vermiciformis, and three of them were entwined in such a manner as to block up the valvula Tulpii, so that nothing could pass from the small to the great guts.—The cabbage bark, however, he tells us, is a safe and effectual remedy, and the most powerful vermifuge yet known; and that it frequently brings away as many worms by stool as would fill a large hat. He owns that it has sometimes violent effects; but this he ascribes to the negroes who make the decoction (in which form the bark is used) too strong, and not to the remedy itself.

Mr Anderson, surgeon in Edinburgh, has also given an account of this bark and its operation, in a letter to Dr Duncan, published in the Edinburgh Medical Commentaries, volume iv. p. 84. From this account it appears, that there are two different kinds of cabbage bark; the one much paler than the other: the pale kind operates much more violently than the other. It often occasions loose stools, great nausea, and such like symptoms, attended with great uneasiness in the belly: in one or two instances it was suspected of inducing syncope. The darker coloured kind resembles the casia lignea, though it is of a much coarser texture. This kind, Mr Anderson thinks, may be exhibited in any case where an anthelmintic is necessary; the dangerous symptoms might have followed either from the use of the first kind, or from an over-dose of the second. The usual method of preparing the medicine is by boiling two ounces and a half of the bark in two quarts of water to a pint and a half. Of this a tea-spoonful may be given at first in the morning, gradually increasing the quantity till we come to four or five table-spoonfuls in a day. When exhibited in this manner, Mr Anderson informs us, that he never saw it produce any violent symptoms, and has experienced the best effects from it as an anthelmintic. After the use of this decoction for eight

Worms. or nine mornings successively, a dose of jalap with calomel must be given, which seldom fails to bring away the worms, some dead, some alive. If at any time the decoction produce more than one or two loose stools, a few drops of liquid laudanum may be given; and, in general, Mr Anderson gave 15 or 20 drops of the spirit of lavender with each dose.

In a letter from Dr Ruth, professor of chemistry at Philadelphia, to Dr Duncan of Edinburgh, the following account is given of another preparation of this medicine. "It has long (says he) been a complaint among physicians, that we have no vermifuge medicine which can be depended upon. Even calomel fails in many cases where there are the most pathognomonic signs of worms in the bowels. But this complaint, it is hoped, is now at an end. The physicians of Jamaica have lately found, that the cabbage bark, as it is called in the West Indies, made into a syrup with brown sugar, is an infallible antidote to them. I have used above 30 pounds of it, and have never found it fail in one instance. The syrup is pleasant; it sometimes pukes, and always purges, the first or second time it is given."

The most accurate botanical description of the geoffrea inermis, or the tree furnishing the worm bark, as it has often been called, is that which was published some years ago in the Philosophical Transactions by Dr Wright, formerly physician at Jamaica, now of Edinburgh, who also highly extolls this remedy as an anthelmintic.

Notwithstanding these encomiums, however, the cabbage bark has not come into general use in Britain. But diseases from the teretes, or lumbri as they are often called, the species of worm against which this bark is employed, much less frequently occur in Britain than in some other countries. When they do occur, in almost every instance they readily yield to more gentle and safe anthelmintics; and the worms may not only be expelled by calomel, but by the vegetable bitters; as the powder of the artemisia santonica, or the like.

4. Coughage, or cow ich. This is the Dolichos urens or purpureus of Linnaeus; and the principles on which it acts have been already explained under the article DOLICHOS. It is somewhat similar to the powder of tin, but bids fair for being more efficacious. It might at first appear to occur as objections to this medicine, that by the hairs of it entangling themselves with one another, calculi might be formed in the intestines, or obstructions equally bad; or if the sharp points and hooks with which it abounds were to adhere to the nervous coats of the intestines themselves, they might occasion a fatal irritation, which could not be removed by any means whatever. But from the experience of those who have employed it extensively in practice, it would appear, that these objections are entirely theoretical: and that it may be employed with perfect safety. The spicules, gently scraped off from a single pod, and mixed with syrup or melasses, are taken for a dose in the morning fasting. This dose is repeated in this manner for two or three days without any sensible operation; but even a very slight purgative taken afterwards has been found to discharge an almost incredible quantity of worms. And according to Dr Bancroft, who has given a very particular account of

its use in his Natural History of Guiana, it is one of the safest and most certain anthelmintics yet discovered; but, as well as the bark of the Geoffrea, it has hitherto been very little used in Britain, probably from its not being necessary.

5. Indian pink. This plant, which is the Spigelia marilandica of Linnaeus, is also an American plant, and was first recommended in the Edinburgh Physical and Literary Essays by Dr Garden of Charleston in South Carolina. He is of opinion that a vomit ought always to precede the use of it; and informs us, that half a dram of it purges as briskly as the same quantity of rhubarb. At other times he has known it produce no effect on the belly though given in very large quantity: In such cases it becomes necessary to add a grain or two of sweet mercury, or some grains of rhubarb; but then it is less efficacious than when it proves purgative without addition. The use of it, however, in small doses, is by no means safe; as it frequently produces giddiness, dizziness of sight, convulsions, &c. The addition of a purgative, indeed, prevents these effects; but at the same time, as already observed, it diminishes the virtue of the medicine. The doctor therefore recommends large doses, as from them he never knew any other effect than the medicine's proving emetic or violently cathartic. The dose is from 12 to 60 or 70 grains of the root in substance, or two, three, or four drams of the infusion, twice a day. This medicine has also had its day, and is now very far from being considered as a specific.

The long round worms seem to be the most dangerous which infest the human body, as they often pierce through the stomach and intestines, and thus bring on a miserable death. The common symptoms of them are nausea, vomiting, looseness, fainting, slender intermitting pulse, itching of the nose, and epileptic fits. By the consumption of the chyle they produce hunger, paleness, weakness, colliquation, tumor of the abdomen, eruptions, and rumbling of the intestines; but it is from the perforation of the intestines that the disease proves so frequently fatal. A child may be known to have worms from his cold temperament, paleness of the countenance, livid eyelids, hollow eyes, itching of the nose, voracity, startings, and grinding of the teeth, in sleep; and more especially by a very fetid breath. Very frequently, however, they are voided by the mouth and anus, in which case there is no room for doubt. In the Medical Commentaries, vol. ii. we have an account of the intestines being perforated by a worm, and yet the patient recovered. The patient was a woman troubled with an inflammation in the lower part of the abdomen. The pain was so violent, that for six days she slept none at all; the tumor then broke, discharged upwards of a pound of thin watery fannies, immediately after which the excrements followed. The next day she was extremely low; her pulse could scarcely be felt; the extremities were cold; and there was a considerable discharge from the wound, which had already begun to mortify. She got a decoction of cinchona with wine, which alleviated the symptoms; but in removing the mortified parts a worm was found among them nine inches long, and as thick as an eagle's quill. By proper applications, the discharge of excrements ceased, and she recovered perfect health. She was sensible of no accident giving rise to

Worms. the inflammation; so that in all probability it arose entirely from the worm itself.

The tænia, or tape worm as it is called, is one of those most difficult to be removed from the human body. It is of two kinds, tænia solium and tænia lata; for a description of which see the article TÆNIA.—The reason of its being so difficult to cure is, that though portions of it are apt to break off and be discharged, it is endowed with a power of reproduction, so that the patient is little or nothing better. The symptoms occasioned by it are not different from those above described. A specific against the tænia lata has been lately so much celebrated in France, that the king thought proper to purchase it from the proprietor (Madame Nouffer), and the account of it has been translated into English by Dr. Simmons. The patients are required to observe no particular regimen till the day before they take the specific. That day they are to take nothing after dinner till about 7 o'clock; after which, they are to take the following soup: "Take a pint and an half of water, two or three ounces of good fresh butter, and two ounces of bread cut into thin slices; add to this salt enough to season it, and then boil it to the consistence of panada." About a quarter of an hour after this, they take a biscuit and a glass of white wine, either pure or mixed with water; or even water alone, if they have not been accustomed to wine. If the patient has not been to stool that day, (which, however, is not usual with patients in this way), the following clyster is to be injected. "Take a small quantity of the leaves of mallows, and boil them in a sufficient quantity of water, mixing with it a little salt, and when strained off add two ounces of olive oil." Next morning, about eight or nine hours after the supper above mentioned, the specific is to be taken. This is no other than two or three drams of the root of male fern, polypodium filix mas of Linnaeus, gathered in autumn, and reduced to fine powder. It is to be taken in any distilled water, or in common water. This medicine is apt to occasion a nausea: to avoid which, Madame Nouffer allows her patients to chew any thing that is agreeable, but forbids any thing to be swallowed; or they may smell to vinegar, to check the sickness: but if, notwithstanding this, the specific be thrown up, a fresh dose must be swallowed as soon as the sickness is gone off, and then they must try to sleep. About two hours after this the following bolus is to be taken. "Take of the panacea of mercury 14 times sublimed, and select resin of scammony, each ten grains: of fresh and good gamboge six or seven grains: reduce each of these substances separately into powder, and then mix them with some conserve into a bolus." This composition is to be swallowed at two different times, washing it down with one or two dishes of weak green-tea, after which the patient must walk about his chamber. When the bolus begins to operate, he is to take a dish of the same tea occasionally, until the worm be expelled; then, and not before, Madame Nouffer gives him broth or soup, and he is directed to dine as is usual after taking physic. After dinner he may either lie down or walk out, taking care to conduct himself discreetly, to eat but little supper, and to avoid every thing that is not of easy digestion.

The cure then is complete; but it is not always effected with the same quickness in every subject. He

who has not kept down the whole bolus, or who is not sufficiently purged by it, ought to take, four hours after it, from two to eight drams of Epsom salt dissolved in boiling water. The dose of this salt may be varied according to the temperament and other circumstances of the patient.

If the worm should not come away in a bundle, but in the form of a thread (which particularly happens when the worm is involved in much tenacious mucus), the patient must continue to sit upon the close stool without attempting to draw it away, drinking at the same time warm weak tea: sometimes this alone is not sufficient, and the patient is obliged to take another dose of purging salt, but without varying his position till the worm be wholly expelled.

