Medicine is the art of preventing and curing diseases.

History of Medicine.

This art is in itself so noble, and so generally useful to mankind, that many have thought it came originally from God by express revelation; and, accordingly, we find the heathens with one voice ascribing the origin of the medicinal art to their gods. Most people, however, are now of opinion, that it is of human invention; and that mankind were naturally led to it from casual observations on the diseases to which they found themselves subject.

At what time medicine was first reduced to rules, and began to be practised as an art, is not known. The most ancient physicians we read of were those who embalmed the patriarch Jacob by order of his son Joseph. The sacred writer styles these physicians servants to Joseph: from whence we may be assured that they were not priests, as the first physicians are generally supposed to have been; for in that age we know the Egyptian priests were in such high favour, that they retained their liberty, when, through a public calamity, all the rest of the people were made slaves to the prince.

It is not probable, therefore, that among the Egyptians religion and medicine were originally connected; and if we suppose this people not to have invented the art, but received it from some other nation, it is as little probable that the priests of that nation were their physicians, any more than those of Egypt already mentioned.

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

What seems most probable on this subject therefore is, that religion and medicine came to be mixed together only in consequence of that degeneracy into ignorance and superstition, which some time or other hath taken place among all nations. The Egyptians, we know, came at last to be sunk in the most ridiculous and absurd superstition; and then, indeed, it is no wonder to find their priests commencing physicians, and mingling charms, incantations, &c., with their remedies. That this was the case, tho' long after the days of Joseph, we are very certain; and indeed it seems as natural for ignorance and barbarism to combine religion with physic, as it for a civilized and enlightened people to keep them separate. Hence we see, that among all modern barbarians their priests or conjurors are their only physicians.

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

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

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

The practice of these ancient Greek physicians, notwithstanding the praises bestowed on them by their poets, seems to have been very limited, and in some cases even pernicious. All the external remedies applied to Homer's wounded heroes were fomentations; while inwardly their physicians gave them wine, sometimes mingled with cheese scraped down. This last we know must have been pernicious in many cases by increasing the inflammation; and it is very probable, that such an improper exhibition was merely a consequence of their ignorance; as we see old women in this country will give ardent spirits to those who are seized with inflammatory fevers, in order to prevent their patients from fainting. A great deal of their physic also consisted in charms, incantations, amulets, &c. of which, as they are common to all superstitious and ignorant nations, it is superfluous to take any farther notice.

In this way the art of medicine continued among the Greeks for many ages. As its first professors knew nothing of the animal economy, and as little of the theory of diseases, it is plain, that whatever they did must have been in consequence of mere random trials, or empiricism, in the most strict and proper sense of the word. Indeed, it is evidently impossible that this or almost any other art could originate from another source than trials of this kind. Accordingly, we find, that some ancient nations were accustomed to expose their sick in temples, and by the sides of highways, that they might receive the advice of every one that passed. Among the Greeks, however, Aesculapius, as he was reckoned the most eminent practitioner of his time, so his name continued to be revered after his death; he was ranked amongst the gods; and the principal knowledge of the medicinal art remained with his family to the time of Hippocrates, who reckoned himself the seventeenth in a lineal descent from Aesculapius, and who was truly the first who treated of medicine in a regular and rational manner.

At last, the Grecian philosophers attempted to introduce particular theories into the medicinal art. Pythagoras, who lived about the 6th Olympiad, and introduces founded the Italic school, is the first we read of whose theory began to take these things into consideration. He believed, that, at the time of conception, a certain substance descended from the brain, which contained a warm vapour, from whence the soul and all the senses derived their original; while the flesh, the nerves, tendons, bones, hair, and all the body in general, were made of the blood and other humours which meet in the matrix. According to him, the body of the infant was formed, and became solid in 40 days; but eleven, nine, or more generally ten months, according to the rules of harmony, were requisite to make him perfectly complete, and that all that happened to him during the whole course of his life was then regulated; and that he carried it along with him in a series or chain proportioned to the laws of the same harmony, every thing necessarily falling out afterwards in its own time. He asserted, that the veins, the arteries, and the nerves, are the cords of the soul. According to him, the soul spreads from the heart to the brain; and that part of it which is in the heart is the same from whence the passions proceed, whereas reason and understanding reside in the brain. This is what may be called the Pythagorean physiology; and if we please we may call the following his pathology. "The air (says he) is all filled with souls, or demons, and heroes, that send dreams, signs, and diseases to men, and even to beasts." As to his practice, we know of no other remedy he esteemed besides cabbage; all his other cures consisted of charms or other superstitions. His doctrine concerning abstinence from flesh are too well known. known, and too absurd to be insisted on here.

A short time after Pythagoras, the philosopher Heraclitus applied himself to the study of physic. The only patient of his we hear of was himself; and indeed, if we may judge of his practice by the method he took to cure himself, it seems to have been for the good of mankind that he had no more. Being a man of a very austere and morose temper, which occasioned the report that he always wept, he retired into a solitary place to avoid the conversation of mankind; where, living only upon water and herbs, he fell into a dropy. This obliged him to return to inhabited places, where he sent for physicians, not with a design to follow their advice, but to expose their ignorance to the world, and to make them witnesses of the cure he intended to perform upon himself. Accordingly, he shut himself up in a stable, where he covered all his body with dung, hoping by that means to consume the superfluous moisture in his entrails: but in this he did not succeed; for he died of the disease soon after.

This may be a sufficient specimen of the ancient philosophic medicine, of which we shall now take no farther notice, but proceed to give an account of the state in which the art was left by Hippocrates, whose name has been celebrated through so many ages. According to Soranus, Hippocrates was born in the island of Cos, in the first year of the 88th Olympiad; but others make him older, so that the exact time in which he lived cannot be ascertained. The works attributed to him are very voluminous, but evidently done by different persons, as many of them are contradictory to each other, so that it is difficult to determine those which are really his writings, and those which are not. Some indeed are so sceptical on this head, as to deny that we have proper evidence that any of those works really belong to Hippocrates, except a single aphorism. Be this, however, as it will, in most of the writings ascribed to Hippocrates, we find a general principle acknowledged which is called nature. To this principle he ascribes a mighty power. "Nature (says he) is of itself sufficient to every animal. She performs every thing that is necessary to them, without needing the least instruction from any one how to do it." Upon this footing, as if nature had been a principle endowed with knowledge, he gives her the title of just; and ascribes virtues or powers to her, which are her servants, and by means of which she performs all her operations in the bodies of animals: they distribute the blood, spirits, and heat, through all parts of the body, which by this means receive life and sensation. And in other places he tells us, that it is this faculty which gives nourishment, preservation, and growth, to all things.

The manner in which nature acts, or commands her subservient powers to act, is by attracting what is good and agreeable to each species, and in retaining, preparing, and changing it; and on the other side in rejecting whatever is superfluous or hurtful, after she has separated it from the good. This is the foundation of the doctrine of depuration, concoction, and crisis in fevers, so much insisted upon by Hippocrates and most other physicians. He supposes also, that every thing has an inclination to be joined to what agrees with it, and to remove from every thing contrary to it; and likewise that there is an affinity between the several parts of the body, by which they mutually sympathize with each other. When he comes to explain what this principle called nature is, he is obliged to resolve it into heat, which, he says, appears to have something immortal in it.

With regard to the anatomical doctrines of Hippocrates, as they must necessarily have been very erroneous, we shall not spend time in recounting them. The health or sickness of the body he reckoned to his discontent in the state of the four humours. These are three of the blood, phlegm, the yellow bile, and the melancholy or black bile. The blood, he says, is naturally the body, hot and moist, of colour red, and sweet to the taste: the phlegm is cold and moist, white, viscid, and salutary; the bile yellow, dry, viscid, bitter, and drawn from the fat part of the blood or aliments; the melancholy, black bile, he said, was cold and dry, very viscid, windy, and fermentative.

On these four humours, as already mentioned, depend health and sickness. Men are well when the humours are in their natural state, or while they balance one another in quality, quantity, and mixture. On the contrary, they are sick when the quantity of any of these is less or greater than it ought to be, or when it is discharged from the rest upon any particular part of the body, and especially when they are not mixed together as they ought to be. Of sickness, however, he gives no definition except in one place, where he calls it all that inconveniences man. He thought that the blood in good condition, nourished; that it was the fountain of the vital heat; that it caused a fresh colour, and good health. The yellow bile, he thought, preserved the body in its natural state, hindering the small vessels from being stopped, and keeping open the drain of the excrements: it also activated the senses, and helped to the concoction of the aliment. The black bile was a sort of ground which served as a support and foundation for other humours. The phlegm served to lubricate and facilitate the motion of the nerves, membranes, cartilages, joints, and other parts.

Besides these four qualities of moisture, dryness, heat, and cold, which Hippocrates attributed to the humours, he believed that they had, or might have, abundance of others which all had their use, and were never hurtful but when one prevailed over the rest or was separated from them. In other palliages, however, he assigns different causes for diseases. In one of his books, entitled, "Of winds, or spirits," he says, that the air and spirits are the true causes of health and diseases, even in preference to the humours, which are only collateral causes as the spirits mix with them. Hence, health and sickness in general are made to depend on the following causes, viz. On the air which surrounds us; on what we eat and drink; on sleep, watching, exercise; on what goes out of our bodies, and what is kept in; and upon the passions.

The four humours he compares with the four ages of man, with the four seasons, and with the climates. Infancy, the spring, and temperate countries, ought, according to him, to produce blood, and consequently more sanguine dispositions than bilious, pituitous, or melancholic ones. Youth, summer, and hot and dry countries, produce bile, and all the maladies which spring from it. Middle age, autumn, and places of a heavy unequal equal air, cause melancholy and melancholic distempers. Old age, winter, and cold moist countries, produce phlegm and phlegmatic distempers. He carefully examines what sorts of food produce blood, bile, &c. He treats also of the effects of sleep, watchings, exercise, and rest, and all the benefit or mischief we may receive from them. Of all the causes of diseases, however, mentioned by Hippocrates, the most general are diet and air. On the subject of diet he has composed several books, and in the choice of this he was exactly careful; and the more so, as his practice turned almost wholly upon it. He also considered the air very much; he examined what winds blew ordinarily or extraordinarily; he considered the irregularity of the seasons, the rising and setting of stars, or the time of certain constellations; also the time of the solstices, and of the equinoxes; those days, in his opinion, producing great alterations in certain distempers.

Hence it may be inferred that Hippocrates looked upon the knowledge of astronomy to be necessary to a physician, and believed that the stars had some influence over our bodies. Some of his ancient commentators also believed that he thought diseases were occasioned by the wrath of the gods. But these commentators are contradicted by Galen, who assures us, that when Hippocrates spoke of something divine in diseases, he meant no more than that the cause of them depended on some latent constitution of the atmosphere.

Hippocrates lays down three principles of which the human body is composed; viz. the solid, the liquid, and the spirits, which he sometimes explains by "that which contains," "that which is contained," and "that which gives the motion." By that which contains is meant the solid parts, as bones, nerves, tendons, ligaments, &c. By that which is contained, he means the four humours already mentioned; and by that which gives the motion, he means the spirits.—The humours and spirits being, as we have already seen, the causes of health and sickness, the solid or containing parts must be the subject of them; because they are found or unfound according to the good or ill disposition which the humours and spirits produce in them, and as the impressions made upon them by foreign bodies is beneficial or mischievous.

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

Hippocrates remarked four stages in distempers; viz. the beginning of the disease, its augmentation, its state or height, and its declination. In such distempers as terminate fatally, death comes in place of the declination. In the third stage, therefore, the change is most considerable, as it determines the fate of the sick person; and this is most commonly done by means of a crisis. By this word he understood any sudden change in sickness, whether for the better or worse, whether health or death succeed immediately. Such a change, he says, is made at that time by nature, either abolishing or condemning the patient. Hence we may conclude, that Hippocrates imagined diseases to be only a disturbance of the animal economy, with which Nature was perpetually at variance, and using her utmost endeavours to expel the enemy. Her manner of acting on these occasions is to reduce to their natural state those humours whose discord occasions the disturbance of the whole body, whether in relation to their quantity, quality, mixture, motion, or any other way in which they become offensive. The principal means employed by nature for this end is what Hippocrates calls concoction. By this we can only understand the bringing the morbid matter lodged in the humours to such a state, as to be easily fitted for expulsion by whatever means nature thinks most proper. When matters are brought to this pass, whatever is superfluous or hurtful immediately empties itself, or nature points out to physicians the way by which such an evacuation is to be accomplished. The crisis takes place either by bleeding, stool, vomit, sweat, urine, tumours or abscesses, scabs, pimples, spots, &c. But we must take notice that these evacuations are not to be looked upon as the effects of a true crisis, unless they are in considerable quantity; small discharges not being sufficient to make a crisis. On the contrary, small discharges are a sign that nature is depressed by the load of humours, and that she lets them go through weakness and continual irritation. What comes forth in this manner is crude, because the distemper is yet too strong; and while matters remain in this state, nothing but a bad or imperfect crisis is to be expected. This shows that the distemper triumphs, or at least... is equal in strength to nature, which prognosticates death, or a prolongation of the disease. In this last case, however, nature often has an opportunity of attempting a new crisis more happy than the former, after having made fresh efforts to advance the concoction of the humours.—It must here be observed, however, that, according to Hippocrates, concoction cannot be made but in a certain time; as every fruit has a limited time to ripen; for he compares the humours which nature has digested to fruits come to maturity.

The time required for concoction depends on the differences among distempers mentioned above. In those which Hippocrates calls very acute, the digestion or crisis happens every fourth day; in those which are only acute, it happens on the seventh, eleventh, or fourteenth day; which last is the longest period generally allowed by Hippocrates in distempers that are truly acute: though in some places he stretches it to the twentieth or one-and-twentieth, nay, sometimes to the fortieth or sixtieth days. All distempers that exceed this last term are called chronic. And whereas in those distempers that exceed fourteen days, every fourth day is critical, or at least remarkable, by which we may judge whether the crisis on the following fourth day will be favourable or not; so in those which come from twenty to forty he reckons only the sevenths, and in those that exceed forty he begins to reckon by twenties; as appears by the following progression, which contains the days particularly marked by Hippocrates. He begins with the fourth; and then he proceeds to the eleventh, the fourteenth, seventeenth, twentieth, seven-and-twentieth, thirty-fourth, the fortieth, the sixtieth, the eightieth, the hundredth, and the hundred-and-twentieth. Beyond this last term the number of days has no power over the crisis. They are then referred to the general changes of the seasons; some terminating about the equinoxes; others about the solstices; others about the rising or setting of the stars of certain constellations; or if numbers have yet any place, he reckons by months, or even whole years. Thus, he says, certain distempers in children have their crises in the seventh month after their birth, and others in their seventh, or even their fourteenth year.

Though Hippocrates mentions the one-and-twentieth as one of the critical days in acute distempers, as already mentioned; yet, in other places of his works, he mentions also the twentieth. The reason he gives for this in one of those places of his works is, that the days of sickness were not entire. In general, however, he is prodigiously attached to the odd days: inasmuch that in one of his aphorisms he tells us, "The fevers that come out upon the third, fifth, seventh, ninth, eleventh, fourteenth, seventeenth, twenty-first, twenty-seventh, thirty-first, or thirty-fourth days, are beneficial; but those that come out upon other days signify that the sick shall be brought low, that his distemper shall be very tedious, and that he shall be subject to relapses." He further says, "That the fever which leaves the sick upon any but an odd day is usually apt to relapse." Sometimes, however, he confesses that it is otherwise; and he gives an instance of a salutary crisis happening on the sixth day. But these are very rare instances, and therefore cannot overthrow the general rule.

Besides the crisis, however, or the change which determines the fate of the patient, Hippocrates often speaks of another which only changes the species of the distemper, without restoring the patient to health; as when a pleurisy turns to an inflammation of the lungs, a vertigo to an epilepsy, a tertian fever to a quartan, or to a continual, &c.

But what hath chiefly contributed to procure the highest respect generally paid to Hippocrates, is his inestimable dexterity in observing the most minute circumstances of distempers, and his exactness in nicely describing every thing that happened before, and every accident that appeared at the same time with them; as also what appeared to give ease, and what to increase the malady, which is what we call writing the history of a distemper.—Thus he not only distinguished one distemper from another by the signs which properly belonged to each; but by comparing the same sort of distemper which happened to several persons, and the accidents which usually appeared before and after, he could easily foretell a distemper before it came, and afterwards give a right judgment of the event of it. In one place, he intimates, that he is the greatest physician who can put this in practice, or who can tell the patient what shall happen to him in the course of the distemper; which is what we call giving the prognostics of a distemper. By this way of prognosticating, he came to be exceedingly admired; and this he carried to such a height, that it may justly be said to be his masterpiece; and Celsus, who lived after him, remarks, that succeeding physicians, though they found out several new things relating to the management of distempers, yet were obliged to the writings of Hippocrates for all that they knew of signs."

The first thing Hippocrates considered when called to a patient, was his looks.—It was a good sign with him to have a visage resembling that of a person in health, and the same with what the sick man had before he was attacked by the distemper. As it varied looks from this, so much the greater danger was apprehended. The following is the description which he gives of the looks of a dying man.—"When a patient (says he) has his nose sharp, his eyes sunk, his temples hollow, his ears cold and contracted, the skin of his forehead tense and dry, and the colour of his face tending to a pale-green, or lead colour, one may give out for certain that death is very near at hand; unless the strength of the patient has been exhausted all at once by long watchings, or by a looseness, or being a long time without eating." This observation has been confirmed by those of succeeding physicians, who have, from him, denominated it the Hippocratic face. The lips hanging relaxed and cold, are likewise looked upon by this author as a confirmation of the foregoing prognostic. He took also his signs from the disposition of the eyes in particular. When a patient cannot bear the light; when he sheds tears involuntarily; when, in sleeping, some part of the white of the eye is seen; unless he usually sleeps after that manner, or has a looseness upon him; these signs, as well as the foregoing ones, prognosticate ill. The eyes deadened (as it were with a mist spread over them, or their brightness lost,) likewise presage death, or is a sign of great weakness. The eyes sparkling, fierce, fierce, and fixed, denote the patient to be delirious, or that he is, or soon will be, seized with a frenzy. When the patient sees any thing red, and like sparks of fire and lightning pass before his eyes, you may expect an hemorrhage; and this often happens before those crises which are to be attended by a loss of blood.

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

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

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

His prognostics from the excretions by stool are as follow. Those that are soft, yellowish, of some consistence, and not of an extraordinary ill smell, that answer to the quantity of what is taken inwardly, and that are voided at the usual hours, are the best of all. They ought also to be of a thicker consistence when the distemper is near the crisis; and it ought to be taken for a good prognostic, when some worms, round and long, are evacuated at the same time with them. The prognostics, however, may still be favourable, though the matter excreted be thin and liquid, provided it make not too much noise in coming out, and the evacuation be not in a small quantity nor too often; nor in so great abundance, nor so often, as to make the patient faint. All matter that is watery, white, of a pale green, or red, or frothy and viscous, is bad. That which is black like grease, or livid like the colour of verdigris, is the most pernicious. That which is pure black, and nothing else but a discharge of cholera adust, or black bile, always prognosticates very ill; this humour, from what part ever it comes, never appearing, but it shews at the same time the ill disposition of the intestines. The matter that is of several different colours, denotes the length of the distemper; and, at the same time, that it may be of dangerous consequence. Hippocrates places in the same class the matter that is bilious or yellow, and mixed with blood, or green and black, or like the dregs or scumings of the guts. The stools that consist of pure bile, or entirely of phlegm, he also looked upon to be very bad.

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

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

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

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

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

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

Having thus seen in what Hippocrates makes the difference between health and sickness to consist, and likewise the most remarkable signs from whence he drew his prognostics, we must now consider the means he prescribed for the preservation of health, and the cure of diseases. One of his principal maxims was this, That, to preserve health, we ought not to over-indulge ourselves with too much eating, nor neglect the preference of exercise and labour. In the next place, That we ought by no means to accustom ourselves to too nice and exact a method of living; because those that have once begun to act by this rule, if they vary in the least from it, find themselves very ill; which does not happen to those who take a little more liberty, and live somewhat more irregularly. Notwithstanding this, he does not neglect to inquire diligently into what those who were in health used for food in his time.

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

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

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

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

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

Hippocrates asserted in the first place, That contraries, or opposites, are the remedies for each other; and this maxim he explains by an aphorism, where he says, that evacuations cure those distempers which come from repletion, and repletion those that are caused by evacuation. So heat is destroyed by cold, and cold by heat, &c. In the second place, he asserted that physic is an addition of what is wanting, and a subtraction or retrenchment of what is superfluous: an axiom which is explained by this, viz. that there are some juices or humours, which in particular cases ought to be evacuated, or driven out of the body, or dried up; and some others which ought to be restored to the body, or caused to be produced there again. As to the method to be taken for this addition or retrenchment, he gives this general caution, That you ought to be careful how you fill up, or evacuate, all at once, or too quickly, or too much; and that it is equally dangerous to heat or cool again on a sudden: or rather, you ought not to do it; every thing that runs to an excess being an enemy to nature. In the fourth place, Hippocrates allowed that we ought sometimes to dilate, and sometimes to lock up: to dilate, or open the passages by which the humours are voided naturally, when they are not sufficiently opened, or when they are closed; and, on the contrary, to lock-up or straiten the passages that are relaxed, when the juices that pass there ought not to pass, or when they pass in too great quantity. He adds, that we ought sometimes to smooth, and sometimes to make rough; sometimes to harden, and sometimes to soften again; sometimes to make more fine or supple; sometimes to thicken; sometimes to rouse up, and at other times to stupify or take away the sense; all in relation to the solid parts of the body, or to the humours. He gives also this fifth lesson, That we ought to have regard to the course the humours take, from whence they come, and whither they go; and in consequence of that, when they go where they ought not, that we make them take a turn about, or carry them another way, almost like the turning the course of a river; or, upon other occasions, that we endeavour if possible to recall, or make the same humours return back again; drawing upward such as have a tendency downward, and drawing downward such as tend upward. We ought also to carry off, by convenient ways, that which is necessary to be carried off; and not let the humours once evacuated, enter into the vessels again. Hippocrates gives also the following instruction, That when we do anything according to reason, though the success be not answerable, we ought not too easily, or too hastily, to alter the manner of acting, as long as the reasons for it are yet good. But as this maxim might sometimes prove deceitful, he gives the following as a corrector to it: "We ought (says he) to mind with a great deal of attention what gives ease, and what creates pain; what is easily supported, and what cannot be endured." We ought not to do anything rashly; but ought to pause, or wait, without doing any thing: by this way, if you do the patient no good, you will at least do him no hurt. In extreme illness we ought to use medicines of the same nature: That which medicines cure not, the sword does; what the sword does not, the fire does; but what the fire cannot cure ought to be looked upon as incurable: And lastly, we ought not to undertake the cure of desperate diseases which are beyond the power of physic.

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

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

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

But though he was of opinion that too much food did not ought not to be allowed to the sick, he was not of the mind of some physicians who preferred long abstinence, especially in the beginning of fevers. The reason he gave for this was, that the contrary practice weakened the patients too much during the first days of the distemper, by which means their physicians were obliged to allow them more food when the illness was at its height, which in his opinion was improper. He complained that "they dried up their patients like herrings, before there was any occasion for it, and destroyed them for want of nourishment." Besides, in acute distempers, and particularly in fevers, Hippocrates made choice of refreshing and moistening nourishment; and amongst other things prescribed orange, melon, melon, spinach, gourd, and dock. This sort of food he gave to those that were in a condition to eat, or could take something more than a pifian.

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

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

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

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

When our physician found that diet and exercise were not sufficient to ease nature of a burden of corrupted humours, he was obliged to make use of other occasions, of which purgation was one. By this word he understood all the contrivances that are made use of to discharge the stomach and bowels; though it properly signifies only the evacuation of the belly by stool. This evacuation he imagined to be occasioned by the purgative medicines attracting the humours to themselves. When first taken into the body, he thought they attracted that humour which was most similar to them, and then the others, one after another.—The purgatives used in his time were mostly emetics also, or at least were very violent in their operation downwards. These were the white and black hellebore; the first of which is now reckoned among the poisons. He used also the Cnidian berries, which are nothing else but the seeds of thymaliza or chamaelea; cencorum, peplum, which is a sort of milk-thistle; thepsia, the juice of hippophae, a sort of rhamnus; elaterium, or juice of the wild cucumber; flowers of bras, coloquintida, scammony, the magnetian stone, which is a sort of limestone, &c.

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

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

Notwithstanding this, however, it is certain that Hippocrates did sometimes exhibit purgatives at the beginning of acute distempers; and he has an aphorism directly contrary to the precedent one, where he says, that in the beginning of distempers we ought to stir the humours, and to purge what we think we have stirred. This aphorism has occasioned no small trouble to physicians of succeeding ages, who have found a great great deal of difficulty in reconciling it with the foregoing. Galen has got off by commenting on the phrase to flir up. This, he says, signifies using all the remedies that are necessary for the ease of the patient; among which he reckons particularly bleeding and purging. According to him, therefore, the flirring up mentioned by Hippocrates consists chiefly in bleeding; that is to say, purgation might be admitted at the beginning of distempers sometimes, but very rarely; and in fact we find, that Hippocrates himself did purge some people at the beginning of distempers, though very seldom.

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

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

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

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

In the distemper called empyema; (or a collection of matter in the breast), he made use of a very rough remedy for an empyema. He commanded the patient to draw in his empyema tongue as much as he was able; and when that was done, he endeavoured to put into the hollow of the lungs a liquor that irritated the part, which, raising a violent cough, forced the lungs to discharge the purulent matter contained in them. The materials that he used for this purpose were of different sorts; sometimes he took the root of arum, which he ordered to be boiled with a grain of salt, in a sufficient quantity of water and oil, dissolving a little honey in it. At other times, when he intended to purge more strongly, he took the flowers of copper and hellebore; after that he shook the patient violently by the shoulders, the better to loosen the pus. This remedy, according to Galen, he received from the Cnidian physicians; and it has never been used by the succeeding ones, probably because the patients could not suffer it. Blood-letting was another method of evacuation pretty much used by Hippocrates. Another aim he had in this, besides the mere evacuation, was to divert or recall the course of the blood when he imagined it was going where it ought not. A third end of bleeding was to procure a free motion of the blood and spirits, as we may gather from the following passage:

"When any one becomes speechless of a sudden, (says he), it is caused by the shutting of the veins, especially when it happens to persons otherwise in good health, without any outward violence. In this case the inward vein of the right arm must be opened, and more or less blood taken away, according to the age or constitution of the patient. Those that lose their speech thus have great flushings in their face, their eyes are stiff, their arms are distended, their teeth gnash, they have palpitations of the arteries, cannot open their jaws, the extremities are cold, and the spirits are intercepted in the veins. If pain ensues, it is by the accession of the black bile and sharp humours. For the internal parts being vexed or irritated by these humours, suffer very much; and the veins, being also irritated and dried, distend themselves extraordinarily, and are inflamed, and draw all that can flow to them; so that the blood corrupting, and the spirits not being able to pass through the blood by their ordinary passages, the parts grow cold by reason of this stagnation of the spirits. Hence come giddiness, loss of speech, and convulsions, if this disorder reaches to the heart, the liver, or to the great veins. From hence come also epilepsies and palsies, if the defluxions fall upon the parts last mentioned; and that they dry up, because the spirits are denied a passage through them. In this case, after fomentation, a vein must be opened, while the spirits and humours are yet suspended and unsettled."

Hippocrates had also a fourth intention for bleeding, and this was refreshment. So in the iliac passion, he orders bleeding in the arm and in the head; to the end, says he, that the superior venter, or the breast, may cease to be overheated. With regard to this evacuation, his conduct was much the same as to purging, in respect of time and persons. We ought, says he, to let blood in acute diseases, when they are violent, if the party be lusty and in the flower of his age. We ought also to have regard to the time, both in respect to the disease and to the season in which we let blood. He also informs us, that blood ought to be let in great pains, and particularly in inflammations. Among these he reckons such as fall upon the principal viscera, as the liver, lungs, and spleen, as also the quinsy and pleurisy, if the pain of the latter be above the diaphragm. In these cases he would have the patients bled till they faint, especially if the pain is very acute; or rather he advises that the orifice should not be closed till the colour of the blood alters, so that from livid it turn red, or from red, livid. In a quinsy he bled in both arms at once. Difficulty of breathing he also reckons among the distempers that require bleeding; and he mentions another sort of inflammation of the lungs, which he calls a swelling, or tumours of the lungs arising from heat; in which case he advises to bleed in all parts of the body; and directs particularly to the arms, tongue, and nostrils. To make bleeding the more useful in all pains, he directed to open the vein nearest the part affected; in a pleurisy he directs to take blood from the arm of the side affected; and for the same reason, in pains of the head, he directs the veins of the nose and forehead to be opened.

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

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

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

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

When bleeding and purging, which were the principal and most general means used by Hippocrates for taking off a plethora, proved insufficient for that purpose, he had recourse to diuretics and sudorifics. The former were of different sorts, according to the constitution of the persons: sometimes baths, and sometimes sweet wine, provoke urine; sometimes the nourishment which we take contributes to it; and amongst those herbs which are commonly eaten, Hippocrates recommends garlic, leeks, onions, cucumbers, melons, gourds, fennel, and all other things which have a biting taste and a strong smell. With these he numbers honey, mixed with water or vinegar, and all salt meats. But, on some occasions, he took four caustharides, and, pulling off their wings and feet, gave them in wine and honey. These remedies were given in a great number of chronic distempers after purging, when he thought the blood was overcharged with a sort of moisture which he calls ichor; or in suppressions of urine, and when it was made in less quantity than it ought. There were also some cases in which he would force sweat as well as urine; but he neither mentions the diseases in which sudorifics are proper, nor lets us know what medicines are to be used for this purpose, except in one single passage, where he mentions sweating, by pouring upon the head a great quantity of water till the feet sweat; that is, till the sweat diffuses itself over the whole body, running from head to foot. After this he would have them eat boiled meat, and drink thereupon pure wine, and, being well covered with clothes, lay themselves down to rest. The disease for which he proposes the above-mentioned remedy is a fever; which is not, according to him, produced by bile or puita, but by mere latitude, or some other like cause; from whence we may conclude that he did not approve of sweating in any other kind of fever.

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

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

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

Fumigations were likewise very often used by Hippocrates. In the quinsy, he burned hyssop with sulphur. History.

Sulphur and pitch, and caused the smoke to be drawn into the throat by a funnel; and by this means he brought away abundance of phlegm through the mouth, and through the nose. For this purpose he took nitre, marjoram, and cress-seeds, which he boiled in water, vinegar, and oil, and, while it was on the fire, caused the patient to draw in the steam by a pipe.

In his works we find a great number of fumigants for the distemper of women, to promote the menstrual flux, to check it, to help conception, and to ease pains in the matrix, or the suffocation of it. On these occasions he used such aromatics as were then known, viz. cinnamon, cassia, myrrh, and several odoriferous plants; as likewise some minerals, such as nitre, sulphur, and pitch, and caused them to receive the vapours through a funnel into the uterus.

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

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

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

Lastly, to complete the catalogue of the external remedies used by Hippocrates, we shall mention a sort of medicine called *collyrium*. It was compounded of powders, to which was added a small quantity of some ointment, or juice of a plant, to make a solid or dry mass; the form of which was long and round, which was kept for use. Another composition of much the same nature was a sort of lozenge of the bigness of a small piece of money, which was burnt upon coals for a perfume, and powdered for particular uses. In his works we find likewise descriptions of powders for several uses, to take off fungous flesh, and to blow into the eyes in ophthalmies, &c.

These were almost all the medicines used by Hippocrates for external purposes. The compound medicines given inwardly were either liquid, solid, or diuretic.

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

The first physician of eminence who differed considerably in his practice from Hippocrates was Praxagoras. From some authors we learn that he accounted for diseases from the qualities of the humours, Hippocrates from the qualities of the humours, Hippocrates, of which he reckoned ten sorts, whereas Hippocrates supposed only four. Cælius Aurelianus acquaints us, that he made great use of vomits in his practice, in order to exhibit them in the iliac passion till the excrements were discharged by the mouth. In this distemper he also advised, when all other means failed, to open the belly, cut the intestine, take out the indurated faeces, and then to sew up all again; but this practice hath not been followed by any subsequent physician.

We must now take notice of a capital distinction among the ancient physicians into the two classes of divided into dogmatists and empirics; or into those who proceeded according to rules derived from reasoning, and those who, without paying any regard to theory or reasoning, trusted solely to the observations arising from their own experience, or that of others. From what has already been said concerning the theories of Hippocrates, it is very easy to see that the dogmatists were in very great danger of committing errors, if they reasoned from such false and absurd hypotheses as were invented by the philosophers in those ages. The natural fondness of mankind, however, for their own theories, prompted the philosophers to explode Chrysippus' experience as much as possible; and accordingly we find, that in the time of Philip, father of Alexander the Great, one Chrysippus, a physician of Cnidus, attempted... tempted to overthrow the practice which had been established on the experience of all the ancient physicians, merely by his talent at declamation and reasoning. He disapproved of venefication and purgatives, though he sometimes made use of purgatives and elysters; but the reasons he had for his conduct cannot now be known, as his books are totally lost.

Erasistratus, the scholar of Chrysippus, was a physician of great eminence, and flourished in the time of Seleucus Nicator. According to Galen, he entirely banished venefication from medicine; though some affirm that he did not totally discard it, but only used it less frequently than other physicians. His reasons for disapproving of venefication are as follows:

"It is difficult to succeed in venefication, because we cannot always see the vein we intend to open, and because we are not sure but we may open an artery instead of a vein. We cannot ascertain the true quantity to be taken. If we take too little, the intention is by no means answered. If we take too much, we run a risk of destroying the patient. The evacuation of the venous blood also is succeeded by that of the spirits, which on that occasion pass from the arteries into the veins. It must likewise be observed, that as the inflammation is formed in the arteries by the blood coagulated in their orifices, venefication must of course be useless and of no effect."

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

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

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

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

The first grand revolution which happened in the medicinal art after the days of Herophilus and Erasistratus was occasioned by the founding of the empiric sect by Serapion of Alexandria about 287 years before Christ. The division into dogmatists and empirics had indeed subsisted before, as already mentioned; but about this time the latter party began to grow strong, and to have champions publicly asserting its cause. Galen informs us, that Serapion used Hippocrates very ill in his writings, in which he discovered an excess of pride, self-sufficiency, and contempt for all the physicians that went before him. We have some sketches of his practice in Celsus Aurelianus, from which we may infer that he retained the medicines of Hippocrates and the other physicians who went before him, though he rejected their reasoning. We know not what arguments he advanced for the support of his sentiments, since his works are lost, as well as those of the other empirics; and we should know nothing at all of any of them, if their adversaries had not quoted them in order to confute them.

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

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

The next remarkable person in the history of physic is Asclepiades, who flourished in the century immediately preceding the birth of Christ. He introduced the philosophy of Democritus and Epicurus into medicine, and ridiculed the doctrines of Hippocrates. He asserted, that matter considered in itself was of an unchangeable nature; and that all perceptible bodies were composed of a number of smaller ones, between which there were interposed an infinity of small spaces totally void of all matter. He thought that the soul itself was composed of these small bodies. He laughed at the principle called nature by Hippocrates, and also at the imaginary faculties said by him to be subservient to her; and still more at what he called attraction. This last principle Asclepiades denied in every instance, even in that of the loadstone and steel, imagining that this phenomenon proceeded from a concourse of corpuscles, and a particular disposition or modification of their pores. He also maintained, that nothing happened or was produced without some cause; and that what was called nature was in reality no more than matter and motion. From this last principle he inferred that Hippocrates knew not what he said when he spoke of nature as an intelligent being, and ascribed qualities of different kinds to her. For the same reason he ridiculed the doctrine of Hippocrates with regard to crises; and asserted that the termination of diseases might be as well accounted for from mere matter and motion. He maintained, that we were deceived if we imagined that nature always did good; since it was evident that she often did a great deal of harm. As for the days particularly fixed upon by Hippocrates for crises, or those on which we usually observe a change either for the better or the worse, Asclepiades denied that such alterations happened on those days rather than on others. Nay, he asserted that the crises did not happen at any time of its own accord, or by the particular determination of nature for the cure of the disorder, but that it depended rather on the address and dexterity of the physician; that we ought never to wait till a distemper terminates of its own accord, but that the physician by his care and medicines must hasten on and advance the cure. According to him, Hippocrates and other ancient physicians attended their patients rather with a view to observe in what manner they died than in order to cure them; and this under pretence that nature ought to do all herself, without any assistance.

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

From these principles the following pathology is deducible: "As long as the corpuscles are freely received by the pores, the body remains in its natural state; and, on the contrary, it begins to recede from that state, when the corpuscles find any obstacle to their passage. Health therefore depends on the just proportion between the pores and the corpuscles they are destined to receive and transmit; as diseases, on the contrary, proceed from a disproportion between these pores and the corpuscles. The most usual obstacle on this occasion proceeds from the corpuscles embracing each other, and being retained in some of their ordinary passages, whether these corpuscles arrive in too large a number, are of irregular figures, move too fast or too slow, &c.

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

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

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

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

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

Themison also asserted, that diseases are sometimes acute, and sometimes chronic; that for a certain time they increase; that at a certain time they are at their height; and that at last they were observed to diminish. Acute diseases, therefore, according to him, must be treated in one way, and chronic ones in another; one method must be followed with such as are in their augmentation, another with such as are at their height, and a third with such as are in their declension. He asserted, that the whole of medicine consisted in the observation of that small number of rules which are founded upon things altogether evident. He said

History.

said, that all disorders, whatever their nature was, if included under any of the kinds abovementioned, ought to be treated precisely in the same way, in whatever country and with whatever symptoms they happen to arise. Upon these principles, he defined medicine to be "a method of conducing to the knowledge of what diseases have in common with each other, and which at the same time is evident."

Themison was old when he laid the foundation of the Methodic sect; and it was only brought to perfection by Theflalus, who lived under the emperor Nero. Galen and Pliny accuse this physician of intolerable insolence and vanity; and report, that he gave himself the air of despising all other physicians; and so intolerable was his vanity, that he assumed the title of the conqueror of physicians, which he caused to be put upon his tomb in the Appian way. "Never was moun-

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

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

About the 131st year after Christ, in the reign of the emperor Adrian, lived the celebrated Galen, a native of Pergamus, whose name makes such a conspicuous figure in the history of physic. At this time the dogmatic, empiric, methodic, and other sects, had each their abettors. The methodics were held in great esteem, and looked upon to be superior to the dogmatists, who were strangely divided among themselves, some of them following Hippocrates, others Erasistratus, and others Aesculapius. The empirics made the least considerable figure of any. Galen undertook the reformation of medicine, and reformed dogmatism. He seems to have been of that sect which was called eclectic, from their choosing out of different authors what they deemed good in them, without being particularly attached to any one more than the rest. This declaration he indeed sets out with; but, notwithstanding this, he follows Hippocrates much more than any of the rest, or rather follows nobody else but him. Though before his time several physicians had commented on the works of Hippocrates, yet Galen pretends that none of them had understood his meaning besides himself. His first attempt therefore was to explain the works of Hippocrates; with which view he wrote a great deal, and after this let about composing a system of his own. In one of his books entitled, "Of the establishment of medicine," he defines the art to be one which teaches to preserve health and cure diseases. In another book, however, he proposes the following definition: "Medicine (says he) is a science which teaches what is found, and what is not so; and what is of an indifferent nature, or holds a medium between what is found and what is the reverse." He affirmed, that there are three things which constitute the object of medicine, and which the physician ought to consider as found, as not. not found, or of a neutral and indifferent nature. These are the body itself, the signs, and the causes. He esteems the human body sound, when it is in a good state or habit with regard to the simple parts of which it is composed, and when besides there is a just proportion between the organs formed of these simple parts. On the contrary, the body is reckoned to be unsound, when it recedes from that state, and the just proportion abovementioned. It is in a state of neutrality or indifference, when it is in a medium between soundness and its opposite state. The salutary signs are such as indicate present health, and prognosticate that the man may remain in that state for the time to come. The insalubrious signs, on the contrary, indicate a present disorder, or lay a foundation for suspecting the approach of one. The neutral signs, or such as are of an indifferent nature, denote neither health nor indisposition, either for the present, or for the time to come. In like manner he speaks of causes salutary, unsalutary, and indifferent.

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

Galen describes at great length the signs of a good or bad constitution, as well as those of what he calls a neutral habit. These signs are drawn from the original qualities of cold, hot, moist, and dry, and from their just proportion or disproportion with respect to the bulk, figure, and situation, of the organical parts. With Hippocrates he establishes three principles of an animal-body; the parts, the humours, and the spirits. By the parts he properly meant no more than the solid parts; and these he divided into similar and organical. Like Hippocrates he also acknowledged four humours; the blood, the phlegm, the yellow and black bile; and of these he gave the same definitions with those already taken notice of under Hippocrates. He established three different kinds of spirits; the vital, the animal, and the natural. The first of these are, according to him, nothing else but a subtle vapour arising from the blood, which draws its origin from the liver, the organ, or instrument of sanguification. After these spirits are conveyed to the heart, they, in conjunction with the air we draw into the lungs, become the matter of the second species, that is, of the vital spirits, which are again changed into those of the animal kind in the brain. He supposed that these three species of spirits served as instruments to three kinds of faculties, which reside in the respective parts where these faculties are formed. The natural faculty is the first of these, which he placed in the liver, and imagined to preside over the nutrition, growth, and generation, of the animal. The vital faculty he lodged in the heart, and supposed that by means of the arteries it communicated warmth and life to all the body. The animal faculty, the noblest of all the three, and with which the reasoning or governing faculty was joined, according to him, has its seat in the brain; and, by means of the nerves, distributes a power of motion and sensation to all the parts, and presides over all the other faculties. The original source or principle of motion in all these faculties, Galen, as well as Hippocrates, defines to be Nature.

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

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

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

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

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

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

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

In consequence of the establishment of such a system, the medicinal art, as well as others during the dark ages of popery, came to be reduced to a heap of quibbling distinctions and metaphysical nonsense.—After the days of Galen, however, the knowledge of medicine did not immediately decline. Dr Freind is of opinion that it continued to advance till the year 600. He censures Mr Le Clerc for placing the physicians Oribasius, Acitius, Alexander, and Paulus Ægineta, all without any distinction, in the fourth century; and still more for placing Diocles Carystius 500 years after Christ, when he should, according to him, have been placed 300 years before him.

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

Aetius lived very near the end of the fifth, or in the beginning of the sixth century. Many passages in his writings serve to show us how much the actual and potential cautery were used by the physicians of that age. In a palsy, he says from the works of another physician, that he should not at all hesitate to make an eschar either way, and this in several places; one in the nape, where the spinal marrow takes its rise, two on each side of it; three or four on the top of the head, one just in the middle, and the three others round it. He adds, that in this case, if the ulcers continue running a good while, he should not doubt of a perfect recovery. He is still more particular when he comes to order this application for an inextirpate asthma, after all other remedies have been tried in vain. One, he says, should be made on each side near the middle of the joining of the clavicle, taking care not to touch the wind-pipe; two other little ones are then to be made near the carotids under the chin, one on each side, so that the cautic may penetrate no further than the skin; two others under the breasts, between the third and fourth ribs; and again, two more backwards towards the fifth and sixth ribs. Besides these there ought to be one in the middle of the thorax near the beginning of the xiphoid cartilage over the orifice of the stomach; one on each side between the eighth and ninth ribs; and three others in the back, one in the middle, and the two others just below it, on each side of the vertebrae. Those below the neck ought to be pretty large, not very superficial, nor very deep; and all these ulcers should be kept open for a very long time.

The use of ulcers was indeed known to Hippocrates. They used both the actual and potential cautery for making them; the former of which is preferred by many, because the eschar made by it separates much sooner than the other. The most considerable difference between the ancient and modern practice with regard to ulcers is, that the ancient physicians sometimes made them near a bone, as in the nape, the clavicles, &c. where if anything is put in to keep the ulcer open, it must press upon the periosteum, and create great pain; besides that in such a part the discharge, on which the cure chiefly depends, can never be so considerable. As for that particular species of ulcers called fetosus, we find them plainly described by Langfranc, above 400 years ago; and if we examine into the writers before Langfranc, we shall find the practice still more ancient. Roland, who lived in the 13th century, not only mentions the thing, but uses the very word, and gives a description how the needle with the thread should be passed.

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

Alexander, who flourished in the reign of Justinian, is a more original author than either of the two former. He confines himself directly to the describing the signs of diseases, and the methods of cure, without meddling with anatomy, the materia medica, or surgery, as all the rest did. He employs a whole book in treating of the gout. One method he takes of relieving this disease is by purging; and in most of the purges he recommends hermodactyls, of which he has a great opinion.—In a caustus, or burning fever, where the bile is predominant, the matter fit for evacuation, and the fever not violent, he prefers purging to bleeding, and says that he has often ordered purging in acute fevers; which method, says Dr Freind, when used with judgment, is frequently attended with surprising success.—In the causus also, if a syncope happens from crude and redundant humours, he recommends bleeding. In a syncope succeeding the suppression of any usual evacuation, he recommends bleeding, with frictions. The diagnostics upon which he founds this practice are the following; viz. a face paler and more swelled than usual, a bloated habit of body, with a little sluggish pulse, having long intervals between the strokes.—In tertian, and much more in quartan fevers, he recommends vomits above all other remedies, and affirms that by this remedy alone he has cured the most inextirpate quartans.—On the bulimus, or canine appetite, he makes a new observation, viz. that it is sometimes caused by worms. He mentions the case of a woman who laboured under this ravenous appetite, and had a perpetual gnawing at her stomack and pain in her head: after taking hiera, she voided a worm above a dozen of cubits long, and was entirely cured of her complaints.—He is also the first author who takes notice of rhubarb; which he recommends in a weakness of the liver and dysentery.—Alexander is recommended by Dr Freind as one of the best practical writers among the ancients, and well worthy the perusal of any modern.

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

With this physician closes the period of the Greek classical physicians. As for the western parts of the world, every art and science had been long lost in them, by the inundation of Goths and other barbarous nations who over-ran the Roman empire. The Arabians, who about this time over-ran the eastern parts of the world, were at first as great enemies to learning of all kinds as the Goths; but at length they applied themselves to the study of several sciences, particularly medicine. They were for the most part, indeed, only copiers of the Greeks; we are, however, indebted to them for some improvements. They were the first who introduced chemical remedies, though of these they used but few, nor did they make any considerable progress in the chemical art. Anatomy was not in the least improved by them, nor did surgery receive any advancement till the time of Albucasis, who lived, probably, in the 12th century. They added a great deal to botany and the materia medica, by the introduction of new drugs, of the aromatic kind especially, from the east, many of which are of considerable use. They also found out the way of making sugar; and by help of that, syrups; which two new materials are of great use in mixing up compound medicines.

With regard to their practice, in some few particulars they deviated from the Greeks. Their purging medicines were much milder than those formerly in use; and even when they did prescribe the old ones, they gave them in a much less dose than formerly. The same reflection may be made concerning their manner of bleeding, which was never to that excessive degree practised by the Greeks. They deviated from Hippocrates, however, in one very trivial circumstance, which produced a terrible controversy. The question was, Whether blood in a plentiful ought to be drawn from the arm of the affected side, or the opposite. Hippocrates had directed it to be drawn from the arm of the affected side; but the Arabians, following some other ancient physicians, ordered it to be drawn from the opposite one. Such was the ignorance of those ages, that the university of Salamanca in Spain made a decree, that no one should dare to let blood but in the contrary arm; and endeavoured to procure an edict from the emperor Charles V. to second it; alleging that the other method was of no less pernicious consequence to medicine, than Luther's hereby had been to religion.

By reason of the general decay of learning in the western parts of the world, the Greek writers became totally forgot, because nobody could read the language; and the Arabians, though mostly copiers from them, enjoyed all the reputation that was due to the others. The Arabian physic was introduced into Europe very early, with the most extravagant applause; and not only this, but other branches of their learning came into repute in the west; insomuch that in the 11th century, the studies of natural philosophy and the liberal arts were called the studies of the Saracens. This was owing partly to the cruelties undertaken against them by the European princes; and partly to the settlement of the Moors in Spain, and the intercourse they and other Arabians had with the Italians. For, long before the time of the crusades, probably in the middle of the 7th century, there were Hebrew, Arabic, and Latin professors of physic settled at Salernum: which place soon grew into such credit, that Charles the Great thought proper to found a college there in the year 802; the only one at that time in Europe. Constantine the African flourished here towards the latter end of the 11th century. He was a native of Carthage; but travelled into the east, and spent 30 years in Babylon and Bagdad, by which means he became master of the oriental languages and learning. He returned to Carthage; but being informed of an attempt against his life, made his escape into Apulia, where he was recommended to Robert Guiscard, created, in 1066, duke of that country, who made him his secretary. He was reputed to be very well versed in the Greek, as well as the eastern tongues; and seems to have been the first who introduced either the Greek or Arabian physic into Italy. His works, however, contain nothing that is new, or material; though he was then counted a very learned man, and for that age no doubt was so.

From this time to the end of the 15th and beginning of the 16th century, the history of physic furnishes us with no interesting particulars. This period, however, is famous for the introduction of chemistry into medicine, and the discovery of three new distempers, the sweating sicknesses, the venereal disease, and the feverly. The sweating sicknesses began in 1483, in the army of Henry VII. upon his landing at Milford haven, and spread itself at London from the 21st of September to the end of October. It returned here five times, and always in summer; first in 1485; then in 1506, afterwards in 1517, when it was so violent that it killed many in the space of three hours, so that numbers of the nobility died, and of the commonalty in several towns often the one-half perished. It appeared the fourth time in 1528, and then proved mortal in six hours; many of the courtiers died of it, and Henry VIII. himself was in danger. In 1529, and only then, it infected the Netherlands and Germany, in which last country it did much mischief. The last return of it was in 1551, and in Westminster it carried off 120 in a day. Dr Caius describes it as a pestilent contagious fever, of the duration of one natural day: the sweat he reckoned to be only a natural symptom, or crisis of the distemper. It first affected some particular part, attended with inward heat and burning, unquenchable thirst, restlessness, sickness at stomach but seldom vomiting, head-ache, delirium, then faintness, and excessive drowsiness. The pulse was quick and vehement, and the breath short and labouring. Children, poor and old people, were less subject to it. Of others, scarce any escaped the attack, and most of them died. Even by travelling into France or Flanders they did not escape; and, what is still more strange, the Scots were not affected: abroad the English only were seized, and foreigners in England were free. At first the physicians were much puzzled how to treat this disease. The only cure they ever found, however, was to carry on the sweat for a long time; for, if stopped, it was dangerous or fatal. The way therefore therefore was to be patient and lie still, and not catch cold. If nature was not strong enough to force out the sweat, it was necessary to assist her by art, with cloaths, wine, &c. The violence of the distemper was over in 15 hours; but there was no security for the patient till 24 were past. In some strong constitutions there was a necessity to repeat the sweating; even to 12 times. The removing out of bed was attended with great danger; some who had not sweated enough fell into very ill fevers. No flesh-meat was to be allowed in all the time of the distemper; nor drink for the first five hours. In the seventh, the distemper increased; in the ninth the delirium came on, and sleep was by all means to be avoided. However terrible this distemper appeared at first, it seldom proved obdurate if treated in the above-mentioned manner.

In the beginning of the 16th century, the famous chemist Paracelsus introduced a new system into medicine, founded on the principles of his art. The Galenical system had prevailed till his time; but their practice had greatly degenerated, and was become quite trifling and frivolous. The physicians rejected the use of opium, mercury, and other efficacious remedies. Paracelsus, who made use of these, had therefore greatly the advantage over them; and now all things relating to medicine were explained on imaginary chemical principles. It will easily be conceived that a practice founded in this manner could be no other than the most dangerous quackery. At this time, however, it was necessary; for now a new disease over-ran the world, and threatened greater destruction than almost all the old ones put together, both by the violence of its symptoms, and its baffling the most powerful remedies at that time known.—This was the venereal disease, which is said to have been imported from the West-Indies by the companions of Christopher Columbus. Its first remarkable appearance was at the siege of Naples in 1494; from whence it was soon after propagated through Europe, Asia, and Africa. The symptoms with which it made the attack at that time were exceedingly violent, much more so than they are at present; and consequently were utterly unconquerable by the Galenists. The quacks and chemists, who boldly ventured on mercury, though they no doubt destroyed numbers by their excessive use of it, yet showed that a remedy for this terrible distemper was at last found out, and that a proper method of treating it might soon be fallen upon. Shortly after, the West-Indian specifics, gunpowder, was discovered; the materia medica was enriched with that and many other valuable medicines, both from the East and West-Indies; which contributed considerably to the improvement of the practice of physic. The scurvy likewise began to spread during the course of this century. It had first appeared in 1486, in Mithra; where it not only proved very dangerous, but was also contagious. It probably owed its origin to an unwholesome sea-diet. The mariners of Saxony called it scharkock, which, in their language, signifies inflammation; and this it seems was one way in which it at first appeared, and terminated often in gangrene. It broke out among the Portuguese sailors in some of their voyages to the East-Indies, and in 1600 spread itself through the most of Europe; nor were the proper remedies for it discovered till very lately.

The revival of learning, which now took place throughout Europe, the appearance of these new distempers, and the natural fondness of mankind for novelty, contributed greatly to promote the advancement of medicine as well as other sciences. It was not, however, till the year 1628 that a foundation of was laid for a solid and rational system. This was done by Dr Harvey, who discovered the circulation of the blood; which may justly be reckoned the most capital discovery that ever was made with regard to the practice of medicine. The immediate consequences of it were, that all the vain and fanciful theories of the ancients were thrown aside, and others more rational established in their place. How far these have yet been ascertained, so as to be safely taken for a direction to the practical physician in all cases, we now proceed to inquire.

**Part I. Theory of Medicine.**

**Sect. I. General account of Theories to the time of Hoffman.**

Before the time of Harvey, who discovered the circulation of the blood, though every physician had some kind of theory of his own, yet, as all of these were built upon principles in themselves erroneous, and inconsistent with what has been since discovered concerning the structure of the human body, they are now quite unworthy of notice. But, on the discovery of the circulation of the blood, matters took a different turn, and physicians began to aim at establishing a theory of medicine upon more solid and consistent principles. It was generally agreed, that the circulation was the capital and vital function of the body, and that upon it the life and health did immediately depend. The blood was considered as it were the *primum mobile* of the whole body; and to something in the blood all the disorders to which the human race are liable, were thought to be owing.

About this time, also, the laws of mechanics began to be better and more generally understood; and various theories were formed with a design to account for all the phenomena of the human body upon mathematical or mechanical principles. Calculations were made concerning the diameters of the vessels, their gradual diminution, the friction of the blood against their sides, the force of the heart, &c. Thus were mathematics introduced into physic, and every thing relative to the human body was thought to be performed by the mere force of such mechanical powers as we are acquainted with, and whose effects we observe in pumps, steam-engines, and other hydraulic machines.

This consequences of this doctrine, however, soon destroyed the principles on which it was founded; and such prodigious powers were attributed to the action of some parts of the body, as were much more than sufficient. Digestion, for example, was thought to be accomplished by the mere mechanical pressure of the stomach upon the aliments contained in it, and Dr. Pitcairn calculated this pressure at more than 3000 pounds weight; but, by a strange and almost unaccountable oversight, he did not advert, that upon his hypothesis the soft texture of the viscera would have been totally destroyed by the hardness of some parts of the aliments swallowed even by the human species, and much more in other animals; as we see that dogs will swallow and digest even the hardest bones. The immense differences also between the calculations of different mathematicians, shewed evidently, that either some other power than mere mechanism was concerned in the operations of the human body, or that its mechanism was of a different kind from that which takes place in machines constructed by art.

The greatest difficulty the mechanical physicians had to encounter arose from the phenomena of molecular motion. The force of the muscles in contraction is observed to be so great, that it seems scarce possible to account for it upon mechanical principles. Attempts were made indeed to overcome this difficulty. The molecular fibres were supposed to be full of small cells, which, being inflated by the animal-spirits derived from the brain through the nerves, shortened the length of the muscle, and thus caused it to contract. But, even allowing this hypothesis to be true, another difficulty, equally great, arose from it; namely, to account for the origin of this prodigious power attributed to the animal-spirits. To evade this difficulty, Stahl maintained, that the rational and immaterial soul itself was the source of all the motions of the human body; and that by the direction of this spiritual being every thing was conducted, both with relation to the motion of the muscle, and to every function both vital and natural.

The consequences of this system were still worse than those of the former; for now metaphysics were superadded to mathematics, and physicians were tempted to neglect the anatomy of the body, and to intermeddle with spiritual subjects which they could by no means comprehend. Neither could the most rigid Stahlians deny, that in many cases the human body is subject to the common laws of mechanism; so that their system, instead of explaining, tended to set aside all kind of reasoning, and to involve every thing in darkness.

But, besides the mechanical theory, another was invented soon after Harvey's discovery of the circulation, by which every thing was ascribed to an alteration in the quality of the blood itself. This took its rise principally from some microscopic observations of Leeuwenhoek; and was adopted by Boerhaave, who hath most fully explained it. He begins with considering the diseases arising from a weakness and laxity of the ultimate and finest fibres of the human body. This, he says, is immediately owing to an obstruction in the conversion of the aliments into healthy juices; and this again to too great a consumption of good fluids, to the flaccidity of the power of the solids over the fluids, or the too great viscidity of the aliments themselves; or it may arise from too weak a motion in the fluids, proceeding chiefly from a defect of muscular motion, or from too great a pulling of the fibre, next to breaking.

Opposite to these are the diseases arising from fibres too stiff and elastic. These are produced by the use of strong aliments, exercise, acid and austere medicines, and in short by every thing that tends to increase the strength of the body.

The simple fibres (or the ultimate and finest fibres of the body), interwoven with each other, according to our author, form the most simple membrane; and this formed into a hollow tube, makes one of the least kind of vessels. If many of the smallest fibres are twisted together in the formation of the membrane, it will be proportionally thicker, and the vessels formed of it will, in like manner, be so much stronger; and hence proceed the diseases of weak and lax, and of too stiff and elastic, viscera.

Our author next considers the most simple and spontaneous defects of our fluids. These are either from the prevalence of an acid, which is again produced by the eating of acid vegetable food, or taking fermented liquors in too great quantity; or from a spontaneous gluten arising from the use of crude and farinaceous aliments, &c.; or from an alkali. This last is produced by the use of animal food, especially such as has a putrid taint, and the use of alkaline vegetables, &c.

Besides all these, however, he says, there are difficulties arising merely from a too great increase of dilated circulatory motion. The immediate cause of this increase is the more frequent and strong contraction of the heart. This again happens when the brain and cerebrum are so strongly compressed, that they send forth too great a quantity of the nervous juice; as in passions of the mind, or in pains. It may arise also from an irritation of the heart itself, either by the blood returning more quickly to it, occasioned by muscular motion, or to some acrimony present in the blood itself.

Opposite to these are the diseases which proceed from a deficiency of the circulation, or from plethora. The plethora first is produced by the spontaneous degeneracy of the humours already mentioned; the second is a greater quantity of well-conditioned blood than what is capable of undergoing those changes which must necessarily happen in life, unless distempers intervene and disturb them. It is produced by every thing which makes a quantity of good chyle and blood, at the same time hindering their attenuation, consumptions, and perspiration through the pores of the skin.

He next goes on to consider the diseases proceeding from the least compound obstructions, and from wounds. An obstruction is the shutting up of a canal, and denying the passage to a fluid which should flow through the same. This may proceed from the narrowness of the vessel, the bigness of the containing body, or from both taken together. The vessel may become too narrow from outward pressure, from its own contraction, or from its sides growing thicker. The bulk of the small bodies contained in the vessels becomes too great, either by the sliminess of the fluid, or their having mistaken their passage; and when these two meet together, the obstruction is more obstinate and difficult to remove. The bulk of the fluid parts is increased to such a degree as to render them incapable... pable of flowing, 1. Either by changing their spherical figure into another, presenting itself in a larger size to the mouth of the canal; or, 2. By the joining together, into one, several particles which were single before. The figure is chiefly altered when that even pressure of the smallest particles, now left to their own elasticity which used to work and press together from all sides equally, is ceased; that is, when the motion is become languid, or the vessel relaxed; or when the quantity of liquid is lessened. The particles run into one, by too much rest; by cold; froth; drying; heat; a violent circular motion, and the pressure of a strong vessel; by an acid, astringent, spirituous, and absorbing coagulum; by a slime; or by an oil. The particles of fluids having mistaken their passage, are stopped when a small body of them runs into the dilated mouth of a canal, through the extremities of which they cannot pass. This dilatation is chiefly occasioned by a fullness, an increased motion, a rarefaction of the fluid, and relaxation of the vessels; and most of all these are soon succeeded by their contraries: "Which is the immediate cause of all colds."

An inflammation he defines to be an attrition of the red arterial blood stagnating in the smallest vessels; occasioned by the motion of the blood circulating with greater force in the larger vessels. This stagnation is occasioned in the smallest arteries by whatever makes the ends of the vessels in their cones and cylinders so narrow that the diameter of their orifices is made less than the globules of the blood; the causes whereof may be heat, violent motion, foreign bodies stuck in, ligatures, the taking inwardly, or applying to the surface of the body, sharp substances of various kinds, cold, too great rubbing, &c. An inflammation is likewise produced by everything that shuts up the passages, and at the same time applies to them either inwardly or outwardly such acrimonious bodies as are both oily and saline: Also by such things as occasion the blood to settle and coagulate in the body; as too violent motions, a draining of the thinnest parts by sweating, urine, spitting, loofness, serous eruptions, and all such things as coagulate, whether medicines or poisons. In the lymphatic arterial vessels, an inflammation is produced, 1. By all the causes which render their mouths sufficiently wide to admit the grots parts of the blood, which, being driven in deeper, meet with narrow passages that give way; and, 2. By all the causes of inflammation in the blood-vessels, so that this disease may take place in every conic vessel through which the red blood flows from the wide to the narrow end.

Fever is inseparably connected with inflammation. To have a just notion of the cause of it, Dr. Boerhaave says, it will be necessary to choose from the innumerable symptoms that occur in all the variety of fevers, some general ones that are common to all; the presence of which makes the physician sensible that his patient has a fever; then, from the consideration of these, the individual and specific nature of the fever is to be found out. In every fever produced by an internal cause, there are to be observed, at some times and in some degree, a shivering, a quick pulse, and a heat. These are present in all fevers; but of the three, there is only the quick pulse which is present from the beginning to the end; so that the physician may from that single phenomenon conclude whether a fever is present or not. The proximate or nearest cause of this quickness is therefore also the proximate cause of the fever. The quickness of the pulse is immediately produced by the quicker contraction of the heart; and that again by the too quick reciprocal influx of the nervous juice, and that of the cerebellum, into the muscles and ventricles of the heart. Almost every fever begins, as already observed, with a sense of coldness, shivering and shaking, greater or less, according to the different constitution of the patient, or the nature of the fever itself. At this time the pulse is quick, small, and often intermittent; the extremities frequently pale, cold, stiff, trembling, and void of feeling: whence it appears, that then the blood stagnates at the ends of the capillary vessels, at the same time that there is present some cause which irritates the heart.

In all fevers, after the symptoms already mentioned, there arises a heat; which is greater or less, of a longer or shorter continuance, according to the different nature of the fever. This heat, as it follows the pre-existent fever, ought rather to be taken for its effect than its cause, so that the too quick contraction of the heart, with an increased resistance at the extremities of the capillary vessels, is sufficient to give us a just idea of all acute fevers; that is, such as quickly pass off, with danger to the patient. Either of these two (viz. the quick contraction of the heart, or the resistance in the capillary vessels) may be occasioned, in a living animal, by an infinite number and variety of causes: which, however, are divided, according as they are either singular or proper to each, or as they are universal and common to many; and these last are generally owing to the use of the same air, diet, and manner of living, by those who are seized with the fever.

The causes of fevers, then, are either singular, or universal, or epidemical. The singular proximate causes fever may be reduced under some heads. 1. The things received into the body being sharp or pricking; whether these things are called meat, drink, preservatives, or poisons; provided they are endowed with such properties that they cannot be digested, moved, or evacuated; or when taken in such a quantity as to irritate the stomach, or to choke and obstruct the passages, and putrefy within the body. 2. The things retained in the body which were wont to be evacuated each in their proper way; and these may be retained by means of cold, unctions, vapours, some thick and fat aliment, drink, medicines, poisons, or air. The same effect will also follow from too long continued rest, the omission of some usual exercise, obstructions and compressions either from the contained or surrounding bodies. 3. From action; such as the too great disturbance of mind or body, occasioning heat and tossings. 4. From external, sharp, pungent, tearing, burning, and inflaming applications. 5. From those things which make a considerable change upon the humours and their motions: which may be done by many externals as well as internals; such as hunger, great evacuations, collections of pus, water and watery blood, in dropsies and empyemas; or sharp serum, inflamed and burnt cholera, suppurations, gangrenes, too much waking, intense study, and excess of venery.

The effects of fever are, a too quick expulsion and propulsion of the circulating humours, too great agitation of the stagnating ones, and a mixture of those those which ought to remain separate; an overcoming and concocting of what resists; a secretion of the concocted matter; and a critical evacuation of what has occasioned the fever by its coagulum and irritation; a change of the found liquors into a diseased state; a change of the found parts into a condition able to bear many things which could not be borne before; an expression of the most thin and liquid juices; a thickening of the remainder; a drought, heat, anxiety, pain, weariness, weakness, heaviness, loss of appetite, and nausea.

The sooner the irritation is allayed and the stagnating liquids resolved, so much the lighter and shorter will be the fever, and the sooner will it tend to health; and so on the contrary: and the fever will also vary according to the different degrees and concurrence of both. Hence we may learn that a fever may often be a medicine instrumental in the cure of other diseases; such as the palsy, &c. Hence the beginnings, full height, declension, crises, changes, and cure of fevers, are various in the very acute fevers, and even in the singular kind.

The cold fit, which happens in the beginning of acute fevers, supposes a smaller attrition of the liquors against each other and their vessels; the lessening of the circular motion; a stagnation of the liquids at the extremities; a less contraction of the heart, a less quantity of the blood forced out of it, and the animal spirits flowing in less quantity from the cerebellum to it. The shaking supposes a wavering of the muscles between their tone and laxness; some causes now extending and soon after relaxing them; and these motions succeeding each other quickly, without the will of the patient, or even against his will; the influx of the arterial and nervous juices, sometimes absent, sometimes present. The cold fit therefore argues, in the beginning of the disease, a rest of both these liquids; towards the end, often too long an absence of the same, after an extravagant expense of the one or both.

The anguish in fevers is occasioned by the blood being stopped in the heart itself, and consequently hindered from passing thro' the lungs and sorts: whence a cramp of the contracted vessels, or an impossibility of the inflamed matter passing through them. The same effect follows from the blood being hindered in its passage through the vena portarum in the liver by the same causes; whence all the venous blood, brought hither by the celiac and mesenteric arteries, cannot return, but stagnates, extends the vessels, refills the approaching blood conveyed through the arteries, and produces all the evils deducible from these causes.

Thirst in fevers owns for its causes a thickness of the liquids, and their inability to flow; a salt, alkaline, or a bilious and oleous acrimony.

Another very common symptom in fevers is loathing. The proximate cause of this is a slight convulsion of the muscular fibres of the fauces, gullet, stomach, intestines, and abdominal muscles. Its causes are,

1. A sharp, putrid, bilious matter derived into the empty stomach, rising towards the fauces, pricking and twitching both, whence, the other parts follow the same motion; or, 2. A viscid, flaccid, and floating matter, which, by watering those parts, doth also twitch them. 3. A slight inflammation of the stomach, gullet, intestines, and neighbouring viscera.

4. The remembrance of things which, when formerly taken, used to occasion loathings. 5. Lastly, The inordinate motion of the nervous juice, no matter whence arising.

Vomiting, which at first is a violent expulsion and vomiting up of the contents of the stomach, and afterwards also of the guts, and lastly of the bowels emptying themselves into the latter, hath, for its proximate cause, a convulsion of the muscular fibres of the fauces, gullet, stomach, intestines, diaphragm, and of the abdominal muscles; and for its remote cause, whatever stimulates these fibres by irritating them or those viscera which are easily convulsed. It happens sometimes, therefore, from a defect of the stomach, which is convulsed, inflamed, impoisoned, scirrhouss, and cartilaginous, together with an acute fever. It may happen also from a defect of the bowels, and the surrounding parts affected in the same manner, and irritated by the distended stomach full of aliments or other matters; or it may happen from all the causes of very great loathings. Hiccups may arise from the same causes.

The weakness in fevers proceeds from the hindrance of the influx and prelure of the nervous juice into the muscles. It may proceed from the emptiness of the vessels, from the liquid being spent, or its being unable to flow; from the obstruction of the canal; or its being pressed and squeezed by an external cause, chiefly about its origin in the brain and cerebrum; and from the weaknesses of the heart.

Heat in fevers is known outwardly by the thermometer, and the sense or feeling of the patient; but the inward heat, from the redness of the urine. It always argues a greater quantity of fire in that place where the heat is greatest. This again arises from an unusually strong rubbing of the fluid parts among each other, against the vessels, and of the vessels against the liquids. This violence arises from the great motion of the parts pushed from the heart, and from the strong resistance of the vessels against the heart.

The great motion of the blood expelled from the heart is measured by the thickness of it, and by its quick or slow running through the vessels. The degree of thickness is known by inspecting the same when extravasated, from the fast dissipation of the thinnest part, and from the hardness of the pulse. The quickness of its running is computed from the number of the beatings of the heart, compared with the greatness of the pulse beatings. The greatness of the resistance is known from the bulk of sluggish liquors that are to be moved; and from the small number, narrowness, or immobility of the canals which are to let the liquids pass. That the liquids to be moved are too bulky, is known from the signs of a plethora, of a cacochymy, or of a sudden solution of these liquids, which just before were stagnating; as it happens in fat people: but this appears most of all to be the case when the veins are much swelled, and at the same time the arteries full and their motions quick. The narrowness of the vessels is understood by seeing, feeling, and knowing, the dry constitution of the patient, whose heat increases greatly upon the least increase of motion. The immobility of the channels, or their unwillingness, as it were, to be dilated, is known by all the signs of stiff fibres, or too great a degree of strength. From all these proximate causes may arise the febrile heat; of which again there may be numberless remote causes. But it may arise from the increase of only one of these causes; in which case, the increase of the heat keeps pace with the increase of the cause. If two causes increase together, then will the increased heat be as the products of the increments of those causes when multiplied by each other. The effects of this increase of heat are, to dissipate the most liquid parts of the blood, i.e., the water, spirits, salts, and most subtile oils; it dries the remaining mass, thickens it, and causes it to run together into an immoveable and irrefusable matter; it extricates the salts and oils, attenuates and makes them sharper, exhales and moves them. The consequence of all this is, that the smallest vessels are worn out and broken; the fibres dried, made stiff, and shrivelled; and hence are produced many acute, dangerous, and mortal diseases; which may be easily accounted for and derived from the first effect of heat mentioned here, viz., the dissipation of the thinnest parts of the blood.

Delirium.

A delirium in fevers always supposes a morbid affection of the medullary part of the brain, which may arise from any obstruction whatever, the hindrance of the influx, the transflux, and flowing out of the nervous juice through the substance of the brain; from a violent quick motion, a stagnation, and many other causes, to find out which the physician ought to use all his sagacity and application.

A coma, or continual propensity to sleep, sometimes with a real sleep, and often without it, always proceeds from such a state of the brain as hinders the free exercise of the senses and animal-motions. It may arise from a defect of the nervous juice derived to the brain, or from the separation of animal-spirits from the blood into the nerves being obstructed, or from those spirits being denied their free passage to and fro through the nerves. This symptom therefore may be produced by several different, and often contrary, causes: such as all violent and great evacuations or repletions; all the too great thickenings of the blood, whether by glutinous, fat, or inflammatory matters and causes; everything compressing the brain itself, of whatever nature it may be; and the same causes will produce the same effects, if they act immediately upon the nerves themselves.

The opposite evil to the former is a constant and obstinate watchfulness. Its cause is generally the first beginning of the slightest inflammation of the brain; which, if increased, generally turns to a coma.

Convulsions in fevers always proceed from a defect of the brain; which is either affected by some matters conveyed thither through the nerves, and thereby twitched; or they proceed from the uneasy arrival, transflux, and issuing forth of the animal-spirits; which may arise from every one of the causes that are able to create a delirium, a coma, or an obstinate watchfulness. If the causes continue long, the evil soon spreads to the whole system of the nerves; whence proceed innumerable mischief.

Sweats, in the beginning of an acute fever, arise from a laxity of the extreme capillary vessels, a violent circulation of the blood, and an easy separation of the thin watery part from the others. A continuance of them deprives the blood of its diluting liquor, thickens the remainder, and occasions mortal obstructions; because the blood afterwards will hardly admit either of being diluted or resolved; whence may be produced almost all the different kinds of acute diseases.

A diarrhoea or loofenets happens pretty frequently in fevers. The matters voided in this case are mucus, lymph, gluten, pus, watery blood, and blood itself; all coming from the nostrils, mouth, fauces, gullet, stomach, liver, gall-bladder, pancreas, the guts themselves, and the mesentery. The causes of their working themselves off in the form of this disease are, such a powerful force as carries them into the intestines, while the contracting force of the intestines is much weakened; or they may arise from impediments in the absorbing vessels of the guts, such as the lacteals hindering the inlets of some of these matters thro' them into the blood. Hence a loofenets in fevers is very various as to its causes, effects, and consequences. If it continues long, it disposes the bowels of the lower belly more and more to this disease; it weakens, inflames, and excoriates them; and it drains and dries the other bowels and vessels. Hence a want of nourishment, leanness, weakness, bloody-flux, a thickness of the fluids through the whole habit, a laxity of the solids, a pituitous bloating all over, a dropfy, and a consumption.

Inflammatory postulates have generally for their matter, something which cannot pass through the least vessels of the skin, but is forced to stop there; and, for their cause, they acknowledge the circulating, secretory, and excretory power of life; so that they are manifold according to these different causes, and from thence fevers take their names; as the erysipelas, scarlet, red, petechial, purple; and variolous or morbillous, from the small-pox and measles.

The above is Dr Boerhaave's theory of continued intermittent fevers. The intermittents, he says, have for their proximate cause a viscofity of the arterial blood, upon which succeeds a too quick and strong contraction of the heart, and after this a resolution of what had been stagnated; which ends the fit.

For a long time this theory continued to prevail, this theory and is still adopted by several physicians. It was not, however, without opposition, even during the lifetime of Dr Boerhaave. His opponent was Dr Hoffman, who was also a man of great learning and eminence in his profession. He found fault with Dr Boerhaave for neglecting the nervous system; and asserted, that so far was the body from depending on the state of the fluids, that the crisis of the fluids themselves was entirely dependent on the nervous power; and that a slight alteration in this power was capable of instantaneously changing the blood and all the other humours into fluids of a quite different nature from what they formerly had. He was of opinion therefore, that all, or at least the greatest part of diseases, were affections of the nervous system. This opinion is now so generally diffused and adopted, that Dr Boerhaave's theory is in a manner totally exploded; and as a system of physic built on principles similar to those of Hoffman, hath for some years been taught by Dr Cullen of Edinburgh, we shall give as full an account of it as our limits will admit. Sect. II. Dr Cullen's Theory.

The Doctor begins with dividing his theoretical part, or the Institutions of Medicine, into three general heads. The first, called physiology, treats of that condition of the human body which is necessary to life and health. The second, called pathology, delivers the general doctrine of diseases; and the third, called therapeutics, delivers the general doctrine concerning the means of prevention and cure.

1. Physiology.

In treating of this subject, our author first considers the solid matter of which our bodies are composed, and which he calls the simple solid. Here he differs remarkably from Dr Boerhaave. The latter, following the doctrines of the chemists, asserted, that the original stamina of the human body are fibres composed of earthly particles cemented together by a kind of glutinous matter. This cementation is denied by Dr Cullen, who very justly observes, that nothing can be deduced from the chemical analysis of these solids, unless we were able to recompose them from the principles to which they are reduced by chemical operations. All that we can know, therefore, with regard to our solid parts, is, that they are formed of water, and a certain matter concreting along with it. The brain is that part of the human body which is first formed; and therefore he is of opinion, that it is the principal or chief organ, upon which the welfare of the body depends. The original stamina of the body he also supposes to be fibrous; and differs from other physiologists, who suppose it totally to consist of cellular texture. This last, he thinks, is superadded to the fibres. How the nutritious matter is applied to the fibres, in order to extend them in length, or to form a cellular texture on their surface, he declares himself unable to explain. "It is probable, however, says he, that for a certain time, at its first beginning, the growth of animal bodies proceeds in the same manner as that of vegetables; but it is evident, that, at a certain period, in the growth of animals, a different economy takes place; and that afterwards the growth seems to depend on an extension of the arteries in length and wideness by the blood propelled into them. It may be supposed that this extension of the arteries is applied to every fibre of the body; and that, by the extension of these, it gives an opportunity for the application and accretion of the nutritious matter, to the growth therefore of the fibre itself, and to the growth of cellular texture on its surface. Perhaps the same extension of the arterial system gives occasion to the secretion of fluids, which, poured into the cellular texture already formed, according to the disposition of these fluids to concret more or less firmly, gives the different degrees of hardness or density to be observed throughout the body.

"By this extension of the arterial system, the several parts of the body are gradually evolved; some of them sooner, others later, as by the constitution of the original stamina; or after occurrences, they are generally put into such conditions as render them less exposed to the impetus of the blood, and fitted to receive a greater quantity of it. But as the parts by these causes first evolved will increase the most in the density of their solid parts, they will therefore more and more resist their former growth; and by the same resistance will determine the blood with more force and in greater quantity into the parts then not so far evolved. Hence the whole system will be at length evolved; and every part of the solids will, in respect of density and resistance, be in balance with every other part, and with the forces to which they are severally exposed.

"The extension of the arteries depends upon the resistances which occur to the free transmission of the blood through them; and further, from a resistance in the veins. For as a considerable portion of the blood does not commonly pass into the smaller branches of the arteries, but must pass very entirely into the veins; to these, by their capacity constantly diminishing as they approach nearer to the heart, and by their coats being of a density and firmness sufficient to prevent further dilatation, considerably resist the free passage of the blood from the arteries into them.

"While these resistances continue, the arteries, and with them almost every fibre of the body, must be extended at every systole of the heart, and with this extension the growth of every part will proceed; but as every part, by its receiving an addition of solid matter, becomes more dense and rigid; so it is less easily extended, and perhaps less readily receives an accretion of new matter than before. Hence it is, that the more the body grows, it admits of any additional growth the more slowly; and unless the extending powers increase in the same proportion with the increasing density of the solids, there must be a period at which these two powers will balance each other, and the growth will proceed no farther. But as it is evident, that the bulk and weight of the heart, and probably therefore its force, does not increase with the increasing bulk of the body, and that the action of the heart is the principal extending power in the system; it is also plain, that the extending power does not extend in the same proportion with the increasing density of the solids; and therefore that these two powers will, at a certain period, come to balance each other.

"But not only is the force of the heart thus constantly diminishing with respect to the resistance of the arteries, but, tho' this force were still subsisting, it has, from other causes, less effect in extending the arteries. The blood is more confined in the arteries, and extends them further in proportion to the resistance of the veins; and this resistance in the veins, and extension of the arteries depending upon it, will be more or less according to the respective density of these two sets of vessels. But it appears from the experiments of Sir Clifton Wintrogham, that the density and firmness of the veins with respect to their corresponding arteries is much greater in young animals than in old ones: and thence it appears, that, during the growth of animals, the arteries are acquiring an increase of density in a greater proportion than the veins are at the same time; and therefore that the resistance in the veins with respect to the arteries must be constantly diminishing; that the veins will therefore receive a greater proportion of blood; that in the same proportion the arteries will be less extended; and lastly, that the diminished resistance in the veins occurring with the diminished force of the heart, will the Theory sooner bring the increasing rigidity of the arteries, and therefore of every fibre in the body, to be in balance with the extending powers; at least so far as to prevent their producing any farther growth.

This account of the change of the resistances in the arteries and veins with respect to one another is agreeable to phenomena which shew that the arteries are larger, and contain more blood in proportion to the veins, in young animals than in old; that arterial hemorrhages occur most frequently in young persons; and that congestions in the veins with haemorrhagies, or hydropic effusions depending upon them, occur most frequently in old age.

It is probable, that the resistance both of arteries and veins goes on increasing, while the force of the heart is not increased at the same time; but it appears also, that from the diminishing force of the heart, and the compression which the smaller vessels are exposed to from the distention of the larger, the action of the muscles, and other causes; the number of small vessels, and therefore the capacity of the whole system, is constantly diminishing; so much, that the heart may still for some time be sufficient for the circulation of the blood. But while the resistances in the vessels are constantly increasing, the irritability of the moving fibres and the energy of the brain are at the same time constantly diminishing; and therefore the power of the heart must at length become unequal to its task, the circulation must cease, and death ensue.

The unavoidable death of old persons is thus in part accounted for; but it is, however, still probable, that the same event proceeds chiefly from the decay and total extinction of the excitement or vital power of the nervous system, and that from causes very much independent of the circulation of the blood, and arising in the nervous system itself, in consequence of the progress of life. This seems to be proved by the decay of sense, memory, intellect, and irritability, which constantly takes place as life advances beyond a certain period."

Thus, according to our author, the nervous system is the substratum or fundamental stamina of the whole body; and indeed, as he explains it, our whole frame is so made up of nerves, that the body may be said to contain nothing else. The nervous system he divides into four parts. 1. The medullary substance contained in the cranium and vertebral cavity; the whole of which seems to consist of distinct fibres, but without the several fibres being separated from each other by any evident developing membranes. 2. Connected with one part or other of the above substance are the nerves, in which the same medullary substance is continued; but here more evidently divided into fibres, each of which is separated from the others by an enveloping membrane derived from the pia mater. 3. Parts of the extremities of certain nerves in which the medullary substance is divested of the enveloping membranes from the pia mater, and so situated as to be exposed to the action of certain external bodies, and perhaps so framed as to be affected by the action of certain bodies only. These he calls the sentient extremities of the nerves. 4. Certain extremities of the nerves so framed as to be capable of a peculiar contractility, and in consequence of their situation and attachments to be by their contraction capable of moving most of the solid and fluid parts of the body. These he calls the moving extremities of the nerves; they are commonly called moving or muscular fibres. The proofs of this last position we shall give in his own words.

XCI. The inherent power (or contractility of Muscles) is supposed to be more vigorous, moveable, and permanent, in certain muscular fibres than in others.

XCII. The inherent power, or the contraction dependent upon it, can be excited by certain applications, made either to the muscles themselves, or to the nerves connected with them; and in either case, the effects of such application are so exactly the same as to allow us to conclude that the matter of the nerves and of the muscular fibres is of the same kind.

XCIII. The muscular fibres are sensible to various impressions, and are otherwise organs of the sensations of consciousness. From this also it is presumed, that the muscular fibres consist of the same matter which is the subject of sense in other parts of the nervous system.

XCIV. From (XCII, XCIII,) and other considerations, we think it probable, that the muscular fibres are continuations of the medullary substance of the brain and nerves as before alleged.

XCV. Though the muscular fibres consist of the same kind of matter as that in the nerves, the latter shew no contractility, because they have not the peculiar organization of the former.

Some physiologists, particularly Dr Haller, have endeavoured to prove, that the muscles have a power of motion independent of that which they receive from the nerves: these our author refutes by some experiments which prove, that both of them continue for an equal length of time, and that when the nerve is irritated, the muscle contracts, even after death, in the same manner as tho' the muscular fibres themselves were irritated.

The Doctor next endeavours to show, that the force power of cohesion and of the muscular fibres are the same. His cohesion words are, "As the force of cohesion in the muscular fibres of living animals is much greater than in those of dead ones, it is probable from this and other considerations that the cause of muscular contraction is an increase only of that same power which gives the contractility of the simple solids, and of other inanimate elasticities. Haller Prim. Lin. 407, 408.

"If this is true, it will also explain why the force of cohesion in muscular fibres is greater than that of the medullary fibres in any other part of the nervous system, though both kinds of fibres consist of the same kind of matter." The power abovementioned he conjectures to be an elastic fluid, the motions of which are excited in the nerves, and by their means accumulated in the muscles. The excitement of the fluid in some measure is what is properly called life, at least as far as that is corporeal; and its collapse, or some diminution of its motion, produces sleep, fainting, &c. or if the collapse is total and irrecoverable, death itself.

With regard to this nervous power, the Doctor absolutely refuses that it is secreted from the blood. "The most common opinion (says he) is, that the brain is a secretion from the blood. secretory organ, which secretes a fluid necessary to the functions of the nervous system; that this fluid is alternately exhausted and recruited, and thereby gives occasion to the alternate states of sleeping and waking. But this supposition is attended with many difficulties. 1. It is probable that the nervous fluid existed in the animal embryo before the action of the heart, or any secretory function could take place. 2. In animals which during the winter suffer a temporary death, when, by heat, they are again restored to life, the vital power of the solids is restored before the fluidity of the blood. 3. The nervous fluid subsists in the nerves and muscular fibres long after they are separated from the brain, and often when cut into small parts. 4. Though it be true that the brain is a secretory organ, the fluid may be destined to another purpose; and, so far as we understand that purpose, the fluid fit for it must be unfit for the purposes of sense and motion. 5. There is no appearance, in any part of the nervous system, of provision made for an occasional accumulation of the secreted fluid; nor is there any evidence of its actually taking place. 6. The phenomena of sleep and waking do not correspond with such a supposition; as sleep often takes place when the secreted fluid must be copiously present, and waking can be protracted when the fluid is exhausted much beyond its usual measure. 7. Both states are induced by many causes which can hardly be supposed to act upon a secretion.

"A certain compression of the brain can produce a state of the system resembling sleep: but that state is in some respects different from that of ordinary sleep; and it does not by any means appear, that natural and ordinary sleep depends upon any compression of the brain.

"As it is therefore probable, that sleep and waking do not depend upon a different quantity of the matter of the nervous fluid for the time present in the system, or upon any causes interrupting its motion, while the condition of the matter remains the same, we are disposed to believe, that those states of sleep and waking depend upon the nature of the nervous fluid itself capable of becoming more or less moveable; that it is chiefly in the brain susceptible of these different conditions; and that especially by its condition there, it has its more general effects on the system."

Speaking afterwards of the nutrition of the body, he says, "From the fibrous parts being evidently, in most instances, parts of the nervous system, and from the gradual formation of the fetus, in which the nervous system is first formed, we think it probable, that the whole of the fibres in the different parts of the body are a continuation of the nerves; and this again will lead to the conclusion, that the nourishment of the soft and homogeneous solid everywhere is conveyed to it by the nerves.

"This supposes also what is otherwise probable, that the cortical part of the brain, or common origin of the nerves, is a secretory organ, in which the gluten of the blood being freed from all saline matter before adhering to it, becomes fit for the nourishment of the solids, and being poured in a sufficiently diluted state upon the organ of the nerves, it is filtrated along the fibres of these; and is thus conveyed to every staminal fibre of the system. We suppose, at the same time, that the medullary, or what may be called the solid matter of the nerves, is, in the living body, constantly accompanied with a subtile elastic fluid, which fits them for being the organs of sense and motion, and which probably is also the means by which the nutritious fluid is carried on in the substance of the nerves from their origin to their extremities.

By this system the blood and its circulation, instead of being the principal or vital function, as it was reckoned by Harvey and others, becomes so much a secondary in the animal economy, that it answers little other purpose besides the nutrition of the body. It hath been objected, however, that this fluid is, somehow or other, of the utmost consequence; since a Why stoppage of the circulation, or a wound in the large vein death vessels about the heart, proves instant death, without waiting for any consumption of the body by reason of the its want of nourishment. This our author explains by reminding us, that the vessels must necessarily be in vessels, a certain state of diffusion, in order to the mobility of the nervous fluid. The evacuation of all the blood causes an irretrievable collapse of the vessels, and consequently of the nervous fluid, upon which death immediately takes place.

We apprehend it would be superfluous here to enter into any particular disquisition concerning the manner in which each of the functions of the animal economy are performed. These may be seen under their proper articles as they occur in the order of the alphabet, and what we have already taken notice of will be sufficient to make his theory of diseases quite intelligible.

II. Pathology.

From the sketch we have given of Dr Cullen's physiology, it may easily be imagined, that the distinguishing characteristic of his pathology will be, that almost all diseases are the consequences of an affection of the nervous system. The nervous power, he thinks, is the same with what Hippocrates called Nature, and to which he ascribed such efficacy in removing diseases. This subject, however, the latter did not profess to any good purpose, and his followers still less. Erastratus took no notice of it; and though Galen ascribed power to an active power to what he called Nature, yet he considered this as chiefly concerned in the support of health and the cure of diseases, and referred the operations of nature in the cure of diseases to the solids and fluids. In the 15th and 16th centuries the reformers of physic for a long time overlooked the nervous power; and though the chemists introduced their doctrines, with regard to the fluids, yet they acquiesced in the former doctrine which ascribed to them the ultimate powers of the animal economy. Van Helmont indeed proposed a very considerable change by his doctrine of the arches; maintaining, that the motion of it had a greater share in the production of diseases than the causes assigned by the chemists and Galenists. But this doctrine was delivered in such an obscure and fanciful manner, that no notice was taken of it; and people continued to imagine that diseases consisted in a certain intemperance of the fluids, and that fever particularly consisted in a preternatural heat. After the discovery of the circulation, Sylvius de la Boe asserted, that fever proceeded from an increased velocity of the blood, and that an increased... quickness of the pulse was its pathognomonic. This, however, we are not to admit as true; because then the cure of fevers would consist only in diminishing the velocity of the blood, which is very easily done; yet sometimes it is necessary to increase this velocity in order to cure the fever. To this doctrine Bellini and Boerhaave added the doctrine of acrimony and a tension or viscosity in the blood; and this theory, such as we have laid down above from the aphorisms of Boerhaave, continued to be followed till very lately.

Hoffman considers fevers as entirely consisting in a change of the state of motion in the molecular fibres; which undoubtedly depends on that of the nervous system. The particular cause is a spasm in the extreme arteries; and the cure consists in a relaxation of that spasm, without regarding the fluids, but only so far as they affect the nervous system.

The following are the general phenomena of fevers as laid down by Dr. Cullen. The person is affected first with a languor, or sense of debility, insensibility, and sluggishness. The face and extremities become pale; the features shrink; the bulk of every external part is diminished, and the skin all over the body appears constricted as if by cold. A coldness of the extremities may now be perceived by another person, though the patient himself takes little or no notice of it. At length the cold becomes also perceptible to him; first, commonly, in his back, and thence passing over the whole body; though now his skin frequently feels warm to another person. The sense of cold continually increases, and at length produces a tremor in all the limbs, with frequent succussions or rigors of the trunk of the body. When this sense of cold and its effects have continued for some time, they become less violent, and alternate with warm flushings. By degrees the cold goes off entirely, and a heat greater than in a natural state prevails all over the body. With this heat the colour of the skin returns; and a preternatural redness appears, especially in the face. With the heat and redness the skin is relaxed and smoothed, but for some time it continues dry. The features of the face, and other parts of the body, recover their usual size, and even become more turgid. When the heat, redness, and turgescence, have increased and continued for some time, a moisture appears upon the face, which by degrees becomes a sweat, and at length prevails over the whole body. As this sweat continues to flow, the heat of the body abates; the sweat, after continuing some time, gradually ceases; the body returns to its usual temperature, and most of the functions are restored to their ordinary state.

From these general appearances, the paroxysm may be divided into three different stages, viz., the cold, the hot, and the sweating stages or fits; in each of which a considerable change happens to several of the functions.

On the first approach of languor, the pulse sometimes becomes slower, and always weaker, than before; and as the sense of cold comes on, it becomes smaller, very frequent, and often irregular. As the cold wears off and the heat comes on, the pulse becomes more regular, hard, and full; and in these respects increases till the sweat breaks out. As the sweat flows, the pulse becomes softer and less frequent, until, the sweat ceasing altogether, it returns to its usual state. The respiration during the cold stage is small, frequent, and anxious; as the hot stage comes on, it becomes fuller, and more free; but is still frequent and anxious, till the flowing of the sweat relieves the anxiety, and renders the breathing less frequent. On the approach of the cold stage, the appetite ceases, and does not return till either the paroxysm is at an end, or the sweat has flowed for some time. Generally, however, during the whole paroxysm, there is not only a want of appetite, but an aversion from all solid food, especially of the animal kind. As the cold stage advances, nausea and vomiting frequently come on, with the discharge of a matter for the most part bilious; but when the hot stage is pretty well advanced, this sickness abates, and commonly goes off altogether when the sweat breaks out. A considerable degree of thirst is commonly felt during the whole course of the paroxysm. In the cold stage, it seems to arise from the dryness and clamminess of the mouth and fauces; and during the hot stage, from the heat which then prevails; but, as the sweat flows, the mouth becomes more moist; and the thirst, together with the heat, gradually abates.