It is unusual for patients who have kept down both the specific and purging dose, not to discharge the worm before dinner-time. This, however, sometimes happens when the dead worm remains in large bundles in the intestines, so that the faeces becoming more limpid towards the end of the purging, pass by it without drawing it with them. The patient may in this case eat his dinner; and it has been observed, that the food, joined to the use of a clyster, has brought about the expulsion of the worm.

Sometimes the worm is brought away by the action of the specific alone, before the patient has taken the purging bolus: when this happens, Madame Nouffer gives only two thirds of it, or substitutes the salt in its stead.

Patients must not be alarmed by any sensation of heat or uneasiness they may feel during the action of the remedy, either before or after a copious evacuation, or just as they are about to void the worm. These sensations are transitory, and go off spontaneously, or by the assistance of the vapour of vinegar drawn in at the nose.

They who have vomited both the specific and bolus, or who have kept down only a part of them, sometimes do not void the worm that day. Madame Nouffer therefore directs them to take again that night the soup, the wine and biscuit; and if circumstances require it, the clyster. If the worm do not come away during the night, she gives them early the next morning another dose of the specific, and, two hours afterwards, six drams or an ounce of purging salt, repeating the whole process of the preceding day; excepting the bolus, which she suppresses.

She observes, that very hot weather diminishes in some degree the action of her remedy; she therefore prefers the month of September for administering it; but as she has not been always able to choose the season, and has been sometimes obliged to undertake the cure of patients in the hottest days of summer, she then gave her specific very early in the morning; and with this precaution she saw no difference in its effects.

On the day appointed for the trial of this medicine before the commissioners nominated by the king of France, it was exhibited to five different persons; but only one of them was certainly known to have the tænia lata by having discharged parts of it before. That person was cured; the second voided a portion of the tænia solium; the third some ascarides, with a part of the tænia solium; the fourth and fifth voided no worms; but

but the last considered much of the viscid slime he voided to be worms in a dissolved state.

This trial was thought sufficient to ascertain the efficacy of the medicine, and further trials were made by those to whom the secret was communicated. The first voided two tænia, after much vomiting and 18 or 20 stools; the second had no vomiting, but was as violently purged, and discharged two worms; the third had 20 copious stools during the night, and discharged the worm in the morning; and the fifth was affected in much the same manner. Some others who were not relieved, were supposed not to have a tænia.

This specific, however, is not to be considered as a new discovery; the efficacy of fern in cases of tænia having been known long ago. Theophrastus prescribes its root, in doses of four drams, given in water sweetened with honey, as useful in expelling flat worms.— Dioscorides orders it in the same dose, and adds, that its effects are more certain when it is mixed with four oboli (40 grains) of scammony or black hellebore; he particularly requires that garlic should be taken before hand. Pliny, Galen, Oribasius, and Aëtius, ascribe this same virtue to fern; and are followed in this by Avicenna, and the other Arabian physicians. Dorstenius, Valerius Cordus, Dodonæus, Mathiolus, Dalechampsus, who commented on Dioscorides, or copied him in many things, all mention the fern-root as a specific against the tænia. Senertus, and Burnet after him, recommended in similar cases an infusion of this plant, or a dram of its powder, for young persons, and three drams for adults. Simon Paulus, quoted by Ray and Geoffroy, considers it as the most efficacious of all poisons against the flat worm, and as being the basis of all the secret remedies extolled by empires in that disease. Andry prefers distilled fern-water to the root in powder, or he employs it only in the form of an opiate, or mixed with other substances.

These are not the only authors who have mentioned the tænia; many others have described this worm, the symptoms it excites, and the treatment proper to expel it. Almost all of them mention the fern-root, but at the same time they point out other remedies as possessing equal efficacy. Amongst these we find the bark of the root of the mulberry-tree, the juice of the auricula murus, the roots of chamæleon niger, ginger, zedoary; decoctions of mugwort, southernwood, wormwood, penny-royal, origanum, hyssop, and in general all bitter and aromatic plants, &c. Some of them direct the specific to be simply mixed and taken in wine or honey and water; others join to it the use of some purgative remedy, which they say adds to its efficacy. Oribasius, Sylvius, &c. distinguish the specific that kills the worm, from the purgative that evacuates it, and direct them to be given at different times. Senertus gives a very satisfactory reason for adopting this method. If we give, says he, the purgative medicine and the specific at the same time, the latter will be hastily carried off before it can have exerted its powers on the worm: whereas, if we give the specific first, and thus weaken the worm, it will collect itself into a bundle, and, being brought away by means of the purge, the patient will be cured. The cure will be more speedy if the prima via have been previously lubricated. These precautions are all of them essential to the success of the remedy, nor are

they neglected by Madame Nouffer in her method of treatment. The panada and injection she prescribes the night before, to lubricate the intestines, and prepare the prima via. The fern root, taken in the morning, kills and detaches the worm; of this the patients are sensible by the cessation of the pain in the stomach, and by the weight that is felt in the lower belly. The purgative bolus administered two hours after this, procures a complete evacuation; it is composed of substances that are at once purgative and vermifuge, and which, even when administered alone, by different physicians, sometimes succeeded in expelling the worm. If this purgative appear to be too strong, the reader is desired to recollect, that it produced no ill effects in either of the cases that came under the observation of the physicians appointed to make the trials; and that in one of those cases, by diminishing the dose, they evidently retarded the evacuations.— Regard however, they observe, is to be had both to the age and the temperament of the patient, and the treatment should always be directed by a prudent and experienced physician, who may know how to vary the proportions of the dose as circumstances may require. If the purgative be not of sufficient strength, the worm, after being detached by the specific, remains too long a time in the intestines, and becoming soon corrupted, is brought away only in detached portions: on the other hand, if the purgative be too strong, it occasions too much irritation, and evacuations that cannot fail to be inconvenient.

Madame Nouffer's long experience has taught her to distinguish all these circumstances with singular adroitness.

This method of cure is, as we have seen, copied in a great measure from the ancients: it may be possible to produce the same effects by varying the remedies; but the manner of applying them is by no means indifferent: we shall be always more certain of success, if the intestines be previously evacuated, and if the specific be given some time before the purgative bolus. It is to this method that Madame Nouffer's constant success is attributed.

Her remedy has likewise some power over the tænia solium; but as the rings of this worm separate from each other more easily than those of the tænia lata, it is almost impossible for it to be expelled entire. It will be necessary therefore to repeat the treatment several times, till the patient cease to void any portions of worms. It must likewise be repeated, if, after the expulsion of one tænia solium, another should be generated in the intestinal canal. This last case is so rare, that it has been supposed that no person can have more than one of these worms; and for this reason it has been named solitary worm, which, being once removed, could never be renewed or replaced by a second: but experience has proved, that this notion is an ill-founded prejudice; and we know that sometimes these worms succeed each other, and that sometimes several of them exist together. Two living tæniae have frequently been expelled from the same patient. Dr De Haen relates an instance of a woman who voided 18 tæniae at once. In these cases the symptoms are usually more alarming; and the appetite becomes excessive, because these worms derive all their nourishment from the chyle. If too austere and ill-judged a regimen deprives

Worms. deprives them of this, they may be expected to attack even the membranes of the intestines themselves. This evil is to be avoided by eating frequently.

Such are the precautions indicated in this disease. The ordinary vermifuge remedies commonly procured only a palliative cure, perhaps because they were too often improperly administered. But the efficacy of the present remedy, in the opinion of the French physicians, seems to be sufficiently confirmed by experience. To the above account, however, it seems proper to subjoin the following observations by Dr Simmons.

"A Swiss physician, of the name of Herrenschwand, more than 20 years ago, acquired no little celebrity by distributing a composition of which he styled himself the inventor, and which was probably of the same nature as Madame Nouffer's. Several very eminent men, as Tronchin, Hovius, Bonnet, Cramer, and others, have written concerning the effects of this remedy. It seems that Dr Herrenschwand used to give a powder by way of preparation, the night before he administered his specific. Nothing could be said with certainty concerning the composition either of one or the other. The treatment was said sometimes to produce most violent effects, and to leave the patients in a valetudinary state. Dr De Haen was dissuaded by his friends from using it, because it disordered the patients too much. It will be readily conceived, now that we are acquainted with Madame Nouffer's method, that these effects were occasioned wholly by the purgative bolus. It is not strange, that resin of scammony or jalap, combined with mercurius dulcis and gamboge, all of them in strong doses, should in many subjects occasion the greatest disorders. It seems likely, however, that much of the success of the remedy depends on the use of a drastic purge. Some of the ancients who were acquainted with the virtues of the fern root, observed that its efficacy was increased by scammony. Resinous purges, especially when combined with mercury, have often been given with success in cases of tænia. Dr De Haen saw a worm of this sort five ells long expelled by the resin of jalap alone. Dr Gaubius knew a woman who had taken a variety of anthelmintic remedies without any effect, though she had voided a portion of tænia an ell and a half long previous to the use of these medicines: but at length, after taking a purge of singular strength, she voided the worm entire. Many other instances of the same kind are to be met with in authors. Other remedies have occasionally been given with success. In Sweden, it has been a practice to drink several gallons of cold water, and then to take some drastic purge. Boerhaave says, that he himself saw a tænia measuring 300 ells expelled from a Russian by means of the sulphate of iron.

From some late accounts, there is reason to believe that Dr Herrenschwand's remedy for tænia does not so exactly agree with that of Madame Nouffer as Dr Simmons seems to imagine. According to the account given us by a gentleman who had his information from Dr Herrenschwand himself, it consists entirely of gamboge and fixed vegetable alkali.

OF POISONS.