In the course of the paroxysm, a considerable change is also made in the state of the secretions. The circumstances already mentioned show it with regard to the saliva, and it is still more remarkable with regard to the urine. In the cold stage, the urine is almost colourless and without cloud or sediment. In the hot stage it becomes high coloured, but is still without sediment. After the sweat has flowed freely, the urine deposits a sediment commonly latertious, and continues to do so for some time after the paroxysm is over. Stools seldom occur till towards the end of a paroxysm, except in certain uncommon cases which are attended throughout with a diarrhoea.

It frequently happens also that tumours, subsisting on the surface of the body, suffer during the cold stage of fevers, a considerable diminution of their bulk; but which returns, though not always, during the sweating stage. In like manner, ulcers are sometimes dried up during the cold stage, and return again to discharge matter during the sweating stage, or after the paroxysm is over.

During the cold stage, the sensibility is often greatly impaired; but when the hot stage comes on, the sensibility is recovered, and often considerably increased. When the cold stage comes on, the attention and recollection become difficult; and continue so, more or less, during the whole paroxysm. Hence some confusion of thought takes place, and often arises to a delirium; which sometimes comes on at the beginning of the cold stage, but more frequently not till the hot stage is formed. With the cold stage also comes on a kind of drowsiness or stupor, which sometimes increases to such a degree that the patient becomes comatose, and almost apopleptic. In this stage also a headache sometimes comes on; but more commonly this is not felt till the hot stage is formed; and then it is usually attended with a throbbing of the temples. The headache continues till the sweat breaks out; but as this flows more freely, that gradually wears off. At the same time there are commonly pains of the back, and some of the great joints; which are to be derived from the same causes with the head-ache.

These are the principal phenomena to be observed in in the paroxysm of a fever; but it is very seldom that the disease is terminated by a single paroxysm such as hath been already described. It more generally happens, that after the series of phenomena above-mentioned, and after the patient has been for a certain length of time free from them, the same series of phenomena begins again to arise, and to observe the same course as before; and these states of fever and apyrexia often continue to alternate with each other for a great number of times. In these cases, the length of time from the end of one paroxysm to the beginning of another is called an INTERMISSION; and the length of time from the beginning of one paroxysm to the beginning of another is called an INTERVAL.

When the disease consists of a number of paroxysms, it is generally to be observed that the intervals between them are nearly equal; but these intervals are of different lengths in different cases. The most usual interval is that of 48 hours; which is named the TERTIAN Period. The next most common is that of 72 hours, and is named the QUARTAN Period. An interval of 24 hours is called the QUOTIDIAN Period. This last is not unfrequent; but all intervals longer than the quartan are extremely rare, and probably only irregularities of the tertian or quartan periods.

The paroxysms of pure intermittent fevers are always finished in less than 24 hours. But it frequently happens that there are fevers which consist of repeated paroxysms without any entire intermission between them; yet in such cases it is observed, that though the hot and sweating stages of the paroxysms do not entirely cease before the 24 hours from their beginning have expired, they suffer, however, before that time, a considerable abatement or REMISSION of their violence; and at the return of the quotidian period, a paroxysm is in some shape renewed, and runs the same course as before. This constitutes what is called a REMITTENT FEVER. In many cases, however, this remission is not considerable, and perhaps takes place without sweat; the returning paroxysm is not marked by the usual symptoms of a cold stage, but is chiefly known by the aggravation or exacerbation of a hot stage; in which cases the disease is called a CONTINUED FEVER. In some cases the remissions and exacerbations are so inconsiderable, that they are not easily observed or distinguished; and this has led physicians to imagine that there is a species of fever subsisting for several days together, and seemingly consisting of one paroxysm only. This they have called a CONTINENT fever; but Dr. Cullen affirms us, that, in a long course of practice, he had no opportunity of observing such a fever.

With respect to the form or type of fevers, it may be observed, that the quartan, while it has the longest interval, has at the same time the longest and most violent cold stage; but, upon the whole, the shortest paroxysm: the tertian, having a shorter interval than the quartan, has, at the same time, a shorter and less violent cold stage; but a longer paroxysm: and, lastly, that the quotidian, with the shortest interval, has the least of a cold stage; but the longest paroxysm. The type of fevers is sometimes changed in their course. When this happens, it is generally in the following manner: Both tertians and quartans change into quotidians; quotidians into remittents; and these last become often of the most continued kind; and in all these cases the fever has its paroxysms protracted longer than usual, before it changes into a type of more frequent repetition.

From all this the Doctor concludes, that every fever consists of repeated paroxysms, and differs from others only in the circumstances and repetition of the paroxysms; and therefore that it was allowable to take the paroxysm of a pure intermittent as an example and model of the whole.

The phenomena of fevers being thus enumerated, Of the Doctor next proceeds to explain their causes. The causes of proximate cause, he says, has hitherto eluded the researches of physicians; but as the hot stage is so constantly preceded by a cold one, he presumes that the cold stage is the cause of the hot one, and consequently that the cause of the cold stage is the cause of all that follows in the course of the paroxysm. The cold stage, he observes, is always preceded by evident marks of a general debility prevailing in the system. The smallness and weakness of the pulse, the paleness and coldness of the extreme parts, with the shrinking of the whole body, sufficiently shew that the action of the heart and larger arteries is for the time extremely weakened. At the same time the languor, inactivity, and debility of the animal-motions, the imperfect sensations, the feeling of cold while the body is truly warm, and some other symptoms, all shew that the energy of the brain itself is on this occasion greatly weakened: and as this weakness of the action of the heart can hardly be attributed to any other cause, it is also a proof of the diminished energy of the brain.—Another proof of the existence of debility is, that when the paroxysms of a fever have ceased to be repeated, they may be again renewed; and are most commonly renewed by the application of debilitating powers.

Hence, says our author, it is evident that there are three states which always take place in fever, viz., a state of debility, a state of cold, and a state of heat; and as these three states regularly succeed each other in the order above-mentioned, it is to be presumed that they are in the series of cause and effect with regard to one another.—The hot stage, he thinks, is an effect of the vis medicatrix nature so famous in the schools of physic, and it is probable that many symptoms of diseases are owing to the same cause. To this cause he also inclines to attribute some of the symptoms of the cold stage; but is obliged to refer them to a law which he says exists in the animal economy, whereby those powers which have a tendency to hurt and destroy the system, often excite such motions as are suited to obviate the effects of the noxious power. That some part of the cold stage is owing to the vis medicatrix, he thinks further probable, because the cold stage appears universally to be a means of producing the hot; because cold, externally applied, has very often similar effects; and especially because it seems to be in proportion to the degree of tremor in the cold stage that the hot one proceeds more or less quickly to a termination of the paroxysm, and to a more complete solution and longer intermission.

In the time of the cold stage, there seems to be a spasmodic induced every where on the extremities of the arteries, particularly of those upon the surface of the body. This appears from the suppression of all the excre- Theory. exertions, and from the shrinking of the external parts: and though this may in part be attributed to the weaker action of the heart in propelling the blood into the extreme vessels; yet as these symptoms often continue after the action of the heart is restored, there is reason to believe that a spasmodic constriction has taken place; and that it subsists for some time, and supports the hot stage; for this stage ceases with the flowing of the sweat, and the return of other exertions, which are marks of the relaxation of vessels formerly constricted.

The idea of fever then may be, that a spasm of the extreme vessels, however induced, may prove an irritation to the heart and arteries; and that this continues till the spasm is relaxed and overcome. Still, however, it will remain a question what is the cause of this spasm; whether it be directly produced by the remote causes of fever, or if it is only a part of the vis medicatrix naturae. The doctor is inclined to the latter opinion; firstly, because it is certain that debility lays the foundation of fever; secondly, because supposing this uncertain, we can more easily perceive how debility induces spasm, than how spasm produces debility, which always more or less appears; and thirdly, because we perceive that the degree of spasm formed, and the obstinacy of its continuance, depend, in many cases, upon the power of the causes inducing debility, and upon the debility induced; for the more powerful the debilitating causes, and the greater the debility produced, the paroxysms are the longer, and the more frequently repeated.—From hence, says he, we are led to believe, that, together with the spasm, there is an atony subsisting in the extreme vessels, and that the relaxation of the spasm requires the restoring of the tone and action of these.

This may be illustrated from considering the symptoms which take place with respect to the functions of the stomach in fevers; such as the anorexia, nausea, and vomiting. The connection, or consent, which we observe between the perspiration and the appetite in healthy persons, renders it probable, that the tone of the extreme vessels on the surface of the body, and that of the muscular fibres of the stomach, are connected or consenting with each other; and that therefore in fevers the want of appetite or of tone in the muscular fibres of the stomach may depend upon the atony of the extreme vessels on the surface of the body.

A further proof that in fevers the fibres of the stomach are affected with an atony, is the nausea and vomiting which so frequently occur, and which so commonly depend upon a debility of the stomach.—That the debility of the stomach which produces vomiting depends upon an atony of the extreme vessels on the surface of the body appears particularly from an observation of Sydenham. In the attack of the plague, a vomiting happens, which prevents any medicine from remaining upon the stomach; and Dr Sydenham tells us, that he could not overcome this vomiting but by external means, applied to produce a sweat or determination to the surface of the body.

The connection between the state of the stomach and that of the extreme vessels on the surface of the body appears from this also, that the vomiting, which so frequently happens in the cold stage of fevers, commonly ceases upon the coming on of the hot, and very certainly upon any sweats coming out. It is indeed probable, that the vomiting in the cold stage of fevers, is one of the means employed by nature for restoring the determination to the surface of the body; and it is a circumstance affording a proof, both of this and of the general connection between the stomach and surface of the body, that emetics thrown into the stomach and operating there in the time of the cold stage, commonly put an end to it, and bring on the hot stage. It also affords a proof of the same connection, that cold water taken into the stomach produces an increase of heat on the surface of body, and is very often a convenient and effectual means of producing sweat.

We draw a proof of the same connection from this also, that cold applied to the surface of the body, when it does not stop perspiration, is always a powerful means of exciting appetite. It may also be considered, whether the fever which so constantly accompanies the digestion of food in the stomach be not induced by filling the stomach, by relaxing its muscular fibres, and thereby inducing an atony of the extreme vessels.

The Doctor acknowledges a difficulty in explaining how an atony and spasm can subsist at the same time in the same vessels; but considers it as a matter of fact which cannot be denied; and at the same time thinks it may be found analogous to what happens upon other occasions in the system, where we often observe atony producing spasm.—This atony is supposed to depend upon a diminution of the energy of the brain; and that this diminution takes place in fevers, he concludes, not only from the debility prevailing in so many of the functions of the body as already mentioned, but from the symptoms peculiar to the brain itself.

Delirium is common in fever: and this symptom commonly depends on some inequality in the excitement of the brain, or intellectual organ; and hence it may be concluded, that, in fever, it denotes some diminution in the energy of the brain. Delirium indeed seems often to depend on an increased impetus of the blood in the vessels of the brain; and therefore attends phrenitis. It frequently appears also in the hot stage of fevers, accompanied with a head-ach and throbbing of the temples. But, as the impetus of the blood in the vessels of the head is often considerably increased, by exercise, external heat, passions, and other causes, without occasioning any delirium; it must be supposed, that the same impetus, in the case of fever, produces delirium; for this reason only, that at the same time there is some cause which diminishes the energy of the brain, and prevents a free communication between the parts concerned in the intellectual functions. Upon the same principles also he supposes that there is another species of delirium which depends more entirely on the diminished energy of the brain; and may therefore arise when there is no unusual increase of the impetus of the blood in the vessels of the brain. Such seems to be the delirium occurring at the beginning of the cold stage of fevers, or in the hot stage of such fevers as shew strong marks of debility in the whole system.

"Upon the whole then," (says he), "our doctrine of fever is explicitly this:—The remote causes of fever are But though he thus reasons against the notion of fevers being an effort of nature for concocting and expelling a morbid matter, the Doctor by no means denies that the cause of fever frequently operates upon the fluids, and particularly produces a putrefactive state of them. This he acknowledges is frequently the case; but at the same time he maintains, that such a change of the fluids is not commonly the cause of fever; that very often it is only an effect; and that there is no reason for believing the termination of the fever to depend upon the expulsion of the putrid matter.

Another opinion with regard to intermittent fevers remains still to be mentioned. In these fevers a great quantity of bile is commonly thrown out by vomiting; and this is so frequently the case, that many have supposed an unusual quantity of bile, and perhaps a peculiar quality of it, to be the cause of intermittent fevers—This, however, does not appear to be well-founded. Vomiting, by whatever means excited, if often repeated, with violent straining, seems to be powerful in emulsifying the biliary ducts, and commonly throws out a great deal of bile. This will happen especially in the case of intermittent fevers. For as, in the state of debility and cold stage of these fevers, the blood is not propelled in the usual quantity into the extreme vessels, and particularly into those on the surface of the body; but is accumulated in the vessels of the internal parts, and particularly in the vena portarum; so this may occasion a more copious secretion of bile. The circumstance, however, which chiefly occasions the appearance of bile in these cases is, the influence of warm climates and seasons. These seldom fail to produce a state of the human body, in which the bile is disposed to pass off by its secretories in greater quantity than usual, and perhaps also changed in its quality; as appears from the disease of the cholera, which so frequently occurs in warm seasons. This disease, however, occurs often without fever; and there are very strong reasons for supposing that intermittent fevers for the most part arise from another cause, viz. marsh effluvia; while at the same time there is no evidence of their arising from the state of the bile alone. The marsh effluvia, however, commonly operate in the same season that produces the change of the bile; and therefore, considering the vomiting and other circumstances of the intermittent fevers which here concur, it is not surprising that autumnal intermittents are so often attended with effusions of bile.

The Doctor now proceeds to consider the difference of fever, and its causes. With other physicians, he supposes, that in every fever there is a power applied to the body which has a tendency to hurt and destroy it, and produces certain motions in it which deviate from the natural state; and, at the same time, in every fever which has its full course, he supposes, that, in consequence of the constitution of the animal economy, there are certain motions excited which have a tendency to obviate the effects of the noxious power, or to correct and remove it. Both these kinds of motions he considers as constituting the disease. The latter, which are of salutary tendency, and considered as the operations of the vis medicatrix naturae, he calls the re-action of the system. From the above doctrine it appears, that, in fever, the circumstances of debility, spasm, and reaction, are chiefly to be considered; and therefore, according as these are different in degree, and different in proportion to one another, they will exhibit the chief differences of fevers.

Every fever of more than one day's duration, consists of repeated paroxysms; and in those in which the paroxysms are distinctly observed, it is constantly to be remarked, that every paroxysm is finished in less than 24 hours; but as we cannot perceive anything in the cause of fevers determining to this, we must suppose it to depend on some general law of the animal economy. Such a law seems to be that which subjects the economy, in many respects, to a diurnal revolution. The cause of this is uncertain; but the returns of sleep and watching, of appetites and excretions, and the changes which regularly occur in the state of the pulse, shew sufficiently that in the human body a diurnal revolution takes place. That the paroxysms are connected with that revolution appears from this, that though the intervals of paroxysms are different in different cases, the times of the accesion of the paroxysms are generally fixed to one time of the day; so that quotidians come on in the morning, tertians at noon, and quartans in the afternoon. It is still, however, to be remarked, that as quartans and tertians are apt to become quotidians, these to pass into the state of remittents, and these to become continued; and that, even in the continued form, daily exacerbations and remissions are generally to be observed: all this shews so much the power of diurnal revolution, that when, in certain cases, the daily exacerbations and remissions are with difficulty distinguished, we may still presume that the general tendency of the economy prevails; that the disease still consists of repeated paroxysms; and, on the whole, that there is no such disease as hath been commonly called a continent fever.

The repetition of the paroxysms depends on the circumstances belonging to them when already formed. The longer these paroxysms are protracted, the sooner they are repeated; and therefore we are to conclude, that the cause of the frequent repetition is to be sought for in the cause of the protraction of the paroxysms. The duration of the whole paroxysm chiefly depends upon that of the hot stage, in which the reaction is operating to take off the spasm formed in the cold stage. We may therefore suspect that the longer duration of the hot stage is owing either to the obstinacy of the spasm, or to the weakness of the reaction; and it is probable, that sometimes the one and sometimes the other of these circumstances takes place.

The degree of spasm which takes place in fevers, may be supposed different, according the degree of irritability in each particular person; and therefore the reaction in fever being given, the paroxysm, or continuance of the hot stage, may be longer or shorter, according to the degree of spasm that has been formed. One of the causes of the obstinacy of spasm is, that in inflammatory diseases there is a diathesis phlogistica prevailing in the body, and this diathesis is supposed by the Doctor to consist in an increased tone of the whole arterial system. When therefore this diathesis accompanies fever, as it sometimes does, it may be supposed to give occasion to the febrile spasms being formed more strongly, and thereby to produce more protracted paroxysms. Accordingly we find, that all inflammatory fevers are of the continued kind, and that all the causes of the diathesis phlogistica have a tendency to change intermittent into continued fevers. As continued fevers, therefore, are in many cases attended with the diathesis phlogistica, our author thence concludes, that this is the cause of their continued form. In many fevers, however, there is no evidence of any diathesis phlogistica being present, or any evidence of more considerable spasm; and in such fevers we must impute the protraction of the paroxysms, and the continued form of the fever, to the weakness of reaction. That this cause takes place, may be concluded from hence, that in many cases of fever wherein the separate paroxysms are the most protracted, and the most difficulty observed, we find the most considerable symptoms of a general debility; and therefore it may be concluded, that in such cases the protracted paroxysms and continued form depend upon a weaker reaction, owing either to the causes of debility applied having been of a more powerful kind, or to circumstances of the patient's constitution favouring their operation.

From the view just now given of the causes of the protraction of paroxysms, and therefore of the form of continued fevers strictly so called, it seems probable, that the remote causes of these operate by occasioning either a phlogistic diathesis, or a weaker reaction; for we can observe, that the most obvious difference of continued fevers depends upon the prevailing of one or other of these states.

With regard to the remote causes of fever, as this Remote causes of fever has been considered as consisting chiefly in an increased action of the heart and arteries, physicians have supposed, that certain direct stimulants, fitted to produce this increased action, are the remote causes of fever. In many cases, however, there is no evidence of such stimulants being applied: and in the cases in which they are applied, they either produce only a temporary frequency of pulse, which cannot be considered as a disease; or, if they do produce a permanent febrile state, it is by the intervention of a topical inflammation, which produces a disease different from what is strictly called a fever.

That direct stimulants are the remote causes of fever seems farther improbable, because the supposition does not account for the phenomena attending the accesion of fevers, and because other remote causes can with greater certainty be assigned. As fevers are so generally epidemic, it is probable, that some matter floating in the atmosphere, and applied to the bodies of men, ought to be considered as the remote cause of fevers. These matters being present in the atmosphere, and acting upon men, may be considered either as Miasma, or as Contagions.

Miasma may arise from various sources, and be of different kinds; but we know little of their variety or effects. We know with certainty only one species of miasma which can be considered as the cause of fever; and from the universality of this it may be doubted whether there be any other. The miasma so universally the cause of fever, is that which arises from marshes or moist ground acted upon by heat. So many observations have now been made with respect Of contagions, a great variety have been supposed to exist; but this seems to be affected without sufficient evidence. The number of genera and species of contagious diseases, of the class of pyrexiae, at present known, is not very great. Whether there are any belonging to the order of phlegmiae, is doubtful; and though it should be supposed, it will not much increase the number of contagious pyrexiae: and as each of the contagious diseases hath been found always to retain the same character, and to differ only in circumstances, which may be imputed to season, climate, and other external causes, or to the peculiar constitution of the persons affected, it may thence be concluded, that in each of these species the contagion is of one specific nature; and that there is one principal, perhaps one common, source of such contagions.

It is now well known, that the effluvia arising from the living human body, if long confined in the same place, without being diffused in the atmosphere, acquire a singular virulence; and, in that state, applied to the bodies of men, become the cause of a fever which is very contagious. The late observations on jail and hospital fevers have fully proved the existence of such a cause; and it is sufficiently obvious, that the same virulent matter may be produced in many other places. At the same time the nature of the fevers arising renders it probable, that the virulent state of human effluvia is the common cause of such fevers, as they differ only in a state of their symptoms; which may be imputed to the circumstances of season, climate, &c., concurring with the contagion, and modifying its force.

With respect to these contagions, though they are spoken of above as a matter floating in the atmosphere, it is proper to observe, that they are never found to act but when they are near to the sources from whence they arise; that is, either near to the bodies of men from which they immediately issue, or near to some substances which, as having been near to the bodies of men, are imbued with their effluvia, and in which substances these effluvia are sometimes retained in an active state for a very long time. The substances thus imbued with an active matter may be called fomites; and the Doctor thinks it probable, that contagions, as they arise from fomites, are more powerful than as they arise immediately from the human body. But though it is probable that fevers generally arise from marsh or human effluvia, we cannot with any certainty exclude some other remote causes which are commonly supposed to have a share in producing them. The first of these causes to be taken notice of is, the operation of cold on the human body.

This acts so differently in different circumstances, that it is difficult to give a satisfactory explanation of it. In certain circumstances cold has manifestly a sedative power. It can extinguish the vital principle entirely, either in particular parts, or through the whole body; and, considering how much the vital principle of animals depends upon heat, it cannot be doubted that the power of cold is always more or less directly sedative. But it is equally manifest, that, in certain circumstances, cold proves a stimulus to the living body, and particularly to the sanguineous system. Besides the sedative and stimulant powers of cold, it is also manifestly a powerful astringent; causing a contraction of the vessels on the surface of the body, and thereby producing pallor and a suppression of perspiration. It is likewise probable, that this contraction is in some measure communicated to the whole body, and that thereby the application of cold proves a tonic with respect to the whole system.

These several effects of cold do not all take place at the same time, but may be variously combined. The stimulant power taking place, obviates the effects that might otherwise have arisen from the sedative, and in some measure from those of the astringent power. But the stimulant and tonic powers of cold are commonly conjoined, and the former perhaps depend in part upon the latter.

In what circumstances these different effects of cold take place, is difficult to determine; but the morbid effects may be observed to be chiefly of four kinds. One is a general inflammatory diathesis of the system; which is commonly accompanied with rheumatism, or other phlegmasia. A second is a catarrhal affection; a third is a gangrene; and a fourth is a proper fever. In producing this last, the operation of cold generally concurs with that of marsh or human effluvia. In all its operations, cold seems to act more powerfully, in proportion as the body, and particularly the vigour of the circulation, is previously more weakened.

Besides cold, there are other powers which seem to be the remote causes of fevers; as fear, intemperance in drinking, excess in venery, and other causes, which evidently weaken the system. But, whether any of these sedative powers be alone the remote cause of fever, or if they only concur with the operation of marsh or human effluvia, or if they give an opportunity to the positive operations of cold, are questions not to be answered with certainty.

The causes of death in fevers are either direct or indirect. The first are those which directly attack and destroy the vital principle as lodged in the nervous system, or destroy the organs immediately connected with it. The second, or the indirect causes of death, are those which interrupt such functions as are necessary to the due continuance and support of the vital principle.

Of these general causes those which operate more particularly in fevers seem to be, first the violence of reaction, which, either by repeated violent excitements destroys the vital power itself, or by its violence destroys the organization of the brain necessary to the action of the vital principle, or by the same violence destroys the organization of the parts more immediately necessary to the circulation of the blood. Secondly, the cause of death in fevers may be a poison, that is, a power capable of destroying the vital principle; and this poison may be either the miasma or contagion which was the remote cause of the fever, or it may be a putrid matter generated in the course of the fever. In both cases, the operation of such a power appears either as acting chiefly on the nervous system, inducing the symptoms of debility; or, as acting upon the mass of blood, inducing a putrefactive state in it, and in the fluids derived from it.

From all this the symptoms shewing the tendency to death in fevers may be discovered, by their being either the symptoms of violent reaction, of great debility, or of a strong tendency to putrefaction in the fluids.

The symptoms which denote the violence of reaction, are, 1. The increased force, frequency, and hardness of the pulse. 2. The increased heat of the body. 3. Those symptoms which are the general marks of an inflammatory diathesis; and more especially those of a particular determination to the brain, lungs, or other important viscera. 4. Those which are the marks of the cause of violent reaction; that is, of a strong spasm appearing in the suppression of the excretions.

The symptoms which denote a great degree of debility are,—in the animal-functions, 1. The weakness of the voluntary motions. 2. The irregularity of the voluntary motions depending on their debility. 3. The weakness of sensation. 4. The weakness and irregularity of the intellectual operations.—In the vital functions, 1. The weakness of the pulse. 2. The coldness or shrinking of the extremities. 3. The tendency to a delirium animi in an erect posture. 4. The weakness of respiration.—In the natural-functions, 1. The weakness of the stomach, as appearing in anorexia, nausea, and vomiting. 2. Involuntary excretions, depending upon a palsy of the sphincters. 3. Difficult deglutition, depending upon a palsy of the muscles of the fauces.—The symptoms denoting a putrefactive state of the fluids, are, 1. In the stomach, a putrefactive loathing of animal food, nausea, and vomiting, great thirst, and a desire of acids. 2. In the mass of blood, an unusual fluidity, so that when drawn out of the veins it does not coagulate as usual; hemorrhage from different parts, without marks of increased impetus; effusions under the skin or cuticle, forming petechiae, macules, and villosores, and effusions of a yellow serum under the cuticle. 3. In the state of excretions, frequent, loose, and fetid stools; high-coloured turbid urine; fetid sweats; and the fetor of blisters. 4. The cadaverous smell of the whole body.

Many physicians have been of opinion that there is something in the nature of fevers which generally determines them to be of a certain duration; and, therefore, that their terminations, whether in health or in death, happen at certain periods of the disease rather than at others. These periods are called the Critical Days. These were carefully observed by Hippocrates and the ancients, but have been denied by many to take place in the fevers of these northern regions. Dr. Cullen, however, is of opinion, that the doctrine of the ancients, and particularly that of Hippocrates, on this subject, was well founded; and that it is just and true even with respect to the fevers of our climate. For this opinion he gives the following reasons: 1. Because the animal economy is readily subjected to periodical movements, both from its own constitution, and from habits which are readily produced in it. 2. Because periodical movements take place in the diseases of the human body with great constancy and exactness, as in the case of intermittent fevers, and many other diseases.

The critical days, or those on which the termination of continued fevers is supposed to happen, are, the third, fifth, seventh, ninth, eleventh, fourteenth, seventeenth, and twentieth. We mark none beyond this last; because though fevers are sometimes protracted beyond this period, the instances are but rare, and we have not a sufficient number of observations to ascertain the course of them; and likewise because it is probable, that in fevers long protracted the movements become less exact and regular, and are therefore less easily observed. This appears from the facts laid down by Hippocrates: as, in 163 cases of fevers, no fewer than 107, or more than two-thirds of the whole number, terminated on one or other of the eight days above-mentioned; none terminated on the second or thirteenth; and upon the eighth, tenth, twelfth, fifteenth, sixteenth, eighteenth, and nineteenth, there are but 18 terminations, or one-ninth of the whole. But though it must be acknowledged that it is the general tendency of the animal-economy to determine the periodical movements in fevers to be chiefly on critical days, it must also be acknowledged that in many cases the regular course of it may be disturbed by particular circumstances. Thus, though the chief and more remarkable exacerbations in continued fevers happen on the critical days, there are truly exacerbations happening every day; and these, from certain causes, may become considerable and critical.

What determines the periods to be changed about the 11th day, hath not been well understood. But the fact is certain: for there is no instance of any termination on the 13th; but on the 14th, 17th, and 20th, there are 43 instances of termination, and only fix on all the intermediate days between these. Hippocrates indeed makes mention of many terminations happening on the 4th day; but, from its inconsistency with the general tendency, and some other considerations, Dr. Cullen is led to think that the terminations on this day are to be looked upon only as irregularities.

The opinions of those modern physicians who refuse the prevalence of critical days, he thinks, are to be little regarded. The observation of the course of continued fevers is difficult and fallacious; and therefore the regulating of that course may have escaped inattentive and prejudiced observers. His own observations amount to this: That fevers with moderate symptoms, generally cases of the synochea, frequently terminate in nine days or sooner, and very constantly on one or other of the critical days which fall within that period: but it is very rare in this climate, that cases of either the typhus or synochea terminate before the 11th day; and when they do terminate on this day, it is most commonly fatal. When protracted beyond this period, their termination hath been very constantly observed on the 14th, 17th, or 20th day.

In such cases, the salutary terminations are seldom attended with any considerable evacuation. A sweating ing frequently appears, but is seldom considerable; and critical and decisive terminations have been hardly ever observed attended with vomiting, evacuations by stool, or remarkable changes in the urine. The solution of the disease is chiefly to be discerned from some return of sleep and appetite, the ceasing of the delirium, and an abatement of the frequency of the pulse. By these symptoms we can often mark a crisis of the disease; but it seldom happens suddenly and entirely, and it is most commonly from some favourable symptoms on one critical day that we can announce a more entire solution on the next following.

Having thus given a pretty full account of the Doctor's general theory of fevers, we now proceed to take notice of his doctrine of inflammation.

When any part of the surface of the body is affected with unusual redness, heat, pain, and tumour, we name the disease an inflammation or phlegmatis. These symptoms of inflammation are never very considerable, without the whole system being at the same time affected with pyrexia. The internal parts are subject to inflammation as well as the external; and we judge them to be inflamed, when, together with pyrexia, there is a fixed pain in any internal part, attended with some interruption in the exercise of its functions. We judge of the presence of inflammation also from the state of the blood drawn from the veins. When the blood, after cooling and concreting, shews a portion of the gluten separated from the rest of the mass, and lying on the surface of the coagulum; as such separation happens in all cases of more evident phlegmatis, so in ambiguous cases, we, from this appearance, joined with other symptoms, conclude the presence of inflammation. At the same time it must be observed, that as several circumstances in blood-letting may prevent this separation of gluten from taking place in blood otherwise disposed to it, so we cannot always conclude, from the want of such appearance, against the presence of inflammation.

The phenomena of inflammation all concur in shewing, that there is an increased impetus of the blood in the vessels of the part affected; and as at the same time the action of the heart is not always considerably increased, Dr Cullen supposes that the increased impetus of the blood in the particular part is owing especially to the increased action of the vessels of the part itself. The cause of this increased action is therefore to be inquired after, and is the proximate cause of inflammation. In many cases we can manifestly perceive, that inflammation arises from the application of stimulant substances to the part. When the application of stimulants therefore is evident, we seek for no other cause of inflammation; but as, in many cases, such application is neither evident, nor (with any probability) to be supposed, we must in such cases seek for some other cause of the increased impetus of the blood in the vessels of the part.

Many physicians have supposed, that an obstruction of the extreme vessels, anyhow produced, may prove a cause of inflammation: but many difficulties attend this doctrine.

1. The supposition of an error loci is not at all probable. For the motion of the blood in the extreme vessels is so weak and slow, as readily to admit a retrograde course of it: and therefore, if a particle of blood should happen to enter a vessel whose branches will not allow its passage, it will be moved backwards till it meet with a vessel fit for transmitting it; and the frequent ramifications and anastomoses of the extreme arteries are very favourable to this.

2. The supposition of a preternatural lento or viscidity of the blood, is not well-founded; for it is probable, that nature has specially provided against a state of the fluids so incompatible with the exercise of the most important functions of the animal economy. While motion continues to prevent any separation of parts, and heat continues to preserve the fluidity of the more viscid, there seems to be always so large a quantity of water present, as to give a sufficient fluidity to the whole.

3. The Doctor supposes that no general lento ever does take place; because, if it did, it must shew more considerable effects than commonly appear.

4. There are no experiments directly in proof of a preternatural lento prevailing in the mass of blood; nor is there any evidence of certain parts of the blood occasionally acquiring a greater density and force of cohesion than ordinary; neither is there any proof of the denser or more coherent parts being present in the mass of blood in such greater proportion than usual, as to occasion a dangerous spilitude. The experiments of Dr Browne Langriff on this subject afford no conclusion, having been made on certain parts of the blood separated from the rest, without attending to the circumstances of blood-letting, which very much alter the state of the separation and concretion of the blood drawn out of the veins.

5. In the particular case of inflammation, there are several circumstances which render it probable that the blood is then more fluid than usual.

6. Though an obstruction should be supposed to take place, it will not be sufficient for producing the effects appearing in inflammation. An obstruction of one vessel does not, as has been imagined, increase the velocity of the blood in the neighbouring vessels which are free; and in fact it appears, from many observations and experiments, that considerable obstructions may be formed, and may subsist, without producing the symptoms of inflammation.

Obstruction, therefore, is not to be considered as the cause of inflammation; but, at the same time, it is probable, that some degree of obstruction does take place in every inflammation. The diffusion, pain, redness, and tumour, attending inflammation, are only to be explained by supposing, that the extremities of the arteries do not readily transmit the unusual quantity of blood impelled into them by the increased action in the course of those vessels. Such an obstruction may be supposed to happen in every case of an increased impetus of the blood; but it is probable, that, in the case of inflammation, there is also a preternatural resistance to the free passage of the fluids.

From the doctrine of fever we are led to believe, that an increased action of the heart and arteries is not supported for any length of time by any other means than a spasm affecting the extreme vessels; with spasms, and that the same spasm takes place in inflammation, Theory seems probable from hence, that every considerable inflammation is introduced by a cold flag, and is accompanied with that and the other circumstances of pyrexia; and it seems also probable, that something analogous to this occurs even in the case of those inflammations which seem less considerable and to be purely topical.

From all this, the nature of inflammation may be explained in the following manner. Some causes of inequality in the distribution of the blood may throw an unusual quantity of it upon particular vessels, to which it must necessarily prove a stimulus. But, further, it is probable, that, to relieve the congestion, the air medicatrix nature increases still more the action of these vessels, which it effects by the formation of a spasm on their extremities, as in all other febrile diseases. A spasm, therefore, of the extreme arteries, supporting an increased action in the course of them, may be considered as the proximate cause of inflammation, at least in all cases not arising from direct stimuli applied. That this is the case, seems probable from the consideration of rheumatism. This is a species of inflammation which is often manifestly produced, either by cold applied to over-distended vessels, or by causes of an increased impetus and over-diffusion in vessels previously constricted. Hence the disease especially appears at seasons liable to frequent and considerable vicissitudes of heat and cold. To this we may add, that the parts of the body most frequently affected with inflammation, are those exposed both to over-distension from a change in the distribution of the fluids, and at the same time to the immediate action of cold. Hence quintes and pneumonic inflammations are more frequent than any others.

That a spasm of the extreme vessels takes place in inflammation is further to be presumed from what is at the same time the state of the whole arterial system. In every considerable inflammation, though arising in one part only, an affection is communicated to the whole system; in consequence of which, an inflammation is readily produced in other parts besides that first affected. This general affection is well known to physicians under the name of the DIATHESIS PHLOGISTICA. It appears most commonly in persons of the most rigid fibres; is often manifestly induced by the tonic or astringent powers of cold; is increased by all tonic and stimulant powers applied to the body; is always attended with a hardness of the pulse; and is most effectually taken off by the relaxing powers of blood-letting. From these circumstances it seems probable, that the diathesis phlogistica consists in an increased tone, or contractility, and perhaps contraction, of the muscular fibres of the whole arterial system. Such a state of the system presumes a spasm of the extreme vessels, and the general state commonly arises from that begun in a particular part; tho' it be also probable, that the general state may arise and subsist for some time without the obvious inflammation of any particular parts.

If an inflammation is cured while the state and texture of the part remain entire, the disease is said to terminate by resolution. This happens when the previous congestion and spasm have been in a moderate degree, and the increased impetus of the blood has been sufficient to overcome the spasm, to dilate the vessels, and to remove the congestion, so that the part is restored to its ordinary and healthy state. A revolution takes place also when the increased impetus of the fluids has produced an increased exhalation into the adjoining cellular texture, or an increased excretion in some neighbouring part, and has thereby relieved the congestion in the vessels, and relaxed the spasm of the inflamed part. Lastly, a resolution may take place, when the increased impetus of the blood in the whole system occasions such an evacuation, as, tho' in a distant part, may prove sufficient to take off the phlogistic diathesis of the whole system, and thereby relieve the congestion and spasm of the particular part affected by inflammation.

The tumour which appears in inflammation may be imputed in part to the congestion of fluids in the vessels; but is owing chiefly to an effusion of matter into the adjoining cellular texture; and accordingly tumours seldom appear but in parts adjoining to a lax cellular texture. If, in this case, the matter effused be only a larger quantity of the ordinary exhalent fluid, this, when the free circulation in the vessels is restored, will be readily absorbed, and the state of the part will become the same as before; but, if the increased impetus of the blood in an inflamed part dilate the exhalent vessels to such a degree that they pour out an entire serum, this will not so readily be re-absorbed; and, from the experiments of Sir John Pringle and Mr Gaber we learn, that under stagnation the serum may undergo a particular change, by having the gluten present in it changed into a white, opaque, moderately viscid, mild liquor, which we name pus. When this change happens in the inflamed part, as it is at the same time attended with an abatement of the redness, heat, and pain, which formerly distinguished the disease, it is said to be terminated by suppuration; and an inflamed part containing a collection of pus, is called an abscess. In inflammation, the tendency of it to suppuration may be discovered by the continuance of the inflammation, without the symptoms of resolution; by some remission of the pain of distension; and by the pain being of a throbbing kind, more distinctly connected with the pulsation of the arteries; by the pulse of the arteries being fuller and softer; and often by the patient's being afflicted frequently with cold shiverings. This happens at no determinate period; and when the tendency is determined, the time necessary to a complete suppuration is different in different cases. When pus is completely formed, the pain formerly in the part entirely ceases, and a weight is felt in it. If the collection is formed immediately under the skin, the tumour becomes pointed, the part becomes soft, and the fluctuation of the fluid within can be commonly perceived; and, at the same time, the redness of the skin, which formerly prevailed, is entirely gone.

In abscesses, while the pus is formed of one part of the matter which had been effused, the other and thinner parts are re-absorbed; so that in the abscess, when opened, pus alone appears. This pus, however, is not the converted gluten alone; for the conversion of this being the effect of a particular fermentation, which may affect the solid substance of the part, and perhaps every solid of animal-bodies; so it most readily and particularly affects the cellular texture, The matter of abscesses, and of the ulcers following them, is various, according to the nature of what is effused, and which may be,

1. A matter thinner than serum. 2. An entire and pure serum. 3. A quantity of red globules. 4. A matter furnished by particular glands seated in the part.

Of these, the second only affords a proper pus, the effusion of which, whether in abscesses or ulcers, seems to be the peculiar effect of an inflammatory state of the vessels; and from this cause it is, that when ulcers do not produce a proper pus, we in many instances bring them to a state of suppuration, by the application of stimulants exciting inflammation, such as balsams, mercury, copper, &c.

When the matter effused into the cellular texture of an inflamed part is tainted with a putrid ferment, this produces, in the effused matter, a change approaching more or less to a complete putrefaction. When this is in a moderate degree, and affects only the fluids effused, with the substance of the cellular texture, the part is said to be affected with gangrene; but if the putrefaction affect also the vessels and muscles of the part, the disease is said to be a sphacelus.

A gangrene may arise from a putrid ferment acting on the matter which is most commonly effused, and likewise from that matter being peculiarly disposed to putrefaction; as particularly seems to be the case of the red globules of blood effused in a large quantity. In a third manner also, a gangrene seems frequently to arise from the violent excitement of the inflammation destroying the tone of the vessels; whereby the whole fluids stagnate and run into putrefaction, which taking place in any degree destroys further the tone of the vessels, and spreads the gangrene.

A tendency to gangrene may be apprehended from an extreme violence of pain and heat in the inflamed part, and from a great degree of pyrexia attending the inflammation. The actual coming on of it is perceived by a change of colour in the part from a clear to a dark red; by blisters arising upon it; by its becoming soft, flaccid, and insensible; and by the ceasing of all pain while these appearances take place. As the gangrene proceeds, the colour of the part becomes livid, and, by degrees, quite black, the heat entirely ceases, the softness and flaccidity of the part increase; it loses its consistence, acquires a cadaverous smell, and may then be considered as affected with a sphacelus.

The schools of physic have commonly reckoned a fourth way in which inflammation may terminate, viz., by a scirrhus, or an indolent hardness of the part. This, however, according to Dr Cullen, is a rare occurrence; and seems not to depend so much upon the nature of inflammation, as upon the circumstances of the part affected. Scirrhosity is chiefly observed in glandular parts, and is owing to the parts readily admitting a stagnation of the fluids.

Besides these there are the following ways, not commonly taken notice of, in which inflammations terminate. One is, by the effusion of a portion of the entire mass of blood, either by means of rupture or anastomosis, into the adjoining cellular texture. This happens especially in inflammations of the lungs, where the effused matter, by compressing the vessels, and stopping the circulation, occasions a fatal suffocation; and this is perhaps the manner in which the peripneumony most commonly proves fatal. Another kind of termination is that of certain inflammations on the surface of the skin, when there is poured out under the cuticle a fluid too gross to pass through its pores; and which therefore separates it from the skin, and raises it up into the form of a vesicle containing the effused fluid. A third way is, when the internal viscera are inflamed, there appears almost always upon their surface an exudation, which appears partly in a viscid concretion upon their surface, and partly in a thin ferous fluid effused into the cavities in which the inflamed viscera are placed. Though these appearances very constantly accompany those inflammations which have proved fatal, it is however probable, that like circumstances may attend those inflammations terminated by resolution, and may contribute to the event, as there are instances of a pneumonic inflammation terminating in an hydrothorax.

The remote causes of inflammation may be reduced to four heads. 1. The application of stimulant substances, among which are to be reckoned the action of fire, or burning. 2. External violence operating mechanically in wounding, bruising, or overstretching the parts. 3. Extraneous substances lodged in any part of the body, though they be neither of an acrid quality, nor of a pointed form. 4. Cold, in a certain degree, not sufficient immediately to produce gangrene.

We cannot perceive, that in different cases of inflammation there is any difference in the state of the proximate cause except in the degree: and though some difference of inflammation may arise from the difference of its remote causes, this is not necessary to be taken notice of here; because the different appearances which attend different inflammations may be referred for the most part to the difference of the part affected, as will appear when we consider the several genera and species of diseases in the Nosology.

Sect. III. Abstract of Dr Gregory's Theory.

In his Conspectus Medicinae Theoreticae, published at Edinburgh in 1780, the Doctor begins with observing, that some functions of the human body relate to itself only, and others to external things. To the latter class natural belong those which by physicians are called the animal functions; such as sense, and voluntary motion: to the former, those named vital functions, because, without them, life could not subsist but a very short time; such as the action of the brain and nerves, the circulation of the blood, and respiration.

By reason of the constant waste of the solids, and evapo- evaporation of the fluid parts of the body, we stand in need of nourishment, which supplies this waste; after which the putrid and excrementitious parts are thrown out by the proper passages. The digestion of the food, secretion of the humours, and excretion of the putrid parts of the food, are called the natural functions; which, though necessary to life, may be interrupted for a considerable time without danger.

A disease takes place, when the body hath so far declined from a sound state, that its functions are either quite impeded, or performed with difficulty. A disease therefore may happen to any part of the body either solid or fluid, or to any one of the functions; and those may occur either single, or several of them joined together; whence the distinction of diseases into simple and compound.

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

Diseases of this kind, however, occur so rarely, that they may rather be accounted imaginary than otherwise; for the most simple diseases are either productive of others, or of symptoms, by which alone they become known to us.—Every thing in which a sick person is observed to differ from one in health is called a symptom; and the most remarkable of these symptoms, and which most constantly appear, define and constitute the disease.

The causes of diseases are various; often obscure, and sometimes totally unknown. The most full and perfect proximate cause is that which, when present, produces a disease, when taken away removes it, and when changed also changes it.—There are also remote causes, which physicians have been accustomed to divide into the predisponent and exciting ones. The former are those which only render the body fit for a disease, or which put it into such a state that it will readily receive one. The exciting cause is that which immediately produces the disease in a body already disposed to receive it.

The predisponent cause is always inherent in the body itself, though perhaps it originally came from without; but the exciting cause may either come from within or from without.

From a junction of the predisponent and exciting causes comes the proximate cause, which neither of the two taken singly is able to produce; seeing neither every exciting cause will produce a disease in every person, nor will every one predisposed to a disease fall into it without an exciting cause.—A body predisposed to disease therefore hath already declined somewhat from a state of perfect health, although none of its functions are impeded in such a manner that we can truly say the person is diseased. Yet sometimes the predisponent cause, by continuing long, may arrive at such an height, that it alone, without the addition of any exciting cause, may produce a real disease.—Of this we have examples in the debility of the simple solids, the mobility of the living solids, and in plethora.—The exciting cause also, though it should not be able immediately to bring on a disease; yet if it continues long, will by degrees destroy the strongest constitution, and render it liable to various diseases; because it either produces a predisponent cause, or is converted into it, so that the same thing may sometimes be an exciting cause, sometimes a predisponent one; of which the inclemencies of the weather, sloth, luxury, &c. are examples.

Diseases, however, seem undoubtedly to have their origin from the very constitution of the animal machine; and hence many diseases are common to every body when a proper exciting cause occurs, though some people are much more liable to certain diseases than others. Some are hereditary; for as healthy parents naturally produce healthy children, so diseased parents as naturally produce a diseased offspring. Some of these diseases appear in the earliest infancy; others occur equally at all ages; nor are there wanting some which lurk unsuspected even to the latest old age, at last breaking out with the utmost violence on a proper occasion. Some diseases are born with us, even though they have no proper foundation in our constitution, as when a fetus receives some hurt by an injury done to the mother; while others, neither born with us, nor having any foundation in the constitution, are sucked in with the nurse's milk. Many diseases accompany the different stages of life; and hence some are proper to infancy, youth, and old age. Some also are proper to each of the sexes; especially the weaker sex, proceeding, no doubt, from the general constitution of the body, but particularly from the state of the parts subservient to generation. Hence the diseases peculiar to virgins, to menstruating women, to women with child, to lying-in women, to nurses, and to old women. The climate itself, under which people live, produces some diseases; and every climate hath a tendency to produce a particular disease, either from its excess of heat or cold, or from the mutability of the weather. An immense number of diseases also may be produced by impure air, or such as is loaded with putrid, marshy, and other noxious vapours. The same thing may happen also from corrupted aliment, whether meat or drink; though even the best and most nutritious aliment will hurt if taken in too great quantity; not to mention poisons, which are endowed with such pernicious qualities, that even when taken in a very small quantity they produce the most grievous diseases, or perhaps even death itself. Lastly, from innumerable accidents and dangers to which mankind are exposed, they frequently come off with broken limbs, wounds, and contusions, sometimes quite incurable; and these misfortunes, though proceeding from an external cause at first, often terminate in internal diseases.

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

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

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

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

This analysis, he owns, is far from being perfect; because nobody hath ever been able, by combining the chemical principles of flesh, to reproduce a compound anything like what the flesh originally was: but, however imperfect the analysis may be, it still hath the advantage of showing in some measure the nature and causes of certain diseases, and thus leads physicians to the knowledge of proper remedies.

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

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

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

The remote causes of these different states, whether predisposing or exciting, are very various. In the first place, idiosyncrasy itself, or the innate constitution of the body, contributes very much to produce the above-mentioned effects. Some have naturally a much harder and drier temperament of the body than others; men, for instance, more than women; which can with the utmost difficulty, indeed scarce by any means whatever, admit of an alteration. The same thing takes place at different periods of life; for, from first to last, the human body becomes always drier and more rigid. Much also depends on the diet made use of, which always produces a corresponding state of the solids, in proportion to its being more or less watery. Neither are there wanting the most weighty reasons for believing, that not only the habit of the body, but even the disposition of the mind, depends very much on the diet we make use of. The good or bad concoction of the aliment also, the application of the nourishment prepared from it, and likewise the state of the air with regard to moisture or dryness, affect the temperament of the body not a little; and hence those who inhabit mountainous or dry countries, are very different from the inhabitants of low marshy places. Lastly, the manner of living contributes somewhat to this effect: Exercise presses out and exhales the moisture of the body, if in too great quantity; on the contrary, sloth and laziness produce an effect directly opposite, and cause a redundancy of humours.

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

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

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

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

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

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

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

The fat is augmented by the use of much animal-food, or of any other that is oily and nourishing, provided the digestion is good; by the use of strong drinks, especially malt-liquors; by much rest of body and mind, much sleep and inactivity, castration, cold, repeated bloodletting, and in general by whatever diminishes the vital and animal powers. Much, however, depends on the constitution of the body itself; nor is it possible to fatten a human creature at pleasure like an ox. A certain degree of fatness, according to the age of the person, is a sign and effect of good health; but when too great, it becomes a disease of itself, and the cause of other diseases. It may always be very certainly removed by strong exercise, little sleep, and a spare and solid diet. The fat always makes up a considerable part of the bulk of the body, and very often by far the greatest part. Its use seems to be to make the motion of the body more easy and free by lessening the friction of the moving parts, and thus preventing the abrasion of the solids, which would otherwise happen. It is also of use to hinder the parts from growing together, which sometimes happens when, by an ulcer or any other accident, a part of the cellular texture containing the fat is destroyed. Besides all this, the fat contributes not a little to the beauty of the body, by filling up the large interfaces between the muscles, which would otherwise give the person a deformed and shocking appearance. It is thought to be nutritious, when absorbed from its cells by the blood; but of this we have no great certainty. It seems to have some power of defending from the cold, seeing nature hath bestowed it in very great quantity on those animals which inhabit the colder regions.

Those parts of the body which enjoy sense and mobility, are called living or vital solids. They are the brain, cerebellum, medulla oblongata, spinal marrow, the nerves arising from these and diffused throughout the whole body, and which are distributed through the various organs of sense and through the muscles, and lastly the muscles themselves. Sensation is much more general than mobility, as being common to all the parts already mentioned. Mobility is proper to the muscular fibres alone: wherever there is sensation, therefore, we may believe that there are nerves; and wherever there is mobility, we may believe that muscular fibres exist. Nay, even mobility itself seems to originate from the connection which the muscles have with the nerves: for soon after the nerves are compressed, or tied, or cut, the muscles to which they are distributed lose their faculties; which happens, too, when the brain itself, or the origin of the nerves, is affected. Some reckon that the muscles are produced from the nerves, and consist of the same kind of matter. Both indeed have a similar structure, as being fibrous and of a white colour: for the muscles when well freed from the blood, of which they contain a great abundance, are of this colour as well as the nerves; neither can the nervous fibres by any means be distinguished from the muscular fibres themselves. Both have also sensation; and both stimulants and sedatives act in the same manner, whether they be applied to the muscles themselves, or to the nerves.

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

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

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

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

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

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

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

Anxiety also frequently accompanies fevers of every kind, sometimes in a greater and sometimes in a lesser degree. In this case it arises as well from the general debility, as from the blood being driven from the surface of the body and accumulated in the large vessels; as in the beginning of an intermittent fever. Or it may arise from an affection of the stomach, when overloaded with crude, corrupted aliment; or distended and nauseated with too much drink, especially medicated drink. As the fever increases, the anxiety of the patient becomes greater and greater; remarkably so, according to the testimony of physicians, either immediately before the crisis, or on the night preceding it; as before the breaking out of exanthema, hemorrhagy, sweat, or diarrhoea, which sometimes remove fevers. The patient feels likewise an anxiety from the striking in of any eruption or critical metastasis. This sensation also accompanies fevers and most other diseases, when the vital power is exhausted, and death approaches, of which it is the forerunner and the sign. It happens at that time, because the vital powers, unable to perform their functions, cannot make the blood circulate. But what kind of anxiety this is, the other signs of approaching death shew very evidently. Moreover, even in the time of sleep, anxiety may arise from the same causes; hence frightful dreams, which frequently disturb our repose with surprize and terror.

Itching, an uneasy sensation, with a desire of scratching the place affected, is often very troublesome, although it seems to be more akin to pleasure than to pain. As pain proceeds from too great an irritation, either chemical or mechanical, so does itching proceed from a slight one. Titillation, or friction, of a woollen shirt, for instance, upon the skin of a person unaccustomed to it, and of a delicate constitution, excites itching; as do also many acid fowls, vegetables, and animals. Hence an itching is the first sensation after the application of cantharides, although the same, when augmented, becomes painful. The same effect is produced by any thing acrid thrown out upon the skin; as in exanthematic fevers, the disease called the itch, &c. Lice, worms, especially acariaces, irritating either the skin or the intestines, excite a troublesome itching. Certain species of internal itching excites people to many necessary actions both in a diseased and healthy state; such as the excretion of the faeces and urine, coughing, Too acute a sensation over the whole body is very rarely if ever observed. In a particular part the sense of feeling is often more acute than it ought to be, either from the cuticle itself being too thin and soft, or being removed; or from the part itself being inflamed, or exposed to too great heat. It becomes obtuse, or is even quite destroyed over the whole body, or in great part of it, from various affections of the brain and nerves; as when they are wounded, compressed, or defective in vital power. This is called anaesthesia, and sometimes accompanies palsy.

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

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

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

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

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

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

Physicians, in almost every disease, but especially in fevers, inquire into the state of the tongue; not, indeed, without the greatest reason: for from this they can judge of the condition of the stomach; of the thirst, or rather the occasion the patient has for drink, when, on account of his delirium or stupor, he neither feels his thirst, nor is able to call for drink. And lastly, from an inspection of the tongue, physicians endeavour to form some judgment concerning the nature, increase, and remission of the fever.

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

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

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

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

The sense of hearing is more frequently vitiated than almost any of the rest, as having a most delicate organ, and one composed of many and very small parts, of which an account is given under the article Anatomy, n° 405. It frequently becomes too acute; either from the general habit of the body being too irritable, such as often happens to hysterical and lying-in women; or from too great a sensibility of the brain itself, which is not unfrequently observed in fevers, as well as in phrenitis, and sometimes in the true mania; or it may be from a disease of the ear itself, as when it is affected with inflammation, pain, or too great tension.—It may be rendered dull, or even altogether destroyed, so that the person shall become totally deaf, from the same causes acting with different degrees of force. This happens especially from the want of the external ear; or from the meatus auditorius being stopped up with mucus, wax, or other matters; or from the sides of the canal growing together, as sometimes happens after suppuration, or the small-pox; or by the membrane of the tympanum becoming rigid or relaxed, or being eroded or ruptured; or the tympanum itself, or the eustachian tube, may from certain causes be obstructed; or some of the little bones or membranes, or some of the muscles of the labyrinth itself, may be affected with concretion, spasm, palsy, or torpor; or lastly, it may happen from diseases of the brain and nerves, all the organs of hearing remaining sound. Hence deafness is often a nervous disease, coming suddenly on, and going off of its own accord. Hence also it is common in old people, all of whose solid parts are too rigid, while their nervous parts have too little sensibility.

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

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

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

A tinnitus sometimes arises from any vehement affection of the mind; sometimes from a disorder in the stomach; sometimes from a rheumatic disorder affecting the ears and head; or from a catarrh, which commonly affects the tube. Sometimes, however, the tinnitus alone affects the patient; and even this is a disease of no small consequence. These various causes, however, both of this and other disorders of the hearing, are often very difficult to be distinguished, as well on account of the inaccessible situation of the organ, as on account of the little knowledge we have of its action. But from whatever cause it arises, both this and the other various affections of the hearing, can neither be cured certainly nor easily.

Concerning the nature of the sense of sight, see Vision. Anatomy, n° 406, and (the Index subjoined to) Optics.—Of this sense some slight disorders, or rather varieties, are often observed. Those persons are called short-sighted who cannot see distinctly unless the object be very near them. This disorder arises from too great a refraction of the rays by reason of their being too soon collected into a focus by the crystalline lens, and diverging again before they fall upon the retina, by which means they make an indistinct picture upon it. The most usual cause is too great a convexity of the eye or some of its humours, as too prominent a cornea. It is a disorder common to young people, which is sometimes removed when they grow older. As soon as the first approaches of short-sightedness are observed, it is supposed it may be obviated by the person's accustoming himself to view remote objects, and keeping his eyes off very small and near ones; as, on the contrary, it may be brought on by the opposite custom; because the eye accommodates itself somewhat to the distances of those objects which it is accustomed to view. But a concave glass, which causes the rays of light to diverge more than naturally they would before falling upon the cornea, is the most simple and certain remedy.

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

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

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

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

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

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

Squinting is frequently occasioned by spasms, palsy, rigidity, &c. of the muscles which manage the eye; by epilepsy; by certain diseases of the head, the hydrocephalus especially; or by any great injury done to the head. Sometimes, though very rarely, it comes on suddenly without any known cause. It is very probable, however, that squinting often arises from a fault of the retina, when their central points, for instance, and those similarly placed with respect to the centre, do not agree. In this case there must be a contortion of the eye, that the object may not be seen double. This seems also to be the reason that squinting is horribly increased when the person brings the object near his eye in order to view it more perfectly. Or if the central point of either, or both, of the retina be insensible, Physicians have referred to the sense of vision that most troublesome sensation which we call a vertigo; though it seems rather to belong to that of feeling, or of consciousness; for the disorder is not removed either in the dark, or by shutting the eye-lids. The vertigo takes place when external objects really at rest seem to reel, to whirl round, to tremble, or to move in any manner of way. If the disorder be very violent, the person is neither able to see, on account of a dimness of sight; nor can he stand, as the powers fail which ought to govern the limbs. A nausea also usually accompanies the vertigo, and the one generally produces the other.

This disorder is observed to be both the symptom and forerunner of some dangerous diseases; such as apoplexy, epilepsy, hysteria; hemorrhages from the nose and other parts; suppressions of the menses; great plethora; fevers, as well as such as are accompanied with debility, as those in which there is an increased impetus of the blood towards the head. An injury done to the head also, but rarely one done to the eyes unless so far as it affects the whole head, brings on a vertigo. A vertigo may be likewise produced by a very great and sudden loss of blood or other fluid; debility; syncope; various diseases of the alimentary canal, of the stomach especially; poisons admitted into the body, particularly of the narcotic kind, as opium, wine, &c., and hence vertigo is a symptom of every kind of drunkenness. Various motions also, either of the head or the whole body, being toiled in a ship, especially if the vessel is small and the sea runs high, produce a vertigo. In these and similar examples, the unusual and inordinate motions of the blood are communicated to the nervous parts which are in the head; or these being affected by sympathy from the neighbouring parts, produce a confused sensation as if of a rotatory motion. Nay, it is often produced from an affection of the mind itself, as from beholding anything turned swiftly round, or a great cataract, or looking down a precipice, or even by intense thought without looking at any thing.

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

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

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

A delirium is either fierce or mild. The fierce delirium is preceded and accompanied by a redness of the countenance, a pain of the head, a great beating of the arteries, and noise in the ears; the eyes in the mean time looking red, inflamed, fierce, shining, and unable to bear the light; there is either no sleep at all, or sleep troubled with horrid dreams; the wonted manners are changed; an unusual peevishness and ill-nature prevail. The depravation of judgment is first observed between sleep and waking, and by the person's crediting his imagination, while the perceptions of sense are neglected, and the ideas of memory occur in an irregular manner. Fury at last takes place, and sometimes an unusual and incredible degree of bodily strength, so that several people can scarce keep a single patient in his bed.

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

The symptoms accompanying either of these deliria, show an unusual, inordinate, and unequal motion of the blood through the brain, and a great change in that state of it which is necessary to the exercise of the mental powers. It is sufficiently probable, that an inflammation of the brain, more or less violent and general, sometimes takes place, although the signs of universal inflammation are frequently slight. This we learn from the dissection of dead bodies, which often show an unusual redness of the brain or of some of its parts, or The state of the brain, however, may be much affected, and a delirium induced, by many other causes besides the motion of the blood. In many fevers, typhus, for instance, the nervous system itself is much sooner and more affected than the blood; and though the morbid affections of the nervous system are as invisible to the senses as the healthy state of it, the symptoms of its injuries plainly show that its action, or excitement as some call it, is unequal and inordinate. In this way, too, a delirium is produced by several poisons.

The pathology of melancholy and mania is much more obscure; as coming on without any fever, or disturbance in the blood's motion. Often also they are hereditary, depending on the original structure of the body, especially of the brain; the fault of which, however, cannot be detected by the nicest anatomist. It is known, however, that various diseases of the brain, obstructions, tumours, either of the brain itself, or of the cranium pressing upon it, any injury done to the head, and, as some physicians relate, the hardness and dryness of the brain, and some peculiar irritations affecting the nervous system, are capable of bringing on this malady. And indeed so great is the irritation of the nervous system in mad people, that they often sleep little or none for a long time.—Yet even this so defective and imperfect knowledge of the diseases of the brain and nerves, is by no means free from difficulties. For tho' we know that the brain, or a certain part of it, is hurt, or that it is irritated by a swelling, or a pointed bone growing into it, nobody can foretell how great, or what may be the nature of the malady from such a hurt: for examples are not wanting of people who, after losing a large part of the brain, have recovered and lived a long time; or of those who have perceived no inconvenience from a large portion of that viscus being corrupted, until at length they have fallen suddenly down and died in convulsions.

Another disease of the internal senses, quite different from these, is satiety or idiotism. Those are called idiots, who are destitute either of judgment or memory, or else have these faculties unequal to the common offices of life. A kind of idiotism is natural and common to all infants; neither is it to be accounted a disease. But if it lasts beyond the state of infancy, it is a real disease, and for the most part incurable. It hath the same causes with the other diseases of the internal senses; although these can scarcely be detected by the eye or by the knife of the anatomist. It frequently accompanies, or is the effect of, epilepsy. Hence, if the epilepsy derives its origin from causes not seated in the head, as from worms lodging in the intestines, the satiety may be cured by dislodging them, and removing the epilepsy. It is not unlikely that the satiety of children, and the dotage of old men, may arise from the brain being in the former too soft, and in the latter too hard.

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

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

Vigour in general is rarely morbid; although sometimes certain muscular parts appear to have too great vigour, and strength. In maniacs and phrenitis, an immense strength is observed in all the muscles, especially in those that serve for voluntary motion; which is not unjustly reckoned morbid. The reason of this excess is very obscure; however, it is plainly to be referred to a diseased state of the brain.

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

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

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

Debility Debility takes place, when the motion of the muscles, either voluntary or involuntary, is not performed with sufficient strength. A greater or lesser share of debility, either general or of some particular part, accompanies almost all diseases, and is indeed no small part of them. It likewise renders a man obnoxious to innumerable disorders, and throws him as it were defenceless in their way. It often depends on the original structure of the body, so that it can be corrected neither by regimen nor medicines of any kind. A different degree of strength also accompanies the different ages of mankind; and thus, in some cases, debility cannot be reckoned morbid. But a truly morbid and unwonted debility arises from the nervous force being diminished; from diseases of the brain and nerves, or of the muscles through which they are distributed; from a decay of the nerves themselves; from a want of the due tension of the fibres, or the fibres themselves becoming torpid; from the body exhausted by spare diet, want, evacuations; or lastly, from diseases affecting the whole body, or some particular parts of it.

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

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

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

Spasm therefore is a violent, constant, and preternatural contraction of the muscular fibres; but a convulsion is an unusual and violent contraction alternated with relaxation. People are rendered liable to spasms by too sensible an habit of body, or too great mobility; and hence it is a disease common in women, in infants, and in weak, luxurious, lazy, and plethoric people. It is brought on, those already predisposed to it, by any kind of stimulus applied to the brain, or to any nerve, muscle, or nervous part connected with it: of which we have examples in dentition; worms lodged in the intestines, and irritating them; any acrid matter infecting the blood, or much affecting the stomach and intestines; the irritation of any nerve, or of the brain itself, by an exfoliation, swelling, too great fulness of the vessels, pain, vehement affections of the mind, sudden evacuation, or poisons admitted into the body. Frequently, however, the malady originates from slight causes, little known, and not easily observed.

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

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

Want of sleep is hurtful in a great many different ways, especially to the nervous system. It renders the organs of sense both external and internal, as well as those of every kind of motion, unfit for performing their offices. Hence the sensations are either abolished, or become imperfect or depraved; and hence imbecility of mind, defect of memory, a kind of delirium, mania itself, pain of the head, weakness of the joints, an imperfect or inordinate action of the vital organs, quickness of pulse, heat, fever, depraved digestion, atrophy, leanness, and an increase... Sleep may be prevented both in healthy and sick people from various causes; such as strong light, noise, pain, anger, joy, grief, fear, anxiety, hunger, thirst, vehement desire, motion of the body, memory, imagination, intense thought, &c. On the other hand, sleep is brought on by a slight impression on the organs of sense, or none at all; by the humming of bees, the noise of falling water, cold and insipid discourse; or lastly, by such an exercise of the memory as is neither too laborious nor disturbing to the mind. Too great an impulse of the blood towards the head, such as often happens in fevers, prevents sleep; but a free and equal distribution of the blood through the whole body, especially the extreme parts, frequently brings it on. Whatever weakens the body also favours sleep; and hence various kinds of evacuations, the bath, fomentations, sometimes heat itself, are useful for promoting it. It also comes on easily after taking food, or indulging venery; the violent sensation being then quieted, and the body itself somewhat weakened. Cold produces a deep sleep of long continuance, not easily disturbed, and often terminating in death. Lastly, there are certain substances which, when applied to the body, not only do not excite the nervous system, but plainly lay us asleep, and render us unfit for sensation: of this kind are those called narcotic, as opium and the like; among which also we may reckon wine taken in too great quantity. Lastly, watching itself is often the cause of sleep; because while a man is awake he always more or less exercises the organs of his body, by which the nervous power is diminished and consumed; and thus the more violently the body is exercised, in the same proportion is the person under a necessity of sleeping.

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

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

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

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

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

The blood is also distributed in various proportions to the different parts of the body, and that proportion the difference differs at different periods of our lives. At first an immense quantity is sent to the head, because that part of the body is first to be evolved and fitted for its offices: but as soon as the parts begin to make a considerable resistance to the efforts of the blood, and the vessels cannot easily be further dilated, it is necessarily sent off to other parts; by which means the rest of the body increases in bulk, and becomes fitted for performing its proper functions. The effect of this change is also very soon observed, namely, when none of the blood passes through the navel, and of consequence a greater quantity is sent by the iliac arteries. Physicians are wont to judge of the state of the circulation by the pulse; which indeed is very various, as well with regard to its frequency, as to the strength and equality of its strokes and intervals.—Its common quickness in a healthy grown-up person is about 70 strokes in a minute. In a fetus, perhaps, it is more than double; and in an infant a few months old, hardly less than 120. As we grow up, this quickness gradually diminishes; so that in extreme old age it sometimes does not exceed 50, or is even slower. This rule, however, is not without exceptions: for many, especially those of an irritable habit, have the pulse much quicker; while others, even in the vigour of their age, have the pulse remarkably slow. It is for the most part somewhat quicker in women than in men.

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

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

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

The pulse is seldom observed too slow, unless when the mobility of the body is much diminished, as in decrepid old age, or from a compression or disease of the brain; but a greater compression of the brain usually produces a vast quickness of the pulse, as in the hydrocephalus, apoplexy, &c. Sometimes also the pulse is too slow in those who are recovering from tedious fevers. But this is a matter of little moment, and seems to be owing to some kind of torpor.

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

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

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

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

Moreover, in some people, though their pulse beats equally while in health, yet the slightest illness makes it intermit; and in others, especially those who have a great deal of mobility in their constitution, such as hypochondriac and hysterical people, the intermission of the pulse is felt, without applying the finger to the artery, merely by the uneasiness which they perceive in their breasts during those intervals in which the pulse is deficient. An intermittent pulse likewise occurs in many diseases of the breast, especially when water is col- difficulty, and more of the thin humour is driven into the exhaling vessels, and by them deposited in such quantities as cannot be reabsorbed by the lymphatics. These diseases, as well as all others proceeding from defects of the circulation, are also more difficult of cure than others, because all the vital powers are weakened at the same time.

Another disorder of the circulation is where the irregular blood is carried to one part of the body in too great distribution quantity, by which means the other parts are deprived of their due. This irregular distribution of the vital fluid frequently arises from a stimulus applied to the part itself, or to the brain, or at length acting on the mind, which, according to the laws of sympathy, produces a certain and definite distribution of the blood. It arises also not unfrequently from a spasm taking place in some other parts, which drives the blood out of its ordinary course.

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

Lastly, some disorders in the motion of the heart itself, and those of no small consequence, remain yet to be taken notice of, namely, palpitation and syncope.

A palpitation is a violent and irregular action of the palpitation heart, such as for the most part is perceived by the patient himself, and that not without a great deal of uneasiness and oppression at his breast; and is also manifest to the bystanders if they apply their hands, or look at his naked breast; the pulse of the arteries in the mean time being weak, unequal, and intermitting. This is a spasmodic disorder; and is induced by various causes affecting either the nervous system in general, or the heart in particular. Every disease of the organ itself, such as a constriction of its valves and blood-vessels, an effusion, enlargement, or polyposis hindering the free action of the heart, and evacuation of blood from it, are capable of exciting it to violent and unusual contractions. The same effect will also follow plethora, or too violent an impulse of the blood, &c. The heart will likewise frequently palpitate from a violent excitement of the nervous system, especially where the constitution is endowed with a great deal of mobility. Hence palpitations from any affection of the mind, and in hysterical women. Palpitation may likewise arise from an affection of the stomach, occasioned by worms, a surfeit, flatus, or stimulation by various acid substances. It frequently also accompanies the gout when driven back, or even when a fit is coming on. Sometimes it arises from debility, whatever may be the cause; frequently from any difficulty in breathing; and many of these causes may be joined at the same time, or some of them produce others.

Hence we may see why the evil is sometimes slight and of short continuance; at other times altogether incurable, and certainly mortal in a longer or shorter time; Syncope.

A syncope is when the action of the heart, and, along with it that of the arteries, is suddenly and very much lessened; whence the animal-powers, the senses, and voluntary motions, immediately cease. This may be produced by almost all the causes of palpitation; because whatever can disturb and disorder the motion of the heart, may also weaken or suspend it. The vitiated structure of the heart itself therefore, violent passions of the mind, whether of the depressing kind, or those which suddenly and vehemently excite, various kinds of nervous diseases, those of the stomach, every kind of debility and evacuation, especially a great loss of blood, excessive and unremitting labour, long watching, heat, pain, many kinds of poisons, &c. produce fainting.

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

With regard to the disorders of the blood itself, our author observes, that the glutinous part of it produces that buff coloured appearance often seen upon blood drawn from people afflicted with inflammatory disorders, and even sometimes when no such diseases are present. This crust indeed is nothing else than the pure glutin of the blood taking longer time than usual to coagulate, by which means the red particles have an opportunity of falling to the bottom. This indicates no lentor, density, thickness, or tenacity of the blood, as was formerly thought; but rather its thinness, or at least a less tendency in it to coagulate. It arises for the most part from a violent agitation and conglomeration of the blood within the body; and hence it accompanies many fevers, all inflammations, haemorrhages sometimes, exanthemata, plethora, pain, and many irritations. Nor is this crust always to be accounted morbid, as it often happens to the most healthy; and may even be produced or destroyed by the slightest causes while the blood is running from the vein, so that frequently we shall see a very thick and tenacious crust on the blood flowing into one cup, while that which runs into another has little or none at all. In general, however, the appearance of this crust shows, that the patient will bear bloodletting well, though those have been in a great mistake who directed this operation to be repeated till no more crust appeared on the blood.

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

The quantity of blood contained in a healthy body is very various, and difficult to be ascertained. Many from ple-diseases, however, may arise from its being either too scanty or too abundant. Too great a quantity of blood is produced by the use of rich, nourishing diet, strong drink, accompanied with a good digestion; from a lazy, sedentary life, or much sleep, especially in those who have been formerly accustomed to much exercise; with many other causes of the same kind. It renders the person dull, weak, and languid, and sometimes almost totally oppresses him; nor are those organs destined for moving the blood sufficient for driving forward such a load. The pulse sinks; and sometimes a syncope, vertigo, or palpitation, takes place. More frequently, however, the vessels are too much distended, and ready to be thrown into violent and irregular motions. Hence a disposition to fevers, inflammations, an unequal distribution of the blood, unusual congestions, rupture of the vessels, and hemorrhages. Moreover, by reason of the close connection between the sanguineous and the nervous system, a fulness of blood produces a disposition to spasm and other diseases of that kind.

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

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

By a great and long-continued deficiency of blood the quality of it also is impaired; because the thin part of it is easily and soon made up; but the glutinous, thick, and red part, not so easily. Hence the blood becomes thin, pale, scarcely capable of coagulation, or affording a proper support to the body. Too great thinness of the blood also proceeds from using much drink, especially of the aqueous kind, slender and little nourishing diet, a bad digestion in the stomach; from diseases of the lungs and those organs which elaborate the red part; or from suppressions of the usual evacuations. A too thin and watery blood makes the face pale, the body weak, languid and torpid; the solid parts become flaccid from want of nourishment and having too great a quantity of water in their composition. It brings on hydropic effusions of water in all parts of the body, by reason of the increased exhalation of that thin fluid which moistens all the inward parts; partly by reason of the blood itself being in some measure dissolved, so that it passes out of the vessels more easily and plentifully than it ought to do; and partly by reason of the vessels being relaxed beyond their usual pitch, and not making a proper resistance. Besides, in this case, the lymphatic veins are so far from absorbing more than usual, that partaking likewise of general debility, they are scarce sufficient for performing their proper offices.

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

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

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

Moreover, even while life continues, putrefaction is going on, and produces much of that substance called animal salt; for into this a great part of our food is converted and passes off by the urine. But if this putrefactive disposition be too great, it will produce too large a quantity of animal salt; especially if much of any saline substance is otherwise thrown into the body without proper dilution: and this kind of disease is well known to sailors who have been long at sea without having an opportunity of getting fresh provisions.

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

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

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

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

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

Many kinds of acrimony indeed may exist in the blood from too liberal an use of spices, wine, &c. but of these we know nothing certain. We are assured, however, that the body is often infected with various kinds of morbid acrimony, which bring on many and dangerous diseases, as the small-pox, measles, cancers, lues venerea, &c. of which the origin and manner of acting are very little known, though the effects are abundantly evident. In most cases, however, nature hath taken no less care to provide against the acrimony than against the too great thickness of the blood. Sometimes an antidote is afforded, either by the excitement of thirst, that the acid substance may be diluted with plenty of drink; or by increasing the evacuations, that it may be thrown out of the body; or lastly, by exciting various motions and actions of the vital powers, by which it may be either subdued, changed, rendered innocent, or expelled from the body by new and unwonted passages.

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

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

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

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

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

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

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

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

The last part of the Doctor's treatise necessary to be taken notice of here, is that which considers diseases arising from a bad digestion, disordered motion of the intestines, and some of the principal secretions. The first of these, he says, are sometimes very troublesome, though seldom dangerous. The principal symptoms are oppression, anxiety, pain at the stomach; eruptions, by reason of air extricated from the fermenting aliments, and irritating the stomach; nausea and vomiting, from the irritation and distention of the same organ; the belly sometimes too colicive, and sometimes too loose; a defect of nourishment; a general debility; relaxation of the solid parts; too great thinness of the fluids; all the functions impeded; pain of the head; vertigo, syncope, asthma, palpitation; great sinking of the spirits, especially if the patient hath been of a peculiar constitution; sometimes the gout, sometimes a dropy, or a slow fever which may prove mortal.

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

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

Looseness, or diarrhoea, is a malady extremely common; being sometimes a primary disease, and sometimes only a symptom or an effect of others. Sometimes it is a salutary effort of nature, such as the physician ought to imitate and bring on by art. It is also familiar to infants, and to people of a certain constitution, and to them coliciveness is very prejudicial. It may arise, in the first place, from something taken into the body, or generated in the intestines; from a fermentation and corruption of the mafs of aliments; from the gall being too abundant and acid, or from blood or pus poured into the intestines; from the intestines themselves being eroded, or deprived of their natural mucous; from the humours being driven from the surface of the body towards the inward parts, as by cold, especially when applied to the feet; or from a general corruption of the whole body, as in the phthisis, hectic, or putrid fever, especially towards the end of these disorders. In fevers it is sometimes salutary, or even puts an end to the disease altogether, or at least renders it milder: more frequently, however, deriving its origin from putrefaction, it is of no service, but rather exhausts the strength of the patient. A diarrhoea likewise, almost incurable, and often mortal in a short time, frequently arises after the operation for the fistula in ano. Some have their intestines to extremely weak and moveable, that from the slightest cause, such as catching cold, any violent commotion of the mind, &c., they are subject to a violent diarrhoea. Lastly, whatever be its origin, if it hath continued for a long time, the viscera are rendered so weak and irritable, that the disease, though often removed, still returns from the slightest cause, and even such as are not easily discovered.

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

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

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

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

A nausea and vomiting are disorders very common, and owing to almost innumerable causes; not only to affections of the stomach itself, but also to affections and irritations of the remotest parts of the body which may act upon the stomach by sympathy. Every irritation and dilution of that viscus therefore, a load of crude aliment, an obstruction about the pylorus, all acid substances taken into it, diseases of the liver, intestines, kidneys, uterus, the head, the feet, of the whole skin, or indeed the whole body, inflammation, the stone, king's evil, scirrhus, apoplexy, compression of the brain, fracture of the skull, vertigo, syncope, violent pain, the gout, especially when repelled, fevers, passions of the mind, disagreeable imaginations or discourses, frequently induce nausea and vomiting.

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

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

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

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

From a suppression of any of the secretions, or a disorder of any of the secretory organs, many mischief may arise. A diminution of perspiration produces plethora, languor, depression of mind, bad digestion, loss of appetite, and even a general corruption of the humours from the retention of such a quantity of putrefactive matter.—The more suddenly the diminution or suppression of the perspiration takes place, the sooner the mischief is produced, and the greater it is; not only by retaining the matter which ought to be thrown out, but by repelling the humours from the surface of the body, and directing them to other parts; whence fevers, inflammations, congestions of the blood, &c. frequently take place.

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

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

A suppression of urine is still more dangerous than that of perspiration, and unless relieved in a short time will certainly prove fatal. This disorder, which is called icterus, may arise from various diseases of the kidneys, ureters, bladder, urethra, &c. Thus any obstruction or irritation of one or other of the kidneys or ureters, by a stone, gravel, mucus, blood, inflammations, spasm, suppuration, scirrhus, swellings of the neighbouring parts, &c. may either prevent the urine from being secreted, or may change its nature in such a manner as to prevent it from entering the bladder.

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

A suppression of urine for any length of time produces an immense dilution of the bladder, oppression, uneasiness, and pain, not only of the part itself,

Theory itself, but of the surrounding ones, and even of the whole body; a spasm, or insuperable contraction of the sphincter; an inflammation, gangrene, or laceration of the bladder itself; a violent irritation of the whole habit; then a nausea, vomiting, vertigo, general stupor, and an oppresion of the whole mass of blood, with a humour of an urinous nature, which at last being poured out into various cavities of the body, especially of the head, soon brings on a deep sleep, convulsions, and death.

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

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

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

The last disorder here to be taken notice of is a disorder of the glands themselves, owing to some kind of obstruction, and is one of the most dreadful diseases incident to human nature. Hence happens a great swelling and surpising hardness, not only without pain, but sometimes even with a diminution of sensation in the part affected; and when the gland is thus affected, it is called a seirrhus. Sometimes it remains in this state for a long time; but sooner or later produces the most excruciating torment. By degrees it is infected with a slow and malignant suppuration, degenerating into an horrid ulcer, consuming not only the part itself, but eating away the neighbouring ones, and corrupting the whole body with the most acrid and incurable poison. This disease is called a cancer, of which the causes are very little known.

Sect. IV. Of Nosology.

Nosology is the general history or description of diseases, arranged in a systematic order.

The diseases described by medical writers are so extremely numerous, that unless they were arranged according to some regular plan, we should never be able to retain their descriptions, nor remember how they are to be treated.

Different writers have adopted different schemes; but the most useful and satisfactory of all is that which was first proposed by Sydenham.

By this, which is termed the systematic method, the histories of diseases, like the subjects of natural history, are arranged into classes, orders, genera, and species.

The classes are marked by certain symptoms and circumstances, which are common to each; the orders all agree in having the same marks with the class to which they belong, together with some additional ones peculiar to the order: the genera have all the marks and circumstances of the class and the order, and besides have some which distinguish the genus; and the species have all the marks and tokens of class, order, and genus, with the still further addition of symptoms or circumstances which give the specific character.

There are people who, probably, have not been at the trouble to make themselves masters of it, and yet pretend to decry the systematic way of arranging the histories of diseases: but if such as have capacity to understand it will take the pains of examining, they will see that this method is more satisfactory than any that has yet been adopted, and tends to establish practice on the most rational foundations; since, by bringing those diseases together which agree in the greater number of circumstances, and demand nearly similar remedies, it shows, that though there may be great variety in the names, there needs not much in the methods of treatment.

This, as hath been already mentioned, is the scheme which Sydenham recommends in the preface to his justly celebrated works, where he insists strongly on the necessity and advantage of "reducing diseases to a certain and determinate species with the same ex- Sauvages was the first who attempted to execute this great task. Linnæus, Vogel, Sagar, and Cullen, have since endeavoured to improve his method. Sauvages enumerates 315 genera, Linnæus 326, Vogel 560, Sagar 350, and Cullen 150. The bare inspection of these numbers, it must be acknowledged, shews that physicians are far from being agreed with regard to what constitutes the generic or specific characters of a disease. Nor is it perhaps probable that they ever can agree in this point: The diagnostic symptoms of diseases are not so easily discovered as the stamens or petals of a flower, or the number of teeth or toes in a quadruped. At the same time, as the utility of a systematic arrangement is indisputable, there can be no hesitation in preferring a method chargeable with some defects, to no method at all. To give our readers therefore an idea of the scheme of classing diseases, we shall lay before them the shortest distribution, being that of Dr Cullen. To exhibit the others would be superfluous to the medical reader, who is already acquainted with them, or can at pleasure consult the Synopsis Nosologica Methodica published by the last-mentioned learned professor; and to ordinary readers, the detail would be equally useless and uninteresting. In the subsequent or practical part of this treatise, however, the synonyma of different nosologists will be carefully noted at the beginning of each disease, and referred to their respective classes, orders, &c.

Cullen's Arrangement.

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

Order I. Febris. Pyrexia without any primary local affection, following the languor, latitude, and other symptoms of debility.

Sect. I. Intermittent. Fevers arising from the miasma of marshes; with an apyrexia, or at least a very evident remission; but the disease returns coquantly, and for the most part with a horror or trembling. There is only one paroxysm in a day.

Genus I. Tertiana. Similar paroxysms at an interval of about 48 hours, coming on at mid-day. A tertian hath either,

I. An apyrexia interposed; 1. Varying the duration of the paroxysm. A. The tertian whose paroxysms are not extended beyond 12 hours. B. The tertian with paroxysms extended beyond 12 hours. 2. Varying in the return of the paroxysms. C. The tertian returning every day with unequal paroxysms alternately similar to one another. D. The tertian returning every third day, with two paroxysms on the same day. E. The tertian returning every day, with two paroxysms on every third day, and only one on the intermediate ones. F. The tertian returning every day, with a notable remission interposed between the odd and the even days, but a less remarkable one between the even and the odd one. 3. Varying in its symptoms.

G. The tertian accompanied with a disposition to sleep. H. Accompanied with spasms and convulsive motions. I. Accompanied with an efflorescence on the skin. K. With phlegmatis. 4. Varying in being complicated with other diseases. 5. Varying as to its origin. II. With the interposition only of a remission between the paroxysms.

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

I. With the interposition of an apyrexia. 1. Varying in the type. A. The quartan with single paroxysms, returning every fourth day, none on the other days. B. With two paroxysms every fourth day, and none on the other days. C. With three paroxysms every fourth day, and none on the intermediate days. D. Of the four days having only the third free from fever, with similar paroxysms every fourth day. E. The quartan coming on every day, with similar paroxysms every fourth day. 2. Varying in its symptoms. 3. Varying in being complicated with other diseases.

II. With a remission only between the paroxysms.

Genus III. Quotidiana. Similar paroxysms with an interval of about 24 hours, coming on in the morning.

I. With the interposition of an apyrexia. 1. Varies in being solitary. A. Universal. B. Partial. 2. Complicated with other diseases.

II. With a remission only between the paroxysms.

Sect. II. Continue. Fevers without any intermission, and not occasioned by marsh miasmas; attended with exacerbations and remissions, though not very remarkable.

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

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

The species are, I. Typhus potecchalis. Typhus for the most part with petechiae. Varying in degree: 1. Mild typhus. 2. Malignant typhus. II. Typhus ulcerosus. Typhus with a yellowness of the skin.

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

Order II. Phlegmatis. A synocha fever, with inflammation or topical pain, the internal function of the part being at the same time injured; the blood covered with lice.

Genus VII. Philogosis. Pyrexia; redness, heat, The species are,

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

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

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

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

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

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

The species and varieties of the ophthalmia, are,

I. Idiopathic.

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

A. Varying in the degree of the external inflammation.

B. In the internal coats affected.

2. Ophthalmia (of the tarbus or cartilaginous edge) of the eye-lids, with swelling, erosion, and glutinous exudation.

II. Symptomatic.

1. From a disease of the eye itself.

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

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

I. Idiopathic.

II. Symptomatic.

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

The species are,

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

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

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

IV. The pharyngae, attended with redness in the bottom of the fauces, very difficult and painful deglutition, respiration sufficiently free, and a synoche.

V. The parotides; with great swelling of the parotids and maxillary glands appearing on the outside; the respiration and deglutition but little injured; a synoche, for the most part mild.

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

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

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

1. Simple idiopathic peripneumonies.

Varying in degree.

2. Idiopathic peripneumonies complicated with fever.

3. Symptomatic peripneumonies.

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

1. Simple idiopathic pleurifies.

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

3. Symptomatic pleurifies.

4. False pleurifies.

The consequences of pleurify are a vomica or empyema.

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

I. Idiopathic.

II. Symptomatic.

Genus XIV. Peritonitis. Pyrexia; pain of the belly, exasperated by an upright posture, without the proper signs of other abdominal phlegmasiae. If the diagnostics of the following diseases are given, they may be reckoned as so many species of this genus.

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

II. Peritonitis (omentumis) in the peritoneum extended through the omentum.

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

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

I. Idiopathic.

1. From internal causes.

A. Gastritis (phlegmonidea) attended with acute pain and violent pyrexia.

2. From external causes.

B. Gastritis (erysipelasidea), with a less violent fever and pain; an erysipelasious redness appearing on the fauces.

II. Symptomatic.

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

I. Idiopathic.

1. Enteritis (phlegmonidea), with acute pain, violent

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

II. Symptomatic.

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

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

Genus XIX. Nephritis. Pyrexia; pain in the region of the kidney, often following the course of the ureter; frequent making of water, either thin and colourless, or very red; vomiting; stupor of the thigh; with a retraction or pain of the testicle of the same side. The species are,

I. Idiopathic. Spontaneous.

II. Symptomatic.

Genus XX. Cystitis. Pyrexia; pain and swelling of the hypogastrium; frequent and painful making of water, or ichuria; and tenesmus. The species are,

I. Those arising from internal causes.

II. Those from external causes.

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

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

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

A. In the muscles of the loins.

B. In the muscles of the coxendix.

C. In the muscles of the breast.

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

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

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

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

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

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

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

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

Genus XXVI. Erysipelas. A synocha of two or three days, for the most part attended with drowsiness, often with a delirium. In some part of the skin, most frequently the face, appears a phlogosis erythema. (G. VII. Sp. 2.) The species are,

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

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

The disease is also symptomatic.

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

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

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

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

Genus XXIX. Varicella. Synocha; papulae breaking out after a short fever, similar to those of the small-pox, but hardly ever coming to suppuration; after a few days going off in small scales, but never leaving any mark.

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

I. Rubiola (vulgaris) with very small confluent, corymbose papulae, scarce rising above the skin.

Varying,

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

2. In being accompanied with a quinsy.

3. With a putrid diathesis.

II. Rubiola (varioloides) with distinct papulae, raised above the skin.

Genus XXXI. Miliaria. Synochus with anxiety, frequent sighing, fetid sweat, and points on the skin. On an uncertain day of the disease, break out red, small, distinct papulae, spread over the whole body as well. Genus XXXII. Scarletina. A contagious synocha, On the fourth day of the disease the face swells a little; at the same time an universal redness occupies the skin in large spots, at length running together; after three days, going off in branny scales; frequently succeeded by an anaerca. The species are,

1. Scarletina (simplicis), not accompanied with cynanche. 2. Scarletina (synanchica), with an ulcerous cynanche.

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

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

Genus XXXV. Aphtha. Synochus. The tongue somewhat swelled and of a livid colour, as well as the fauces; ulcers first appearing in the fauces; but at length occupying the whole internal part of the mouth, of a white colour, sometimes distinct, often running together; quickly growing again when taken off; and remaining for an uncertain time.

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

Order IV. Hemorrhagia. Pyrexia, with a profusion of blood, without any external violence; the blood drawn from a vein hath the same appearance as in phlegmatis.

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

1. Idiopathic. Varying according to the time of life. 1. Epistaxis of young people, with symptoms of an arterial plethora. 2. Epistaxis of old people, with symptoms of a venous plethora.

II. Symptomatic. 1. From internal causes. 2. From external causes.

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

The idiopathic species are, 1. Hemoptysis (plethorica), without any external violence, and without being preceded by any cough or suppression of a customary evacuation. 2. Hemoptysis (violentia), from external violence applied. 3. Hemoptysis (phthisica), after a long-continued cough, with leanness and debility. 4. Hemoptysis (calculus), in which some calculous molecules, for the most part of a calcareous nature, are thrown up.

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

Besides these, there are a number of symptomatic species mentioned by different authors. The consequence of an hemoptysis is, a Phthisis. A wasting and debility of the body, with a cough, hectic fever, and for the most part a purulent expectoration. The species are,

I. An incipient phthisis, without any expectoration of pus. II. A confirmed phthisis, with an expectoration of pus.

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

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

1. Hemorrhoids (tumens), external from mariscis. Varying: A. Bloody. B. Mucous.

2. Hemorrhoids (procedens), external from a proctodentia ani.

3. Hemorrhoids (fluent), internal, without any swelling or proctodentia ani.

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

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

The species are,

1. Menorrhagia (rubra), bloody in women neither with child nor in child-birth. 2. Menorrhagia (abortus) bloody in women with child. 3. Menorrhagia (lobialis) bloody in child-bed women. 4. Menorrhagia (vittorum) bloody from some local disease. 5. Menorrhagia (alba) serous, without any local disease, in women not with child. 6. Menorrhagia (Nabothi) serous in women with child.

Order V. Profusia. Pyrexia, with an increased secretion, naturally not bloody.

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

The species are for the most part symptomatic.

1. From cold. 2. From contagion.

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

Varying: 1. Accompanied with worms. 2. With the excretion of small fleshy or sebaceous bodies. 3. With an intermittent fever. 4. Without blood. 5. With a miliary fever.

Class II. Neuroses.—An injury of the sense and motion, without an idiopathic pyrexia or any local affection. ORDER I. Comata.—A diminution of voluntary motion, with sleep, or a deprivation of the senses.

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

The idiopathic species are,

1. Apoplexia (anguinea) with symptoms of universal plethora, especially of the head. 2. Apoplexia (erga) with a leucophlegmatia over the whole body, especially in old people. 3. Apoplexia (hydrocephalica) coming on by degrees; affecting infants, or those below the age of puberty, first with languor, a slight fever and pain of the head, then with slowness of the pulse, dilatation of the pupil of the eye, and drowsiness. 4. Apoplexia (atrabilaria) taking place in those of a melancholic constitution. 5. Apoplexia (traumatica) from some external injury mechanically applied to the head. 6. Apoplexia (venenata) from powerful sedatives taken internally or applied externally. 7. Apoplexia (mentaliz) from a passion of the mind. 8. Apoplexia (cataleptica) in the contractile muscles, with a mobility of the limbs by external force. 9. Apoplexia (suffocata) from some external suffocating power.

The apoplexy is frequently symptomatic.

1. Of an intermittent fever. 2. Continued fever. 3. Phlegmata. 4. Exanthema. 5. Hysteria. 6. Epilepsy. 7. Podagra. 8. Worms. 9. Itchuria. 10. Scurvy.

Genus XLIII. Paralysis. Only some of the voluntary motions diminished, frequently with sleep.

The idiopathic species are,

1. Paralysis (partialis) of some particular muscles only. 2. Paralysis (hemiplegica) of one side of the body. Varying according to the constitution of the body. a. Hemiplegia in a plethoric habit. b. In a leucophlegmatic habit. 3. Paralysis (paraplegica) of one half of the body taken transversely. 4. Paralysis (venenata) from sedative powers applied either internally or externally.

A symptom either of an Aethenia or Palsy is,

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

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

ORDER II. Adynamia. A diminution of the involuntary motions whether vital or natural.

Genus XLIV. Syncope; a diminution, or even a total stoppage, of the motion of the heart for a little.

I. Idiopathic.

1. Syncope (cardiaca), returning frequently without any manifest cause, with violent palpitations of the heart during the intervals.—From a fault of the heart or neighbouring vessels. 2. Syncope (occasionalis) arising from some evident cause.—From an affection of the whole system.