Of many poisons we have already treated, but there
VOL. XIII. Part II.

are some of which nothing has hitherto been said. Among the most fatal of these are the bites and stings of serpents, scorpions, &c. According to Dr Mead, the symptoms which follow the bite of a viper are, an acute pain in the place wounded, with a swelling, at first red, but afterwards livid, which by degrees spreads farther to the neighbouring parts; with great faintness, and a quick, low, and sometimes interrupted pulse; great sickness at stomach, with bilious convulsive vomitings, cold sweats, and sometimes pains about the navel. Frequently a fanguous liquor runs from the small wound, and little pustules are raised about it: the colour of the whole skin in less than an hour is changed yellow, as if the patient had the jaundice. These symptoms are very frequently followed by death, especially if the climate be hot, and the animal of a large size. This is not, however, the case with all kinds of serpents. Some, we are assured, kill by a fatal sleep; others are said to produce an universal haemorrhage and dissolution of the blood; and others an unquenchable thirst. But of all the species of serpents hitherto known, there is none whose bite is more expeditiously fatal than that of the rattle-snake. Dr Mead tells us, that the bite of a large serpent of this kind killed a dog in a quarter of a minute; and to the human species they are almost equally fatal. Of this serpent it is said, that the bite makes the person's skin become spotted all over like the skin of the serpent; and that it has such a motion as if there were innumerable living serpents below it. But this is probably nothing more than a dissolution of the blood, by which the skin becomes spotted as in petechial fevers, at the same time that the muscles may be convulsed as in the distemper called hieranosos, which was formerly thought to be the effect of evil spirits: but it is even not improbable that observers have been somewhat aided by fancy and superstition when they thought that they detected such appearances.

It has justly appeared surprising to philosophers, how such an inconsiderable quantity of matter as the poison emitted by a viper at the time of biting should produce such violent effects. But all inquiries into this matter must necessarily be uncertain; neither can they contribute any thing towards the cure. It is certain that the poison produces a gangrenous disposition of the part itself, and likewise seemingly of the rest of the body; and that the original quantity of poison continues some time before it exerts all its power on the patient, as it is known that removing part of the poisonous matter by suction will alleviate the symptoms. The indications of cure then are three: 1. To remove the poisonous matter from the body: Or, 2. If this cannot be done, to change its destructive nature by some powerful and penetrating application to the wound: And, 3. To counteract the effects of that portion already received into the system.

The poisonous matter can only be removed from the body by sucking the wound either by the mouth, or by means of a cupping glass; but the former is probably the more efficacious, as the saliva will in some measure dilute and perhaps obtund the poison. Dr Mead directs the person who sucks the wound to hold warm oil in his mouth, to prevent inflammation of the lips and tongue: but as bites of this kind are most likely to happen in the fields, and at a distance from houses, the want of oil ought by no means to retard

the operation, as the delay of a few minutes might prove of the most fatal consequence; and it appears from Dr Mead's experiments, that the taking the poison of a viper into the mouth undiluted, is attended with no worse consequences than that of raising a slight inflammation. A quick excision of the part might also be of very great service.

The only way of answering the second indication is, by destroying the poisoned part by a red-hot iron, or the application of alkaline salts, which have the power of immediately altering the texture of all animal substances to which they are applied, provided they are not covered by the skin; and as long as the poison is not totally absorbed into the system, these must certainly be of use.

To answer the third indication, Dr Mead recommends a vomit of ipecacuanha, encouraged in the working with oil and warm water. The good effects of this, he says, are owing to the shake which it gives to the nerves, whereby the irregular spasms into which their whole system might be drawn are prevented. After this the patient must go to bed, and a sweat must be procured by cordial medicines; by which the remaining effects of the poison will be carried off.

It has been confidently asserted by many, that the American Indians are possessed of some specific remedy by which they can easily cure the bite of a rattlesnake. But Mr Cateby, who must have had many opportunities of knowing this, positively denies that they have any such medicine. They make applications indeed, and sometimes the patient recovers; but these recoveries he ascribes to the strength of nature overcoming the poison, more than to the remedies made use of. He says, they are very acute in their prognostics whether a person that is bit will die or not; and when they happen to receive a bite in certain parts of the body, when the teeth of the animal enter a large vein, for instance, they quietly resign themselves to their fate, without attempting any thing for their own relief. Indeed, so violent and quick is the operation of this poison, that unless the antidote be instantly applied, the person will die before he can get to a house. It would seem therefore eligible for those who are in danger of such bites, to carry along with them some strong alkaline ley, or dry alkaline salt, or both, which could be instantly clapt on the wound, and by its dissolving power would destroy both the poison and the infected parts. Strong cordials also, such as ardent spirits, volatile alkali, &c. might possibly excite the languid powers of nature, and enable her to expel the enemy, which would otherwise prove too powerful. This seems to be somewhat confirmed from the account we have in the Philosophical Transactions of a gentleman bit by a rattlesnake, who was more relieved by a poultice of vinegar and vine-ashes put to his wound than any thing else. The vine-ashes being of an alkaline nature, must have saturated the vinegar, so that no part of the cure could be attributed to it: on the other hand, the ashes themselves could not have been saturated by the small quantity of acid necessary to form them into a poultice; of consequence they must have operated by their alkaline quality.—Soap ley, therefore, or very strong salt of tartar, may reasonably be thought to be the best external applica-

tion, not only for the bites of vipers, but of every venomous creature; and in fact we find dry salt universally recommended both in the bites of serpents and of mad dogs. Dr Mead recommends the fat of vipers immediately rubbed into the wound; but owns that it is not safe to trust to this remedy alone.

Some years ago the volatile alkali was strongly recommended by M. Sage of the French academy, as a powerful remedy against the bite of the viper: and, by a letter from a gentleman in Bengal to Dr Wright, it would appear that this article, under the form of the eau de l'oeuf, which is very little if any thing different from the spiritus ammonice succinatus of the London Pharmacopoeia, has been employed with very great success against this affection in the East Indies: but from the trials made with it by the abbé Fontana, published in his Treatise on the Poison of the Viper, it would appear that it by no means answered his expectation; and the efficacy of this, as well as of the snake pills mentioned under the article HYDROPHOBIA, still requires to be confirmed by further experience.

This is a disemper not very common, but it has been observed by the ancient physicians, and is described by Hippocrates under the name of morbis niger. It shows itself by a vomiting and purging of black tar-like matter, which Hippocrates, Boerhaave, and Van Swieten, supposed to be occasioned by atrabilis. But Dr Home, in his Clinical Experiments, endeavours to shew that it is owing to an effusion of blood from the mesenteric vessels, which, by its stagnation and corruption, assumes that strange appearance. The disease, he says, frequently follows hemorrhage; and those of a scorbutic habit are most subject to it. It is an acute disease, and terminates soon; yet it is not attended with any great degree of fever. In one of Dr Home's patients the crisis happened on the eighth day by diarrhoea; in another, on the 14th, by sweat and urine; and a third had no evident critical evacuation.

As to the cure, Dr Home observes, that bleeding is always necessary where the pulse can bear it; nor are we to be deterred from it by a little weakness of the pulse, more than in the enteritis. Emetics are hurtful, but purgatives are useful. But the most powerful medicine for checking this hemorrhage is the sulphuric acid: and, that this might be given in greater quantity, he mixed it with mucilage of gum arabic; by which means he was enabled to give double the quantity he could otherwise have done. The cold bath was tried in one instance, but he could not determine whether it was of any service or not. The cure was completed by exercise and cinchona.

Dr Buchan observes, that from the annual registers of the dead, it appears that about one half of the children born in Great Britain die under twelve years of age; and this very great mortality he attributes in a great measure to wrong management. The particulars of this wrong management enumerated by him are,

1. Mothers not suckling their own children. This, he owns, it is sometimes impossible for them to do; but

Diseases of Children. but where it can be done, he affirms that it ought never to be omitted. This, he says, would prevent the unnatural custom of mothers leaving their own children to suckle those of others; on which he passes a most severe censure, and indeed scarce any censure can be severe enough upon such inhumanity. Dr. Buchanan informs us, "He is sure he speaks within bounds, when he says not one in a hundred of these children live who are thus abandoned by their mothers." For this reason he adds, that no mother should be allowed to suckle another's child till her own be fit to be weaned. A regulation of this kind would save many lives among the poorer sort, and would do no harm to the rich; as most women who make good nurses are able to suckle two children in succession upon the same milk.

2. Another source of the diseases of children is the unhealthiness of parents: and our author insists that no person who labours under an incurable malady ought to marry.

3. The manner of clothing children tends to produce diseases. All that is necessary here, he says, is to wrap the child in a soft loose covering; and the softness of every part of the infant's body sufficiently shows the injury which must necessarily ensue by pursuing a contrary method.

4. A new-born infant, instead of being treated with syrups, oils, &c. ought to be allowed to suck the mother's milk almost as soon as it comes into the world. He condemns the practice of giving wines and spirituous liquors along with the food soon after birth; and says, that if the mother or nurse has a sufficient quantity of milk, the child will need little or no other food before the third or fourth month. But to this it may reasonably be objected, not only that the nursing would thus be very severe on the mother; but if the child be left thus long without other food, it will not easily relish that food for some time, and its stomach is apt to be easily hurt by a slight change of diet after it has been long accustomed to one thing. The human species are unquestionably fitted by nature for a mixed aliment, both from the vegetable and animal kingdom. And the analogy of other animals belonging to the class of mammalia for whom milk is equally provided at the earliest periods of life, would lead us to the conclusion, that mixed aliment is well fitted for the human species even in the earliest periods of infancy. The lamb is no sooner dropped than, by natural instinct, it crops the grass as well as it sucks its mother. And the stomach in the human species, immediately after birth, can digest other food as well as milk. Neither can it be shown, that the strongest and most healthy infants are those which get no other food but the mother's milk during the first months of their life. In fact, children are evidently of a weak and lax habit of body, so that many of their diseases must arise from that cause; all directions which indiscriminately advise an antiphlogistic regimen for infants as soon as they come into the world, must of necessity be wrong. Many instances in fact might be brought to show, that by the preparatory method of starving infants, and at the same time treating them with vomits and purges, they are often hurried out of the world. Animal food indeed, particularly under the form of broths, is excessively agreeable to children, and they ought to be indulged

with it in moderation. This will prove a much better remedy for those acidities with which children are often troubled, than magnesia alba, crabs eyes, or other absorbents, which have the most pernicious effects on the stomachs of these tender creatures, and pall the appetite to a surprising degree. The natural appetites of children are indeed the best rule by which we can judge of what is proper or improper for them. They must no doubt be regulated as to the quantity; but we may be assured that what a child is very fond of will not hurt it, if taken in moderation. When children are sick, they refuse every thing but the breast; and if their distemper be very severe, they will refuse it also, and in this case they ought not to be pressed to take food of any kind; but when the sickness goes off, their appetite also returns, and they will require the usual quantity of food.

According to Dr. Armstrong, inward fits, as they are called, are in general the first complaint that appears in children; and as far as he has observed, most, if not all infants, during the first months, are more or less liable to them. The symptoms are these: The child appears as if it was asleep, only the eyelids are not quite closed; and if you observe them narrowly, you will see the eyes frequently twinkle, with the white of them turned up. There is a kind of tremulous motion in the muscles of the face and lips, which produces something like a sinner or a smile, and sometimes almost the appearance of a laugh. As the disorder increases, the infant's breath seems now and then to stop for a little; the nose becomes pinched; there is a pale circle about the eyes and mouth, which sometimes changes to livid, and comes and goes by turns; the child starts, especially if you attempt to stir it though ever so gently, or if you make any noise near it. Thus disturbed, it sighs, or breaks wind, which gives relief for a little, but presently it relapses into the dozing. Sometimes it struggles hard before it can break wind, and seems as if falling into convulsions; but a violent burst of wind from the stomach, or vomiting, or a loud fit of crying, sets all to rights again. As the child increases in strength, these fits are the more apt to go off spontaneously and by degrees; but in case they do not, and if there is nothing done to remove them, they either degenerate into an almost constant drowsiness, (which is succeeded by a fever and the thrush), or else they terminate in vomitings, sour, curdled, or green stools, the watery gripes, and convulsions. The thrush indeed very often terminates in these last symptoms. As these complaints naturally run into one another, or succeed one another, they may be considered, in a manner, as only different stages of the same disease, and which derive their origin from the same cause. Thus, the inward fits may be looked upon as the first stage of the disorder; the fever, and thrush (when it happens), as the second; the vomitings, sour, curdled, green or watery stools, as the third; and convulsions, as the last.

As to the cause of these complaints, he observes, that in infants the glandular secretions, which are all more or less glutinous, are much more copious than in adults. During the time of sucking, the glands of the mouth and fauces being squeezed by the contraction of the muscles, pour forth their contents plentifully; which afterwards mixing with the mucus of the gullet

and stomach, render the milk of a slimy consistence, by which means it is not so readily absorbed into the lacteals; and as in most infants there is too great an acidity in the stomach, the milk is thereby curdled, which adds to the load; hence sickness and spasms, which, being communicated by sympathy to the nerves of the gullet and fauces, produce the convulsive motions above described, which go commonly by the name of inward fits. The air, likewise, which is drawn in during respiration, mixing with the milk, &c. in the stomach, perhaps contributes towards increasing the spasms above mentioned. Dr Armstrong is the more induced to attribute these fits to the causes now assigned, that they always appear immediately after sucking or feeding; especially if the child has been long at the breast, or fed heartily, and has been laid down to sleep without having first broken wind. Another reason is, that nothing relieves them so soon as belching or vomiting; and the milk or food they throw up is generally either curdled, or mixed with a large quantity of heavy phlegm. If they be not relieved by belching or vomiting, the fits sometimes continue a good while, and gradually abate, according as the contents of the stomach are pushed into the intestines; and as soon as the former is pretty well emptied, the child is waked by hunger, cries, and wants the breast; he sucks, and the same process is repeated.—Thus, some children for the first weeks are kept almost always in a dose, or seemingly so; especially if the nurses, either through laziness or want of skill, do not take care to rouse them when they perceive that it is not a right sleep, and keep them awake at proper intervals. This dozing is reckoned a bad sign amongst experienced nurses; who look upon it as a forerunner of the thrush, as indeed it often is; and therefore, when it happens, we ought to be upon our guard to use the necessary precautions for preventing that disorder.

For these disorders, the only remedy recommended by Dr Armstrong is antimonial wine, given in a few drops, according to the age of the infant. By this means the superabundant mucus will no doubt be evacuated; but at the same time we must remember, that this evacuation can only palliate, and not cure the disease. This can only be effected by tonics; and, when from inward fits and other symptoms it appears that the tone of the stomach is very weak, a decoction of cinchona, made into a syrup, will readily be taken by infants, and may be safely exhibited from the very day they come into the world, or as soon as their bowels are emptied of the meconium by the mother's milk or any other means.

Dr Clarke observes, that fractures of the limbs, and compressions of the brain, often happen in difficult labours; and that the latter are often followed by convulsions soon after delivery. In these cases, he says, it will be advisable to let the navel-string bleed two or three spoonfuls before it be tied. Thus the oppression of the brain will be relieved, and the disagreeable consequences just mentioned will be prevented. But if this has been neglected, and fits have actually come on, we must endeavour to make a revulsion by all the means in our power; as by opening the jugular vein, procuring an immediate discharge of the urine and meconium, and applying small blisters to the back, legs, or behind the ears. The semicupium, too, would seem

to be useful in this case, by driving the oppressive load of fluids from the head and upper parts.

It sometimes happens after a tedious labour, that the child is so faint and weak as to discover little or no signs of life. In such a case, after the usual cleansing, the body should be immediately wrapped in warm flannel, and briskly tossed about in the nurse's arms, in order, if possible, to excite the languid circulation. If this fail, the breast and temples may be rubbed with brandy or other spirits; or the child may be provoked to cry, by whipping, or other stimulating methods, as the application of onion, or salt and spirit of hartshorn, to the mouth and nostrils. But after all these expedients have been tried in vain, and the recovery of the child absolutely despaired of, it has sometimes been happily revived by introducing a short catheter or blowpipe into the mouth, and gently blowing into the lungs at different intervals. Such children, however, are apt to remain weak for a considerable time, so that it is often no easy matter to rear them; and therefore particular care and tenderness will be required in their management, that nothing may be omitted which can contribute either to their preservation or the improvement of their strength and vigour.

All the disorders which arise from a retention of the meconium, such as the red gum, may easily be removed by the use of gentle laxatives; but the great source of mortality among children is the breeding of their teeth. The usual symptoms produced by this are fretting; restlessness; frequent and sudden startings, especially in sleep; coliciveness; and sometimes a violent diarrhoea, fever, or convulsions. In general, those children breed their teeth with the greatest ease, who have a moderate laxity of the bowels, or a plentiful flow of saliva during that time.

In mild cases, we need only, when necessary, endeavour to promote the means by which nature is observed to carry on the business of dentition in the easiest manner. For this purpose, if a coliciveness be threatened, it must be prevented, and the body kept always gently open; the gums should be relaxed by rubbing them frequently with sweet oils, or other softening remedies of that kind, which will greatly diminish the tension and pain. At the same time, as children about this period are generally disposed to chew whatever they get into their hands, they ought never to be without something that will yield a little to the pressure of their gums, as a crust of bread, a wax candle, a bit of liquorice root, or such like; for the repeated muscular action, occasioned by the constant biting and gnawing at such a substance, will increase the discharge from the salivary glands, while the gums will be so forcibly pressed against the advancing teeth, as to make them break out much sooner, and with less uneasiness, than would otherwise happen. Some likewise recommend a slice of the rind of fresh bacon, as a proper masticatory for the child, in order to bring moisture into its mouth, and facilitate the eruption of the teeth by exercising the gums. If these means, however, prove ineffectual, and bad symptoms begin to appear, the patient will often be relieved immediately by cutting the inflamed gum down to the tooth, where a small white point shows the latter to be coming forward. When the pulse is quick, the skin hot and dry, and the child of a sufficient age and strength, emptying the vessels by bleeding,

Diseases of Children. ing, especially at the jugular, will frequently be necessary here, as well as in all other inflammatory cases; and the belly should be opened from time to time by emollient, oily, or mucilaginous clysters. But, on the contrary, if the child be low, sunk, and much weakened, repeated doses of the spirit of hartshorn, and the like reviving medicines, ought to be prescribed. Blisters applied to the back, or behind the ears, will often be proper in both cases. A prudent administration of opiates, when their use is not forbid by costiveness or otherwise, is sometimes of great service in difficult teething, as, by mitigating pain, they have a tendency to prevent its bad effects, such as a fever, convulsions, or other violent symptoms; and often they are absolutely necessary, along with the testaceous powders, for checking an immoderate diarrhoea.

When cathartics are necessary, if the child seems too tender and weak to bear their immediate operation, they should be given to the nurse; in which case they will communicate so much of their active powers to the milk as will be sufficient to purge the infant. This at least certainly holds with regard to some cathartics; such, for example, as the infusion of senna, particularly if a very weak infusion be employed, and not used to such an extent as to operate as a purgative to the nurse.

As most young children, if in health, naturally sleep much, and pretty soundly, we may always be apt to suspect that something is amiss when they begin to be subject to watching and frights; symptoms which seldom or never occur but either in consequence of some present disorder not perceived, or as the certain forerunners of an approaching indisposition. We should immediately, therefore, endeavour to find out the cause of watchfulness, that we may use every possible means to remove or prevent it; otherwise the want of natural rest, which is so very prejudicial to persons of all ages, will soon reduce the infant to a low and emaciated state, which may be followed by a hectic fever, diarrhoea, and all the other consequences of weakness. These symptoms, being always the effects of irritation and pain, may proceed, in very young infants, from crudities or other affections of the primæ viæ producing flatulencies or gripes; about the sixth or seventh month, they may be owing to that uneasiness which commonly accompanies the breeding of the teeth; and after a child is weaned, and begins to use a different kind of food, worms become frequently an additional cause of watchings and disturbed sleep. Hence, to give the necessary relief on these occasions, the original complaint must first be ascertained from the child's age and other concomitant circumstances, and afterwards treated according to the nature of the case. Women and nurses are too apt to have recourse to opiates in the watchings of children, especially when their own rest happens to be much disturbed by their continual noise and clamour. But this practice is often prejudicial, and never ought to have place when the belly is in the least obstructed.