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

Genus XLV. Dyspepsia. Anorexis, nausea, vomiting, inflation, helicing, rumination, cardalgia, gatrodynia, more or fewer of these symptoms at least concurring; for the most part with a constipation of the belly, and without any other disease either of the stomach itself or of other parts.

1. Idiopathic. 2. Symptomatic. 1. From a disease of the stomach itself. 2. From a disease of other parts, or of the whole body.

Genus XLVI. Hypochondriasis. Dyspepsia with languor, sadness and fear without any adequate cause, in a melancholic temperament.

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

ORDER III. Spasms. Irregular motions of the muscles or muscular fibres.

Sect. I. In the animal functions.

Genus XLVIII. Tetanus—a spasmodic rigidity of almost the whole body.

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

Genus XLIX. Trismus. A spasmodic rigidity of the lower jaw.—The species are,

1. Trismus (nascentium) seizing infants under two months old. 2. Trismus (traumaticus) seizing people of all ages either from a wound or cold.

Genus LI. Convulsion.—An irregular clonic contraction of the muscles without sleep.

I. Idiopathic. II. Symptomatic.

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

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

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

The idiopathic species are,

1. Epilepsia (cerebralis) suddenly attacking without any manifest cause, without any sense of uneasiness preceding, excepting perhaps a slight vertigo or scotoma. 2. Epilepsia (sympathica) without any manifest cause, but preceded by the sensation of a kind of air rising from a certain part of the body towards the head. 3. Epilepsia (occasionalis) arising from a manifest irritation, and ceasing on the removal of that irritation.

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

From injuries of the head; pain; worms; poison; from the repulsion of the itch, or an effusion of any other acrid humour; from crudities in the stomach; from Part I.

Sect. II. In the vital functions.

In the action of the heart.

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

In the action of the lungs.

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

1. Asthma (spontaneum) without any manifest cause or other concomitant disease. 2. Asthma (exanthematicum) from the repulsion of the itch or other acrid effusion. 3. Asthma (plethoricum) from the suppression of some customary sanguineous evacuation, or from a spontaneous plethors.

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

The idiopathic species are,

1. Dyspnoea (catarrhalis) with a frequent cough, bringing up plenty of viscid mucus. 2. Dyspnoea (aerea), with a cough for the most part dry. 3. Dyspnoea (aerea), increased by the least change of weather. 4. Dyspnoea (terrea), bringing up with the cough an earthy or calcareous matter. 5. Dyspnoea (aquea), with scanty urine and oedematous feet; without any fluctuation in the breast, or other signs of an hydrothorax. 6. Dyspnoea (pinguedinosa), in very fat people. 7. Dyspnoea (thoracica), from an injury done to the parts surrounding the thorax, or from some bad conformation of them. 8. Dyspnoea (extrinsica), from evident external causes.

The symptomatic species of dyspnoea are symptoms,

1. Of diseases of the heart or large vessels. 2. Of a swelling in the abdomen. 3. Of various diseases.

Genus LVII. Pertussis. A contagious disease; convulsive strangulating cough reiterated with noisy inspiration; frequent vomiting.

Sect. III. In the natural functions.

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

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

The idiopathic species are,

1. Colica (spontanea), with retraction of the navel, and spasms of the abdominal muscles. Varying, by reason of some symptoms superadded. Hence,

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

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

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

a. From metallic poison. b. From acids taken inwardly. c. From cold. d. From a contusion of the back.

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

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

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

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

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

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

I. Idiopathic.

1. Cholera (spontanea) arising in a warm season, without any manifest cause. 2. Cholera (accidentalis) from acrid matters taken inwardly.

II. Symptomatic.

Genus LXI. Diarrhoea. Frequent stools; the defecate not infectious; no primary pyrexia.

I. Idiopathic.

1. Diarrhoea (crapulosa), in which the excrementa are voided in greater quantity than naturally. 2. Diarrhoea (biliosa), in which yellow feces are voided in great quantity. 3. Diarrhoea (mucosa), in which either from acrid substances taken inwardly, or from cold, especially applied to the feet, a great quantity of mucus is voided. 4. Diarrhoea (callosa), in which a milky humor of the nature of chyle is passed. 5. Diarrhoea (lentaria), in which the aliments are discharged with little alteration soon after eating. 6. Diarrhoea (hepatirrhoea), in which a bloody serous matter is discharged without pain.

II. Symptomatic.

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

I. Idiopathic.

1. Diabetes (melitius), with urine of the smell, color, and taste of honey. 2. Diabetes (insipidus), with limpid, but not sweet urine.

II. Symptomatic.

Genus LXIII. Hysteria. Rumbling of the bowels;

Theory. A sensation as of a globe turning itself in the belly, ascending to the stomach and fauces, and there threatening suffocation; sleep; convulsions; a great quantity of limpid urine; the mind involuntarily tickle and mutable.

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

A. From a retention of the menes. B. From a menorrhagia cruenta. C. From a menorrhagia serosa, or fluor albus. D. From an obstruction of the viscera. E. From a fault of the stomach. F. From too great salacity.

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

I. Hydrophobia (rabies), with a desire of biting the bystanders, occasioned by the bite of a mad animal.

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

Order IV. Vesania. Disorders of the judgment, without any pyrexia or coma.

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

I. Amentia (congenita), continuing from a person's birth.

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

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

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

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

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

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

3. With violent love, without satyriasis or nymphomania.

4. With a superstitious fear of a future state.

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

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

7. With a weariness of life.

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

The Doctor reckons that there is no such disease as that called demonomania, and that the diseases mentioned by Sauvage under that title are either

1. Species of melancholy or mania; or 2. Of some disease by the spectators falsely ascribed to the influence of an evil spirit; or 3. Of a disease entirely feigned; or 4. Of a disease partly true and partly feigned.

Genus LXVII. Mania; universal madness.

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

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

Varying according to the different disease of the body.

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

The symptomatic species of mania are,

1. Paraphrolyne from poisons. 2. Paraphrolyne from passion. 3. Paraphrolyne febrilis.

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

1. Oneirodynia (adiva), exciting to waking and various motions.

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

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

Order I. Marcres; a wasting of the whole body.

Genus LIX. Tabes. Leanness, athens, hectic pyrexia. The species are,

1. Tabes (purulenta), from an external or internal ulcer, or from a vomit.

Varying in its situation; hence,

2. Tabes (serophalosa), in serophilous constitutions.

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

Genus LXX. Atrophia. Leanness and athens, without hectic pyrexia. The species are,

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

1. Atrophia (samelicorum), from a deficiency of nourishment.

3. Atrophia (cacoehymica), from corrupted nourishment.

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

Order II. Intumescence. An external tumour of the whole or greatest part of the body.

Sect. I. Adipose.

Genus LXXI. Polyfascia; a troublesome swelling of the body from fat.

Sect. II. Flatus.

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

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

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

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

4. Pneumatosis (hysterica), with hysteria.

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

1. Tympanites (intestinalis), with a tumour of the abdomen frequently unequal, and with a frequent evacuation of air relieving the tension and pain. Genus LXXIV. Physometra; a slight elastic swelling in the epigastrium, having the figure and situation of the uterus.

Sect. III. Aquofix or Hydrops.

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

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

2. Anasarca (epipila) from a compression of the veins.

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

4. Anasarca (anemia) from the thinness of the blood produced by hemorrhage.

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

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

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

Genus LXXVIII. Hydrothorax. Dyspnoea; paleness of the face; oedematous swellings of the feet; scanty urine; lying down difficult; a sudden and spontaneous waking out of sleep, with palpitation; water fluctuating in the breath.

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

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

Varying according to the cause.

A, From an obstruction of the viscera.

B, From debility.

C, From a thinness of the blood.

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

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

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

Sect. IV. Solids.

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

Phyconia hepatica. Phyconia splenica. Phyconia renalis. Phyconia uterina. Phyconia ab ovario. Phyconia mesenterica. Phyconia intestinalis. Phyconia omentalis.

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

Varying.

1. Simple, without any other disease.

2. Joined with other diseases.

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

Genus LXXXIV. Scrophula. Swellings of the conglomerate glands, especially in the neck; swelling of the upper lip and support of the nose; the face florid, skin thin, abdomen swelled. The species are,

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

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

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

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

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

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

Varying in degree.

a, Scorbutus incipiens.

b, Scorbutus crescens.

c, Scorbutus inverteratus.

Varying also in its symptoms.

d, Scorbutus lividus.

e, Scorbutus petechialis.

f, Scorbutus pallidus.

g, Scorbutus ruber.

h, Scorbutus calidus.

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

Genus LXXXVIII. Lepra; the skin rough, with white, branny, and chopped effluvia, sometimes moist beneath, with itching.

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

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

Genus XCI. Icterus; yellowness of the skin and eyes; The idiopathic species are,

1. Icterus (calculus), with acute pain in the epigastric region, increasing after meals; biliary concretions voided by stool. 2. Icterus (pseudocholic), without pain, after spasmodic diseases and passions of the mind. 3. Icterus (hepaticus), without pain, after diseases of the liver. 4. Icterus (gravidaeum), arising during the time of pregnancy, and going off after delivery. 5. Icterus (infantum), coming on in infants a few days after birth.

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

ORDER I. Dysesthesia. The senses depraved or destroyed, from a disease of the external organs.

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

1. Caligo (lentis), occasioned by an opaque spot behind the pupil. 2. Caligo (cornea), from an opacity of the cornea. 3. Caligo (pupillae), from an obstruction of the pupil.

Varying according to the different causes from which it proceeds.

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

Varying according to the different state of the humour.

5. Caligo (palpebrarum) from a disease inherent in the eye-lids.

Varying according to the nature of the disease in the eye-lids.

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

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

Varying according to the nature of the remote cause.

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

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

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

Genus XCIV. Dysopia. A deprivation of the sight, so that objects cannot be distinctly perceived except at a certain distance and in a certain situation. The species are,

1. Dysopia (tenebrarum), in which objects are not seen unless they are placed in a strong light. 2. Dysopia (luminis), in which objects are not distinctly seen unless by a weak light. 3. Dysopia (distantium), in which distant objects are not perceived. 4. Dysopia (proximorum), in which the nearest objects are not perceived. 5. Dysopia (lateralis), in which objects are not perceived unless placed in an oblique posture.

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

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

Varying according to the nature of the imagination.

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

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

Genus XCVI. Dysecca. A diminution or total abolition of the sense of hearing. The species are,

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

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

2. Dysecca (atonia), without any evident disease of the organs transmitting the sounds.

Varying according to the nature of the cause.

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

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

Varying,

a. With a dulness of hearing. b. With an hearing too acute and sensible. c. When a single external sound is doubled by some internal causes. d. When the sounds which a person desires to hear are not perceived, unless some other violent sound is raised at the same time.

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

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

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

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

Varying according to the nature of the disease.

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

Genus XCIX. Agheutia; a diminution or abolition of the sense of taste.

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

2. Agheutia (atonia), without any evident disease of the tongue.

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

1. Anesthesia a spina bifida. 2. Anesthesia plethorica. 3. Anesthesia nascentium. 4. Anesthesia melancholica.

ORDER II. Dyforexia; error or defect of appetite.

Sect. I. Appetitus erronci.

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

The idiopathic species are,

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

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

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

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

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

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

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

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

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

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

Varying in degree.

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

1. Noitalgia (simples), without any other disease.

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

Sect. II. Appetitus deficientes.

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

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

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

Genus CVIII. Adipsia; a want of thirst. Always a symptom of some disease affecting the sensorium commune.

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

The true species are,

1. Anaphrodisia paralytica.

2. Anaphrodisia gonorrhoeica.

The false ones are,

1. Anaphrodisia a mariscis.

2. Anaphrodisia ab urethra vitio.

Order III. Dyscinesia. An impediment, or deprivation of motion from a disorder of the organs.

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

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

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

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

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

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

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

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

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

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

2. Paraphonia (raucus), in which, by reason of the dryness or scalded tumour of the faucies, the voice becomes rough and hoarse.

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

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

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

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

Genus CXIII. Pfellismus; a defect in the articulation of words. The species are,

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

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

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

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

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

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

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

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

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

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

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

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

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

a. From the muscles becoming rigid by inflammation.

b. From muscles become rigid by spasm.

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

d. From... d. From muscles contracted by an irritating acrimony.

e. Contractura (articularis), from stiff joints.

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

Genus CXVI. Profusio; a flux of blood.

Genus CXVII. Ephidrosis; a preternatural evacuation of sweat.

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

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

Genus CXIX. Ptyalismus; a flux of saliva.

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

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

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

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

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

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

Gonorrhoea (mucosa), in which, after an impure gonorrhoea, a mucus humour flows from the urethra with little or no dysuria.

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

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

Order V. Epischeses; suppressions of evacuations.

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

1. Oblitipatio (debilitans), in lax, weak, and for the most part dyspeptic persons.

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

3. Oblitipatio (obstructorum), with symptoms of the colica i.a., 2d, 4th, and 7th, abovementioned.

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

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

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

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

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

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

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

1. Dysuria (ardens), with heat of water, without any manifest disorder of the bladder.

2. Dysuria (spasmatica), from a spasm communicated from other parts to the bladder.

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

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

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

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

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

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

2. Dyspermatismus (nodosus), from knots on the cavernous bodies.

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

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

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

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

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

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

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

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

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

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

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

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

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

Genus CXXIX. Ecchymoma; a diffused, and scarce eminent, livid tumour.

Genus CXXX. Scirrus; an hard tumour of some part, generally of a gland, without pain, and difficultly brought to suppuration.

Genus CXXXI. Cancer. A painful tumour of a seirrous nature, and degenerating into an ill-conditioned ulcer. Genus CXXXII. Bubo; a suppurating tumour of a conglomerate gland.

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

Genus CXXXIV. Verruca; a harder scabrous swelling.

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

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

Genus CXXXVII. Ganglion. An harder, moveable swelling, adhering to a tendon.

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

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

Genus CXL. Exostosis; a hard tumour adhering to a bone.

Order VII. Ecstropia; tumours occasioned by the removal of some part out of its proper situation.

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

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

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

Order VIII. Dialyse. A solution of continuity, manifest to the sight or touch.

Genus CXLIV. Vulnus; a recent and bloody solution of the unity of some soft part by the motion of some hard body.

Genus CXLV. Ulcus. A purulent or ichorous solution of a soft part.

Genus CXLVI. Herpes; a great number of phlyctenous or small ulcers, gathering in clusters, creeping, and obstinate.

Genus CXLVII. Tinea; small ulcers among the roots of the hair of the head, pouring out a humour which changes to a white friable scurf.

Genus CXLVIII. Pflora. Itchy pustules and little ulcers of an infectious nature, infecting the hands.

Genus CXLIX. Fractura; bones broken into large fragments.

Genus CL. Caries; an exulceration of a bone.

Part II. Practice of Medicine; or the Description and Cure of most Diseases incident to Human Nature, arranged according to Dr Cullen's Nosology.

SAUVAGES, as has been already observed, was the first who attempted to arrange diseases according to the plan suggested by Sydenham; and his work still continues the only one that merits the title of Methodical Nosology. For though Linnæus, Vogel, Cullen, and Sagar, have successively endeavoured to improve his method of classification, they have contented themselves with an enumeration and arrangement of the different genera, without entering into their history and cure: so that, though we have since had various Schemes of Arrangement, we have had, properly speaking, no complete System of Nosology; that is, no complete Course of Medicine according to any of these arrangements. Presuming, therefore, that a Practice formed upon the most approved Classification, in imitation of the work of Sauvages, might be esteemed an acquisition by our medical readers, we have endeavoured to execute that task in the present part of this treatise: Wherein the Practice is modelled by the arrangement of Dr Cullen; and the outline is filled up from the best authors, so as to exhibit the most approved methods of treatment, with the latest discoveries and improvements in the healing art.

Class I. PYREXIAE, (the Febrile Diseases of other Authors.)

Order I. FEBRES.

Sauvag. Clas II. Veg. Clas I. Sagar. Clas XII. Morbi Febriles Critici, Lin. Clas II.

Sect. I. INTERMITTENTS.

Intermittent of some authors; Sauv. Clas II. Or-

der III. Lin. Clas II. Order II. Veg. Clas I. Order I. Sag. Clas XII. Order III.

The remittents of others, Sauv. Clas II. Order II. Sag. Clas XII. Order II.

Exacerbantes, Lin. Clas II. Order III.

Continue, Veg. Clas I. Order II.

Genus I. TERTIANA; the TERTIAN FEVER.

(Tertiana, Sauv. G. 88. Lin. 16. Hoffm. Stahl. Cleghorn. Senac.)

I. The Genuine TERTIAN.

(Tertiana legitima, Senec. Hoffm. Cleghorn, Minor., Sauv. Sp. I.)

1. Description. This disease comes on in the morning, or from breakfast to dinner-time. It begins with a remarkable shivering, increasing frequently to a kind of convulsive shaking of the limbs. The extremities are always cold, sometimes remarkably so. The cold for the most part is first perceived about the lumbar regions, and from thence ascending along the spine turns towards the pit of the stomach. Sometimes it begins in the first joint of the fingers and tip of the nose. Sometimes attacks only a particular part of the body, as one of the arms, the side of the head, &c. This cold is preceded by a heavy and sleepy torpor, languor and listlessness, which we are partly to ascribe to real weakness, and partly to mere laziness. To these symptoms succeed yawning and stretching; after which the cold comes on as above described, not unfrequently with a pain of the back, and a troublesome sensation of tension in the precordia and hypochondria. To this succeed nausea and vomiting; and the more genuine the disease, the more certainly does the vomiting come on, by which a great deal of tough mucous matter, and sometimes bilious stuff or indigested food, is evacuated during the first paroxysm. In some there is only a violent straining to vomit, without bringing up any thing: sometimes, instead of these symptoms, a diarrhoea occurs; and this chiefly in weak, phlegmatic, and aged people, or where an indigested mucous salivary has long remained in the primæ vis.

When these symptoms have continued for an hour or two, the cold begins to go off, and is succeeded by a latitude, languor, and flaccidity of the whole body, but chiefly in the limbs, with an uneasy foreboding as if the parts had been bruised; excepting in those cases where the nausea continues for a longer time. After this languor a heat comes on, the increase of which is generally slow, but sometimes otherwise, with pain of the head, thirst, and bitterness in the mouth. The pulse is quick and unequal; sometimes beating 130 strokes in a minute. As soon as this heat hath abated, a little moisture or sweat is observed to break forth; not always indeed in the first, but always in the succeeding paroxysms, and the urine lets fall a quantity latentitious sediment. The whole paroxysm is scarce ever over in less than six hours, more frequently eight, and in violent cases extends to 12 hours; but that which exceeds 12 hours is to be reckoned a spurious kind, and approaching to the nature of continued fevers. All these symptoms, however, are repeated every third day, in such a manner that the patient is quite free from fever for at least 24 hours. The paroxysms return much about the same time, though sometimes a little sooner or later.

3. Causes of this disease, and persons subject to it. The genuine tertian attacks men rather than women, young people rather than old; the latter being more subject to anomalous tertians. It likewise seizes the lusty and active, rather than the lazy and indolent. Those, however, who are very sensible and apt to nauseate their meat, fall easily into a tertian fever. The cause, according to Dr Cullen, is the miasma of marshes, and that only. Other physicians have taken in many more causes, almost everything indeed which debilitates the body: but the Doctor denies that any of these, though they may dispose the body for receiving the disease, or may augment it, can by any means produce it without the concurrence of the marsh miasma.

3. Prognosis. The genuine simple tertian, unless improper medicines are administered, is generally very easily cured; nay, the vulgar reckon it of such a salutary nature, that after it they imagine a person becomes more strong and healthy than before. Hippocrates hath justly observed, that these fevers terminate of their own accord after seven or nine paroxysms. Juncker tells us, that it frequently terminates before the seventh paroxysm, but rarely before the fourth. He also denies that any thing critical is to be observed in its going off; but in this he differs from Vogel, who tells us, that the urine, for some days after the fever is quite gone off, appears slimy, and lets fall much sediment. The latter also informs us, that besides the common crisis by sweat and urine, the tertian hath one peculiar to itself, namely, dry scabby ulcers breaking out upon the lips. These sometimes appear about the third or fourth paroxysm; and then we may venture to foretel that the disease will go off spontaneously after the seventh. But though the disease is never dangerous, in cold climates at least, when properly treated; yet the improper use of hot and stimulating medicines may change it into a continued fever, more or less dangerous according to the quantity of medicines taken and the constitution of the patient; in which case the prognosis must be regulated by the particular symptoms which occur.

Cure. The treatment of all genuine intermittents, whether tertians, quotidians, or quartans, being precisely the same, the general method of cure applicable to them all may be here given, to which it will be easy to refer when we come to describe the others.

In treating intermittent fevers, physicians have formed indications of cure according to their different theories. The followers of Boerhaave, Stahl, &c., who imagined that the disease proceeded from a lentor or other disorder in the blood and juices, always thought it necessary to correct and evacuate these peccant humours by emetics and purgatives before they attempted to stop the disease by the bark or any other medicine. The bark indeed seems to be held in very little estimation by them; since Vogel affirms, that this medicine, instead of deserving to have the preference of all other febrifuge medicines, ought rather to be ranked among the lowest of the whole; and for this reason he attributes the cures hereafter mentioned, by the external application of the bark, entirely to nature.

According to Dr Cullen, the indications of cure in intermittent fevers may be reduced to the following:

1. In the time of intermission, to prevent the return of the paroxysms.

2. In the time of paroxysms, to conduct these in such a manner as to obtain a final solution of the disease.

3. To take off certain circumstances which might prevent the fulfilling of the two first indications.

The first indication may be answered in two ways:

1. By increasing the action of the heart and arteries some time before the period of accession, and supporting that increased action till the period of accession be over, and thus to prevent the recurrence of that atony and spasm of the extreme vessels which give occasion to the recurrence of paroxysms.

2. By supporting the tone of the vessels, and thereby preventing atony and the consequent spasm, without increasing the action of the heart and arteries, the recurrence of paroxysms may be prevented.

The action of the heart and arteries may be increased, 1. By various stimulant remedies internally given or externally applied, and that without exciting sweat.

2. By the same remedies, or others, managed in such a manner as to excite sweating, and to support that sweating till the period of accession be for some time past.

3. By emetics, supporting for the same time the tone and action of the extreme vessels.

The tone of the extreme vessels may be supported without increasing the action of the heart and arteries, by various tonic medicines; as, 1. Astringents alone.

2. Bitters alone.

3. Astringents and bitters conjoined.

4. Astringents and aromatics conjoined.

5. Certain metallic tonics; and, 6. Opiates. A good deal Of all the tonic remedies mentioned, the most celebrated, and perhaps the most certainly effectual, is the Peruvian bark; but it must be observed, that good effects are only to be expected from this medicine when given in substance and in large quantity; and for its use the following rules or observations have been given.

1. The bark may with safety be employed at any period of intermittent fevers, providing that at the same time there be neither a phlogistic diathesis prevailing in the system, nor any considerable or fixed congestion present in the abdominal viscera.

2. The proper time for exhibiting the bark in intermittent fevers is during the time of intermission, and it is to be obtained from in the time of paroxysms.

3. In the case of genuine intermittents, while a due quantity of bark is employed, the exhibition of it ought to be brought as near to the time of accession as the condition of the patient's stomach will allow.

4. In all cases of intermittents, it is not sufficient that the recurrence of paroxysms be stopped for once by the use of the bark; a relapse is commonly to be expected, and should be prevented by the exhibition of the bark repeated at proper intervals.

Our second indication for conducting the paroxysms of intermittent fevers, so as to obtain a final solution of the disease, may be answered, 1. By exhibiting emetics during the time of the cold stage, or at the beginning of the hot stage. 2. By opiates given during the hot stage.

The circumstances which may especially prevent the fulfilling of these two indications, and therefore give occasion to the third, are, a phlogistic diathesis prevailing in the system, and congestions fixed in the abdominal viscera. The first must be removed by bloodletting and the antiphlogistic regimen; the second, by vomiting and purging.

It is not, however, very common for intermittents to be cured by medicines given during the time of the paroxysm. The bark is the medicine to which we are chiefly to trust. Our physicians are now generally agreed, that very little preparation of the body is requisite previous to the administration of the bark, in intermittent fevers. It is sufficient to cleanse the stomach and alimentary canal by an emetic or cathartic. Where the disease is attended with sicknesses or nausea, six or eight grains of ipecacuanha may be given; but where there are no symptoms of this kind, it is better to give a stomachic purge, as an ounce or two of tinctura sacra, or a few grains of pil. Rufi. These are to be administered in the intermission, immediately after the paroxysm hath ceased, so that their operation may be over before its return; and after their operation is completed, the bark may be given with perfect safety. If the paroxysm be moderate, we need not have recourse to the bark till another fit hath manifested the true nature of the disease; but if it proves severe, there is often an absolute necessity for administering the bark on the first intermission of the fever, and even with hardly any preparation of the patient.

The advantage of administering the bark as early as possible, was fully ascertained by Dr Lind in the years 1765, 66, and 67, during an uncommon prevalence of intermittents. When the disease was stopped by the bark immediately after the first or second fit, which was the case with 200 of the Doctor's patients as well as himself, neither a jaundice nor dropy ensued; whereas, when the bark could not be administered, on account of the imperfect remission of the fever, or when the patient had neglected to take it, either a dropy, jaundice, or constant headache, were the certain consequences; and the violence of the disease was in proportion to the number of the preceding fits, or to the continuance of the fever. By every paroxysm the dropsical swellings were visibly increased, and the colour of the skin rendered of a deeper yellow. When the fever continued a few days without remission, the belly and legs generally swelled; a violent headache, likewise, and vertigo, for the most part distressed the patient; so that some, even after the fever had left them, were not able to walk across their chamber for a fortnight or three weeks. When the returns of the fever were regular and even, but slight, four or five fits of a simple tertian were sometimes followed by the most dangerous symptoms; especially in the year 1765, when these fevers raged with the greatest violence. If, as frequently happened, a dropsical patient relapsed into the ague, there was an absolute necessity for putting an immediate stop to it by the bark; and in upwards of 70 such patients, Dr Lind observed the most beneficial effects to accrue from this practice. He never prescribed the bark until the patient was free from all symptoms of the fever; but in that case, without regard to a cough, or any other chronic indisposition, he ordered it to be given in large doses, but never prescribed it during the continuance of the paroxysm.

The bark hath been often observed to fail in removing intermittents, from not continuing the use of it for a sufficient length of time, from administering it in too small a dose, or from giving it in an improper form. It was a prevailing opinion, that an ounce, or an ounce and an half, of the bark, taken during one intermission, is sufficient to prevent the return of another paroxysm. But this is not always the case; for a severe fit will often attack a patient who hath taken such a quantity. When this happens, the patient ought to persevere during the following intermissions, with an increase of the dose, till five or six ounces at least have been taken. The medicine also ought not to be omitted as soon as one fit is stopped, but should be continued in a smaller dose for at least ten days or a fortnight. Even for several months after the disease is entirely removed, it would be advisable to take a little bark occasionally in damp weather, or during an easterly wind, to prevent a relapse. Where the intervals between the fits are short, as in quotidians and double tertians, from one to two drachms of it ought to be taken every two or three hours.

The form in which this medicine is administered is of some consequence. Mucilages and syrups have been recommended to conceal the taste of it; but, from various experiments, Dr Lind found nothing more effectual for this purpose than small-beer or milk, especially the latter. A drachm of bark mixed with two ounces of milk, and quickly drank, may

Practically be taken by a person of the most delicate taste, and by washing the mouth afterwards with milk there will not remain the least flavour of the bark; but if the mixture is not drank immediately, the bark will impart a bitter taste to the milk. This medicine is commonly given in electuaries or boluses; but Dr Lind observes, that in these forms it proves much less efficacious than when administered in juleps or draughts, with the plentiful addition of wine or spirits. He has remarked, that six drachms of powdered bark, given in a julep, consisting of one fourth or one third of brandy, is as effectual as an ounce of the powder in the form of an electuary, and proves less disagreeable to the stomach. For patients unaccustomed to wine or spirits, each draught should be warmed with spiritus fatis ammoniaci, or tinct. myrrh, by both of which the efficacy of the bark is increased. The Doctor is also fully convinced that wine or spirits improve the virtues of the bark much more than elixir vitrioli, tinct. rofar. or such other medicines as have been recommended by other physicians.

For those who nauseate the bark from a weakness of the stomach or other cause, he advises it to be given in clysters, in which form it is as efficacious as when taken by the mouth. For this purpose the extract is most proper with the addition of a sufficient quantity of the tinctura thebaica in order to its being longer retained. For children labouring under intermittent fevers, Dr Lind orders the spine of the back to be anointed, at the approach of the fit, with a liniment composed of equal parts of tinctura thebaica and liniment sapon. which has often prevented it. If this should not produce the desired effect, he informs us, that two or three tea-spoonfuls of syrup. e mecon. given in the hot fit, will generally mitigate the symptoms. But for the entire removal of the disease, after purging with magnesia alba, he prescribes a drachm of the extract. cort. Peruvian. with a few drops of tinct. thebaica, in a clyster, to be repeated every three hours for a child of about a year old. When the stomach is oppressed with phlegm, the magnesia frequently occasions vomiting, which should be promoted with warm water. The constant heaviness of the head occasioned by those fevers in such tender constitutions is best relieved by the application of a blister to the back.

The bark hath also proved effectual for the cure of intermittents in children, even when externally applied, by putting the powder of it into a quilted waistcoat. Of its efficacy in this way several instances are related by Dr Samuel Pye in the second volume of Medical Observations and Inquiries. In short, so effectual was the bark found in removing these fevers when properly applied, that of between four and five hundred afflicted with them in the year 1765, Dr Lind lost only two, neither of whom had taken this medicine.

In all these fevers, a vomit was administered whenever the patient complained of a sickness and reaching to vomit, or was seized with a spontaneous vomiting; and the bark was never given till this sickness was removed, or a purgative taken to clear more perfectly the whole alimentary canal. In those patients who were troubled with a cough, attended with a pain in the side affecting the breathing, when the pain was not relieved by warm fomentations, the balsamum anodynum Batwi, or by a blister, the Doctor generally ordered a few ounces of blood to be taken away, and endeavoured to stop the fever as soon as possible by the administration of the bark; having found that every return of the fever increased all such pains.—When the headache was very violent, and harassed the patient during the intermissions, the success of the bark was rendered more complete by the application of a blister to the back.—A giddiness of the head, which is the symptom most common remaining after even a slight intermittent fever, was generally relieved by the sal C. C. and the bark in wine. The former of these was administered in the following manner.

B. Aq. Alex. Simp. 3vii. Sal. C. C. 3fs. Spr. & Cort. Aurant. 3i. M. f. julep. Cap. cochlear. ij. subinde.

If from the continuance of the fever the patient was distressed with flatusence, a distention of the abdomen, and a swelling of the legs, a spoonful of tinctura saera, with the addition of 30 drops of the spirit lavend. compos. was ordered to be taken every night.—A continuance of the bark, a change of air, and the cold bath, were often found requisite to prevent a relapse.

Such is the method of cure recommended by this experienced author, who has also discovered the efficacy and success of opium in intermittent fevers. He informs us, that he hath preferred an opiate to upwards of 300 patients labouring under this disease; and he observed, that, if taken during the intermission, it had not the least effect either in preventing or mitigating the succeeding paroxysm: when given in the cold fit, it once or twice seemed to remove it; but when given half an hour after the commencement of the hot fit, it generally gave immediate relief.—When given in the hot fit, the effects of opium are as follow. 1. It shortens and abates the fit; and this with more certainty than an ounce of the bark is found to remove the disease. It generally gives a sensible relief to the head, takes off the burning heat of the fever, and occasions a profuse sweat. This sweat is attended with an agreeable softness of the skin, instead of the burning sensation which affects patients sweating in the hot fit, and is always much more copious than in those who have not taken opium. 2. It often produces a soft and refreshing sleep to a patient tortured in the agonies of the fever, from which he awakes bathed in sweat, and in a great measure free from all complaints.

The Doctor has always observed, that the effects of opium are more uniform and constant in intermittent fevers than in any other disease, and are then more quick and sensible than those of any other medicine. An opiate thus given soon after the commencement of the hot fit, by abating the violence and lessening the duration of the fever, preserves the constitution to entirely uninjured, that, since he used opium in agues, a drop of jaundice has seldom attacked any of his patients in those diseases. When opium did not immediately abate the symptoms of the fever, it never increased their violence. On the contrary, most pa- patients reaped some benefit from an opiate given in the hot fit, and many of them bore a larger dose at that time than they could do at any other. The Doctor assures us, that even a delirium in the hot fit is not increased by opium, though opium will not remove it. Hence he thinks it probable, that many symptoms attending these fevers are spasmodic; but more especially the head-ach. However, if the patient is delirious in the fit, the administration of the opiate ought to be delayed until he recovers his senses, when it will be found greatly to relieve the weakness and faintness which commonly succeed the delirium. Dr Lind is of opinion, that opium in this disease is the best preparative for the bark; as it not only produces a complete intermission, in which case alone that remedy can be safely administered; but occasions such a salutary and copious evacuation by sweat, as generally to render a much less quantity of bark requisite. He commonly prescribes the opiate in about two ounces of tinctura sacra, when the patient is coltive, who is to take the bark immediately after the fit. By these means the paroxysm is shortened, and the intestines are cleansed, previous to the administration of the bark; as the opiate doth not prevent, but only somewhat retard, the operation of the purgative. When a vomit is given immediately before the paroxysm, the administration of the opiate should be postponed till the hot fit is begun.

II. The Irregular or Spurious Tertian. Sp. I. var. 1. B. Tertiana notha five spuria, Sauv. sp. 2. Sennert. Cleghorn. Hoffman.

The characteristic marks of this fever are, that its paroxysms last longer than 12 hours, and consequently it inclines more to the quotidian or continued fever than the former. Its paroxysms have no stated hour of attacking. The cure, however, is precisely the same with that above described, observing the proper cautions already mentioned with regard to the use of the bark.

III. The Double Tertian. Sp. I. var. 2. C. Tertiana duplex, Sauv. sp. 13. Vog. G. 12. Sennert. Cleghorn.

Duplicana, Lin. 18.

The double tertian comes on every day; but differs from the quotidian in so far, that its paroxysms do not answer to each other singly, but alternately. The first day, for instance, the fit will come on in the forenoon, the second in the afternoon, the third in the forenoon, &c.

Of these fevers we shall give the following description from Cleghorn's treatise on the diseases of Minorca: "They are called double tertians when there are two fits and two intervals within the time of each period. But commonly there is some difference between the two fits, either in respect of the hour they come at, the time of their duration, or the nature and violence of their concomitant symptoms. Some double tertians begin in this manner.—On the evening of Monday, for example, a slight fit comes on, and goes off early next morning; but on Tuesday, towards the middle of the day, a more severe paroxysm begins, and continues till night. Then there is an interval to Wednesday evening, when a slight fit commences a new period of the fever, which proceeds in the same manner as the first; so that (according to the way physicians calculate the days of diseases, by beginning to reckon from the first hour of their invasion,) both paroxysms happen on the odd days, while the greatest part of the even days is calm and undisturbed. But in most double tertians the patient has a fit every day of the disease; the fever one commonly appearing at noon upon the odd days, the slight one towards evening on the even days; though sometimes the worst of the two fits happen on the even days.

"There is a tertian fever sometimes to be met with, during each period of which there are three different fits, and as many intervals. For example, towards Monday noon the patient is seized with a paroxysm, which declines about five or six o'clock the same evening; a few hours after, another fit begins, and continues until morning; from which time there is an interval to Tuesday evening, when a third fit comes on, and lasts most part of the night. On Wednesday there are again two paroxysms, as on Monday and on Thursday, like that of Tuesday; and thus the fever goes on with a double fit on each of the odd days, and a single fit on the even days.

"In double tertians, that interval is the most considerable which follows the fever fit; for the slight fit oftener ends in a remission than intermission, and frequently lingers till the other approaches: Hence it is, that the night preceding the vehement fit is much more restless than that which comes after it, as has been observed by Hippocrates. In double tertians, the vehement fit often comes on a little earlier in each period, while the slight fit returns at the same hour, or perhaps later and later every other day: so that the motions of one have no influence on those of the other; from whence it appears, that each of these fits hath its own proper independent causes."

IV. Duplicated Tertian. Sp. I. var. 2. D. Tertiana duplicata, Sauv. sp. 14. Jones, River.

This hath two fits on the same day, with an intermediate day on which there are none. This also doth not differ in any remarkable particular from those already described.

V. The Triple Tertian. Sp. I. var. 2. E. Tertiana tripes, Sauv. sp. 15. Cleghorn. Semiteriana, Hoffman.

Semiteriana primi ordinis, Galen. Spig.

This differs from the former in having a single and double fit alternately: thus, for instance, if there are two fits the first day, there is only one the second, two the third, one the fourth, &c. Its cure the same as before.

VI. The Semi-Tertian. Sp. I. var. 2. F. Hemitritzes, Celt. Semiteriana, Cleghorn.

Semiteriana secundi ordinis, Galen. Spig.

Amphimerina hemitrizes, Sauv. sp. 6. Amphimerina pseudo hemitrizes, Sauv. sp. 9.

The semiterian is described by Dr Cullen as having only an evident remission between its paroxysms; more remarkable between the odd and even day, but less between the even and odd one. For this reason, he adds, that possibly some semiterians ought rather to be classed among the remittents; and owns that it is diffi- Practice difficult to settle the boundaries between them. But Cleghorn, whom he quotes, describes it in the following manner. "A fit begins on Monday noon, for example, and goes off the same night. On Tuesday afternoon a second fit comes on, and gradually increases till Wednesday night, when it terminates. On Thursday morning there is such another interval as happened on Tuesday morning; but on Thursday afternoon another long fit like the preceding commences; and returning regularly every other day, leaves only a short interval of ten or twelve hours during the eight-and-forty."

Concerning the cure of these fevers Dr Cullen observes, that though no entire apyrexia occurs, the bark may be given during the remissions; and it should be given even though the remissions be inconsiderable; if, from the known nature of the epidemic, intermissions or considerable remissions are not to be expected, and that great danger is apprehended from repeated exacerbations.

VII. The Sleepy Tertian. Sp. I. var. 3. G. Tertiana catarrhica, Sauv. sp. 10. Werthoff. Tertiana hemiplegica, Sauv. sp. 20. Werthoff. Quotidiana soporosa, Sauv. sp. 8. Car. Pif. Febris caput impetens, Sydenham, ep. ad R. Brady.

This, according to Vogel, is a most dangerous species, and very commonly fatal; for which reason he ranks it among those intermittents which he calls malignant. Sometimes he tells us the alarming symptom of a sleepiness comes on, not at the beginning of the disease, but will unexpectedly occur during the third, fourth, fifth, or sixth paroxysm. It commonly begins with the cold fit, and continues during the whole time of the paroxysm, and, becoming stronger at every succeeding one, at last terminates in a mortal apoplexy. Sometimes fevers of this kind rage epidemically. Vogel relates, that he saw a simple tertian changed into one of these dangerous fevers. The patient was a woman of a delicate constitution, and the symptom appeared in consequence of her being put in a violent passion; however, it occurred but once, and she recovered. Hoffman mentions a case in a double tertian occurring seven times without proving mortal; tho' Vogel says, that the powers of nature are very seldom sufficient to conquer the disease.

In 1678, Dr Sydenham tells us that intermittents raged epidemically at London, where none had appeared before from 1664. Of them "it is to be noted (says he), that though quartans were most frequent formerly, yet now tertians or quotidians were most common, unless the latter be entitled double tertians; and likewise, that though these tertians sometimes began with chills and shivering, which were succeeded first by heat, and soon after by sweat, and ended at length in a perfect intermission, returning again after a fixed time, yet they did not keep this order after the third or fourth fit, especially if the patient was confined to his bed and used hot cardines, which increase the disease. But afterwards this fever became so unusually violent, that only a remission happened in the place of an intermission; and approaching every day nearer the species of continued fevers, it seized the head, and proved fatal to abundance of persons."

From this description of Sydenham's we may have an idea of the nature of the disease. As to its cure, our author strongly recommends the bark; telling us, that, even in the most continued kind of intermittent, "the nearer the intermittent approaches to a continued fever, either spontaneously, or from using too hot a regimen, so much the more necessary is it to exhibit a larger quantity of the bark; and that he took advantage of a remission, though ever so small.

VIII. The Spasmodic or Convulsive Tertian. Sp. I. var. 3. H. Tertiana asthmatica, Sauv. sp. 6. Bonnet. Tertiana hysterica, Sauv. sp. 8. Wedel. A. N. C. Dec. I. A. II. obf. 193. Hyferia febricola, Sauv. G. 135. sp. 8. A. N. C. Dec. I. Ann. II. Tertiana epileptica, Sauv. sp. 16. Calder. Lautter. Quotidian epilepsy, Sauv. Sp. 3. Edinb. Essays, vol. 5. art. 49. Eclampsia febricola, Sauv. G. 133. sp. 17. Epilepsia febricola, Sauv. G. 134. sp. 9. Tertiana tetanoides Medici Beobacht. I. Band. Tetanus febricola, Sauv. G. 122. sp. 10. Stork. Ann. Med. II.

Tertians of this kind occur with very different symptoms from those of the true ones, and sometimes even with those which are very extraordinary. In some they are attended with symptoms of asthma, in others with those of hysterics, in others with convulsions.—Where the symptoms of asthma occur, the disease must be treated with diuretics and antispasmodics joined with the bark.—In the hysteric asthma the fit comes on with cold, yawning, cardialgia, terror and dejection of mind. The disease is to be removed by mild aperients and antihysterics joined with the bark.

Of the convulsive tertian we have a most remarkable instance in the Edinburgh Medical Essays, Vol. V. The patient was a farmer's son about 26 years of age, of a strong plethoric habit of body. He had laboured under an ague half-a-year, and had taken a great deal of bark. While he was telling his case to the surgeon (Mr Baine of Pembroke) he was suddenly taken with a violent stamping of his feet; and the convulsions gradually ascended from the soles of the feet, to his legs, thighs, belly, back, and shoulders. His head was then most violently convulsed, with a total deprivation of speech; but he had a most dismal vociferation, that might have been heard at a considerable distance, his abdomen and thorax working and heaving violently and unusually in the mean time. This fit having lasted half an hour, a profuse sweat broke out over all his body, which relieved him; and he then became capable of answering such questions as were put. These extraordinary fits, he said, had been occasioned by a fright, and his neighbours had concluded that he was bewitched. They returned sometimes twice a-day, and always at the times the ague used to return. During the paroxysm his pulse was very high and quick, his face much inflamed, and his eyes ready to start out of his head. After the fit was over, he complained of a most torturing pain of the bowels. His tongue was generally moist, and he had a suppression of urine.—This formidable disease, however, was totally subdued by the use of IX. The Eruptive Tertian. Sp. I. var. 3. I. Tertiana petechialis, Sauv. sp. 3. Denat. Lautter. Tertiana scorbutica, Wedel. A. N. C. Dec. I. A. II. obf. 193. Tertiana urticata, Sauv. sp. 22. Planckon. Journ. de Med. 1765. Cleghorn. Tertiana miliares, Sauv. sp. 21. Walther. This species of tertian is accompanied with red or livid blotches on the skin, or an eruption like that occasioned by the stinging of nettles. In the latter case Dr Cleghorn says the disease is very dangerous; and as the former indicates an incipient dissolution and putrefaction of the blood, it must also be reckoned of very dangerous tendency.

X. The Inflammatory Tertian. Sp. I. var. 3. K. Tertiana pleuritica, Sauv. sp. 4. Vallet. Lautt. Pleuritis periodica, Sauv. G. 103. sp. 14. Tertiana arthritica, Sauv. sp. 5. Morton, Lautt. Sauvages informs us, that he hath seen a true and genuine pleurisy having all the pathognomonic signs of the disease, but assuming the form of an intermittent; that is, the patient is one day affected with the pleurisy, and the next seemingly in perfect health. He also tells us, that in the month of May 1760 a tertian raged epidemically, which after the third fit imitated a pleurisy, the pain of the side and difficulty of breathing coming regularly on, and the fever from an intermittent becoming remittent; the blood had also the same appearance with that of pleuritic persons, and the distemper yielded to bleeding and gentle cathartics.—Morton also informs us, that he has observed similar disorders a hundred times over, which were always certainly and safely cured by the Peruvian bark.

XI. The Tertian complicated with other Disorders. Sp. I. var. 4. Tertiana scorbutica, Sauv. sp. 9. Ettmuller. Titmus. Tertiana syphilitica, Sauv. sp. 17. Deidier. Tertiana verminosa, Sauv. sp. 18. Stifter. in act. Helmitad. Lancif. de noxibus palud. Pringle. Ramazzini. Van den Bosch. The scrofulous tertian, according to Sauvages, is exceedingly anomalous, its periods being sometimes much anticipated, and sometimes much postponed. It is exceedingly obstinate, and will return even seven times, if the body is not cleared of its scrofulous taint. The patient is affected with lancinating pains of a wandering nature. The urine lets fall a dusky red sediment, or a thick branny matter is copiously scattered up and down in it, seemingly tinged with blood. The usual symptoms of scurvy, viz. livid spots, and rotten seid gums, also frequently occur. For this the Peruvian bark is very useful, both as a febrifuge and antiscorbutic.

The tertian accompanied with worms is taken notice of by Sir John Pringle in his treatise on the diseases of the army. The worms, he tells us, were of the round kind; and though we are by no means to reckon them the cause of the fever, they never failed to make it worse, occasioning obstinate gripings or sickness at stomach. In these cases lichens were frequent; but, being flatulent, were not often relieved by bleeding. The worms were discharged by vomiting as well as by stool. For discharging these worms, he commonly gave half a drachm of rhubarb with twelve grains of calomel; without observing any inconvenience from such a large dose of mercury. Anthelmintics, which act slowly, had little chance of doing good; for, though worms will sometimes lie long in the bowels, without giving much uneasiness to a person otherwise well, yet in a fever, especially one of a putrid kind, (to which his intermittents always seemed to incline), the worms being annoyed by the increase of heat, and the corruption of the humours in the prime via, begin to move about, and struggle to get out. Lancifus, who makes this remark, adds, that upon opening the bodies of some who had died at Rome of fevers of this kind, wounds were found in the intestines, made by the biting of the worms; nay, that some of them had even pierced through the coats of the guts, and lay in the cavity of the abdomen. Pringle never had any instance of this; but knew many cases in which the worms escaped by the patient's mouth, though there had been no previous retching to bring them up. One soldier was thrown into violent convulsions, but was cured by the above-mentioned powder.