There is no complaint more frequent among children than that of worms, the general symptoms of which have been already enumerated; but it must be observed, that all the symptoms commonly attributed to worms, may be produced by a foulness of the bowels. Hence practitioners ought never to rest satisfied with admini-

stering to their patients such medicines as are possessed only of an anthelmintic quality, but to join them with those which are particularly adapted for cleansing the primæ viæ; as it is uncertain whether a foulness of the bowels may not be the cause of all the complaints. This practice is still the more advisable, on account of viscoid humours in the intestines affording lodgement to the ova of worms; which, without the convenience of such a receptacle, would be more speedily discharged from the body.

The difficulty of curing what is called a worm fever, arises, according to Dr Musgrave, from its being frequently attributed to worms, when the cause of the disorder is of a quite different nature. He does not mean to deny that worms do sometimes abound in the human body, nor that the irritation caused by them does sometimes produce a fever; but he apprehends these cases to be much more uncommon than is generally imagined, and that great mischief is done by treating some of the disorders of children as worm cases, which really are not so. Dr Hunter is of the same opinion on this point. He has, we are told, dissected great numbers of children who have been supposed to die of worm fevers, and whose complaints were of course treated as proceeding from worms, in whom, however, there appeared, upon dissection, to be not only no worms, but evident proofs of the disorder's having been of a very different nature.

The spurious worm fever, as Dr Musgrave terms it, has, in all the instances he has seen of it, arisen evidently from the children having been indulged with too great quantities of fruit. Every sort of fruit eaten in excess will probably produce it; but an immoderate use of cherries seems to be the most common cause of it. The approach of this disorder has a different appearance, according as it arises from a habit of eating fruit in rather too large quantities, or from an excessive quantity eaten at one time. In the former case, the patient gradually grows weak and languid; his colour becomes pale and livid; his belly swells and grows hard; his appetite and digestion are destroyed; his nights grow restless, or at least his sleep is much disturbed with startings, and then the fever soon follows, in the progress of which, the patient grows comatose, and at times convulsed; in which state, when it takes place to a high degree, he often dies. The pulse at the wrist, though quick, is never strong or hard; the carotids, however, beat with great violence, and elevate the skin so as to be distinctly seen at a distance. The heat is at times considerable, especially in the trunk; though at other times, when the brain is much oppressed, it is little more than natural. It is sometimes accompanied by a violent pain of the epigastric region, though more commonly the pain is slight, and terminates in a coma; some degree of pain, however, seems to be inseparable from it, so as clearly to distinguish this disorder from other comatose affections.

When a large quantity of fruit has been eaten at once, the attack of the disorder is instantaneous, and its progress rapid; the patient often passing, in the space of a few hours, from apparently perfect health, to a stupid, comatose, and almost dying state. The symptoms of the fever, when formed, are in both cases nearly the same; except that, in this latter sort, a little purulent matter is sometimes discharged, both by vomit

mit and stool, from the very first day. The stools, in both cases, exhibit sometimes a kind of curd resembling curdled milk, at other times a floating substance is observed in them; and sometimes a number of little threads and pellicles, and now and then a single worm.

Strong purgatives, or purges frequently repeated, in this disorder, are greatly condemned by Dr Armstrong, as they in general not only aggravate the symptoms already present, but are sometimes the origin of convulsions. Bloodletting is not to be thought of in any stage of the disorder.

Although frequent purging, however, be not recommended, yet a single vomit and purge are advised in the beginning of the disorder, with a view to evacuate such indigested matter and mucus as happens to remain in the stomach and bowels. These having operated properly, there is seldom occasion for repeating them; and it is sufficient, if the body be costive, to throw up, every second or third day, a clyster, composed of some grains of aloes, dissolved in five or six ounces of infusion of chamomile.

The principal part of the cure, however, depends upon external applications to the bowels and stomach; and as the cause of the disorder is of a cold nature, the applications must be warm, cordial, and invigorating; and their action must be promoted by constant actual heat.

When any nervous symptoms come on, or remain after the disorder is abated, they are easily removed by giving a pill with a grain or two of asafoetida once or twice a day.

The diagnostics of worms are very uncertain; but, even in real worm cases, the treatment above recommended would, it is imagined, be much more efficacious than the practice commonly had recourse to. As worms either find the constitution weakly, or very soon make it so, the frequent repetition of purges, particularly mercurials, cannot but have a pernicious effect. Bear's foot is still more exceptionable, being in truth to be ranked rather among poisons than medicines. Worm feed and biters are too offensive to the palate and stomach to be long persisted in, though sometimes very useful. The powder of coralline creates disgust by its quantity; and the infusion of pink root is well known to occasion now and then vertiginous complaints and fits.

Fomenting the belly night and morning with a strong decoction of rue and wormwood, is much recommended. It is a perfectly safe remedy, and, by invigorating the bowels, may thereby have some influence in rendering them capable of expelling such worms as they happen to contain. After the fomentation, it is advised to anoint the belly with a liniment, composed of one part of essential oil of rue, and two parts of a decoction of rue in sweet oil. It is, however, a matter of great doubt whether these external applications, in consequence of the articles with which they are impregnated, exert any influence on the worms themselves.

The diet of children disposed to worms should be warm and nourishing, consisting in part at least of animal food, which is not the worse for being a little seasoned. The drink may be any kind of beer that is well hopped, with now and then a small draught of

porter or negus. A total abstinence from butter is medical, not so necessary, perhaps, as is generally imagined. Poor cheese must by all means be avoided; but such as is rich and pungent, in a moderate quantity, is particularly serviceable. In the spurious worm fever, the patient should be supported occasionally by small quantities of broth; and, at the close of it, when the appetite returns, the first food given should be of the kinds above recommended.

The diet here recommended will, perhaps, be thought extraordinary, as the general idea is at present, that, in the management of children, nothing is so much to be avoided as repletion and rich food. It is no doubt an error to feed children too well, or to indulge them with wine and rich sauces; but it is equally an error to confine them to too strict or too poor a diet, which weakens their digestion, and renders them much more subject to disorders of every kind, but particularly to disorders of the bowels. In regard to the spurious worm fever, if it be true that acid fruits too plentifully eaten are the general cause of it, it follows as a consequence, that a warm nutritious diet, moderately used, will most effectually counteract the mischief, and soonest restore the natural powers of the stomach. Besides, if the disorder does not readily yield to the methods here directed, as there are many examples of its terminating by an inflammation and suppuration of the navel, it is highly advisable to keep this probability in view, and, by a moderate allowance of animal food, to support those powers of nature, from which only such a happy crisis is to be expected.

Besides these, many other diseases might here be mentioned, which, if not peculiar to infants, are at least peculiarly modified by the infant state. But into details respecting these we cannot propose to enter. It is sufficient to say, that due regard being paid to age and constitution, the cure is to be conducted on the same general principles as in the adult state.

MEDICAL JURISPRUDENCE.

During the progress of science in Europe this subject has not been altogether neglected. But we may safely venture to assert, that even from many enlightened governments it has hitherto claimed much less attention than its importance merits. At the British universities this has been two much the case. It is indeed true, that for near 20 years a few lectures on this subject have been delivered at the university of Edinburgh, by the professor of the institutions of medicine. But he could by no means consider the subject on that extensive scale which its importance merited. And he had often expressed his regret, that, as in several of the foreign universities, a professorship had not been instituted for the express purpose of giving a course of lectures on medical jurisprudence. That defect, however, in medical education at Edinburgh is now supplied. When that able and upright statesman Lord Grenville, to whom every thing that regarded the laws of his country was an object of peculiar attention, was at the head of his majesty's councils, a regius professorship of juridical and political medicine was established in the university of Edinburgh by a royal warrant. And

Medical Jurisprudence. And there is every reason to hope, that this appointment will be attended with many effects highly beneficial to the nation.

A short view of the extent and importance of this subject will, we presume, not be unacceptable to the intelligent reader.

Whatever aid the science of medicine can contribute towards the good of the state, and the execution of its laws, has been by the Germans denominated State Medicine; a new, but not improper, appellation, for that branch of knowledge which many writers have termed Medical Jurisprudence.

It comprehends both medical police and juridical medicine. The former consists of the medical precepts which may be of use to the legislature or to the magistracy. The latter is the aggregate of all the information, afforded by the different branches of medicine, which is necessary for elucidating doubtful questions in courts of law.

Although there are some traces of juridical medicine in the Justinian code; such as determining the real period of birth, with a view to prevent the imposition of spurious children: it properly originated with the code of laws enacted by the emperor Charles V. under the name of Constitutio criminalis Carolina; in which it is ordained, that the opinions of physicians should be taken, with regard to the danger of wounds, child-murder, murder, poisoning, procured abortion, concealed pregnancy, &c. These directions, and the impossibility which was found of determining many questions by simply legal means, induced some legislators to enjoin, that all tribunals and judges should procure from sworn physicians, appointed to this office, their opinions concerning all the subjects to be mentioned hereafter.

Since that time, it has been treated systematically by many learned men; such as Fortunatus Fidelis, Zacchias, Alberti, Hebenstreit, Haller, Ludwig, Plenck; and lastly, in the most masterly manner, by Metzger. Numberless dissertations have been written on all its parts; and among those who contributed to its advancement, we may reckon Ambrose Parry, Bohn, Butener, Morgagni, Camper, and Gruner. Collections of cases, illustrating its principles, have been made by Amman, Daniel, Bucholz, Pyl, Seherf and Metzger. These are only a few of the principal writers, who have attended to this science: to enumerate more would be unnecessary.