XII. The Tertian arising from various Causes. Sp. I. var. 5. Tertiana accidentalis, Sauv. sp. 12. Sydenham. Tertiana a scabie, Sauv. sp. 12. Junker, tab. 80. Hoffman, II. p. 12. The existence of fevers of this kind, as we have already observed, is denied by Dr Cullen; the accidental fever of Sauvages was said to arise from any slight error in the non-naturals, and consequently was very easily cured. That which arose from the repulsion of the itch, was cured as soon as the eruption returned.

XIII. The Tertian with only an intermission between the fits. Sp. II. Tritrophya, Sauv. Gen. 85. Sag. p. 695. Trizetus, Lin. 21. Hemitritza, Lin. 23. Tertiana remittentes et continuae Auctorum. Tertiana subintrantes, proportionate, subcontinuae, Torti. Tertiana subcontinua, Sauv. sp. 19. Quotidianae deceptiva, Sauv. sp. 2. Amphimerina semiquintana, Sauv. sp. 24. Tritrophya deceptiva, Sauv. sp. 10. Causa Hippocratis. Tritrophya causus, Sauv. sp. 2. Febris ardens Boerhaaviae, aph. 738? Tertiana perniciosa, quae simulata tertiani circuitus effigie lethalis, et mille accidentibus periculofoissimis implicata, exsilit. Lud. Mercatus. Tertiana pestilens, P. Sal. Diversus. Tertiana maligna pestilens, Riverii. Morbus Hungaricus, Lang. Lamb. Sennert. Jordan. Languor Pannonicus, Cober. Amphimerina Hungarica, Sauv. sp. 10. Hemitritzae pestilens, Schenck. ex Corn. Gamma. Febres pestilentiae Ægyptiorum, Alpin. Febres tertiana epidemia, Bartholin. Febris epidemicæ, autumni 1657 et 1658, Willis. Febris synœches epidemicæ, ab anno 1658 ad 1664, et postea ab anno 1673 ad 1691, Morton. Febris autumnales incipientes, Sydenham. Afflictus epidemicus Leidenis, Fr. Sylvius. Morbus epidemicus Leidenis, 1669, Faneis. Tertiana apopleptica, Morton. Exerc. I. cap. ix. Practici hili. 25. Tertiana soporosa, Werleff. de febr. p. 6. Febris epidemicæ Urbetana, Lancisi de noxis pal. effluv. I. II. c. 3.

The remittent fevers are much more dangerous than the true intermittents, as being generally attended with much greater debility of the nervous system and tendency to putrefaction in the fluids than the latter. Sauvages divides his tritrophya, a remittent tertian, into the following species:

1. Tritrophya syncopalis, or that attended with fainting. It begins like a tertian, with cold succeeded by heat and profuse sweating; but attended with much more dangerous symptoms, such as cardialgia, enormous vomiting, great weakness, small contracted pulse, coldness of the extremities, and, unless timely assistance be given, kills during the second or third paroxysm.

2. The causus, or burning fever of Hippocrates, returns every third day without any new sensation of cold; and is attended with great thirst, heat, but without diarrhea or sweat, and continues only for one week or two at the utmost. It attacks chiefly young people of a robust and bilious habit of body, who have been accustomed to much exercise, and exposed to the sun during the heats of summer, and have also used a phlogistic regimen. The tongue is dry, sometimes black; the urine of a red or flame colour; together with pain of the head, anxiety, and sometimes other symptoms still more dangerous.

3. Tritrophya Wratilavensis, was a pestilential disease occasioned by famine, during which the people fed on putrid aliments: the air was infected by the vast numbers of bodies of those slain in battle, and the inhabitants were also dejected by reason of being deprived of their harvest, and other calamities; to all which was added the continuance of a calm in the atmosphere for a long time. It began with an acute fever, leipyria or coldness of the external parts and sensation of burning heat inwardly; general weakness; pain of the head and precordia; ferous or bilious diarrhoea; a delirium, in some furious, and accompanied with a dread of being exposed to the air; on the second day the thirst was violent, attended with a bilious vomiting as well as diarrhoea, tough viscid spitting, fainting, burning heat in the bowels, the tongue dry and seeming as if burnt with a hot iron, a suppression of the voice, anxiety, stupor, after which quickly followed convulsions and death. In some fevers a leipyria came on with an exceeding great cold of the extremities, presently followed by an intolerable heat of the viscera, with symptomatic sweats, violent diarrhoea, followed by a very itchy miliary eruption. On the fourth day came on copious sweats, spasms of the lower jaw, nausea, involuntary passing of urine, slight delirium, a flux of ichorous matter from the nostrils, an exceeding tough spitting, an epilepsy, and death. Professor Hahn himself, who gives the history of this disease, was attacked by it, and suffered in the following manner. On the first day was a violent feverish paroxysm without rigor, a sharp pain in the occiput, and immediately an inflammatory pain over the whole head; the feet were extremely cold, and the extremities rigid with spasms. The pain continued to increase daily to such a degree, that the contact of the air itself became at last intolerable; a de- Part II.

Practice

dejection of mind and incredible weakness followed; he passed restless nights with continual sweating, heavy and pained eyes, and an universal sensation of rheumatism over the whole body. On the third day the pains were assuaged, but he had a very bad night. On the fourth day all the symptoms were worse, the feet quite chilled, the hands very red and agitated with convulsive motions; he was terrified with apprehensions of death, and had a vomiting every now and then; this day sponges dipped in cold water were applied over the whole body, and he used cold water for his drink. On the eighth day the pulse was convulsive; and the pains were so violent, that they made him cry out almost continually. On the ninth day he was delirious, and threw up some grumous blood. On the tenth his pulse was more quiet, and he had a sweat; a decoction of the bark was given: his voice was broken, his speech interrupted, and his teeth chattered upon one another. On the twelfth his jaw was convulsed, he had a rufus faradonicus, and deafness; after which, the paroxysms returned less frequently, and only towards night. On the fourteenth he had a chilling cold over the whole body, a cold sweat; frequent lotions were applied, and all the symptoms became milder. On the eighteenth he had a quick delirium, but fainted as soon as taken out of bed; a sensation of hunger, followed by copious sweats; profound sleep; an aversion from noise; everything appeared new and extraordinary. On the thirty-sixth a cholera; on the forty-eighth a scaling off of the skin, and falling off of the nails.

4. Tritrophya typhodes. The principal symptom of this fever was a continual sweat with which the patients were almost always wet; with paroxysms returning every third day. Sauvages tells us, that he had twice an opportunity of observing this fever; one was in the teacher of an academy, about forty years of age, and of a melancholic temperment. He sweated every other night so plentifully, that he was obliged to change his linen nine times; and even on the intermediate days was never perfectly free of fever, and had his skin moistened with sweat. The other was of a woman who went about in man's clothes, and was discovered only after her death. The disease began with a slight sensation of cold, after which she sweated for eight hours. It was attended with the highest debility, anxiety, and at the same time an infatuated hunger.

5. Tritrophya cloides, was an inflammatory epidemic, but not contagious, terminating about the fourteenth or fifteenth day. The disease came on in the night-time, with disturbed rest, universal weakness, watchings, great heat and sweat, redness of the face and almost of the whole body, sparkling eyes, the tongue dry and white; a hard, tense, and turgid pulse: about the third day a kind of frenzy frequently came on with the feverish paroxysm, the forerunner of an universal military eruption; or, what was worse, with purple spots so close together, that they looked like an erysipelas of the whole body. Sometimes blisters of the size of small pearls, filled with acrid serum, appeared on the neck, armpits, and trunk of the body, which were of all others the most dangerous. There was a variety of the disease, which our author calls the hamparalis, and in which the pulse was soft and feeble, with greater weakness over the whole body, and the disposition to sleep more frequent than in the other; the eyes languid; the tongue very white, but not dry; and worms were discharged.

6. Tritrophya afebrilis. This species, our author informs us, arose from a fouling of the prime viz., and the effluvia of waters in which hemp had been steeped. It began with rigor, followed by great heats, restlessness, tossing of the limbs, terrible faintings, immediate thirst, dryness of tongue, delirium, and at length excessive watchings; these last, however, were less dangerous than vertigoes or comatose dispositions, which brought on convulsions or apoplexies.

7. Tritrophya carctica. This had exacerbations every other evening; and its distinguishing symptom was an excessive inclination to sleep, preceded by a severe headache, and followed by delirium, and sometimes convulsions; the tongue was black, and the patient insensible of thirst after the delirium came on. In those cases where the disease proved fatal, a fulsome tendinous and other grievous symptoms came on.

8. Tritrophya leptria is only a variety of the tritrophya caudus, already described.

9. Tritrophya decepta. This species at first assumes the appearance of a continued fever; but afterwards degenerates into a remittent, or even an intermittent. It is described by Sydenham, but attended with no remarkable symptoms.

10. The last of Sauvages's species of Tritrophya belonging to the remitting tertian is the Americana; and even this seems doubtful to Dr Cullen. This, according to Sauvages, is the ardent fever with which the Europeans are usually seized on their first coming to America, and generally carries off one half of them. Of this there are two varieties, the very acute and the acute. The very acute ends before the seventh day. It comes on a few days after the person's arrival, with loss of appetite, with dyspnoea and sighing from weakness, head-ach, lassitude, pain of the loins: a pyrexia succeeds, with great thirst, sweat, and heat; the sickness increases, nausea comes on, with vomiting of purracious bile; the tongue rough, the extremities often cold; watching, furious delirium; and the patient frequently dies on the third day. Copious sweats, and a plentiful hemorrhage from the nose on the fifth day, but not sooner, are serviceable; but a bilious diarrhoea is the best crisis of all.

The acute kind terminates most frequently on the ninth, but very rarely goes beyond the fifteenth. Death frequently comes on between the fourth and seventh days. It begins with head-ach, pain in the loins, and sometimes shivering; great lassitude, dyspnoea, thirst; burning fever, increasing every third day; inflation of the abdomen, pain at the pit of the stomach, nausea, and bilious vomiting. Such is the state of the disease within twenty-four hours. The eyes are red, and full of tears; the urine pellucid; there is a low delirium, and continual anxiety; the tongue is dry and red, and sometimes, though rarely, black, which is a still worse sign; the pulse, formerly strong and full, sinks about the fourth day, and becomes tense and spasmodic; if a crisis then comes on, the patient dies the fifth or sixth day; but if the pulse keeps up, and no crisis comes on, a crisis is to be expected by sweat, a copious hemorrhage from the nose, or, which is still more safe, by a bilious diarrhoea, which is never salutary if it comes on before the fifth day.

To the remitting tertian also belong the following species. 1. *Tertiana subcontinua.* This begins like a genuine tertian, and at first hath distinct paroxysms; but these grow gradually more and more obscure, the disease acquiring daily more of the appearance of continued fever, by which it is to be distinguished from the other varieties of this species. It is not unfrequently joined with those symptoms which attend the pernicious fever already mentioned; as cardialgia, cholera, lyncope, &c., but in a much less degree. The disease commonly begins with little or no sense of cold, but rather a sensation of heat: when the tertian is doubled, it has first a slighter and then a more severe fit; and thus goes on with an exacerbation on the even days; and though it should change from a double into a single tertian, we are still to suspect it, if a weak fit is the forerunner of a very strong one. This change of the tertian into a continued fever is also to be prognosticated if a heat remarkable to the touch is perceived on the day of intermission, together with some disturbance of the pulse, thirst, and distress of the tongue; all of which show an universal tendency to inflammation; the same is foretold by the urine being in small quantity, and very red, or of a saffron colour; also an ulcerous or aphthous inflammation of the throat, with difficulty of swallowing, or any very feverish symptom coming on in the beginning of the disease, excepting only a delirium, which is easily removed.

2. *Quotidiana deceptiva.* This is a disorder of an inflammatory kind, with a strong tendency to putrefaction, and sometimes assumes the form of a quotidian. In it the patient frequently complains of cold when he really is hot and the remission is very indistinct, and the disease is known by the great languor of the patient and the foulness of his tongue.

3. *Amphimerina cardiaca* is an acute malignant fever, with daily exacerbations, attended with fainting and vomiting of green bile. Afterwards, the weakness increasing, the patient's extremities grow cold, and a profuse cold sweat comes on, which is frequently succeeded by death on the fourth day. Another species resembling this he calls the *synephalis*; but the cardiaca differs from it in being attended with cardialgia.

4. *Amphimerina paludosa.* This is the fever described by the British physicians under many different names, and appearing under various forms, according to the different constitutions of the patients. Its appearance in the East Indies, according to Dr Lind of Edinburgh, generally comes on suddenly, and begins with a sense of debility and a very great lowness of spirits. These symptoms are attended with a greater or less degree of chilliness, a dizziness, a nausea, very acute pains in the head and loins, and a trembling of the hands; the countenance is pale, the skin commonly very dry and corrugated, the eyes dull and heavy, the pulse quick and small, the breath generally difficult, and interrupted with hiccups.

As the paroxysm increases the chilliness now and then gives way to irregular heats, which soon become violent and permanent; the nausea likewise increases; and in some there comes on a vomiting, in which they throw up a great deal of bile. Sometimes bile is likewise voided by stool. The skin grows red; the eyes small, and sometimes not a little inflamed. The pulse becomes fuller and the breath more difficult, attended with great restlessness and a troublesome thirst; notwithstanding which (so great is the nausea) the patient cannot endure any kind of liquids. The tongue becomes foul, and the pain of the head and loins more violent; a delirium then follows; a slight moisture appears on the face, and from thence spreads to the other parts; whilst the violence of the other symptoms abates, and shows the beginning of a remission, which is completed by plentiful sweats.

On the fever's remitting, the pulse returns almost to its natural state; the pains of the head and loins still continue, though somewhat less violent, as likewise the nausea and want of appetite. When the disease gains strength, the remission is scarcely obvious, and is immediately followed by another paroxysm; which begins, not indeed with so great a shivering, but is attended with a greater pain of the head, the greatest anxiety, a heartburn, nausea, vomiting, and bilious stools. The matter most commonly evacuated by vomiting and stool was whitish like chalk and water, or curdled milk which is vomited by sucking children, when the curd is much broke down. A heat, immoderate thirst, and delirium, now come on. The tongue becomes more foul; the teeth and inside of the lips are covered with a black crust; the breath grows hot and fetid; another remission ensues, attended with a sweat; but this remission is both shorter and less obvious than the first.

This second remission is succeeded by a paroxysm, in which the symptoms are far more violent than in the former; that which the patient discharges by vomiting and purging is more fetid; the mouth, teeth, and inside of the lips, are not only covered with a black crust, but the tongue becomes so dry and stiff, that the patient's voice can scarce be heard. Violent delirium, with restlessness and anxiety, come on chiefly during the paroxysm; nor do these symptoms abate till the fever remits, and the patient sweats.

When the fever becomes so violent, during the third fit, as to end in death, which is generally the case, some of the sick have a coma; in others the delirium becomes more violent. The discharges now become more fetid, and have a cadaverous smell; the stools are involuntary; the pulse is too quick, small, and irregular, that it is scarce to be counted, or even felt; a cold sweat is diffused over the whole body, especially the head and neck; the face becomes Hippocratic and convulsed; the patient picks the bed-clothes; a subcutaneous tendinous comes on; the sick lie constantly on their backs, and insensibly slide down to the foot of the bed; their extremities grow cold; they are then seized with convulsions, with which the scene closes.

In this fever, the urine, which at the beginning is pale, becomes of a deeper colour by degrees, but without depositing any sediment. There seldom or never appear any petechiae, and the prickly heat which was before on the skin vanishes on the first appearance of the fever. But though these were the general symptoms of this disorder, they varied in different subjects, and at different seasons of the same year. The pulse, for example, in some, was quick in the beginning of the disorder; in others, it varied The skin was generally dry in the beginning of the fit; but in some it was moist, and covered with sweat from the very first beginning of the disease. In the month of September, when the disorder raged most, the remissions were very imperfect and obscure; but, on the return of winter and the healthy season, they became more regular, and the disease assumed the appearance of an intermitting fever, to such a degree as at length not to be distinguished from it. In some the remissions could scarcely be perceived, and the fever continued for two weeks without any material change for the better or the worse. At this time numbers were seized with it. When the disorder continued for any time without a change, it generally ended in death; while the weather grew better, it sometimes, in the space of a few days, from a common fever became an intermittent one, and the patient recovered, unless his liver, which was sometimes the case, happened to be affected. The cure of an inflammation of the liver proved uncertain, and tedious; as it was generally followed by a colligative diarrhoea, which greatly endangered the patient's life.—Every succeeding paroxysm was observed to be more dangerous than the preceding; the third generally proved fatal; some died during the first. When this happened, the fever, in the language of the country, was called a pusa, that is, a strong fever.

This disease, according to Dr Lind of Hafler hospital, is the autumnal fever of all hot countries, the epidemic disease between the tropics, and the disease most fatal to Europeans in all hot and unhealthy climates. All authors agree that intermittents in general, but particularly this dangerous kind of them, are produced by heat and moisture. Dr Cullen, however, is of opinion, that in Scotland the heat is never sufficiently powerful for this purpose, but that intermittents are first imported from some other country, after which they spread. Dr Lind of Edinburgh remarks that the European seamen are very subject to the fever above-mentioned when they happen to arrive at Bengal in autumn. They are predisposed to it from the nature of their food, their confinement on board, the very great heats to which they are exposed during the voyage, and their lying for hours together exposed to the night colds.

Most of the meat used by the crews of these ships is salted, and often in a putrid state, without any fresh vegetables, they having only biscuits, and some other farinaceous matters. The quantity of the vinous or spirituous liquors allowed them is by far too small to subdue the putrefactive disposition of their animal-food. Their fluids consequently become, from day to day, more and more putrefactive, and of course the more apt to breed and contract this disorder. This disposition is likewise induced by their being flowed very close together, and that for a considerable length of time, and in a foul air, especially when the weather happens to be too stormy to permit the hatches and port-holes to be kept open.

Though the heats they endure in the voyage to India are less considerable than those of the country itself, yet they are too much for an European constitution to bear. The general heat at sea within the tropics is about 84° of Fahrenheit's thermometer, which is sufficient to relax them, and promote a corruption of their humours, especially when it coincides with the above causes. It likewise creates a languor and indolence, which alone are sufficient to increase that putrefaction. These causes are apt to be considerably aggravated by the men being often exposed, when on duty, for hours together, to rain, damp, and cold air; a circumstance which frequently happens them when working their ships up the river Ganges in the night-time. Hence the perspiration is checked, and the excrementitious fluid which used to be discharged by the skin being retained in the body, contributes vastly towards the predisposition to this disease.

But the most powerful of all the remote causes is justly thought to be the effluvia of marshes replete with putrid animal-substances. We have not, however, been able to determine from what kind of putrid animal-substances these effluvia derive their virus. For that every kind of putrefaction has not such an effect appears from this, that neither practical anatomists, nor those who by their trades are exposed to the putrid effluvia of animals, for instance such tanners and butchers as keep their shops and stalls very dirty, are more subject than others to putrid diseases. Nor are the ship-crews and their servants, whose business it is to deliver out their provisions to the ships' crews, and who spend the most of their time amongst the putrid and rancid effluvia of the places in which these provisions are kept, more subject to putrid fevers than their ship-mates. But whatever be in this, we are well assured that some particular putrid fermentations produce noxious vapours, which, united with those of marshes, render them more pernicious. Hence evidently proceeds the extreme unhealthfulness of a place called Culpi, on the eastern bank of the Ganges. The shores hereabouts are full of mud, and the banks covered with trees. Opposite to the place where the ships lie there is a creek, and about a mile from its entrance stands the town of Culpi: the ships lie about a mile from the shore. None of the sailors on board the ships stationed at this place enjoyed their health. The burying-ground also contributed not a little to spread the infection. The ground being marshy, the putrid water flowed from the old graves into the new ones, which infected the grave-diggers and those that attended the funerals; and from this cause many were suddenly seized while they were performing the last duty to their companions. This place has ever been remarkable for the unhealthfulness of its air. It was once customary to send some of the Company's servants here to receive the cargoes of the ships, and send them to Calcutta; but so many of them died on this duty, that the Company was at length obliged to dispense with it.

Hence it plainly appears, how apt putrid animal and vegetable substances are to render the effluvia of fenny places more pernicious than they would otherwise be. The reason why great inundations of the Nile and Ganges are followed by a healthy season is, that by this means the putrid animal and vegetable substances dispersed over the contiguous countries are carried off into the sea.—The noxious vapours arising from fens spread but a little way. Dr Lind has often known ships' crews at a very little distance from the shore quite free from this disorder. But although these marsh miasmata first bring on the disease, yet contamina- Thus the Drake East Indiaman continued free from the disorder for two weeks together, when she had no communication with the other ships; whereas, as soon as the disorder was brought on board, many were seized with it within a few days in such a manner as to leave no room to entertain the least doubt concerning its pestilential nature.

Dr Lind of Haslar-hospital has given a very curious and learned account of the appearance of this fever throughout the various parts of the globe. It was very common in England in the years 1765 and 1766, one obvious cause of which was the prevalence of the eastern wind. This wind in England is often said to bring with it a fog from the sea; but the truth of the matter is, that in many places of this island the east wind frequently raises a copious vapour from water, mud, and all marshy or damp places. To this exhausting quality of the eastern wind Dr Lind hath often been an eye-witness. When the wind changes to the east, the mud sometimes sends up a vapour as thick as smoke; and the doctor hath observed two fish-ponds in his neighbourhood, one of fresh and the other of salt water, which on the approach of an easterly wind sometimes also emit a dense vapour as from a pot of boiling water. In order to view this phenomenon distinctly, the person should stand at about 100 yards distance from the mud or ponds. If the sun shines when the wind changes to the east, he will observe a constant steam of vapours arising out of the ponds, from about five to ten yards in height, while the air about him remains serene. As the vapour or fog arising from other bodies glides along the surface of the earth, and is brought by the easterly wind to the ponds, he will still be able, for some time, to distinguish the vapours ascending perpendicularly out of the ponds from those which are carried in an horizontal direction by the wind; especially if the sun continues to shine, though faintly.

This evaporating quality of the east-wind seems to manifest itself also by its effects both on the thermometer and the human body; for a thermometer hung over a damp piece of ground during the fogs or exhalations arising from it, will often indicate a degree of cold below the freezing point. The chills of the body, so sensibly perceived when in this situation, seems to proceed from the same cause, and to produce nearly the same sensations, which the damp arising from the wet floor in a chamber communicates to those who happen to be in it.

Winds are not constant in their effects, as we have sometimes warm weather with a north-wind, and sometimes very little heat with one blowing from the south; so the fogs attending an east-wind are not constant, neither is the evaporation above-mentioned at all times to be perceived. It is possible, however, that in all this there may be a deception; and that, instead of supposing the quantity of vapours exhaled to be increased by an easterly wind, the coldness of that wind may be only supposed to condense and render visible the vapours in the air at that time. But even this supposition is liable to great objections, as our coldest north-winds seldom or never produce such an effect, but on the contrary are attended with dry and fierce weather.

Be this as it will, however, an east-wind is usually accompanied with a cold, damp, and unwholesome vapour, which is observed to affect the health both of animals and vegetables, and in many places to produce obstinate intermittent fevers, as also to occasion frequent relapses. In particular spots of the low damp island of Portsea, the ague frequently prevails during the autumnal season, and in some years is much more frequent and violent than in others. It is also observable, that this disease always attacks strangers, or those who have formerly lived on a drier soil, and in a more elevated situation, with greater severity than those who are natives of the island.

The year 1765 was remarkable, not only for the long continuance of the easterly winds, but for an excessive degree of heat, which produced a more violent and general rage of those diseases than had been known for many years before. In the month of August, the quicksilver in Fahrenheit's thermometer often rose to 82° in the middle of the day. This considerable addition of heat, together with the want of refreshing rains, greatly spread the fever, increased its violence, and even changed its form in many places. At Portsmouth, and throughout almost the whole island of Portsea, an alarming continual or remitting fever raged, which extended itself as far as Chichester. At the same time, the town of Gosport, though distant only one mile from Portsmouth, enjoyed an almost total exemption from sickness of every kind; whereas in the neighbouring villages and farm-houses, a mild regular tertian ague distresses whole families. The violence of the fever, with its appearances in a continued remitting or intermittent form, marked in some measure the nature of the soil. In Portsmouth the symptoms were bad, worse at Kingston, and still more dangerous and violent at a place called Half-way House; a street so called, about half a mile from Portsmouth, where scarcely one in a family escaped this fever, which generally made its first attack with a delirium. In the large suburb of Portsmouth called the Common, it seemed to rage with more violence than in the town, some parts excepted; but even whole streets of this suburb, together with the houses in the dock-yard, escaped its attack.

The marines, who were three times a-week exercised early in the morning on South Sea beach, suffered much from the effect of the stagnant water in an adjoining morass. Half a dozen of them were frequently taken ill in their ranks when under arms; some being seized with such a giddiness of their head, that they could scarcely stand; while others fell down speechless, and upon recovering their senses complained of a violent head-ach. When such patients were received into the hospital, it was observed that some few had a regular ague, but that far the greater number laboured under a remitting fever, in which sometimes indeed there was no perceptible remission for several days. A constant pain and giddiness of the head were the most ineparable and distressing symptoms of this disease. Some were delirious, and a few vomited up a quantity of bile; but in all the countenance was yellow. A long continuance of the fever produced a dropsy or jaundice, or both. Even a slight attack reduced the most robust constitution to a state of extreme debility; and this weakness, together with the giddiness, continued... more freely, and removes further from the nature of a continued fever. The higher ranks of people in general are least liable to the diseases of the marshes; for such countries require dry houses, apartments raised above the ground, moderate exercise, without labour in the sun or evening damps, a just quantity of fermented liquors, plenty of vegetables, and fresh meats. Without such helps, not only strangers, but the natives themselves are sickly, especially after hot and close summers. The hardest constitutions are very little excepted more than others; and hence the British in the Netherlands have always been subject to fevers.

By this distemper the British troops were harassed throughout the whole of the war from 1743 to 1747. It appeared in the month of August 1743; the paroxysms came on in the evening, with great heat, thirst, a violent headache, and often a delirium. These symptoms lasted most of the night, but abated in the morning, with an imperfect sweat, sometimes with an hemorrhage of the nose or a looseness. The stomach from the beginning was disordered with a nausea and sense of oppression, frequently with a bilious and offensive vomiting. If evacuations were either neglected, or too sparingly used, the patient fell into a continued fever, and sometimes grew yellow as in a jaundice. When the season was farther advanced, this fever was attended with a cough, rheumatic pains, and viscid blood. The officers being better accommodated than the common men, and the cavalry who had cloaks to keep them warm, were not so subject to it; and others who belonged to the army, but lay in quarters, were least of all affected; and the less in proportion to their being little exposed to heats, night-damps, and the other fatigues of the service.

In this manner did the remitting fever infect the army for the remaining years of the war; and that exactly in proportion to their distance from the marshy places, of which we have several notable instances in Pringle's observations. In Hungary the same disease appears with still more violence, and is readily complicated with fevers of a truly pestilential nature, by which means it becomes extremely dangerous. This country is acknowledged to be the most sickly climate in Europe, and indeed as bad as any in the world. Here it was where the crusaders, in only marching through the country to invade Asia, often lost half their number by sickness; and where the Austrians not long since buried, in a few years, above 40,000 of their best troops, who fell a sacrifice to the malignant disposition of the Hungarian air. The reason of this uncommon malignity is, that Hungary abounds with rivers, which, by often overflowing, leave that low flat country overspread with lakes and ponds of stagnating water, and with large unwholesome marshes. So great is the impurity of these stagnant waters, that by them the rivers, even the Danube, whose course is slow, become in some places corrupted and offensive. The air is moist, and in summer quite fultry. In the nights of harvest, Kramer tells us, it was so very damp, that the Austrian soldiers could not secure themselves from the moisture even by a triple tent-covering. Here epidemic distempers begin constantly to rage during the hottest months of the year; which are July, August, and September; and these complaints, according to the observations of the physician above-mentioned, are the same with those which are epidemic upon the coast of Guinea, and in the sickly climates of the East and West Indies, of which malignant fevers of the remitting and intermittent kind are the most common and dangerous.

The heat of the sun in Hungary, according to the same author, is more intense than in any other country of Europe; and in proportion to the heat is the pestilential quality of the marshy exhalations. It is constantly observed, that the nearer any city or fort is to a morass, or a large river with foul and oozy banks, the more unhealthy are the inhabitants. At such seasons and places, the air swarms with numberless insects and animalcules, a sure sign of its malignant disposition; and the hotter the summer, the more frequent and mortal are the diseases. In short, this country, on account of its unhealthiness, has been termed the grave of the Germans; and in Italy, the Campania of Rome is almost equally unhealthy. Lanchius, physician to Pope Clement XI. furnishes us with a very striking instance of the malignant quality of the air of Campania. Thirty gentlemen and ladies of the first rank in Rome having made an excursion, upon a party of pleasure, towards the mouth of the Tyber, the wind suddenly shifting, blew from the south over the putrid marshes, when 29 were immediately seized with a tertian fever, only one escaping.

The island of Sardinia is annually visited with an epidemical sickness, which rages from June to September, and is called by the natives the intemperies. In some years there is a want of rain for four or five months; and then it is that this sickness exerts its utmost violence, being always more fatal in some places than in others, and in particular to strangers. Of this the British had a severe proof in 1758.—Admiral Broderick, in the Prince ship of war, anchored in the bay of Orillane, where 27 of his men, sent ashore on duty, were seized with the epidemical distemper of this island; twelve of them in particular, who had slept on shore, were brought on board delirious. All of them in general laboured under a low fever, attended with great oppresion on the breast and at the pit of the stomach, a constant retching, and sometimes a vomiting of bile; upon which a delirium often ensued. These fevers changed into double tertians, and terminated in obstinate quartan agues. It is worthy of remark, that in this ship, which lay only two miles from the land, none were taken ill but such as had been on shore, of whom seven died. The prior of a convent, making a visit to the English officers, informed them, that the intemperies of the island was a remitting or intermittent fever, and that he himself had suffered several attacks of it. Sardinia was formerly so remarkable for its unwholesome air, that the Romans used to banish their criminals thither; and it is at present but thinly peopled, owing to the mortality occasioned by this annual sickness. For although it is about 140 miles long, and in several places 75 miles broad, yet it is computed that the whole number of its inhabitants does not exceed 250,000: an inconsiderable number, when compared with the inhabitants of the lesser, but comparatively more healthful, island of Corsica; though even there the French lost a number of their troops by intermittent and remitting fevers. In the island of Minorca too, Dr Cleghorn informs us, that fevers of this kind prevail exceedingly; that their types are various, their symptoms violent; the intermissions fallacious, and that they frequently and suddenly prove fatal. It is more than probable, he adds, from the accounts of several physicians and travellers, that epidemical tertians are not wholly confined to the coasts and islands of the Mediterranean, but that they are equally frequent and destructive in many other parts of the globe; and perhaps may be deemed the anniversary autumnal distempers of most hot countries in the world. And though in the mild climate of Britain, a tertian may always easily be cured when once it is discovered; yet, in warm climates, such is the rapid progress of the distemper, that it is necessary to know it in the very beginning, which is very difficult for those who have never seen any but the tertians usually met with in Britain.

From this gentleman's account of Minorca, however, it doth not appear why that island should be so much infected with fevers of this kind, seeing it is far from being a marshy country; nay, on the contrary, is very dry. The south-wind, he observes, is very unhealthy; and it is the prevalence of this wind which brings on the fever: but still the difficulty is not removed, because the sea-air is so far from bringing on such dangerous diseases, that it is one of the greatest preservatives against them when it can be had. As to the moisture which must necessarily accompany an insular situation, that cannot reasonably be admitted as a cause of this or any other disease. In the Medical Observations we find a paper on a subject very similar to the present, namely, the mischief produced by lying in damp sheets, or being exposed to moist vapour. Our author tells us, that he hardly knows a distemper the origin of which hath not by some been ascribed to lying in a damp bed, or sitting in a wet room; and yet he does not know any one which will certainly be produced by these causes, and people frequently expose themselves to such causes without suffering any ill effects. "It must be owned indeed, (says he,) that the vapours arising from the bilge-water of ships tend to produce the scurvy. The swampy plains also near the mouths of great rivers which are often overflowed, and low grounds which cannot readily be drained, and those tracts of land where the thickness and extent of the woods keep the ground moist and half putrid for want of ventilation, are destructive to the neighbouring inhabitants, by occasioning obstinate intermittents in the colder climates, and pestilential fevers in the hotter regions. But all this mischief arises not merely from moisture, but from an unventilated and putrid moisture; for the insufficiency of mere wetness, untainted with putridity, may be reasonably inferred from the following considerations. The air is often fully saturated with moisture, and could not be more filled by the vapours arising from a chamber covered with water; and yet neither is any epidemical distemper produced by it, nor are those remarkably aggravated with which the sick happen at that time to be afflicted. The air from rivers and from the sea is probably more replenished with vapours than inland countries cleared of their woods: yet the most celebrated of the ancient physicians recommended the bank of a running river for the situation of a house, on account of its peculiar healthfulness; and many invalids are sent by the modern physicians Where the sailors are cleanly, and not too much crowded, they are often as healthy during long voyages at sea, as they would have been upon any part of the land. Venice is not observed to be less healthy than London or Paris.

Those who are much disposed to sweat, lie many hours in bed-clothes impregnated probably with a less wholesome moisture than would have been left in the sheets half-dried after washing; and I have not yet had reason to think that any remarkable injury was done to the health by the continuance of such sweats almost every night for weeks, and for months, except what arose from the too great copiousness of this evacuation.

Children, and such as are troubled with the stone, and those who, from other infirmities or age, constantly wet their beds with their urine, do not appear to suffer in their health on this account.

It is a common practice, in some disorders, to go to bed with the legs or arms wrapped in linen cloths thoroughly soaked in Malvern water, so that the sheets will be in many places as wet as they can be; and I have known these patients and their bedfellows receive no harm from a continuance of this practice for many months. Nor can it be said that the Malvern water is more innocent than any other water might be, on account of any ingredients with which it is impregnated; for the Malvern water is purer than that of any other springs in England which I ever examined or heard of.

The greatest valetudinarians do not scruple to sprinkle lavender-water upon their sheets; and yet, when the spirit is flown off, there is left what is as truly water, as if it had been taken from the river.

Is it observed, that laundresses are peculiarly unhealthy above other women, though they live half their time in the midst of wet-linen, in an air fully saturated with vapours? Many other employments might be mentioned, the persons occupied in which are constantly exposed to wet floors or pavements, or to be surrounded with watery vapours, or to have their clothes often wet for many hours together.

Is it the coldness of wet linen which is feared? But shirts and sheets, colder than any unfrozen water can be, are safely worn and lain in by many persons, who, during a hard frost, neither warm their shirts nor their sheets.—Or does the danger lie in the dampness? But then how comes it to pass, that a warm or cold bath, and long-continued fomentations, can be used, without the destruction of those who use them?—Or is it from both together? Yet we have long heard of the thickness and continuance of the cold fogs in the seas north-west of England, but have never yet been told of any certain ill effect which they have upon those that live in these countries."

With regard to the causes of fevers, however, Dr Lind is of opinion, that noxious vapours arising from the earth are for the most part to be blamed. Even in countries seemingly dry, and where violent rains are not frequent, he thinks that the air may load itself with putrid exhalations from the ground; and that, except in the burning deserts of Arabia or Africa, people are nowhere exempt from diseases occasioned by putrid moisture. In most of the hot countries, however, the pernicious effects of the putrid vapours are by no means equivocal. In Guinea, they seem to be more extraordinary than anywhere else in the world; neither indeed can it be supposed that a hot and moist atmosphere can be without putrefaction. It may in general be remarked, that in sultry climates, or during hot weather, in all places subject to great rains, where the country is not cleared and cultivated, but is overrun with thickets, shrubs, or woods, especially if there are marshes or stagnating waters in the neighbourhood, sickness may be dreaded, and the remitting fever of which we now treat. The fens, even in different countries of England, are known to be very prejudicial to the health of those who live near them, and still more so to strangers; but the woody and marshy lands in hot countries are much more pernicious to the health of Europeans. In all those unhealthy places, particularly during fogs or rains, a raw vapour, disagreeable to the smell, arises from the earth, and especially in the huts or houses. But of all the vapours which infect the torrid zone, the most malignant and fatal are the harmattans: They are said to arise from the confluence of several rivers in the king of Dormo's dominions at Benin, (the most unwholesome part of Guinea), where travellers are obliged to be carried on men's backs for several days journey, through swampy grounds, and over marshes, amidst stinking ooze, and thickets of mangrove trees which are annually overflowed. These vapours come up the coast, to a surprising distance, with the south-east and north-east winds; and it has been observed, that, in their progress, they have often changed both the course of the winds and of the sea-currents. The times of their appearance at Cape Coast are the months of December, January, or February. The north-east and south-east winds are always unhealthy, but particularly so during the harmattan season. Some years this vapour is scarcely perceptible; but in others it is thick, noxious, and destructive to the blacks as well as whites. The mortality is in proportion to the density and duration of the fog. It has a raw putrid smell; and is sometimes so thick, that a person or house cannot be discerned though it, at the distance of 15 or 20 yards; and it continues so for 10 or 14 days; during which it opens the seams of ships, splits or opens the crevices of wood as if shrunk or dried with a great fire, and destroys both man and beast.—In the year 1754 or 1755, the mortality occasioned in Guinea by this stinking fog was so great, that in several negro towns the living were scarce sufficient to bury the dead. Twenty women brought over from Holland by a new governor to the Castle del Mina, perished, together with most of the men in the garrison. The gates of Cape Coast Castle were shut up for want of sentinels to do duty; the blacks dying at this time as well as the white people. It is lucky that it is only in some years that harmattans are so very thick and noxious, otherwise that part of the country would be depopulated. It is observed that all fogs are extremely unhealthy in those parts, particularly before and after the rainy season; but the above account of the harmattans appeared so very extraordinary and incredible to some of Dr Lind's readers, that he thought proper to publish a further corroboration of the facts above-mentioned. "A gentleman, (says he), who had long resided at Cape Coast castle, informed me, that during the time of this fog, being in the upper chambers of the fort, the boards of the floor shrunk so much, that he could discern the candles burning in the apartments below him (there are no plaster ceilings used in these hot countries), and that he could then even distinguish what people were doing in the apartments below; the seams of the floor having opened above half an inch, while the fog lasted, which afterwards, upon its being dispelled, became close and tight as before."

In this country the rains and dews seem to be possessed of qualities almost equally pernicious with the fogs. Thus much is certain, that in Guinea, many of the principal negroes, and especially of the mulatto Portuguese, take the utmost precaution to avoid being wet with those rains, especially such as fall first. At the setting in of the rainy season, they generally shut themselves up in a close well-thatched hut, where they keep a constant fire, smoke tobacco, and drink brandy, as preservatives against the noxious quality of the air at that time. When wet by accident with the rain, they immediately plunge themselves into salt-water if near it. Those natives generally bathe once a day, but never in the fresh-water rivers when they are overflowed with the rains: at such times they prefer for that purpose the water of springs. The first rains which fall in Guinea are commonly supposed to be the most unhealthy. They have been known, in 48 hours, to render the leather of the shoes quite mouldy and rotten; they stain clothes more than any other rain; and soon after their commencement, even places formerly dry and parched swarm with frogs. At this time skins, part of the traffic of Senegal, quickly generate large worms; and it is remarked, that the fowls, which greedily prey on other insects, refuse to feed on these. It has been farther observed, that woollen cloths wet in those rains, and afterwards hung up to dry in the sun, have sometimes become full of maggots in a few hours.—It is also probable, that as in some of those countries the earth, for six or eight months of the year, receives no moisture from the heavens but what falls in dews, which every night renew the vegetation, the surface of the ground in many places becomes hard and incrusted with a dry scurf, which pens up the vapours below: until by the continuance of the rains for some time, this crust is softened, and the long pent up vapours set free. That these dews do not penetrate deep into the earth is evident from the constant dryness and hardness of such spots of ground in those countries as are not covered with grass and other vegetables. Thus the large rivers in the dry season being confined within narrow bounds, leave a great part of their channel uncovered, which having its moisture totally exhaled becomes a solid hard crust; but no sooner the rains fall, than by degrees this long parched up crust of earth and clay gradually softens, and the ground, which before had not the least smell, begins to emit a stench, which in four or five weeks becomes exceedingly noisome, at which time the sickness is generally most violent.

This sickness, however, is not different from the remitting fever which hath been described under so many various forms and names. An inflammatory fever is seldom observed, during the season of sickness, in this part of the world; and we shall conclude our description of the *amphimerina paludosa* with some extracts from the surgeon's journal of a ship that sailed up the rivers of Guinea.

"On the 5th of April we sailed up the river of Gambia, and found all the English in the fort in perfect health. The surgeon of the factory informed me, that a relaxation of the stomach, and consequently a weakened digestion, seemed to bring on most of the diseases so fatal to Europeans in the sickly season. They were generally of a bilious nature, attended with a low fever, sometimes of a malignant, at other times of a remitting kind.—On the 12th of April, after sailing 30 miles up the river St Domingo, we came to Catchou, a town belonging to the Portuguese, in Lat. 20° N.—In this town were only four white people, the governor and three friars. The number of whites in the trading ships were 51. One morning, towards the latter end of April, a little rain fell. On the 13th of May there was a second shower, accompanied with a tornado. One the 18th of May it rained the whole day; and the rain continued, with but short intervals, until the beginning of October.

"In the month of June, almost two thirds of the white people were taken ill. Their sickness could not be well characterized by any denomination commonly applied to fevers: it however approached nearest to what is called a *nervous fever*, as the pulse was always low, and the brain and nerves seemed principally affected. It had also a tendency to frequent remissions. It began sometimes with a vomiting, but oftener with a delirium. Its attack was commonly in the night; and the patients, being then delirious, were apt to run into the open air. I observed them frequently recover their senses for a short time, by means of the heavy rain which fell upon their naked bodies. But the delirium soon returned: they afterwards became comatose, their pulse sunk, and a train of nervous symptoms followed; their skin often became yellow; bilious vomitings and stools were frequent symptoms. The fever reduced the patient's strength so much, that it was generally six weeks or two months before he was able to walk abroad. A consuming flux, a jaundice, a dropfy, or obstructions in the bowels, were the consequences of it. Of 51 white men, being the companies of four ships which were at Catchou, one third died of the fever, and one third more of the flux, and other diseases consequent upon it; and of these not one was taken ill till the rains began.

"I believe, on the whole face of the earth, there is scarce to be found a more unhealthy country than this during the rainy season: and the idea I then conceived of our white people was by making a comparison of their breathing: such a noxious air, with a number of river-fish put into stagnating water; where, as the water corrupts, the fish grow less lively, they droop, pine away, and many die.

"Thus some persons became dull, inactive, or slightly delirious, at intervals; and, without being so much as confined to their beds, they expired in that delirious and comatose state in less than 48 hours, after being in apparent good health. The white people in general became yellow; their stomach could not receive much food without loathing and retchings. Indeed it is no wonder..." I wonder that this sickness proved so fatal, that recoveries from it were so tedious, and that they were attended with fluxes, dropsies, the jaundice, ague-cakes, and other dangerous chronical distempers. It seemed more wonderful to me that any white people ever recover, while they continue to breathe so pestiferous an air as that at Catchou during the rainy season. We were, as I have already observed, thirty miles from the sea, in a country altogether uncultivated, overflowed with water, surrounded with thick impenetrable woods, and over-run with slime. The air was vitiated, noisome, and thick; insomuch that the lighted torches or candles burnt dim, and seemed ready to be extinguished; even the human voice lost its natural tone. The smell of the ground and of the houses was raw and offensive; but the vapour arising from putrid water in the ditches was much worse. All this, however, seemed tolerable, when compared with the infinite numbers of insects swarming everywhere, both on the ground and in the air; which, as they seemed to be produced and cherished by the putrefaction of the atmosphere, so they contributed greatly to increase its impurity. The wild bees from the woods, together with millions of ants, over-ran and destroyed the furniture of the houses; at the same time, swarms of cockroaches often darkened the air, and extinguished even candles in their flight; but the greatest plague was the musquetoes and sand-flies, whose incessant buzz and painful stings were more insupportable than any symptom of the fever. Besides all these, an incredible number of frogs on the banks of the river made such a constant and disagreeable croaking, that nothing but being accustomed to such a hideous noise could permit the enjoyment of natural sleep. In the beginning of October, as the rains abated, the weather became very hot; the woods were covered with abundance of dead frogs, and other vermin, left by the recess of the river; all the mangroves and shrubs were likewise overspread with flanking slime.

After so particular a description of the remitting fever in many different parts of the world, we presume it will be needless to take notice of any little varieties which may occur in the warm parts of America, as both the nature and cure of the distemper are radically the same; neither shall we lengthen out this article with further descriptions of remitting fevers from the works of foreign authors, as, from what we have already said, their nature cannot well be mistaken.

Cure. The great difficulty in the cure of remitting fevers arises from their not being simple diseases, but a complication of several others. Fevers, properly speaking, have but three or four different appearances which they can assume without a complication. One is, when they are attended with a phlogistic diathesis; another is, when they assume the form of genuine intermittents; a third is, when they produce a great debility of the nervous system; and the fourth is, when, along with this debility, there is also a rapid tendency to putrefaction. If, therefore, all these species happen to make an attack at once, the most dangerous fever we can imagine will be produced; and however contrary it may be to our theories to admit the possibility of such an attack, the truth of the fact is too often confirmed by fatal experience. In the beginning of remittent fevers, for instance, the symptoms indicate a high degree of inflammation; but if the practitioner attempts to remove this inflammation by bloodletting or other evacuations, the pulse sinks irrecoverably, and the person dies with such symptoms as show that the nervous system hath been from the beginning greatly affected; at the same time that the high stimulants and cordials, or the bark, which would have conquered the nervous part of the disease, increase the inflammatory part of it to such a degree, that, by a too early exhibition of them the patient also dies, but after another manner.

In the remitting fever of the East Indies, Dr Lind of Edinburgh formed the following indications of cure. 1. To allay the violence of the fever. 2. To evacuate the putrid humours, and take great care to prevent the body from inclining to putrefaction. 3. To keep up the strength of the patient as much as possible during the disorder. 4. To lose no time in preventing the return of the paroxysm.

To allay the violence of the fever, everything that can contribute to increase it ought to be carefully avoided or removed; such as great heat, too strong a light falling on the eyes, noise, and motion. If during the paroxysm the head and loins are affected with violent pains, the pulse is full and hard, and the heat intense, bleeding may be used, but with the greatest caution; for, however useful this operation may be in cold climates, the success of it in warm ones is so far from being certain, that the lives of the patients have been often very much endangered, nay even destroyed, by it. Dr Badenoch, and the surgeon of the Ponborne, endeavoured each of them to relieve two patients by blood-letting; and the consequence was, that each of them lost one patient. Dr Lind bled two patients; one of whom was Mr Richardson, the first mate of the ship, who complained of a most violent pain in his head, with a full hard pulse. About four or five ounces of blood were taken from him, by which he was greatly relieved; nor was the cure retarded by it; nay, the fever afterwards became less irregular. At the time the other patient was bled, the disease was exceedingly frequent and violent. He was so earnest for bleeding, that he fired all the rest with the same desire, swearing, that, by refusing them this only remedy, every one of them would be sent to their graves. To quiet them therefore, and get rid of their importunities, the Doctor complied with their request, and took about five or six ounces from him who had been the first to require it. The consequence was, that he immediately lost his strength; and in less than an hour, during which time he made his will, was carried off by the next fit. It is proper, however, to observe, and indeed the Doctor himself makes the observation, with regard to this patient, that he was bled at an improper time, namely, between the fits; whereas, had he been bled in the hot fit, it is possible he might have been relieved; and here he quotes the authority of Cleghorn and Pringle.

As Dr Cleghorn practised in a very hot country, his observations must in the present case have greater weight than that of Pringle, who practised in a colder one. The former acquaints us, that if he was called in early enough, he always used to take away some blood, unless there was a strong contra-indication, from people of all ages; namely, from robust adults, ten or twelve ounces; from others a smaller quantity, in proportion to their strength and years. And further, if a violent head-ach, obstinate delirium, and great heat or pains of the bowels, were urgent, the bleeding was repeated within a day or two. By this reasonable evacuation, he found the vehemence of all the paroxysms somewhat diminished; the apyrexies became more complete; the operation of emetics and cathartics rendered safer and more successful; and the terrible symptoms which happened about the height of the distemper, such as raving fevers, difficulty of breathing, inflammations of the abdominal viscera, &c. were either prevented or mitigated. But if the fever had continued for some time before he was called, and the mass of blood appeared to be too much melted down or inclined to a putrid dissolution, he either abstained from bleeding entirely, or took away a very small quantity, though some unfortunate symptoms might seem to require a larger evacuation. As to the time of performing the operation, he acquaints us, that it is safe enough, except when the cold fit lasts or is soon expected, or while the skin is covered with critical sweats; and that he usually opened a vein in the beginning of the hot fit; by which means the sick were relieved, the immoderate heat of the body, which is often productive of fatal effects, was diminished, and the critical sweats brought on sooner and in greater abundance.

But though Dr Lind found venefection to be of such pernicious tendency in his patients, cooling acidulated liquors were of the utmost service, as they corrected the putrid humours, lessened the heat and thirst, and of course prevented the fever from arriving at so great an height as it would otherwise have done. Those cooling liquids are the best which are made up with some farinaceous substance, as they most easily unite with our fluids. Fossil acids too, and crystals of tartar, especially the latter, are of considerable use, not only in this but in other fevers. The neutral salts, prepared with the juice of lemons, were likewise given with success during the heat of the fever. They lessen the nausea, the fits become more regular, and the remissions more full; and they are particularly grateful when given in a state of effervescence. The good effects of these draughts we are in a great measure to ascribe to the antiseptic quality of the fixed air extracted from them during the effervescence; of which we shall speak more fully when treating of the typhous fevers.

During the remission, it is proper to evacuate the putrid humours by small doses of ipecacuanha, or rather tartar emetic. The tartar emetic indeed appears to be endowed with some kind of febrifuge virtue, which Dr Callen thinks is owing to its relaxing the febrile spasms taking place in the capillary vessels, as shall be fully explained when we come to treat of continued fevers. But should there appear any symptoms of a topical inflammation in some of the abdominal viscera, a thing which never happens unless the disorder has been of some standing, vomiting is to be avoided, and we are to depend upon purgatives alone for the evacuation of the putrid bile, which are always useful in the cure of this disorder. But all acid and strong purgatives are to be carefully avoided, and only the mild antiseptic ones made use of, such as crystals of tartar, or tamarinds made up with manna or with Glauber's salt.

Under the article Gall, we have observed, from Dr Percival, the effect which vegetable acids have in sweetening putrid bile; whence it seems probable, that a liberal use of these acids would be much more serviceable than a repetition of any kind of purgatives. Though in these diseases there is a great quantity of putrefied bile collected in the body, yet it seems much more probable that this is the effect rather than the cause of the disorder; and therefore, though we carry off the quantity collected ever so often, more of the same kind will still be produced by the putrefactive disposition of the other juices, at the same time that the strength of the patient must necessarily be diminished by repeated evacuations, when it ought rather to be kept up by all possible means. We ought well to observe, however, that the mineral acids have not that property of sweetening putrid bile which the vegetable ones have; and therefore the same relief will not be given by them which might reasonably be expected from vinegar or lemon-juice.

In order to keep up the strength of the patient, good food is absolutely necessary. Dr Lind allowed the sick small messes of panada made with boiled rice and barley mixed with currants or raisins and prunes, seasoned with sugar and a little wine, especially claret. During the paroxysms, they had gruel made of flour and rice, with sugar and the juice of acid fruit; and when the fit went off, a little wine was added to this mixture.

The shirts and bedding must be very often changed and well aired; their stools, and all filth and nastiness, are to be immediately removed; the places where they are lodged should be well aired and frequently sprinkled with vinegar; and, in the last place, the sick must be exceedingly well nursed. Blisters, according to Dr Lind, should never be used till the fever has been of long continuance, or the spirits and pulse of the patient have begun to flag. But here our author has implicitly followed Dr Huxham, whose theory concerning the use of blisters is now found to be erroneous. According to that celebrated author, blisters are capable of doing considerable hurt in all cases where there is a tendency to inflammation, by increasing the motion of the fluids and the oscillatory power of the vessels, both of which are already too great. They are also improper, according to him, where there is a considerable tendency of the fluids to putrefaction; because he supposes the salts of these flies to operate in the same manner with volatile alkalies, that is, by dissolving and putrefying the blood still farther. But Sir John Pringle hath shown, that, in inflammatory fevers as well as those of the putrid kind, both blisters and volatile salts may be of service; the latter, particularly, he hath experimentally proved to be so far from promoting putrefaction, that they are exceedingly strong antiseptics.

In the East Indies, Dr Lind found it altogether necessary to exhibit the bark in large quantities, and as early as possible. By this method he not only secured the patient from the imminent danger of death to which he was exposed at every fit, but likewise conquered those obstructions which were apt to ensue in the abdominal viscera, and which are to be attributed to the continuance of the disorder, and not to the bark employed to cure it. He always gave the bark remission gave four or five grains of ipecacuanha, with practice from half a grain to two grains of emetic tartar. This powder he repeated in two hours, taking care that the patient should not drink before the second dose; for then the medicine more readily passed into the bowels after it had operated by vomiting. If after two hours more the operation either way was small, he gave a third dose, which commonly had a good effect in opening the first passages; and then the fever either went quite off, or intermitted in such a manner as to yield to the bark. On the continent, he found little difficulty after the intermission; but in the West Indies, unless he gave the bark upon the very first intermission, tho' imperfect, the fever was apt to assume a continued and dangerous form.

In the remitting fevers of hot countries, however, it must be observed, that the lancet must in all cases be much more sparingly used than in similar diseases of the colder regions; and we must also be sparing of venesection in those countries where the marsh effluvia are very strong and prevail much. For this reason Dr Lind of Haflar greatly condemns the practice of indiscriminate bleeding when people first arrive in hot climates. The first diseases indeed which occur in a voyage to the southward are for the most part of an inflammatory nature, and owing to a sudden transition from cold to hot weather. This occasions a fulness and distention of the vessels; whence all Europeans, on their first arrival under the tropic, bear evacuations much better than afterwards. The practice of indiscriminate bleeding, however, a number of the ship's company when they first come into a warm latitude, is by no means found to answer the purpose of a preventative. In such cases, indeed, as plainly indicate a plethoric disposition brought on by the heat, blood-letting is certainly useless. The signs of this are a pain and giddiness in the head; a heaviness and dullness of the eyes, which sometimes appear slightly inflamed; there is also commonly a sense of weight and fulness in the breast, the pulse at the same time being quick and oppressed.

But the case is quite different after a longer continuance of sultry weather, and when the constitution is in some measure habituated to the hot climate. For it is then observed, that the symptoms of inflammations in the bowels, even the most dangerous, are not near so severe in such climates as in cold countries; nor can the patients bear such large evacuations. The physician, however, must take care not to be misled by the apparent mildness of the symptoms; for he will find, notwithstanding such deceitful appearances, that the inflammation makes a more rapid progress in hot countries than in cold, suppurations and mortifications being much more suddenly formed; and that in general all acute distempers come sooner to a crisis in the southern than in colder regions. Hence it is an important rule of practice in those climates, to seize the most early opportunity, in the commencement of all threatening inflammations, to make frequent, though not copious evacuations by blood-letting. For by delay the inflammation swiftly passes from its first to its last or fatal stage; at least an imperfect crisis in such inflammatory fevers ensues, which fixes an obstruction in the visceræ extremely difficult to remove.

It is indeed a general maxim with some physicians Practice in the West Indies, that in most acute distempers bleeding in that country is prejudicial. This is founded upon a supposition that the effusamentum of the blood is thinned, and the solids greatly weakened, by the heat of the climate. It is therefore objected, that bleeding in such an habit of body weakens the powers of nature, and withdraws the strength which is requisite to support the patient until the crisis of the fever.

This reasoning is partly just; but, like all general maxims, will admit of exceptions. First, with regard to sailors, it is to be remembered, that they are more exposed to quick vicissitudes of heat, cold, damps, and to various changes of the air and weather, than most of the other inhabitants of the Torrid Zone. Add to this, that their intemperance, and the excesses they are apt to fall into whenever it is in their power to commit them, render them more liable to inflammations than any other set of people. Hence their deficiencies require more plentiful evacuations than the land-inhabitants of those parts of the world, and generally they bear them better. But with regard to the natives of the country, or those who have remained long in it, it must be proper to bleed them very sparingly, making a small allowance for the different seasons of the year, the temperature of the air, and the situation of the places where they reside. Thus, in some parts, even on the island of Jamaica, at particular seasons, the weather is cool; wherefore, in these places, and at such seasons, the inhabitants having their fibres more rigid, and a firmer crisis of their blood, bear venefection much better.

In cold countries the state of the air greatly assists in restoring the impaired spring of the fibres; whereas every thing almost in warm weather, such as heat, moisture, &c. concur to relax and weaken the habit of body. Thus, we may daily see persons in Britain, after having suffered a most severe fit of sickness, recover their strength and spirits in a few days, and in a very short time their natural constitution. But the case is very different in the sultry regions of the Torrid Zone, or indeed in any part of the world where the heat of the season causes the mercury to stand for any length of time at the 77th degree and upwards of Fahrenheit's thermometer. During such an excess of heat, debility after fevers is apt to remain with European constitutions for several months. In Jamaica, the convalescents are sent to the cool summits of the mountains; but a retreat to a more northern climate is often absolutely necessary to recover their wonted tone and vigour of body. It is a well-established observation, that the negroes, and aborigines of the Torrid Zone cannot bear plentiful evacuations by the lancet. They commonly mix the most stimulating poignant spices with their ordinary light food, and this is found by experience suitable to their constitutions.

As proper preventatives for the dangerous fevers of which we are treating, Dr Lind on all occasions recommends the avoiding of flagrant water, or putrid marshes; the use of proper food, cleanliness, and sobriety. Of the propriety of removing from the neighbourhood of those places whose pestilential effluvia produce the disorders, we cannot possibly entertain a doubt; and of the efficacy of proper food in preventing putrid disorders he gives a remarkable instance in the Sheerens man of war, bound to the East Indies. As they went out, the men being apprehensive of sickness in so long a voyage, petitioned the captain not to oblige them to take up their salt provisions, but rather to permit them to live upon the other species of their allowance. It was therefore ordered, that they should be served with salt-meat only once a-week; and the consequence was, that, after a passage of five months and one day, the ship arrived at the Cape of Good Hope without having a single person sick on board. As the use of Sutton's pipes had been then newly introduced into the king's ships, the captain was willing to ascribe part of such an uncommon healthfulness to their beneficial effects; but it was soon discovered, that, by the neglect of the carpenter, the cock of the pipes had been all this while kept shut. This ship remained in India some months, where none of the men, except the boats crews, had the benefit of going on shore; notwithstanding which, the crew continued to enjoy the most perfect state of health; they were, however, well supplied with fresh meat. On leaving India, knowing they were to stop at the Cape of Good Hope, and trusting to a quick passage, and the abundance of refreshments to be had there, they eat their full allowance of salt-meats, during a passage of only ten weeks; and it is to be remarked the air-pipes were now open. The effect of this was, that, when they were arrived at the Cape, 20 of them were afflicted in a most miserable manner with scorbutic and other disorders. These, however, were speedily recovered by the refreshments they met with on shore. Being now thoroughly sensible of the beneficial effects of eating, in these southern climates, as little salt meat as possible when at sea, they unanimously agreed, in their voyage home from the Cape, to refrain from their too plentiful allowance of salt flesh. And thus the Sheerens arrived at Spithead, with her full complement of 160 men in perfect health and with unbroken constitutions; having in this voyage of 14 months and 15 days buried but one man, who died in a mercurial salivation.

Thus we see, that a free and pure air is not a sufficient preservative against a putrefactive state of the fluids, without proper food; and, on the other hand, our author gives a very remarkable instance of the inefficacy of the most salutary food to prevent putrid deficiencies, in a very noxious state of the atmosphere. In the year 1717, at the siege of Belgrade in Hungary, the fever of the country, and the flux, occasioned a most extraordinary mortality among the troops. The dread of these diseases caused every one, as may naturally be supposed, to have recourse to different precautions for self-preservation. Prince Eugene, the commander in chief, had water and the provisions for his table sent him twice a-week from Vienna. The pure stream of the river Kahlenberg was regularly brought to him; he avoided all excesses, and lived regularly, or rather abstemiously; refreshed himself often by eating a cool melon; and mixed his usual wine, which was Burgundy, with water. Yet notwithstanding his utmost care, he was seized with a dysentery; which would have quickly put an end to his life, had not the speedy conclusion of that campaign permitted him to make quick retreat. At this unhealthy season, when hardly one imperial officer, much less their several domestics, escaped those malignant diseases, the renowned Count Bonneval and his numerous retinue continued in perfect health, to the surprise, or, to use the words of Dr. Kramer, to the envy of all who beheld him. The only precaution he used was to take, two or three times a day, a small quantity of brandy in which the bark was infused; and he obliged all his attendants and domestics to follow his example. It is no less remarkable that the count, placing his certain preservation in the use of this single medicine, lived for many years afterwards in the most unhealthy spots of Hungary, without any attack, or apprehension of disease; and continued to enjoy a perfect state of health during the hottest and most sickly seasons. And thus, with an unbroken and sound constitution, which is seldom the case of those who reside long in such climates, he lived to a great age. There is an instance produced by the same author of a whole regiment in Italy having been preserved by the use of the bark from the attack of these malignant diseases, viz., the flux and bilious fever, as it is frequently called, when the rest of the Austrian army, not pursuing that method, became greatly annoyed with them.

The intemperance and irregular living of those Europeans who visit the hot climates is frequently accused as the cause of their destruction; but, our author thinks, without sufficient reason: for though intemperance will make the body more liable to receive such diseases, it will not bring them on. It must by no means, however, be imagined, that in these climates Europeans may with impunity be guilty of excesses in eating or drinking; for the least error in that way will often prove fatal by debilitating the body, whose utmost strength in time of full health was perhaps scarce sufficient to resist the pestilential miasmata of the atmosphere.

It appears, therefore, from the concurrent testimony of the most eminent physicians, that the most proper medicine to be used, either as a preventative or cure for remitting and intermittent disorders is the Peruvian bark, administered with proper precautions, and after the prime vice have been evacuated of the putrid bilious matter collected in them. In those species of tritosophya, &c., belonging to this class, enumerated by Sauvages, the same remedies only were useful; but in that pestilential distemper which he calls tritosophya Vratissivensis, he tells us, that washing the body with water sometimes hot sometimes cold, watery clysters, and plenty of aqueous drink, were likewise of use. This method of treating malignant fevers is but lately come into practice, and shall be more fully considered under the cure of continued fevers.

Genus II. QUARTANA; the Quartan Fever. Quartana auctorum, Sauv. Gen. 89. Lin. 17. Vog. 3. Sag. 711. Hoffm. II. p. 23. Junck. tab. 81.

XIV. The Genuine Quartan. Sp. I. var. 1. A. Quartana legitima, Sauv. sp. 1. Sydenham de morb. acut. cap. v.

Description. The genuine quartan, according to Juncker, keeps its form more exactly than other intermittents; scarcely coming on at any other time than four or five in the afternoon. The cold is less violent than in the tertian; but is very perceptible, though it doth not proceed to such a height as to make the limbs shake; and continues for about two hours. It is preceded and accompanied by a languor both of body and mind. There is seldom any vomiting unless when the stomach is manifestly overloaded with aliment; neither is there any diarrhoea, but the belly in general is rather bound, not only on the days on which the paroxysm takes place, but also on the intermediate ones. The heat which slowly succeeds the cold, is less troublesome to the patient by its violence than by the uneasy dryness of the skin, which is scarce ever moistened with sweat. This heat rarely continues longer than four or five hours, unless perhaps at the first or second paroxysm. It is accompanied also with a giddiness and dull pain of the head. On the termination of the paroxysm, the patient returns to a middling state of health, and continues in the same for the rest of the intermediate days; only there remains somewhat of a loathing, and a deep-seated pain as if the person was all over bruised or broken, which kind of sensation the physicians are wont to call aftersense. The fit returns every fourth day, and that precisely at the same hours, being rarely postponed.

Causes of, and persons subject to, this disorder. The same general causes concur in producing this as in other intermittents, namely marsh miasmata, and whatever can dispose the body to be easily affected by them. Studious people, and those of a melancholic turn, are said to be particularly subject to quartans; but what are the immediate causes which produce a return of the fits every fourth day, instead of every day, or every third day, must no doubt lie for ever concealed, as depending upon the secret and inexplicable mechanism of the human body.

Prognosis. A simple quartan, where there is no reason to dread any induration of the viscera, may very certainly admit of a cure; and the prognosis can never be unfavourable, unless in cases of extreme weakness, or where the distemper hath been unskillfully treated.

Cure. This does not in the least differ from that which hath been fully laid down for the simple tertian, and which it is therefore needless to repeat here.

XV. The Duplicated Quartan. Sp. I. var. 1. B. Quartana duplicata, Sauv. sp. 4. Bonet.

This is entirely similar to the duplicated tertian already mentioned; proper allowance being made for the difference between the type of a tertian and quartan.

XVI. The Triplicated Quartan. Sp. I. var. 1. C. Quartana triplicata, Sauv. sp. 16.

This hath three paroxysms every fourth day, while the intermediate days are entirely free from fever.

XVII. The Double Quartan. Sp. I. var. 1. D. Quartana duplex, Sauv. sp. 3. Vog. sp. 13.

In the double quartan, the fits come on every day except the third; but so that the first paroxysm answers to the third, the second to the fourth, and so on.

XVIII. The Triple Quartan. Sp. I. var. 1. E. Quartana triplex, Sauv. sp. 5. Vog. sp. 14. Bartholin. H. anat. c. i. 95.

This comes on every day, but the quartan type is still preferred by the times of accession; that is, the time of the fourth paroxysm's coming on answers to that of the first, the fifth to the second, the sixth to XIX. The Quartan, accompanied with Symptoms of other diseases. Sp. I. var. 2.

Quartana cataleptica, Sauv. sp. 7. Bonet. polyalth. vol. 1. p. 805. Quartana comatosa, Sauv. sp. 15. Werlholf. de febr. C. Pisonis Observ. de morbis a convicve serof. obf. 166, 167, 168, 169, 171, 172, 173, 174. Quartana epileptica, Sauv. sp. 8. Scholzii Conf. 379, 380. Quartana hysterica, Sauv. sp. 10. Morton, Pyret. exerc. i. cap. ix. H. 10, 11. Quartana nephralgica, Sauv. sp. 9. Quartana metallica, Sauv. sp. 17. Quartana amens, Sauv. sp. 12. Sydenham de morb. acut. cap. v. Quartana splenetica, Sauv. sp. 2. Etmuller, Coll. consult. caf. 25.

XX. The Quartan complicated with other Diseases. Sp. I. var. 3.

Quartana syphilitica, Sauv. sp. 6. Plateri, observ. L. III. p. 676. Edin. Eff. art. xlvii. obf. 8. Quartana arthritica, Sauv. sp. 11. Musgr. de Arthr. sympt. cap. ix. H. 4. et 5. Arthritis febrifuga, Sauv. sp. 10. Arthritis febricola, Sauv. sp. 10. Werlholf. de febr. Cockburn de morbis navigantium, obf. 19. Quartana scorbutica, Sauv. sp. 14. Barthol. de med. Dan. diff. iv. Tim. L. VIII. caf. 18.

XXI. The Remitting Quartan. Sp. II.

Tetartophya, Sauv. gen. 85. Sag. 699. Lin. 21. Quartana remittens auctorum. Var. 1. Tetartophya simplex, Sauv. sp. 1. 2. Amphimerina semiquartana, Sauv. sp. 23. 3. Tetartophya semiteriana, Sauv. sp. 5. 4. Tetartophya maligna, Sauv. sp. 6. Lauter. Hist. med. caf. 21. M. Donat. L. III. cap. 14. ex M. Gatenaria Horst. L. I. obf. 15. 5. Tetartophya carotica, Sauv. sp. 4. Werlholf. de febr. Bianchi Hist. hep. pars III. confl. ann. 1718. p. 751. 6. Tetartophya splenalgica, Sauv. sp. 2. 7. Tetartophya, hepatalgica, Sauv. 3. Car. Pif. in prefat. p. 33. 8. Amphimerina spasmodica, Sauv. sp. 16.

To the tertian or quartan fevers all belong the Er- raticus of authors. As all those abovementioned differ only in the slight circumstance, of the type from the intermitting and remitting tertians already decried at length, it is unnecessary here to take up time in describing every minute circumstance related by physicians concerning them, especially as it could contribute nothing towards the laying down a better method of cure than what hath been already suggested.

Genus III. QUOTIDIANA; the Quotidian Fever.

Quotidiana auctorum, Sauv. gen. 86. Lin. 15. Veg. I. Hofm. II. 33. Junck. tab. 79.

XXII. The Genuine Quotidian. Sp. I. var. 1. A.

Quotidiana simplex, Sauv. sp. 1. Quotidiana legitima, Sennert. de febr. cap. 18.

Description. This kind of fever generally comes on about six or seven o'clock in the morning, beginning with a considerable degree of cold and shivering, which lasts for about an hour; and is often accompanied with vomiting, or spontaneous diarrhoea, or both. It is succeeded by a pretty strong heat, accompanied with thirst, restlessness, and pain of the head. When the heat abates a little, a spontaneous sweat commonly follows, and the whole paroxysm rarely exceeds six hours. It returns, however, every day almost always at the same hour, unless it is evidently disturbed.

Causes of, and persons subject to, the disease. The same general causes are to be assigned for the quotidian as for other intermittents. This kind occurs but rarely: and is said to attack people of a phlegmatic temperament rather than any other; also old people rather than young, and women rather than men.

The prognos and method of cure are not different from those of tertians and quartans.

XXIII. The Partial Quotidian. Sp. I. var. 1. B.

Quotidiana partialis, Sauv. sp. 16. Cronfeld, E.N.C. D. I. A. III. obf. 205. Edin. Med. Eff. vol. i. art. 31. vol. ii. art. 16.

Quotidiana cephalalgica, Sauv. sp. 6. Mort. pyretol. exerc. i. hift. 27. Van Swieten in Boerh. p. 534. Cephalalgia intermittens, Sauv. sp. 7. Cephalalgia febricola, Sauv. sp. 4. Quotidiana ophthalmica, Morton, ibid. hift. 17. Van Swieten, ibid.

Ophthalmia febricola, Sauv. sp. 23.

These distempers attack only some particular part of the body, as the head, the eye, arm, &c. producing periodical affections of those parts returning once in 24 hours; and are to be cured by the bark, as other intermittents. They are known to belong to this class, by the evident intermission of the pain or other affection of the part. The quotidiana hysterica, Sauv. sp. 3. quotidiana catarrhalis, Sauv. sp. 9. and quotidiana stranguriosa, Sauv. sp. 11. seem to be symptomatic disorders.

XXIV. The Remitting Quotidian. Sp. II.

Amphimerina, Sauv. gen. 84. Lin. 20. Quotidiana continua, Veg. 15. Quotidiane remittentes et continue auctorum. Amphimerina latica, Sauv. sp. 1. Febris continua lymphatica, Etmuller, Coll. conf. caf. 32. River. Obf. cent. i. obf. 57. Amphimerina fingultuosa, Sauv. sp. 14. Febris continua Lyngodes, Veg. 26.

Concerning these also nothing remains necessary to be mentioned in this place, having already so fully discussed the remitting fevers in all the different parts of the world. Many other varieties of these fevers mentioned by different authors are to be accounted merely symptomatic.

Sect. II. CONTINUED FEVERS.

Continua, Sauv. clas ii. ord. 1. Veg. clas I. ord. 2. Sag. 666. Boerh. 727. Continentes, Lin. clas ii. ord. 1. Stahl. Caf. mag. 35. Caf. min. 87. Junck. 58. Sennert. de febr. L. ii. cap. 2. et 10.

XXV. SYNOCHA. Genus IV.

Synocha, Sauv. gen. 80. Lin. 12. Junck. 58. Synocha, five febris acuta sanguinea, Hofm. II. 105. Synochus, Veg. 16.

Continua Continua non putris, Boerh. 729. Ephemeris, Sauv. g. 79. Boerh. 728. Junck. 57. Diaria, Lin. 11. Febris inflammatoria auctorum.

Description. The most simple kind of synocha is the ephemera or diary fever. It begins without any sensation of cold or shivering, unless there is some internal inflammation, or the smallpox or measles happen to be present. A continual heat without any intermission constitutes the essence of this disease. The heat, however, is more tolerable than in the synocha properly so called. In some pains of the head are pungent and throbbing, answering to the pulsations of the arteries; but in others they are dull and heavy. The face is red and bloated; and there is a remarkable laxitude of the limbs, with a great, full, and frequent pulse. The urine is red, and deposits a sediment almost of the colour of orange-peel; and in the very first day of the disease, signs of concoction, (according to the Hippocratic phrase), appear in it. The fever commonly goes off with a gentle sweat, but more rarely with an hemorrhage of the nose. Its shortest period is 24 hours; but if it goes beyond the fourth day, it is then a synocha properly so called.

The simple synochus, according to Vogel, begins with cold and shivering, succeeded by vehement heat, redness, and dryness of the skin. The face, especially, is very red, and the thirst intense. The head is either pained or heavy. The patient either doth not sleep at all, or is disturbed with dreams. A moist sweat then breaks out all over the skin. The pulse is full, quick, and frequent; the judgment is sometimes a little disturbed: young people are apt to be terrified with imaginations; and they for the most part incline to sleep: the respiration is difficult, and the belly collyve; at the same time that a tenive kind of laxitude is perceived over the whole body. A complete crisis takes place either on the fourth, or at the farthest on the eleventh day. The characteristic marks of the simple synochus, therefore, are, a redness of the face, moisture of the skin, and great and frequent pulse.

Causes of, and persons subject to, this disease. The causes of inflammatory fevers assigned by Dr Cullen have been already largely discussed in the first part of this treatise; and as we have already remarked of intermittent, so must we also now remark of continued fevers, that it is impossible to discover those minute causes which occasion the difference of type betwixt one inflammatory fever and another, though most authors pretend to enumerate these with great certainty. Thus Juncker tells us, that the cause of the simple ephemera is plethora, together with any immoderate agitation and commotion of the fluids while in that state. Vogel reckons among the causes of his febris diaria, passions of the mind, pain, want, exposure to the sun, &c.; a repulsion or absorption of certain humours; wounds, fractures, luxations, &c.: so that in general we may reckon every thing tending to increase the action of the arterial system to be in certain circumstances a cause of inflammatory fever. Hence we find those are most subject to the synocha whose constitution is either naturally robust, or who are exposed to those causes which tend to produce an increased action of the arterial system; such as hard labour, high living, &c.

Prognosis. The most simple kind of synocha, that is, the ephemera or diary fever, is commonly cured without the assistance of medicine; and therefore the prognosis is for the most part favourable: yet, if it is improperly treated by heating medicines, it may easily be converted into the other kind; or, if there is a putrid disposition of the fluids, into a fever of a very dangerous nature. The same thing is to be understood even of the most violent kind; for simple inflammatory fevers are not dangerous unless complicated with an affection of some particular part, as the pleura, stomach, &c.

Cure. Here Dr Cullen objects to the hypothesis of those who are for leaving the cure of continued fevers to the operations of nature; because these operations are neither certain in themselves, nor are they so well understood as to enable us to regulate them properly; and it is likewise possible to supersede them by art. The plan therefore on which he proceeds is, to form his indications of cure upon the means of obviating the tendency to death in fevers; and these he reduces to three. 1. To moderate the violence of reaction. 2. To remove or obviate the causes of debility; and, 3. To obviate or correct the tendency of the fluids to putrefaction.

The first indication may be answered, 1. By all those means which diminish the action of the heart and arteries. 2. By those which take off the spasm of the extreme vessels, which, according to his theory, is the chief cause of violent reaction.

I. The action of the heart and arteries may be diminished, 1. By avoiding or moderating those irritations which, in one degree or other, are almost constantly applied to the body. 2. By the use of certain sedative powers. 3. By diminishing the tension and tone of the arterial system.

II. The irritations above-mentioned are the impressions made upon our senses, the exercise of the body and mind, and the taking in of aliments. The avoiding of these as much as possible, or the moderating their force, makes what is properly called the antifebrifuge regimen, proper to be employed in almost every continued fever. This regimen is to be directed in the following manner.

1. Impressions on the external senses, as stimulant to the system, and a chief support of its activity, should be avoided as much as possible; especially such as are of a stronger kind, and which give pain and uneasiness. No impression is to be more carefully guarded against than that of external heat; and at the same time every other means of increasing the heat of the body is to be shunned. Both these precautions are to be avoided as soon as a hot stage is fully formed, and to be attended to during its continuance, except in certain cases, where a determination to sweating is necessary, or where the stimulant effects of heat may be compensated by circumstances which determine it to produce a relaxation and revulsion.

2. All motion of the body is to be avoided as much as possible, and that posture only chosen which employs the fewest muscles, and keeps none of them long in a state of contraction. Speaking, as it accelerates respiration, is particularly to be avoided. It must also be observed, that every motion of the body is more stimulant in proportion as the patient is weaker.

3. The exercise of the mind is also to be avoided as being a stimulus to the body; but here an exception is to be made in the case of a delirium coming on, when the presenting of accustomed objects may divert the irregular train of ideas then arising in the mind.

4. The presence of recent aliment in the stomach proves always a stimulus to the system, and ought therefore to be as moderate as possible. A total abstinence for some time may be of service; but as this cannot be long continued with safety, we must avoid the stimulus of aliment by choosing that kind which gives the least. Alimentary matters are also to be accounted more stimulant in proportion to their alkaline qualities; and this leads us to avoid all animal, and use only vegetable food. For the same reason, aromatic and spirituous liquors are to be avoided; and in answering the present indication, we must abstain from all fermented liquors except those of the lowest quality. Other stimuli are, the sensation of thirst, crudities or corrupted humours in the stomach, a preternatural retention of the faeces in the intestines, and a general acrimony of all the humours, which is in most fevers to be suspected. These are to be removed by such methods as the urgency of the symptoms require, by diluting liquors, vomiting, the use of acids, laxative syrups, and large quantities of antiseptic drinks.

[2.] The second method of moderating the violence of re-action is by the employment of certain sedative powers with a view to diminish the activity of the whole body, and particularly that of the sanguiferous system. The first of these to be mentioned is the application of cold. Heat is the chief support of the activity of the animal-system; and the system is therefore provided with a power of generating heat in itself; but at the same time we observe, that this would go to excess, were it not constantly moderated by a cooler temperature in the surrounding atmosphere. When, therefore, the generating power of heat in the system is increased, as is commonly the case in fevers, it is necessary not only to avoid all further means of increasing it, but also to apply air of a cooler temperature; or at least to apply it more entirely and freely than in a state of health. This is shown, from some late observations, to be a very powerful means of moderating the violence of re-action; but what is the mode of its operation, to what circumstances of fever it particularly applies, or what limitations it requires, are not yet well ascertained.

Another sedative power very frequently employed in fevers, is that of certain medicines known in the materia medica by the name of refrigerants. The chief of these are acids of all kinds when sufficiently diluted, and which are, in several respects, remedies adapted to continued fevers. Those especially in use are the vitriolic and vegetable; and on many accounts the latter are to be preferred. Another set of refrigerants are the neutral salts formed of the vitriolic, nitrous, or vegetable acids, with alkalis either fixed or volatile. All these neutrals, while they are dissolved in water, generate cold; but as that cold ceases soon after the dissolution is finished, and as the salts are generally exhibited in a dissolved state, their refrigerant power in the animal-body does not at all depend upon their power of generating cold with water. Nitre is the refrigerant chiefly employed; but all the others, compounded as above-mentioned, partake more or less of the same quality. Besides these neutrals, some metallic salts have also been employed in fevers, particularly the sugar of lead; but the refrigerant powers of this salt are by no means well ascertained, and its deleterious qualities are too well known to admit of its being freely used.

[3.] The third general method of diminishing the re-action of the system, is by lessening the tension, tone, and activity of the sanguiferous system. As the activity of the system in a great measure depends upon the tone, and this again upon the tension, of the vessels, given to them by the quantity of fluids they contain, it is evident, that the diminution of the quantity of these must diminish the activity of the sanguiferous system. The most efficacious means of diminishing the quantity of fluids is by the evacuations of blood-letting and purging. The former is evidently one of the most powerful means of diminishing the activity of the whole body, and especially of the sanguiferous system; and it must therefore be the most effectual means of moderating the re-action in fevers. When the violence of re-action, and its constant attendant a phlogistic diathesis, are sufficiently evident; when these constitute the principal part of the disease, and may be expected to continue through the whole of it, as in the cases of synocha; then blood-letting is the principal remedy, and may be employed as far as the symptoms of the disease may seem to require, and the constitution of the patient will bear. It must, however, be attended to, that a greater evacuation than is necessary may occasion a slower recovery, and render the person more liable to a relapse, or bring on other diseases. It is also to be observed, that this evacuation is the more effectual as the blood is more suddenly drawn off, and as the body is at the same time more free from all irritation; and, therefore, when it is in a posture in which the fewest muscles are in action.

With regard to purging, when we consider the quantity of fluids constantly present in the cavity of the intestines, and the quantity which may be drawn off from the innumerable excretories that open into this cavity, it will be obvious, that a very great evacuation may be made by purging; and if this be done by a stimulus that is not at the same time communicated to the rest of the body, it may, by emptying both the cavity of the intestines and the arteries which furnish the excretions poured into it, induce a considerable relaxation in the whole system; and is therefore suited to moderate the violence of re-action in fevers. But it is to be observed, that as the fluid drawn from the excretories opening into the intestines is not all drawn immediately from the arteries, and as what is even more immediately drawn from these is drawn off slowly; so the evacuation will not, in proportion to its quantity, occasion such a sudden depletion of the red vessels as blood-letting does; and therefore cannot act so powerfully in taking off the phlogistic diathesis of the system.

At the same time, the evacuation may induce a considerable degree of debility; and therefore, in those cases in which a dangerous state of debility is likely to occur, purging is to be employed with a great deal of caution; and this caution is more difficult to be observed than in the case of blood-letting; and it is further to be noticed, that as purging takes off in some measure the determination of the blood to the vessels on on the surface of the body, it seems to be an evacuation not well adapted to the cure of fevers.

II. The other method of moderating the violence of reaction in fevers is by the exhibition of those remedies suited to take off the spasm of the extreme vessels, supposed to be the irritation which chiefly supports the reaction. The means to be employed for this purpose are either internal or external.

Firstly, the internal means are, 1. Those which determine the force of the circulation to the extreme vessels on the surface of the body, and, by restoring the tone and activity of these vessels, overcome the spasm on their extremities. 2. Those medicines which have the power of taking off spasms in any part of the system, and which are known under the title of Antispasmodics.

(1.) Those remedies which are fit to determine to the surface of the body are, 1. Diluents. 2. Neutral salts. 3. Sudorifics. 4. Emetics.

1. Water enters, in a large proportion, into the composition of all the animal-fluids, and a large quantity of it is always diffused through the whole of the common maws. In a sound state, the fluidity of the whole maws depends upon the quantity of water present in it. Water therefore is the proper diluent of our maws of blood, and other fluids are diluent only in proportion to the quantity of water they contain.

In a healthy state also, the fullness of the extreme vessels and the quantity of excretion are in proportion to the quantity of water present in the body. But in fever, though the excretions are in some measure interrupted, they continue in such quantity as to exhale the more fluid parts of the blood; and, while a portion of them is at the same time necessarily retained in the larger vessels, the smaller and the extreme vessels, both from the deficiency of fluid and their own contracted state, are left filled, and therefore allowed to remain in that condition. To remedy this contracted state, nothing is more necessary than a large supply of water or watery fluids taken in by drinking or otherwise; for as any superfluous quantity of water is forced off by the several excretories, such a force applied may be a means of dilating the extreme vessels, and of overcoming the spasm affecting their extremities. Accordingly, the throwing in of a large quantity of watery fluids has been, at all times, a remedy much employed in fevers; and in no instance more remarkably than by the Spanish and Italian physicians, in the use of what they call the dieta aquosa. This practice consists in taking away every other kind of aliment and drink, and in giving, in divided portions, every day for several days together, six or eight pounds of plain water, generally cold, but sometimes warm. All this, however, is to be done only after the disease has continued for some time, and at least for a week.

2. A second means of determining to the surface of the body, is by the use of neutral salts. These neutrals, in a certain dose, taken into the stomach, produce soon after a sense of heat upon the surface of the body; and, if the body be covered close and kept warm, a sweat is readily brought out. The same medicines taken during the cold stage of a fever, very often put an end to it, and bring on the hot one; and they are also remarkable for stopping the vomiting which so frequently attends the cold stage of fevers. All this shows, that neutral salts have a power of determining the blood to the surface of the body, and may therefore be of use in taking off the spasm which subsists there in fevers. The neutral most commonly employed in fevers, is that formed of an alkali with the native acid of vegetables. But all the other neutrals have more or less of the same virtue; and perhaps some of them, particularly the ammoniacal salts, possess it in a stronger degree. As cold water taken into the stomach often shows the same diaphoretic effects with the neutral salts, it is probable that the effect of the latter depends upon their refrigerant powers above-mentioned.

3. A third method of determining to the surface of the body, and taking off the spasm subsisting there, is by the use of sudorifics and of sweating. The propriety of this remedy hath been much disputed; and many specious arguments may be adduced both for and against the practice. In its favour may be urged, 1. That in healthy persons, in every case of increased action of the heart and arteries, a sweating takes place, and is, seemingly, the means of preventing the bad effects of such increased action. 2. That, in fevers, their most usual solution and termination is by spontaneous sweating. 3. That, even when excited by art, it has been found useful at certain periods, and in certain species of fever.—On the other hand, it may be urged against the practice of sweating, 1. That in fevers, as a spontaneous sweating does not immediately come on, there are some circumstances different from those in the state of health, and which may render it doubtful whether the sweating can be safely excited by art. 2. That in many cases the practice hath been attended with bad consequences. The means commonly employed have a tendency to produce an inflammatory diathesis; which, if not taken off by the sweat succeeding, must be increased with much danger. Thus sweating employed to prevent the accessions of intermittent fevers has often changed them into a continued form, which is always dangerous. 3. The utility of the practice is doubtful, as sweating, when it happens, does not always give a final determination, as must be manifest in the case of intermittents, and in many continued fevers which are sometimes in the beginning attended with sweatings which do not prove final; and, on the contrary, whether they be spontaneous or excited by art, seem often to aggravate the disease.

From these considerations, it is doubtful if the practice of sweating can be admitted very generally; but, at the same time, it is also very doubtful if the failure of the practice, or the mischiefs said to arise from it, have not been owing to the improper conduct of the practitioner. With respect to the last, it is almost agreed among physicians, 1. That sweating has been generally hurtful when excited by stimulant, heating, and inflammatory medicines. 2. That it has been hurtful when excited by much external heat, and continued with a great increase of the heat of the body. 3. That it is always hurtful when it does not relieve; and rather increases the frequency and hardness of the pulse, the anxiety and difficulty of breathing, the headache, and delirium. 4. That it is always hurtful if it is urged when the sweat is not fluid, and when it is partial and on the superior parts of the body only.

In these cases, it is probable, that either an inflammatory diathesis is produced, which increases the spasm on the extreme vessels; or that, from other causes, the spasm is too much fixed to yield easily to the increased action of the heart and arteries; and upon either supposition it must be obvious, that urging the sweat may produce determinations to some of the internal parts, with very great danger.

Notwithstanding these doubts, however, it still remains true, 1. That sweating has certainly been often useful in preventing the accessions of fevers when they have been certainly foreseen, and a proper conduct employed. 2. That even after fevers have in some measure come on, sweating has interrupted their progress when properly employed, either at the very beginning of the disease, or during its approach and gradual formation. 3. That even after pyrexia have continued for some time, sweating has been successfully employed in curing them, as particularly in the case of a rheumatism. 4. That certain fevers produced by a very powerful sedative contagion, have been generally treated most successfully by sweating.

These instances are in favour of sweating, but give no general rule; and it must be left to farther experience to determine how far any general rule can be established in this matter. In the mean time, if the practice of sweating is to be attempted, the following rules may be laid down for the conduct of it. 1. That a sweat should be exhibited without the use of stimulant inflammatory medicines. 2. That it should be excited with as little external heat, and with as little increase of the heat of the body, as possible. 3. That, when excited, it should be continued for a due length of time; not less than 12 hours, and sometimes for 24 or 48 hours; always, however, supposing that it proceeds without the dangerous circumstances already mentioned. 4. That for some part of the time, and as long as the person can easily bear, it should be carried on without admitting of sleep. 5. That it should be rendered universal over the whole body; and therefore particularly that care be taken to bring the sweating to the lower extremities. 6. That the practice should be rendered safer by moderate purging excited at the same time. 7. That it should not be suddenly checked by cold any how applied to the body.

When attention is to be given to these rules, the sweating may be excited, 1. By warm bathing, or a fomentation of the lower extremities. 2. By frequent draughts of tepid liquors, chiefly water, rendered more grateful by the addition of a light aromatic, or more powerful by that of a small quantity of wine. 3. By giving some doses of neutral salts. 4. Most effectually, and perhaps most safely, by a large dose of an opiate, joined with a portion of neutral salts, and of an emetic.

The fourth mean of determining to the surface of the body, and thereby taking off the spasm affecting the extreme vessels, is by the use of emetics. These, particularly of the antimonial kind, have been employed in the cure of fevers ever since the introduction of chemical medicines; and though of late their use has become very general, their efficacy is still disputed, and their manner of operating is not commonly explained.

Vomiting is in many respects useful in fevers; as it evacuates the contents of the stomach, as it emulates the biliary and pancreatic ducts, and evacuates the contents of the duodenum, and perhaps also of a larger portion of the intestines; as it agitates the whole of the abdominal viscera, it expedites the circulation in them, and promotes their several secretions; and lastly, as it agitates also the viscera of the thorax, it has like effects there.

It is not to this cause, however, that we are to impute the effect vomiting has in determining to the surface of the body. This must be attributed to the particular operation of emetics upon the muscular fibres of the stomach, whereby they excite the action of the extreme arteries on the surface of the body, and thereby effectually determine the blood to these vessels, remove the atony, and take off the spasm affecting them. For this purpose they are exhibited in two different ways; that is, either in such doses as may excite full and repeated vomitings, or in such doses as may excite sickness and nausea only, with little or no vomiting at all.

Full vomiting is well suited to determine to the surface of the body, and thereby to obviate the atony and spasm which lay the foundation of fever. Thus, vomiting excited a little before the expected accession of the paroxysm of an intermittent, has been found to prevent the paroxysm altogether. It has been observed also, that when contagion has been applied to a person, and first discovers its operation, a vomit given will prevent the fever which otherwise was to have been expected.

These are the advantages to be obtained by exciting vomiting at the first approach of fevers, or of the paroxysm of fevers; and they may also be applied after fevers are formed, to take off, perhaps entirely, the atony and spasm, or at least to moderate these, so that the fever may proceed more gently and safely. It is seldom, however, that vomiting is found to produce a final solution of fevers; and after they are once formed, it is commonly necessary to repeat the vomiting several times; but this is attended with inconvenience, and sometimes with disadvantage. The operation of full vomiting is tranitory, and the exercise of vomiting is a debilitating power; and therefore, when the vomiting does not remove the atony and spasm very entirely, it may give occasion to their recurrence with greater force. For these reasons, after fevers are fully formed, physicians have thought proper to employ emetics in nauseating doses only. These are capable of exciting the action of the extreme vessels, and their operation is more permanent. At the same time they often show their power by exciting some degree of sweat, and their operation is rendered more safe by their commonly producing some evacuation by stool.

The emetics chiefly in use at present are, ipecacuanha and antimony. The former may be employed for determining to the surface of the body; but, even in very small doses, it so readily excites vomiting, that it is with difficulty employed for the purpose of nauseating only; and in whatever manner employed, there is reason to suspect that its effects are less permanent, and less powerfully communicated from the stomach to the rest of the system, than those of antimony. This last is therefore generally preferred; and its preparations, seemingly various, may all be reduced to two heads; one comprehending those in which the reguline part is in a condition to be acted upon by acids, and therefore on meeting with acids in the stomach it becomes active; and another, comprehending those preparations in which the reguline part is already joined with an acid, rendering it active. Of each kind there are are great numbers, but not differing essentially from one another; the two most worthy of notice are, the calx nitratæ antimonii and emetic tartar of the Edinburgh dispensatory. Both these are very efficacious medicines; but the latter seems preferable, because its dose is capable of being better ascertained; though the former, on account of its slower operation may have some advantages, and in certain cases be more efficacious as a purgative and sudorific.

The time most proper for exhibiting these medicines is a little before the accession, when that can be certainly known. In continued fevers the exacerbations are not always very observable; but there is reason to believe, that one commonly happens about noon or soon after it; and that these, therefore, are the most proper times for exhibiting emetics.