From its very nature, it is evident how necessary a knowledge of this science must be to every medical practitioner, who is liable to be called upon to illustrate any question comprehended under it before a court of justice. On his answers, the fate of the accused person must often depend; both judge and jury regulating their decision by his opinion. On the other hand, while he is delivering his sentiments, his own reputation is before the bar of the public. The acuteness of the gentlemen of the law is universally acknowledged; the versatility of their genius, and the quickness of their apprehension, are rendered almost inconceivable, by constant exercise. It is their duty to make every possible exertion for the interest of their client, and they seldom leave unnoticed any inaccurate or contradictory evidence. How cautious must, then, a medical practitioner be, when examined before such men, when it is their duty to expose

his errors, and magnify his uncertainties, till his evidence seem contradictory and absurd? How often must he expose himself to such severe criticism, if he be not master of the subject on which he is giving evidence, and have not arranged his thoughts on it according to just principles? On the other hand, he may deserve and gain much credit, by so public a display of judgement and professional knowledge.

Some acquaintance with this part of medical science must be useful at least, and sometimes necessary, to judges and lawyers. They will thus be enabled to estimate how much they may depend on the opinion of any physician, and will know how to direct their questions, so as to arrive at the truth, and avoid being misled by his partiality or favourite opinions. To the lawyer who conducts the defence of an accused person, in a criminal case, it is almost indispensable; without it, he cannot do justice to the cause of his client.

Before criminal courts, the questions which occur most generally are, respecting

1. 1. The cause of death, as ascertained from the examination of the body.
2. 2. The sufficiency of the supposed cause to have produced death.
3. 3. Probable event of wounds, contusions, &c.
4. 4. The importance of the part injured.
5. 5. Supposed child-murder; whether still-born or not.
6. 6. Whether death accidental or intended.
7. 7. Abortion; its having occurred.
8. 8. Spontaneously, from habit; accidentally, from external violence or passions of the mind; or intentionally, from the introduction of a sharp instrument, use of certain drugs, &c.
9. 9. Rape; its being attempted or consummated; recent or previous defloration.
10. 10. The responsibility of the accused for his actions.

Before civil courts the questions generally regard,

1. 1. The state of mind; madness, melancholy, idiotism.
2. 2. Pregnancy; concealed, pretended.
3. 3. Parturition; concealed, pretended, retarded, premature.
4. 4. The still-born of twins.
5. 5. Diseases; concealed, pretended, imputed.
6. 6. Age and duration of life.

Before consistorial courts, the subjects investigated are,

1. 1. Impotence; general, relative, curable, incurable.
2. 2. Sterility; curable, relatively incurable, absolutely incurable.
3. 3. Uncertainty of sex; hermaphrodites.
4. 4. Diseases preventing cohabitation; venereal disease, leprosy, &c.

MEDICAL POLICE.

Of incomparably greater consequence, and more widely extended influence, is the second division of this subject. It regards not merely the welfare of individuals, but the prosperity and security of nations. It is perhaps the most important branch of general police; for its influence is not confined to those whom accidental circumstances bring within its sphere, but extends over the whole population of the state.

Many

Many of its principles have been long acknowledged, and considered as necessary consequences of medical and political truths; and some few of them have acquired the authority of laws. But it was reserved for the philanthropic Frank, to collect the whole into one vast and beneficent system, and to separate it from juridical medicine; in the old systems of which, it was neglected, or mentioned only in a few short paragraphs. His enlarged mind perceived at once, and fully vindicated its importance. The very name of Medical Police, is now sufficient to attract the attention of legislators and of magistrates, and to make them desirous of becoming acquainted with its principles, and anxious to see them carried into execution. In fact, its influence is already visible in the countries where it is cultivated. If the principles of medical police were separated from the professional part of medicine, and communicated in a form generally intelligible, in what country have we reason to expect more beneficial effects from its influence than this? Where is the spirit of patriotism and benevolence so prevalent? What nation is more generous in its public institutions? Where does the individual sacrifice a part of his wealth so willingly for the benefit of the community? It seems only necessary to prove that an undertaking will be of advantage to the state, to have it carried into instant execution. But, can medical knowledge be more usefully employed than in pointing out the means of preserving or improving health; of supplying healthy nourishment to the poor, especially in times of scarcity; of opposing the introduction of contagious diseases, and of checking their progress; of securing to the indigent the advantages intended by their benefactors; of rearing the orphan to be the support of the nation which has adopted him; and of diminishing the horrors of confinement to the poor maniac and the criminal? These good effects are not to be promoted so much by rigid laws, as by recommendation and example. Nor can it be reasonably objected to a system of medical police, that it is a pleasing dream, which flatters the imagination, but the execution of which is in reality impracticable. As well might we entirely throw aside the rules of humanity, because no one is able to observe them all; or live without laws, because no existing code is unexceptionable.

Medical police may be defined,—The application of the principles deduced from the different branches of medical knowledge, for the promotion, preservation and restoration of general health.

The effects to be expected from it are the general welfare of the state, and increase of healthy population; and are to be attained by means of public institutions, express laws, and popular instruction. Instructing the people, and convincing them of the propriety of certain precautions and attentions, in regard to their own and the general state of health, are necessary to secure the good effects of our public institutions and regulations; to obtain respect and obedience in many things, to which no express law can be adapted; and, to induce them to forego what may be prejudicial to the safety of the community, and of themselves.

Public medical institutions and laws, must be adapted to the country for which they are intended. Many local circumstances, national character, habits of life, prevalent customs and professions, situation, climate, &c,

make considerable varieties necessary. And many institutions, many a law which would be highly beneficial to the public health, in some circumstances, would be useless, impracticable, and even hurtful, in others. These causes and their effects, must, therefore, be particularly attended to.

The principal authors who have written on this subject, are Alberti, Heister, Plaz, Frank, Hussey, Metzger, and Hebenstreit; to whom we may add Howard and Rumford.

The subjects which it comprehends, cannot be classed very regularly or systematically. Its views will be different, according to occasional and temporary causes; and its interference may sometimes be advantageously extended beyond what may seem the strict limits of a branch of the medical profession.

MEDICAL POLICE RELATES TO

THE SITUATION OF PLACES OF ABODE. Construction of houses.

AIR. Means of counteracting its impurity—Its various impregnations.

WATER. Its necessity and purity.

FOOD. Its various kinds—Comparative quantities of nourishment afforded by them—Cheaper kinds, which may be safely substituted in times of scarcity—Bread—Animal food—Butcher meat—Fish—Vegetables—Vessels—Cookery; Healthy; Economical.

DRINK. Beer—Ale—Porter—Cyder—Spirituoso liquors—Wine—Warm drinks—Adulterations of these liquors—Hurtful additions—Vessels.

FIRE and LIGHT.

CLOTHING.

CLEANLINESS.

PROFESSIONS. Manufacturers—Mechanics—Soldiers—Sailors—Men of letters.

HEALTHY PROPAGATION.

PREGNANT and PUPPERAL WOMEN.

NEW-BORN INFANTS. Registers of birth.

PHYSICAL EDUCATION.

PREVENTION OF ACCIDENTS. From poison—Hurtful Effluvia—Maniacs—Rabid animals.

RESTORATION of the APPARENTLY DEAD. Humane Societies—Care of the dying—Danger of too early—too late burial—Places of interment—manner of conducting it—Bills of mortality.

CONTAGIOUS and EPIDEMIC DISEASES. Plague—Purpura—Typhus—Dysentery—Smallpox—Inoculation—Extirpation of them—Leprosy—Itch and pox—Precautions to be taken, to prevent their introduction, to diminish their violence, to destroy their cause, and to counteract their effects.

MANAGEMENT of PUBLIC INSTITUTIONS, in which many people are collected under the care of the public.

Hospitals for the Indigent:

1. 1. Lying-in Hospitals.
2. 2. Foundling ditto.
3. 3. Orphan ditto.
4. 4. Hospitals for Education.

1. 5. Aged.
2. 6. Blind.
3. 7. Maimed.

• Prisoners of War.
• Lazarettos.
• Work-houses.
• Prisons.

• Maniacs.
• Convalescents.
• Incurables.

Having now treated of all the most important diseases to which the human body is subjected, we shall conclude the article MEDICINE, with a few observations on the means of preserving health, both for the general management of valetudinarians, and of those also who wish to obtain long life and good health by avoiding the causes of those diseases which the human species often bring upon themselves. On this subject much has been written at almost every period of medicine. And we may refer those readers who wish for a full and extensive view of this interesting subject to a very elaborate work lately published by Sir John Sinclair Bart. entitled the Code of Health and Longevity. Here we cannot propose to give even an abridged view of this extensive inquiry; but must content ourselves with offering only a very few general observations.

THAT part of the medical system which lays down rules for the preservation of health, and prevention of diseases, termed Hygiene, is not to be strictly understood as if it respected only those people who enjoy perfect health, and who are under no apprehensions of disease, for such seldom either desire or attend to medical advice; but is rather considered as relating to valetudinarians, or such as, though not actually sick, may yet have sufficient reason to fear that they will soon become so: hence it is that the rules must be applied to correct morbid dispositions, and to obviate various particulars which were shown to be the remote or possible causes of diseases.

From the way in which the several temperaments are commonly mentioned by systematic writers, it should seem as if they meant that every particular constitution might be referred to one or other of the four; but this is far from being the case, since by much the greater number of people have temperaments so indistinctly marked, that it is hard to say to which of the temperaments they belong.

When we actually meet with particular persons who have evidently either,

1. 1. Too much strength and rigidity of fibre, and too much sensibility;
2. 2. Too little strength, and yet too much sensibility;
3. 3. Too much strength, and but little sensibility;
4. or,
5. 4. But little sensibility joined to weakness;

we should look on such persons as more or less in the

valetudinarian state, who require that these morbid dispositions be particularly watched, lest they fall into those diseases which are connected with the different temperaments.

People of the first mentioned temperament being liable to suffer from continued fevers, especially of the inflammatory species, their scheme of preserving health should consist in temperate living, with respect both to diet and exercise; they should studiously avoid immoderate drinking, and be remarkably cautious lest any of the natural discharges be checked. People of this habit bear evacuations well, especially bleeding: they ought not, however, to lose blood but when they really require to have the quantity lessened; because too much of this evacuation would be apt to reduce the constitution to the second-mentioned temperament, in which strength is deficient, but sensibility redundant.

Persons of the second temperament are remarkably prone to suffer from painful and spasmodic diseases, and are easily ruffled; and those of the softer sex who have this delicacy of habit, are very much disposed to hysterical complaints. The scheme here should be, to strengthen the solids by moderate exercise, cold bathing, cinchona, and chalybeate waters; particular attention should constantly be had to the state of the digestive organs, to prevent them from being overloaded with any species of saburra which might engender flatulence, or irritate the sensible membranes of the stomach and intestines, from whence the disorder would soon be communicated to the whole nervous system. Persons of this constitution should never take any of the drastic purges, or strong emetics; neither should they lose blood but in cases of urgent necessity. But a principal share of management, in these extremely irritable constitutions, consists in avoiding all sudden changes of every sort, especially those with respect to diet and clothing, and in keeping the mind as much as possible in a state of tranquillity: hence the great advantages which people of this frame derive from the use of medicinal waters drunk on the spot, on account of that freedom from care and serious business of every kind, which generally obtains in all the places planned for the reception of valetudinarians.

The third-mentioned temperament, where there is an excess of strength and but little sensibility, does not seem remarkably prone to any distressing or dangerous species of disease; and therefore it can hardly be supposed that persons so circumstanced will either of themselves think of any particular scheme of management, or have recourse to the faculty for their instructions: such constitutions, however, we may observe, bear all kinds of evacuations well, and sometimes require them to prevent an over-fullness, which might end in an oppression of the brain or some other organ of importance.

But the fourth temperament, where we have weakness joined to want of sensibility, is exceedingly apt to fall into tedious and dangerous diseases, arising from a defect of absorbent power in the proper sets of vessels, and from languor of the circulation in general; whence corpulency, dropsy, jaundice, and different degrees of scorbutic affection. In order to prevent these, or any other species of accumulation and deprivation of the animal fluids, the people of this constitution should use a generous course of diet, with brisk

exercise, and be careful that none of the secretions be interrupted, nor any of the natural discharges suppressed. These constitutions bear purging well, and often require it; as also the use of emetics, which are frequently found necessary to supply the place of exercise, by agitating the abdominal viscera, and are of service to prevent the stagnation of bile, or the accumulation of mucous humours, which hinder digestion, and clog the first passages. The free use of mustard, horseradish, and the like sort of stimulating dietetics, is serviceable in these torpid habits.

When the general mass of fluids is increased beyond what is conducive to the perfection of health, there arises what the writers term a plethora, which may prove the source of different diseases; and therefore, when this overfullness begins to produce languor and oppression, care should be taken in time to reduce the body to a proper standard, by abridging the food and increasing the natural discharges, using more exercise, and indulging less in sleep.

But in opposite circumstances, where the fluids have been exhausted, we are to attempt the prevention of further waste by the use of strengthening stomachics, nourishing diet, and indulgence from fatigue of body or mind.

Vitiated fluids are to be considered as tainted either with the different kinds of general acrimony, or as betraying signs of some of the species of morbid matter which give rise to particular diseases, such as calculus, scurvy, &c.

During the state of infancy, we may sometimes observe a remarkable acidity, which not only shows itself in the first passages, but also seems to contaminate the general mass of fluids. As it takes its rise, however, from weak bowels, our views, when we mean to prevent the ill consequences, must be chiefly directed to strengthen the digestive organs, as on their soundness the preparation of good chyle depends; and hence small doses of rhubarb and chalybeates (either the natural chalybeate waters mixed with milk, or the murias ammoniae et ferris in doses of a few grains, according to the age of the child), are to be administered; and the diet is to be so regulated as not to add to this acid tendency: brisk exercise is likewise to be enjoined, with friction on the stomach, belly, and lower extremities.

Where the fluids tend to the putrescent state, which shows itself by fetid breath, sponginess and bleeding of the gums, a bloated look and livid cast, the diet then should be chiefly of fresh vegetables and ripe fruits, with wine in moderation, due exercise, and strengthening bitters.

Where acrimony shows itself by itching eruptions, uncommon thirst, and flushing heats, nothing will answer better than such sulphureous waters as the Harrowgate and Moffat, at the same time using a course of diet that shall be neither acrid nor heating.

So far with respect to those kinds of morbid matter which do not invariably produce a particular species of disease: but there are others of a specific nature, some of which are generated in the body spontaneously, and seem to arise from errors in diet, or other circumstances of ill management with respect to the animal economy; and hence it is sometimes possible, to a certain degree if not altogether, to prevent the ill con-

sequences. Thus, there are instances where returns of the geut have been prevented by adhering strictly to a milk diet.

The rheumatism has also been sometimes warded off by wearing a flannel shirt, or by using the cold bath without interruption.

Calculus may be retarded in its progress, and prevented from creating much distress, by the internal use of soap and lime-water, by soaps taken in milk or in veal-broth, or by the use of aerated alkaline water, which may perhaps be considered as being both more safe and more efficacious, and at the same time more pleasant, than any of the other practices.

The scurvy may be prevented by warm clothing and perseverance in brisk exercise, by drinking wine and cyder, and eating freely of such vegetable substances as can be had in those situations where this disease is most apt to show itself.

In constitutions where there is an hereditary disposition to the scrofula, if early precautions be taken to strengthen the solids by cold bathing, a nourishing course of diet, and moderate use of wine, the constitution which gives rise to the disease will probably be prevented from producing any very bad effects.

The other kinds of morbid matter, which are of the specific nature, are received into the body by infection or contagion.

The infection of a putrid fever or dysentery is best prevented by immediately taking an emetic on the first attack of the sickness or shivering; and if that do not completely answer, let a large blister be applied between the shoulders: by this method the nurses and other attendants on the sick in the naval hospitals have often been preserved. As to other infectious morbid matter, we must refer to what has already been said when treating of hydrophobia, poisons, gonorrhœa, &c.

The ill effects which may arise from the different species of faburra, are to be obviated, in general, by the prudent administration of emetics, and carefully abstaining from such kinds of food as are known to cause the accumulation of noxious matters in the first passages.

Crude vegetables, milk, butter, and other oily substances, are to be avoided by persons troubled with a fowels in the stomach; brisk exercise, especially riding, is to be used, and they are to refrain from fermented liquors: the common drink should be pure water; or water with a very little of some acident spirit, such as rum or brandy. Seltzer and Pyramont waters are to be drunk medicinally; and aromatic bitters, infusions, or tinctures, acidulated with sulphuric acid, will be found serviceable, in order to strengthen the fibres of the stomach, and promote the expulsion of its contents, thereby preventing the too hasty fermentation of the alimentary mixture. In order to procure immediate relief, magnesia alba, or creta preparata, will seldom fail; the magnesia, as well as the chalk, may be made into lozenges, with a little sugar and mucilage; and in that form may be carried about and taken occasionally by people afflicted with the acid faburra.

In constitutions where there is an exuberance or stagnation of bile, and a troublesome bitterness in the mouth, it is necessary to keep the bowels always free, by taking occasionally small doses of pure aloes, oleum ricini,

Means of preserving Health. ricini, superatartrite of potash, some of the common purging salts, or the natural purging waters.

When there is a tendency to the empyreumatic and rancid faburra, people should carefully avoid all the various kinds of those oily and high-seasoned articles of diet generally termed made-dishes, and eat sparingly of plain meat, without rich sauces or much gravy; and in these cases the most proper drink is pure water.

414 II. RULES for those who enjoy perfect HEALTH.

THERE can be no doubt, that, in general, temperance is the true foundation of health; and yet the ancient physicians, as we may see in the rules laid down by Celsus, did not scruple to recommend indulgence now and then, and allowed people to exceed both in eating and drinking: but it is safer to proceed to excess in drink than in meat; and if the debauch should create any extraordinary or distressing degree of pain or sickness, and a temporary fever should ensue, there are two ways of shaking it off, either to lie in bed and encourage perspiration, or to get on horse-back and by brisk exercise restore the body to its natural state. The choice of these two methods must always be determined by the peculiar circumstances of the parties concerned, and from the experience which they may before have had which agrees best with them.

If a person should commit excess in eating, especially of high-seasoned things, with rich sauces, a draught of cold water, acidulated with sulphuric acid, will take off the sense of weight at the stomach, and assist digestion by moderating and keeping within bounds the alimentary fermentation, and thus preventing the generation of too much flatus. The luxury of ices may be here of real service at the tables of the great, as producing similar effects with the cold water acidulated. Persons in these circumstances ought not to lay themselves down to sleep, but should keep up and use gentle exercise until they are sensible that the stomach is unloaded, and that they no longer feel any oppressive weight about the præcordia.

If a man be obliged to fast, he ought, if possible, during that time, to avoid laborious work: after suffering severe hunger, people ought not at once to gorge and fill themselves; nor is it proper, after being overfilled, to enjoin an absolute fast: neither is it safe to indulge in a state of total rest immediately after excessive labour, nor suddenly fall hard to work after having been long without motion: in a word, all changes should be

made by gentle degrees; for though the constitution of the human body be such that it can bear many alterations and irregularities without much danger, yet, when the transitions are extremely sudden, there is a great risk of producing some degree of disorder.

It is also the advice of Celsus to vary the scenes of life, and not confine ourselves to any settled rules: but as inaction renders the body weak and listless, and exercise gives vigour and strength, people should never long omit riding, walking, or going abroad in a carriage. Fencing, playing at tennis, dancing, or other similar engagements, which afford both exercise and amusement, as each shall be found most agreeable or convenient, are to be used in turn, according to the circumstances and tendency to any particular species of disease. But when the weakness of old age shall have rendered the body incapable of all these, then dry frictions with the flesh-brush will be very requisite to preserve health, by accelerating the flow of humours through the smallest orders of vessels, and preventing the fluids from stagnating too long in the cellular interstices of the fleshy parts.

Sleep is the great restorer of strength; for, during this time, the nutritious particles appear to be chiefly applied to repair the waste, and replace those that have been abraded and washed off by the labour and exercise of the day; but too much indulgence in sleep has many inconveniences, both with respect to body and mind, as it blunts the senses, and encourages the fluids to stagnate in the cellular membrane; whence corpulency, and its necessary consequences languor and weakness.

The proper time for sleep is the night, when darkness and silence naturally bring it on: sleep in the day time, from noise and other circumstances, is in general not so found or refreshing; and to some people is really distressful, as creating an unusual giddiness and languor, especially in persons addicted to literary pursuits. Custom, however, frequently renders sleep in the day necessary; and in those constitutions where it is found to give real refreshment, the propensity to it ought to be indulged, particularly in very advanced age.

With regard to the general regimen of diet, it has always been held as a rule, that the softer and milder kinds of aliment are most proper for children and younger subjects: that grown persons should eat what is more substantial; and old people lessen their quantity of solid food, and increase that of their drink both of the diluent and cordial kind.

Index.

M E D I C I N E.

Inflammation of the lungs, N° 183; of the mententry, 191; of the omentum, 190; of the peritoneum, 189; of the spleen, 199; of the stomach, 192; of the uterus, 204; Inflammatory tertian, 135; Inoculation, 225; Intermittent, 125; Intumescence, 334; Irregular tertian, 127; Itching, 77; Jaundice, 350; Jewish physicians, 1; King's evil, K. 349; L. 353; LEPRO, Gen. 88. 353; Leucorrhœa, 250; Lientery, 316; Locules, 357; Lochial discharge, immoderate, 248; Locked jaw, 280; Looseness, 109; Loss of voice, 379; Lues venerea, 350; Lumbago, 206; M. 328; MANIA, Gen. 67. 327; MELANCHOLIA, Gen. 66. 245; MENORRHAGIA, Gen. 39. 229; MILIARIA, Gen. 31. 380; MUTITAS, Gen. 111. 327; Madness, melancholy, furious, 328; Malignant sore throat, 179; Marcorret, 331; Measles, 227; Melancholy and mania, 85; Melane, 409; Memory, 83; Menstr, immoderate flow of, 246; Methodical test, 36; Misplaced gout, 215; Mobility, 88; Moderns, 54; Morbid thinness of the blood, 101; thickness of the blood, 102; Mumps, 182; N. 200; NEPHRITIS, Gen. 19. 374; NOSTALGIA, Gen. 106. 373; NYMPHOMANIA, Gen. 105. 112; Nausea, 231; Nettle rash, 333; Nervous consumption, fever, 166; Nightmare, 329; Nirles, 228; O. 393; OSTIPIATIO, Gen. 122. 210; ODONTALGIA, Gen. 23. 329; ONEIRODYNIA, Gen. 68.

OPHTHALMIA, Gen. 8. N° 174; Obstructed perspiration, 115; Occasional syncope, 274; Oesophagus, dangerous affection of, 406; Oribasius, 42; Origin of diseases, 62; P. 290; PALPITATIO, Gen. 54. 364; PARACUSIS, Gen. 97. 265; PARALYSIS, Gen. 43. 381; PARAPHONIA, Gen. 112. 232; PERIFRIGUS, Gen. 34. 189; PERITONITIS, Gen. 14. 299; PERTUSSIS, Gen. 57. 221; PESTIS, Gen. 27. 171; PHLOGOSIS, Gen. 7. 175; PHRENITIS, Gen. 9. 346; PHYSCONIA, Gen. 82. 338; PHYSOMETRA, Gen. 74. 371; PICA, Gen. 103. 336; PNEUMATOSIS, Gen. 72. 184; PNEUMONIA, Gen. 11. 370; POLYDIPSIA, Gen. 102. 335; POLYSARGIA, Gen. 71. 386; PROFUSIO, Gen. 116. 362; PSEUDOBLETTIS, Gen. 95. 382; PSYLLISMUS, Gen. 113. 389; PTYALISMUS, Gen. 119. 300; PYROSIS, Gen. 38. 75; Pain, 97; Palpitation, 265; Palsy, 269; from poisons, 52; Paracelsus, 268; Paraplegia, 45; Paulus, 184; Peripneumonia, 171; Phlegmatic, 173; Phlegmone, 237; Phthisis, 240; Pilet, 241; external, 242; from a procidentia ani, 243; running, 244; blind, 221; Plague, 100; Plethora, 355; Plica polonica, 185; Pleuritis, 211; Podagra, 408; Poisons, 30; Praxagoras, 59; Predisponent cause, 61; Proximate cause, 404; Puerperal fever, 237; Pulmonary consumption, 96; Pulsation of the arteries, 167; Putrid fever, 179; Putrid sore throat, 124; Pyrexia, 153; Q. 160; QUARTANA, Gen. 2. 153; QUOTIDIANA, Gen. 3.

Qualities of the animal solids, N° 69; Quartern with symptoms of other diseases, 158; complicated with other diseases, 159; Quotidian, genuine, 161; partial, 162; remitting, 163; Quotidiana deceptiva, 150; R. 347; RACHITIS, Gen. 83. 285; RAPHANIA, Gen. 52. 205; RHEUMATISMUS, Gen. 22. 227; RUBEOLA, Gen. 30. 212; Regular gout, 212; Remittent tertian, 138; Remitting quartan, 160; Respiration, 104; Retrocedent gout, 214; Rheumatism in the loins, 206; in the hip-joint, 227; in the thorax, 208; Rhazes, 47; Rickets, 347; Rules for preserving health, 414; for valetudinarians, 413; S. 372; SATYRIASIS, Gen. 104. 203; SCARLATINA, Gen. 32. 351; SCORBUTUS, Gen. 86. 349; SCROPHULA, Gen. 84. 350; SYPHILIS, Gen. 85. 199; SPLENITIS, Gen. 18. 383; STRABISMUS, Gen. 114. 272; SYSCOPE, Gen. 44. 163; SYNOCHIA, Gen. 4. 168; SYNOCHUS, Gen. 6. 218; St Anthony's fire, 284; St Vitus's dance, 256; Sanguineous apoplexy, 389; Salivation, 207; Sciatica, 122; Scirrhus, 351; Scurvy, 351; Sea scurvy, 401; Semen, difficult emission of, 131; Semi-tertian, 34; Serapion, 257; Serous apoplexy, 81; Sight, 94; Sleep, 132; Sleepy tertian, 222; Smallpox, 223; distinct, 224; confluent, 225; inoculated, 79; Smell, 365; Smelling, depraved, 106; Sneezing, 39; Soranus, 93; Spasm, 278; Spasmi, 302; Spasmodic colic, 133; tertian, Spina

Tertian complicated with other disorders,

VARICELLA, Gen. 29.

MEDICIS, COSIMO DE, was born in the year 1389, and was in the prime of life, at the death of his father, Giovanni. His conduct was distinguished for urbanity and kindness to the superior ranks of his fellow-citizens, and by a constant attention to the wants of the lower class, whom his munificence abundantly relieved. His prudence and moderation, however, could not repress the ambitious designs of the rival families, the Florentines and Medici; for in 1433, Rinaldo de Albizzi, at the head of a formidable party, carried the appointment of the magistracy. On returning from his country he was seized upon by his adversaries, and committed to prison. The conspirators not agreeing as to the proper method of dispatching their prisoner, one Peruzzi recommended poison, which was heard by Cosimo, who refused to take any other sustenance than a small portion of bread. In this dismal situation he remained four days, shut up from all his kindred and friends, where he soon expected to be numbered with the dead. But the man employed to take him off, unexpectedly proved his friend. Malavolta, the keeper of the prison, relented, and declared that he had no just reason to be alarmed, as he hesitated not to eat of every thing that was brought him.

His brother Lorenzo, and his cousin Averardo, raised a considerable body of men in Romagna and other districts; and being joined by the commander of the republican forces, they marched to Florence to relieve him. A decree was obtained from the magistracy, by which he was banished to Padua for ten years, his brother to Venice for five, and several of their relations shared a similar fate. Padua was in the dominions of Venice, and he received a deputation from the senate before he reached it, promising him their protection and assistance in whatever he should de-

fire. He rather experienced the treatment of a prince than of an exile, as they entertained the highest expectations from his great commercial knowledge. From this period his life may be considered as one continued scene of uninterrupted prosperity, and his family received education equal to that of the greatest potentates. In his public and private charities he was almost unbounded, and perhaps possessed more wealth than any single individual in Europe at that period. In his promotion of science and encouragement of learned men he was truly exemplary, and from this source he acquired the greatest honour and esteem.

His fostering hand protected the arts as well as the sciences; and architecture, sculpture, and painting, all flourished under his powerful protection. The countenance he showed to these arts was not such as their professors generally receive from the great; for the sums of money which he expended on pictures, statues, and public buildings, appear almost incredible. When he approached the period of his mortal existence, his faculties were still unimpaired; and 20 days before he died, he requested Ficino to translate from the Greek the treatise of Xenocrates on death. He died on the 11th of August 1464, at the age of 75, and gave strict injunctions, that his funeral should be conducted with as much privacy as possible. By public decree he was honoured with the title of Pater Patrie, an appellation which was inscribed on his tomb, and was declared by competent judges, to be founded in real merit.

MEDICI, LORENZO DE, filled, with great propriety, the Magnificent, was the grandson of Cosimo, and about 16 years of age at his decease. In 1469 his father died, and he succeeded to his authority as if it had constituted a part of his fortune. In the year 1474, Lorenzo incurred the displeasure of the pope for the opposition he