With respect to the manner of administration, that of the calx nitratæ is simple, as the whole of what is thought a proper dose may be given at once; and no more can be properly given till the next accession. The administration of the emetic tartar is different. It is to be given in small doses, not sufficient to excite vomiting; and these doses are to be repeated, after short intervals, for several times, till sickness, nausea, and some, though not much, vomiting come on. The difference of administration must depend upon the dose, and the length of the interval at which it is given. If it is intended that the medicine should certainly operate by stool, the doses are made small, and the intervals long. On the contrary, when vomiting is proper, or when much purging ought to be avoided, and therefore some vomiting must be admitted, the doses are made larger, and the intervals shorter. With respect to both kinds of preparations, the repetition is to be made at the times of accession, but not very often: for if the first exhibitions, duly managed, have little effect, it is seldom that the after exhibitions have much; and it sometimes happens that the repeated vomiting, and especially repeated purging, does harm by weakening the patient.

(2.) The other set of internal medicines which are supposed useful in taking off the spasm of the extreme vessels, are those named antispasmodic. But whatever may be the virtues of some of them in this way, such is their power of stimulating at the same time, that very few of them can with safety be administered in fevers of an inflammatory nature. Almost the only one which can with safety be exhibited in these cases is camphire; and the operations of this are by no means well ascertained. Dr Huxham mentions it as a corrector of the acrimony of cantharides; and assures us, that it very effectually promotes a diaphoresis. But from the remarks of other practitioners, we have no just reason to suppose that it acts perceptibly in a dose of five or six grains, though in 15 or 20 it produces a particular kind of intoxication.

Secondly, The external means suited to take off the spasm of the extreme vessels, are blistering and warm bathing.

1. What are the effects of blistering so frequently employed in fevers, is not yet agreed upon among physicians. Dr Cullen is of opinion, that the small quantity of cantharides absorbed from a blistering plaster, is not sufficient to change the consistence of the mass of blood; and therefore, that such a quantity can neither do good by resolving phlogistic lector if it exists, nor do harm by increasing the dissolution of the blood arising from a putrid tendency in it. The effects of cantharides upon the fluids, therefore, may be entirely neglected. The inflammation produced by the application of cantharides to the skin, affords a certain proof of their stimulant power; but in many persons the effect of that stimulus is not considerable; in many it is not communicated to the whole system; and even when it does take place in the whole system, it seems to be taken off very entirely by the effusion and evacuation of serum from the blistered part. It may be concluded, therefore, that neither much good is to be expected, nor much harm to be apprehended, from the stimulant power of blistering; and the certainty of this conclusion is established by the great benefit arising from the proper practice of blistering in inflammatory diseases. Much has been imputed to the evacuation made by blistering; but it is never so considerable as to affect the whole system; and therefore can neither by a sudden depletion relax the sanguiferous system, nor by any revolution affect the general distribution of the fluids. The evacuation, however, is so considerable as to affect the neighbouring vessels; and the manifest utility of blistering near the part affected in inflammatory diseases leads us to think, that blistering, by deriving to the skin, and producing an effusion there, relaxes the spasm of the deeper seated vessels. It is in this manner, most probably, that the tumour of a joint, from an effusion into the cellular texture under the skin, takes off the rheumatic pain formerly affecting that joint. Analogous to this, probably, is the good effect of blistering in continued fevers; and arises from the relaxation of the spasm of the extreme vessels by a communication of the blistered part with the rest of the skin. A blister may be employed at any period in continued fevers; but it will be of most advantage in the advanced state of such fevers, when, the reaction being weaker, all ambiguity from the stimulating power of blistering is removed, and when it may best concur with other circumstances tending to a final solution of the spasm.

From this view of the matter it will appear, that the part of the body to which blisters ought to be applied is indifferent, except upon the suspicion of topical affection, when the blistering is to be made as near as possible to the part affected. Whether snapiums and other rubefacientia act in a manner analogous to what we have supposed of blistering, may be doubtful; but their effects in rheumatism and other inflammatory diseases render it probable.

2. The other external means of taking off the spasm of the extreme vessels is warm bathing. This was frequently, and in different circumstances, employed by the ancients; but has, till very lately, been neglected by modern physicians. As the heat of the bath stimulates the extreme vessels, and, with the concurrence of moisture, also relaxes them, it seems to be a safe stimulus, and well suited to take off the spasm affecting these vessels. It may be applied to the whole body by immersion; but this is in many respects inconvenient; and whether some of the inconveniences of immersion might not be avoided by a vapour-bath, we have not yet learned by experience; but we know from much experience, that most of the purposes of warm bathing can be obtained by a fo- mentation of the legs and feet, if properly administered, and continued for a due length of time, not less than an hour. The marks of the good effects of such a fomentation are, the patient's bearing it easily, its relieving delirium, and inducing sleep.

Thus doth the learned professor lay down the cure of inflammatory fevers in so full a manner, that nothing further seems necessary to be added on the subject. His other two indications, namely, removing the debility, and correcting the putrefactive disposition of the fluids, shall be taken notice of under the following genus.

GENUS V. TYPHUS; the Typhus Fever.

Typhus, Sauv. Gen. 82. Sag. 677.

XXVI. The Slow Nervous Fever. Sp. I. var. 1. Febris maligna hectica convulsiva, five lines inscribed, Willis, de morb. convulv. cap. 8. Febris pestilens, Fracastor. de morb. contag. L. II. cap. 4. Febris pestilens sine charactere venenii, Foresti, L. VI. obs. 26. Febris hectica pestilens, Foresti, L. VI. obs. 32. Febris nova ann. 1685, Sydenham, Sched. monitor. Febris putrida nervosa, Winteringh. Com. Nosolog. ad ann. 1720, 1721. Febris lenta nervosa, Huxham on fevers, chap. 8. Febris contagiosa, Lind on fevers and infection, passim. Typhus nervosus, Sauv. sp. 2. Typhus comatosus, Sauv. sp. 3. Tritaeophya typhodes Mangetti, Sauv. sp. 11. Raym. Fort. de febribus.

Description. Of all the descriptions we have of the nervous fever, that of Dr Huxham is the best. According to him, the patient at first grows somewhat listless, and feels slight chills and shudders, with uncertain flushes of heat, and a kind of weariness all over, like what is felt after great fatigue. This is always attended with a sort of heaviness and dejection of spirit, and more or less of a load, pain, or giddiness of the head; a nausea and distaste of every thing soon follows, without any considerable thirst, but frequently with urging to vomit, though little but thin phlegm is brought up. Though a kind of lucid interval of several hours sometimes intervenes, yet the symptoms return with aggravation, especially towards night; the head grows more giddy or heavy; the heats greater; the pulse quicker, but weak; with an oppressive kind of breathing. A great torpor, or obtuse pain and coldness, affects the hinder-part of the head frequently, and oftentimes a heavy pain is felt on the top all along the coronary sutures; this, and that of the back-part of the head, generally attend nervous fevers, and are commonly succeeded by some degree of a delirium. In this condition the patient often continues for five or six days, with a heavy, pale, sunk countenance; seemingly not very sick, and yet far from being well; restless, anxious, and commonly quite void of sleep, though sometimes very drowsily and heavy; but although he appears to those about him actually to sleep, he is utterly insensible of it, and denies that he doth so. The pulse during all this time is quick, weak, and unequal; sometimes fluttering, and sometimes for a few moments slow; nay, even intermitting, and then, with a sudden flush in the face, immediately very quick, and perhaps soon after surprisingly calm and equal; and thus alternately. The heats and chills are as uncertain and unequal; sometimes a sudden colour and glower in the cheeks, while the tip of the nose and ears is cold, and the forehead at the same time in a cold dewy sweat. Nay, it is very common, that a high colour and heat appear in the face, when the extremities are quite cold. The urine is commonly pale, and often limpid; frequently of a whey colour, or like vapid small-beer, in which there is either no manner of sediment, or a kind of loose matter like bran irregularly scattered up and down in it. The tongue at the beginning is seldom or never dry or discoloured, but sometimes covered with a thin whitish mucus: at length, indeed, it often appears very dry, red, and chapped, or of the colour of pomegranate-rind; but this mostly at the state or close of the disease: yet, however dry the tongue and lips seem, the patient scarce ever complains of thirst, though sometimes of a heat in the tongue. About the seventh or eighth day, the giddiness, pain, or heaviness of the head become much greater, with a constant noise in it, or tinnitus aurium; which is very disturbing to the sick, and frequently brings on a delirium. The load on the precordia, anxiety and faintness, grow much more urgent; and they often fall into an actual delirium, especially if they attempt to sit up; coldish sweats suddenly come out on the forehead, and on the backs of the hands, (though at the same time there is too much heat in the cheeks and palms,) and as suddenly go off. If the urine now grows more pale and limpid, a delirium is certainly to be expected, with universal tremors and subfultus tendium; the delirium is seldom violent, but as it were a confusion of thought and action, muttering continually to themselves, and faltering in their speech. Sometimes they awake only in a hurry and confusion, and presently recollect themselves, but forthwith fall into a muttering dozy state again. The tongue grows often very dry at the state, especially in its middle-part, with a yellowish tincture on each side, and trembles greatly when the sick attempts to put it out. Frequently profuse sweats pour forth all at once about the ninth, tenth, or twelfth day, commonly coldish and clammy on the extremities; oftentimes very thin stools are discharged, and then nature sinks asleep; the extremities grow cold, the nails pale or livid; the pulse may be said to tremble and flutter, rather than to beat, the vibrations being so exceeding weak and quick that they can scarcely be distinguished; though sometimes they creep on surprisingly slow, and very frequently intermit. The sick become quite insensible and stupid, scarce affected with the loudest noise or the strongest light; though, at the beginning, strangely susceptible of the impressions of either. The delirium now ends in a profound coma, and that soon in eternal sleep. The stools, urine, and tears, run off involuntarily, and announce a speedy dissolution, as the yest tremblings and twitchings of the nerves and tendons are preludes to a general convulsion, which at once snaps off the thread of life. In one or other of these ways are the sick carried off, after having languished for fourteen, eighteen, or twenty days; nay, sometimes much longer. All persons grow deaf and stupid towards the end of this

Practice this disease (some extremely deaf), though too quick and apprehensive at the beginning; insomuch that the least noise or light greatly offended them. Many from their immoderate fears seem to hurry themselves out of life, where little danger is apparent at the beginning: nay, some will not allow themselves to sleep, from a vain fear of dozing quite away; and others from the vast hurry, anxiety and confusion they are sensible of in it, or at their waking.

Causes of, and persons subject to, the disorder. The nervous fever is a consequence of contagion received by means of some corrupted animal-substance. It most commonly attacks persons of weak nerves, a lax habit of body, and a poor thin blood; those who have suffered great evacuations, a long dejection of spirits, immoderate watchings, studies, fatigue, &c.; also those who have used much crude unwholesome food, vapour impure drinks, or who have been confined long in damp foul air; who have broken the vigour of their constitutions by salivations, too frequent purging, immoderate venery, &c. Hence we see that the disease consists principally in an extreme debility of the nervous system; for, when people are prepared for this fever by having their nerves already weakened, the contagious particles immediately attack the nervous system, without so much affecting the state of the blood or juices, though the latter are greatly affected in the putrid malignant fevers.

Prognosis. In nervous fevers, the prognostic is very much the same with that of the putrid malignant kind. See below.

Cure. As this fever is produced by a contagion affecting the nervous system of a person already debilitated, and thus producing weakness in an extreme degree, we have now occasion to consider Dr Cullen's two indications of cure omitted under the Synopsis; namely, to remove the cause and obviate the effects of debility, and to correct the putrefactive tendency of the fluids; for though, in the beginning of nervous fevers, the tendency to putrefaction is not remarkable, it becomes exceedingly great towards their conclusion.

[1.] In answering the first indication, Dr Cullen observes, that most of the sedative powers inducing debility cease to act soon after they have been first applied; and therefore the removing them is not an object of the present indication. There is only one which may be supposed to continue to act for a long time, and that is the contagion applied; but we know nothing in the nature of contagion that can lead us to any measures for removing or correcting it. We know only its effects as a sedative power inducing debility, or as a ferment inducing a tendency to putrefaction in the fluids, the former of which at present falls under our consideration.—The debility induced in fevers by contagion, or other causes, appears, especially in the weaker energy of the brain; but in what this consists, or how it may be restored, we do not well know; but as nature, seemingly for this purpose, excites the motion of the heart and arteries, we must ascribe the continuance of the debility to the weaker re-action of the sanguiferous system: the means, therefore, which we employ for obviating debility, are immediately directed to support and increase the action of the heart and arteries; and the remedies employed are tonics or stimulants.

In contagious diseases we know, both from the effects which appear, and from dissections, that the tone of the heart and arteries is considerably diminished; and that tonic remedies are therefore properly indicated. We are to consider these remedies as of two kinds; 1. The power of cold; 2. That of tonic medicines.

The power of cold as a tonic in fevers may be employed in two ways; either as thrown into the stomach, or as applied to the surface of the body. As we have already observed that the power of cold may be communicated from any one part to every other part of the system, so it will be readily allowed that the stomach is a part as fit as any other for this communication, and that cold drink taken into the stomach may prove an useful tonic in fevers.—This the experience of all ages has confirmed; but at the same time it has been frequently observed, that, in certain circumstances, cold drink taken into the stomach has proved very hurtful; and therefore that its use in fevers requires some limitations. What these limitations should be, and what are all the circumstances which may forbid the use of cold drink, it is difficult to determine; but it seems clearly forbidden in all cases where a phlogistic diathesis prevails in the system, and more especially when there are topical affections of an inflammatory nature.

The other method of employing cold as a tonic, is by applying it to the surface of the body, as a refrigerant power fit to moderate the violence of reaction; but probably it may here also be considered properly as a tonic, and useful in cases of debility.—Not only cool air, but cold water also, may be applied to the surface of the body as a tonic. The ancients frequently applied it with advantage to particular parts as a tonic; but it is a discovery of modern times, that, in the case of putrid fevers attended with much debility, the body may be washed all over with cold water. This was first practised at Breslau in Silesia, as appears from a dissertation under the title of Epidemia Verna, qua Wratislaviam anno 1737 afflictit, to be found in the Acta Nat. Curios. vol. x. And from other writers it appears, that the practice has passed into some of the neighbouring countries; but in this island it doth not appear that we have yet had any experience of it.

The medicines which have been employed in fevers as tonics are various. If the saccharum sativum hath been found useful, it is probably as a tonic rather than as a refrigerant; and the ens veneris, or other preparations of iron which have been employed, can act as tonics only. The preparations of copper, from their effects in epilepsy, are presumed to possess a tonic power; but whether their use in fevers be founded on their tonic or emetic powers, is uncertain. And upon the whole there may no doubt occur some instances of fevers being cured by tonics taken from the fossil kingdom; but the vegetable tonics are the most efficacious, and among these the Peruvian bark certainly holds the first place.

The bark has commonly been considered as a specific, or a remedy of which the operation was not understood. We must observe, however, that, as in many cases the effects of the bark are perceived soon after The putrid or putrefactive matter already present in the body, may be evacuated partly by frequent evacuations of the contents of the intestines; and more effectually still by supporting the excretions of perspiration and urine by the plentiful use of diluents. That which remains in the body may be rendered more mild and innocent by the use of diluents, or may be corrected by the use of antiseptics. These last are of many and various kinds; but which of them are conveniently applicable, or more particularly suited to the case of fevers, is not well ascertained. Those most certainly applicable and useful are acetic acids, acids of all kinds, and neutral salts.

The progress of putrefaction may be considerably retarded, and its effects obviated, by supporting the tone of the vessels; and this may be done by tonic medicines, of which the chief are Cold, and the Peruvian bark, as already mentioned. The violence of re-action increasing the tendency to putrefaction, may be moderated by the means already mentioned under synoica.

These are the proper indications to be observed in the cure of the slow nervous fever. Dr Huxham observes, that evacuations (especially bleeding) are improper at the beginning. Even a common purge given at this time hath been followed by surprising languors, syncope, and a train of other ill symptoms. However, it may sometimes be necessary to cleanse the stomach and prime viz by a gentle emetic, or a little rhubarb, manna, &c. Indeed, where nausea, sickness, and load at stomach, are urgent, as is frequently the case in the beginning of this fever, a vomit is necessary. Clysters of milk, sugar, and salt, may be injected with safety and advantage every second or third day, if nature wants to be prompted to stool.—The temperate, cordial, diaphoretic medicines are certainly, according to our author, most proper in these fevers; and a well-regulated, supporting, diluting diet is necessary. The latter of itself, judiciously managed, will go a great way in the cure, especially afflicted by well-timed and well-applied blisters, and a due care to keep the patient as quiet as possible both in body and mind. But it should be noted, that any strong opiates are commonly very pernicious, however much the want of sleep and restlessness may seem to demand them. Mild diaphoretics, as pulv. contrayeru. comp., with a little caffor and saffron, and small quantities of theriac, Andromedae or elixir pargaricum, have much better effects; which, by raising a gentle easy sweat, or at least a plentiful perspiration, calm the hurry of the spirits, and a refreshing sleep ensues. Where the confusion and dejection of spirits are very considerable, galbanum or sulphur should be added, and blisters forthwith applied to the neck, occiput, or behind the ears; and during all this a free use of thin wine-whey, some pleasant pifan or gruel, with a little soft wine, must be indulged. Indeed the patients, in this case, should drink frequently: though such quantities may not be necessary as in the ardent, or even putrid malignant fevers; yet they should be sufficient to carry on the work of dilution, support the feasts, and supply the blood with fresh and wholesome fluids, in place of that noxious matter which is continually passing off. In this view also a thin chicken-broth is RACTICE of service, both as food and physic, especially towards the decline of the disease; and for the same reason thin jellies of hawthorn, fago, panada, are useful, adding a little wine to them, and the juice of Seville orange or lemon.

It is observable, that the sick are never so easy as when they are in a gentle sweat; for this soon removes the hurry of spirits, exacerbations of heat, &c. But profuse sweats should never be encouraged, much less attempted, by very strong heating medicines, especially in the beginning or advance of the fever; for they too much exhaust the vital powers, and are followed by a vast dejection of spirits, tremors, startings of the tendons, and sometimes end in rigors, cold clammy sweats, syncope, or a comatose disposition. Sometimes irregular partial heats and flushes succeed, with great anxiety, restlessness, delirium, difficulty of breathing, and a vast load and oppression in the precordia, so as to incline the least cautious observer to think there may be something peripneumonic in it; but even here we must beware of bleeding, as the pulse will be found very small and unequal, tho' very quick. Nor is bleeding contra-indicated only by the weakness and fluttering of the pulse, but also by the pale, limpid, and watery urine which is commonly attendant. These symptoms denote the load, anxiety, and oppression on the precordia to proceed from an affection of the nervous system, and not from a peripneumonic obstruction or inflammation. The breathing, in this case, though thick and laborious, is not hot, but a kind of sighing or sobbing respiration, nor is there often any kind of cough concomitant; so that it evidently proceeds from some spasm on the vitals. Here therefore the nervous cordial medicines are indicated, and blisters to the thighs, legs, or arms. Our author commonly used the following bolus and saline draught.

B. Pulv. contrayerv. c. gr. xv. Croc. Angl. gr. iii. Confect. Ralegh. 3j. Syr. Croci q. f. M. f. Bolus.

B. Sal. C. C. 3f. Suc. limon. 3ij. Aq. alexit. simpl. 3f. M. Peraltæ effervescens. add. sp. lavend. c. f. yr. croc. ana 3f. M. f. Haust.

If great tremors and subfultus tendinum come on, he substitutes half a scruple of musk instead of the contrayerva in the bolus, with advantage. One or other of these, or similar prescriptions, are to be taken every fifth, sixth, or eighth hour, and a temperate cordial julep; spiritus volatilis aromaticus or fustidus, may be now and then given out of thin wine, or cyder-whey, or, which is in many cases better, out of mustard-whey; which last is by no means a contemptible medicine. The saline draught made as above is much more apt to pass thro' the pores of the skin than when made with salt of wormwood, which rather moves thro' the urinary passages.

The above-mentioned difficulty of breathing, anxiety, and oppression, many times precede a miliary eruption, which often appears on the seventh, ninth, or eleventh day of the fever, and sometimes later. Indeed great anxiety and oppression on the precordia always precede pustular eruptions of any kind in all sorts of fevers. This eruption should be promoted by soft easy cordials, and proper diluents; to which should be sometimes added a little theriaca andromachi or elixir asthmaticum. These tend to calm the universal uneasiness commonly complained of, and also very effectually promote a diaphoretics, or breathing kindly sweats, with which the miliary eruptions freely and easily advance. But however advantageous these commonly are, profuse sweats are seldom or never so, even though attended with a very large eruption. Two or three crops of these miliary pustules have been known to succeed one another, and large sweats, not only without advantage, but with great detriment to the patients, as they were thereby reduced to an extreme degree of weakness; so that they may justly be reckoned symptomatical rather than any thing else, and the consequent eruption is often merely the symptom of a symptom; for the miliary glands of the skin appear very turgid, and mimic a rash, after profuse sweating, even in the most healthy.

In these profuse colliquative sweatings a little generous red wine (diluted somewhat, if necessary) may be given with the greatest advantage; as it presently moderates the sweats, supports the patient, and keeps up the miliary papule if they happen to attend. Towards the decline of the fever also, where the sweats are abundant and weakening, small doses of the tincture of the bark with saffron and snake-root were given with the greatest advantage, frequently interpolating a dose of rhubarb to carry off the putrid colluvies in the first passages; which withal makes the remissions or intermissions that often happen in the decline of nervous diseases more distinct and manifest, and gives a fairer opportunity of throwing in the bark; for in the proper exhibition of this medicine we are to place our chief hope of curing both the nervous and putrid malignant fevers.

XXVII. The putrid, pestilential, or malignant Fever. Sp. I. var. 2. Febris pestilens, P. Sal. Diverf. de febre pestilenti. Febris pestilens Ægyptiorum, Alpin. de med. Ægypt. l. i. cap. 14. Typhus Ægyptiacus, Sauv. sp. 6. Febris pestilens maligna, Senert. de febribus, l. iv. cap. 10. Febris maligna pestilens, River. l. xvii. sect. iii. cap. 1. Febris pestilens maligna, ann. 1643, Willis, de febribus, cap. 14. Typhus carcerum, Sauv. sp. 1. Febris nautica pestilentialis, Huxham de æcre ad ann. 1740. Miliaris nautica, Sauv. sp. g. Febris patrida contagiosa in carceribus genita, Huxham de æcre ad ann. 1742. Miliaris purpurea, Sauv. sp. h. Febris carcerum et nolocomiorum. Ill. Pringle, Diseases of the army, p. 294. Ill. Van Swieten, Maladies des armées, p. 136. Typhus castratus, Sauv. sp. 5. Febris castratus, quam vulgo cephalalgiam epidemicam vocant, Henr. Mai et A. Ph. Kopf. Diff. apud Hallerum, tom. v. Febris Hungarica five castratus, Juncker. 74. et plu- Febris castrensis Gallorum in Bohemia, ann. 1742. Scrinici. Diff. apud Haller. tom. v. Febris petechialis, Sennert. l. iv. cap. 13. River. prax. l. xvii. sect. iii. cap. 1. Hoffm. II. p. 84. Junker. 73. Huxham on fevers, chap. 8. Ludu- wig. Inst. med. clin. n° 146. Schreiber von er- kentniss, und cur der Krankheiten. p. 126. Monro. Diseases of military hospitals, p. 1. Febris catarrhalis maligna petechizans, Junker 72. Hoffm. II. 75. Eller de cogn. et cur. morb. sect. vi. Febris qua lenticularis, puncticula, aut peteculas vo- cant, Fracastorius de morb. contag. lib. ii. cap. 6. Febris petecularis Tridenti, ann. 1591. Robertet de febr. petecul. Febris petechialis epidemica Coloniae ann. 1672. Doncker, Idea febris petechialis. Febris petechialis epidemica Pofonii 1683, C. F. Locu in App. ad A. N. C. vol. ii. Febris petechialis epidemica Mutinæ, 1692. Ra- mazzini. Const. Mutinensis, oper. p. 187. Febris maligna petechizans, ann. 1698. Hoffm. II. p. 80. Febris petechialis Wratislaviae ann. 1699. Hel- wich, Ephem. Germ. D. III. A. VII. et VIII. obf. 132. p. 616. Febris epidemia Lipsia 1718. M. Adolph. A. N. C. III. obf. 131. p. 296. Febris endemicæ et epidemica Corcagiensis ann. 1768, 1718, et seq. Rogers, Essay on epidemic diseases. Febris continua epidemica Corcagiensis ann. 1719. et seq. M. O'Connell Obf. de morbis. Febris petechialis epidemica Cremonæ 1734. Val- charenghi Med. ration. sect. iii. Febris petechizans Petropoli 1735. Weitbrecht. Diff. apud Haller. tom. v. Febris petechialis, ann. 1740, 1741, in Hassia, Ritter. A. N. C. vol. vii. obf. 4. Febris maligna petechialis Rintelli 1741. Furste- mayr. A. N. C. vol. vii. obf. 5. Febris petechialis epidemica Silifæ 1741 et seq. Brandtshoff. Diff. apud Haller. tom. v. Febris petechialis epidemica Vienæ 1757. Haf- ner. Hist. med. cap. 2. Febris petechialis epidemica Lipsia 1757. Ludu- wig. Adversar. tom. i. pars 1. Febris petechialis epidemica variis Germaniae locis ab. ann. 1755 ad 1761. Strack de morbo cum petechis.

Description. This is a disease of the most dangerous nature, as, besides the extreme debility of the nervous system, there is a rapid tendency of the fluids to putrefaction, which sometimes cuts off the patient in a few days, nay, in the warm climates, in 12 or 14 hours; or if the patient recovers, he is for a long time, even in this country, in an exceedingly weak state, and requires many weeks to recover his former health.

The putrid fevers, according to Huxham, make their attack with much more violence than the slow nervous ones; the rigors are sometimes very great, though sometimes scarce felt; the heats much sharper and permanent; yet, at first, sudden, transient, and remittent: the pulse more tense and hard, but commonly quick and small; though sometimes slow, and seemingly regular for a time, and then fluttering and unequal. The head-ach, nausea, and vomiting, are much more considerable even from the beginning. Sometimes a severe fixed pain is felt in one or both temples, or over one or both eye-brows; frequently in the bottom of the orbits of the eyes. The eyes always appear very dull, heavy, yellowish, and very often a little inflamed. The countenance seems bloated, and more dead-coloured than usual. Commonly the temporal arteries throb much, and a tinnitus aurium is very troublesome: a strong vibration also of the carotid arteries frequently takes place in the advance of the fever, though the pulse at the wrist may be small, nay even slow: this is a certain sign of an impending delirium, and generally proceeds from some considerable obstructions in the brain.

The prostration of spirits, weakness, and faintness, are often surprisingly great and sudden, though no inordinate evacuation happens; and this too sometimes when the pulse seems tolerably strong. The respiration is most commonly laborious, and interrupted with a kind of sighing or sobbing, and the breath is hot and offensive.

Few or none of these fevers are without a sort of lumbago, or pain in the back and loins; always an universal weariness or soreness is felt, and often much pain in the limbs. Sometimes a great heat, load, and pain, affect the pit of the stomach, with perpetual vomiting of porraceous or black cholera, and a most troublesome singultus; the matter discharged is frequently of a very nauseous smell. The tongue, tho' only white at the beginning, grows daily more dark and dry; sometimes of a shining livid colour, with a kind of dark bubble at top; sometimes exceeding black; and so continues for many days together; nor is the tinge to be got off many times for several days, even after a favourable crisis: at the height of the disease, it generally becomes vastly dry, stiff, and black, or of a dark pomegranate colour. Hence the speech is very inarticulate, and scarce intelligible. The thirst in the increase of the fever is commonly very great, sometimes unquenchable; and yet no kind of drink pleases, but all seem bitter and mawkish; at other times, however, no thirst is complained of, tho' the mouth and tongue are exceedingly foul and dry; this is always a dangerous symptom, and ends in a frenzy or coma. The lips and teeth, especially near the state, are furrowed up with a very black tenacious froth. At the onset of the fever, the urine is often crude, pale, and vapid, but grows much higher-coloured in the advance, and frequently resembles a strong lixivium, or citrine urine, tinged with a small quantity of blood; it is without the least sediment or cloud, and so continues for many days together: by degrees it grows darker, like dead strong high-coloured beer, and smells very rank and offensive. In petechial fevers, the urine hath often been seen almost black and very fetid. The stools, especially near the state, or in the decline of the fever, are for the most part intolerably fetid, green, livid, or black, frequently with severe gripes and blood. When they are more yellow or brown, the less the danger; but the highest when they run off insensibly, whatever their colour may be. It is likewise a very bad symptom when the belly continues tense, Sometimes black, livid, dun, or greenish spots appear, which always indicate a high degree of malignity; however, the more florid the spots are, the less danger is to be feared. It is also a good sign when the black or violet petechiae become of a brighter colour. The large, black, or livid spots, are almost always attended with profuse hemorrhages; and the small, dusky, brown spots, like freckles, are not much less dangerous than the livid or black; though they are seldom accompanied with fluxes of blood: excessively profuse, cold, clammy sweats are often concomitant, by which also they sometimes vanish, though without any advantage to the patient. The eruption of the petechiae is uncertain; sometimes they appear on the fourth or fifth day, though sometimes not till the eleventh, or even later. The vibices, or large, dark, greenish marks, seldom appear till very near the fatal period. Frequently also we meet with an efflorescence like the measles in malignant fevers, but of a much more dull and livid hue; in which the skin, especially on the breast, appears as it were marbled or variegated. This in general is an ill symptom, and is often attended with fatal consequences.

Sometimes about the 11th or 14th day, on the coming on of profuse sweats, the petechiae disappear, and vast quantities of white milky pustules break out. This is seldom found of any considerable advantage; but an itching, smarting, red rash, commonly gives great relief; and so do the large, fretting, watery bladders, which many times rise upon the back, breast, shoulders, &c. A scabby eruption likewise about the lips and nose is certainly one of the salutary symptoms; and the more hot and angry it is, so much the better. But of much more uncertain and dangerous event are the brown-coloured aphthae; nor are those that are exceeding white and thick like lard, of a very promising aspect. They are soon succeeded by great difficulty of swallowing, pain and ulceration of the fauces, oesophagus, &c. and with an incessant singultus: the whole prima via become at last affected; a bloody dysentery comes on, followed by a sphacelation of the intestines; as is evident from the black, fœtid, and bloody stools, extremely fetid and infectious. Vibices, or large, black, and bluish marks resembling bruises, are frequently seen towards the close of the fever; and, when attended with lividity and coldness of the extremities, are certain tokens of approaching death. In some cases, the blackness hath been known to reach almost to the elbows, and the hands have been dead-cold for a day or two before the death of the patient.

Such are the general appearances of the putrid malignant fever in this country, among those who enjoy a free air, and are not crowded together, or exposed to the causes of infection: but in jails, hospitals, or other places where the sick are crowded, and in some measure deprived of the benefit of the free air, the symptoms are, if possible, more terrible. Sir John Pringle, who had many opportunities of observing it, tells us, that the jail or hospital fever, in the beginning, is not easy to be distinguished from a common fever. The first symptoms are slight interchanges of heat and cold, a trembling of the hands, sometimes a sense of numbness in the arms, weakness of the limbs, loss of appetite; and the disorder increasing towards night, the body grows hot, the sleep is interrupted, and not refreshing. With these symptoms, for the most part, there is some pain or confusion in the head; the pulse at first is a little quicker than natural, and the patients find themselves too much indisposed to go about business, though too well to be wholly confined. When the fever advances, the above-mentioned symptoms are in a higher degree; and in particular the patient complains of a languor, nausea, pains in his back, a more constant pain and confusion in his head, attended with an uncommon dejection of spirits. At this time the pulse is never sunk, but beats quick, and often varies in the same day both as to strength and fulness. It is little affected by bleeding once, if a moderate quantity of blood is taken away; but if the evacuation is large, and especially if it is repeated, to answer a false indication of inflammation, the pulse, increasing in frequency, is apt to sink in force, and often irrecoverably, whilst the patient becomes delirious. But withal we must observe, that, in every case, independent of evacuations, the pulse sooner or later sinks, and then gives certain intelligence of the nature of the disease. The appearance of the blood is various; for though it is commonly little altered, yet sometimes it will be viscid, not only on the first attack, but after the fever is formed. The worst appearance is when the crustamentum is dissolved; though this does not happen till the advanced state of the fever; though indeed this seems not easy to be ascertained, as blood has been so seldom taken away at that time. The urine is also various. Sometimes it is of a reddish or flame colour, which it preserves a long time; but it is oftener pale, and changes from time to time in colour as well as crudity, being sometimes clear, sometimes clouded: towards the end, upon a favourable crisis, it becomes thick, but does not always deposit a sediment. If the sick lie warm, and have had no preceding flux, the belly is generally bound; but when they lie cold, as they often do in field-hospitals, the pores of the skin being shut, a diarrhoea is a common symptom, but is not critical. In the worst cases, a flux appears in the last stage; then the stools are involuntary, colligative, ichorous, or bloody, and have a cadaverous smell; the effects of a mortification of the bowels, and the sign of approaching death. When the hospitals are filled with dysenteric patients, some of the nurses will be infected with the flux only, and others with this fever, ending in these bloody and gangrenous stools.

In the beginning the heat is moderate; and even in the advanced state, on first touching the skin, it seems inconsiderable; but upon feeling the pulse for some time, we are sensible of an uncommon ardour, leaving an unpleasant sensation on the fingers for a few minutes after. A day or two before death, if care is not taken, the extremities become cold, and the pulse is then hardly to be felt. The skin is generally dry and parched; though sometimes there are longer or shorter sweats, especially in the beginning. Such as are produced by medicine are of no use, except on the first attack, at which time they will often remove the fever; and natural sweats are never critical till the distemper begins to decline. These last are rarely profuse, but gentle, continued, and equally diffused over the body: sometimes the disease will terminate by an almost imperceptible moisture of the skin; the sweats are usually fetid, and offensive even to the patient himself.

The tongue is commonly dry; and, without constant care of the nurse, becomes hard and brown, with deep chops: but this symptom is common to most fevers. At other times, though rarely, the tongue is soft and moist to the taste, but with a mixture of a greenish or yellowish colour. The thirst is sometimes great, but more frequently moderate. In the advanced state, the breath is offensive, and a blackish furring gathers about the roots of the teeth.

Some are never delirious, but all lie under a stupor or confusion; few retain their senses till death: many lose them early, and from two causes; either from immoderate bleeding, or the premature use of warm and spirituous medicines. They rarely sleep; and, unless delirious, have more of a dejected and thoughtful look than what is commonly seen in other fevers. The face is late in acquiring either a ghastly or a very morbid appearance; yet the eyes are always muddy, and generally the white is of a reddish cast as if inflamed. The confusion of the head generally rises to a delirium, especially at night; but, unless by an unseasonable hot regimen, it seldom turns to rage, or to those high flights of imagination common in other fevers. When the delirium comes to that height, the face is flushed, the eyes red, the voice is quick, and the patient struggles to get up. But when that symptom is owing to large evacuations, or only to the advanced state of the disease, the face appears meagre; the eye-lids in slumber are only half shut; and the voice, which is commonly low and slow, sinks to a degree scarce to be heard. From the beginning there is generally a great dejection and failure of strength. A tremor of the hands is more common than a starting of the tendons; or if the subfultus occurs, it is in a lesser degree than in many other fevers. In every stage of the disease, as the pulse sinks, the delirium and tremor increase; and in proportion as the pulse rises, the head and spirits are relieved. Sometimes in the beginning, but for the most part in the advanced state, the patient grows dull of hearing, and at last almost deaf. When the fever is protracted, with a slow and low voice, the sick have a particular craving for something cordial, and nothing is so cordial or acceptable as wine. They long for no food, yet willingly take a little panada if wine be added. But such as are delirious, with a quick voice, wild looks, a subfultus tendinum, or violent actions, though their pulse be sunk, yet bear neither hot medicines, wine, nor the common cordials.

Vomiting, and complaints of a load and sickness at stomach, though usual symptoms, are not essential to the disease; nor are pleuritic stitches, difficulty in breathing, or flying pains, to be referred so much to it as to the constitution of the patient, or to a preceding cold.

A petechial efflorescence is a frequent, though not an inseparable, attendant of this fever. It sometimes appears of a brighter or paler red, at other times of a livid colour, but never rises above the skin. The spots are small; but generally so confluent, that at a little distance the skin appears only somewhat redder than ordinary, as if the colour was uniform; but upon a nearer inspection there are interstices seen. For the most part this eruption is so little conspicuous, that unless it is looked for attentively it may escape notice. The spots appear thickest on the back and breast, less on the legs and arms, and our author never remembers to have seen any on the face. As to the time of their appearance, he agrees entirely with Dr Huxham. These spots are never critical, nor are they reckoned among the mortal symptoms; but only concur with other signs to ascertain the nature of the disease. The nearer they approach to purple, the more they are to be dreaded. In a few cases, instead of spots, purple streaks and blotches were observed. Sometimes the petechiae did not appear till after death; and there was one case in which, after bleeding, the petechiae were seen only on the arm below the ligature, and nowhere else on the skin.

The hospital-fever, though accounted one of the continued kind, yet has generally some exacerbation at night, with a remission and often partial sweats in the day; and after a long continuance it is apt to change into a hectic, or an intermittent form. The length of the disease is uncertain. Sometimes it will terminate, either in death or recovery, in seven days after the patient took to his bed; but in the hospitals it generally continued from 14 to 20, and some died or recovered after four weeks. From the time of the sinking of the pulse until death or a favourable crisis, there is perhaps less change to be seen from day to day in this than in most other fevers. When its course is long, it sometimes terminates in suppurations of the parotid or axillary glands; and when these do not appear, it is probable that the fever is kept up by the formation of some internal abscess. The parotid glands themselves do not suppurate, but only some of the lymphatic glands that lie over them. Our author observed one instance of a swelling of this kind on both sides, without any previous indisposition, when the person, not suspecting the cause, and applying different cataplasms, was, upon the tumour subsiding, seized with the hospital-fever. Many patients after the crisis of this fever complain of a pain in the limbs, and want of rest; and almost all of them mention great weakness, confusion in their head, vertigo, and a noise in their ears.

Ten of the bodies of those who died of this distemper in Houghton's regiment were opened. In some, all the cavities were examined; in others, only the brain or the bowels. In some of them, the brain appeared to be suppurated. The first of this kind our author met with at Ghent; but the man being brought into the hospital from the barracks no earlier than two days before he died, he could only conjecture from the symptoms and the imperfect accounts he had of him, that his death was owing to a fever of this kind, after lingering near a month in it. About three ounces of purulent matter were found in the ventricles of the brain, and the whole cortical and medullary substance was uncommonly flaccid and tender; nay, some of the same kind of matter was found in the substance of Galen assigns two causes for pestilential fevers:

1. The great heat of the weather, when the humours happen to be in a more putrefactive state than usual. 2. A putrid state of the air, arising either from a multitude of dead bodies left unburnt, as after a battle, or from the evaporation of corrupted lakes and marshes.

One of the most remarkable diseases incident to an army is related by Diodorus, as breaking out among the Carthaginians at the siege of Syracuse. That author not only relates some of its most distinguishing symptoms, but reasons well about its cause. He observes, that pains in the back and eruptions were common; that some had bloody stools; that others were seized with a delirium, so as to run about and beat all that came in their way; that the physicians knew no cure; and that it was the more fatal as the sick were abandoned by every body on account of the contagion. As to the cause, the author takes notice of the multitude of people confined within a narrow compass; of the situation of the camp in a low and wet ground; of the scorching heats in the middle of the day, succeeded by the cold and damp air from the marshes in the night-time; he adds, the putrid steams arising first from the marshes, and afterwards from the bodies of those who lay unburied. This distemper seems to have been a compound of the marsh and pestilential fever.

Forelius remarks, that, from the putrefaction of the water only, the city of Delft, where he practised, was scarce ten years together free from the plague or some pestilential distemper. He adds, that the magistrates, upon his representation of the cause, erected a wind-mill for moving and refreshing the water. At that time Holland was much more subject to inundations and the stagnation of water than at present. In 1694, a fever broke out at Rochfort in France, which, on account of the uncommon symptoms and great mortality, was at first believed to be the plague. But M. Chirac, who was sent by the court to inquire into its nature, found the cause to arise from some marshes that had been made by an inundation of the sea; and observed, that the corrupted steams, which smelled like gun-powder, were carried to the town by the wind, which had long blown from that quarter. About two-thirds of those who were taken ill died. In such as were opened, the brain was found either inflamed or loaded with blood; the fibres of the body were uncommonly tender; and the bowels had either suppurred or were mortified.

It is needless to mention more instances of pestilential fevers being brought on by the steams of corrupted substances, whether animal or vegetable. In general it may be remarked, that the putrefaction of these substances in a dry air is more apt to bring on a fever of the continued form; but in a moist air hath a greater tendency to produce remitting fevers. But it must also be observed, that, even in cases where the most malignant fevers prevail, all persons are not equally disposed to receive the infection, tho' equally exposed to it with others. Some, through mere vigour of body and mind, cannot be infected with the most contagious diseases; while, on the other hand, those whose bodies are debilitated by a former disease, Practice by study, low diet, or want, or those who have laboured under any of the depressing passions of the mind for some time, seldom or never escape. Men, therefore, who have been weakened by accidents (as those who have undergone a mercurial salivation) are very apt to fall into this distemper. Those who are taken into crowded hospitals, ill of the small-pox, however good the fort may be, fall readily into this fever, and run a greater risk of dying of it than others. The second fever is attended with double danger, seeing the patient has been so much weakened by the first. A sure sign of the corruption of the air in an hospital is when many of the nurses fall sick.

Prognosis. In these fevers we cannot draw a prognostic from any symptom by itself; and perhaps all of them together are more fallible than in others. Generally the following are good: To have little delirium; the strength little impaired; turbid urine in the decline of the disease; and at that time a gentle sweat or moisture diffused over the body, or even the skin soft and the tongue moist; or to have some loose stools succeeded by a diaphoresis; the pulse to rise by wine or cordials, with an abatement of the stupor, tremor, and other affections of the brain. Deafness is rather a good sign. A sediment in the urine, without other changes to the better, is no sure sign of recovery; and some have recovered in whose water there was no sediment.—The bad signs are, a subcutaneous tendinous; the eyes much inflamed and staring; the speech quick; and the sound of the voice altered; a high delirium; perpetual watchfulness; constant sickness at the stomach, and vomiting; frequent stools, with a sinking pulse, and the disorder of the head increased; coldness of the extremities, and a tremulous motion of the tongue. It is observed to be among the worst signs when the patient complains of blindness; when he swallows with difficulty, or cannot put out his tongue when desired to do it; when he can lie on his back only, and pulls up his knees; or when insensible he endeavours to uncover his breast, or makes frequent attempts to get out of bed without assigning any reason. If to any of these are added ichorous, cadaverous, and involuntary stools, it is a sign of a mortification of the bowels and approaching death. It will not seem strange to find most of these prognostics common to the advanced state of other fevers, when we consider, that from whatever cause fevers begin, by a long continuance the humours are corrupted, and the brain and nerves affected much in the same manner as in those which arise from infection.

Prevention and cure. As distempers of the putrid kind never arise without an infection received from some quarter or other, the methods of prevention must evidently be reduced to two general heads. 1. To avoid receiving the infection into the body; and, 2. To put the body in such a situation as may enable it to resist the infection when received. On both these methods scarce any writer hath equalled Dr Lind of Hallar, whose opinions and directions therefore we shall give pretty fully.

As putrid diseases are very common and violent in the hot countries, it is very necessary for Europeans who visit these climates to be well informed, in the first place, of the signs of an unhealthy country, that they may be upon their guard as soon as they enter any foreign region. These signs are by our author enumerated as follows.

1. A sudden and great alteration in the air, at sunset, from intolerable heat to a chilling cold. This is perceived as soon as the sun is down, and is for the most part accompanied with a very heavy dew: it shows an unhealthy swampy soil, the nature of which is such, that no sooner the sun-beams are withdrawn, than the vapours emitted from it render the air damp, raw, and chilling, in the most sultry climates; so that even under the equator, in some unhealthy places, the night-air is very cold to an European constitution.

2. Thick noisome fogs, chiefly after sunset, arising from the valleys, and particularly from the mud, slime, or other impurities. In hot countries, the smell of these fogs may be compared to that of a new-cleaned ditch. Diseases therefore, arising from this cause, generally take place in the night, or before sun-rising.

3. Numerous swarms of flies, gnats, and other insects which attend stagnated air and unhealthy places covered with wood.

4. When all butchers meat soon corrupts, and in a few hours becomes full of maggots; when metals are quickly corroded on being exposed to the air; and when a corpse becomes intolerably offensive in less than six hours; these are proofs of a close, hot, and unwholesome country. And in such places, during excessive heats and great calms, it is not altogether uncommon for Europeans, especially such as are of a gross habit of body, to be seized at once with the most alarming and fatal symptoms of what is called the yellow fever, without even any previous complaint of sickness or other symptoms of the disease. There has first been perceived an uneasy itching sensation, commonly in the legs; and upon pulling down the stockings, streams of thin dissolved blood followed, a ghastly yellow colour quickly diffused itself over the whole body, and the patient has been carried off in less than forty-eight hours.

5. A sort of sandy soil, commonly a small, loose, white sand, as that at Pensacola, Whydah, and the island of Bonavista, which is found by experience to be injurious to health. The pestiferous vapour arising, during the summer months and in the heat of the day, from such a sandy soil, is best characterized by its effects in the extensive deserts of Asia and Africa. It there constitutes what is called the Sambu wind; a blast which, in the parched desert, proves instantly fatal both to man and beast: but when it passes over a soil well covered with grass and vegetables, has its effects greatly mitigated; it is, however, even then, productive of sickness: thus the southerly winds, while they blow from the deserts of Libya during the summer, at Algiers, Tunis, and Tripoli, produce an unhealthy season; and at Madras the winds, which, in the months of April and May, pass over a large tract of sand, are always hot, disagreeable, and unwholesome.

During these land-winds, sudden gusts of a more hot and suffocating nature are often observed to come from those sands once or twice, or even more frequently, in a day, which seem to be this vapour in a purer form. These gusts pass very quickly, and affect persons who happen to stand with their faces towards them in the same manner as the hot air which issues from from a burning furnace, or from a heated oven, and obliges them immediately to turn away from it in order to recover breath. The effect of this hot suffocating blast or vapour on the human body, even when mitigated by passing through a moist atmosphere, is the same as that of intense cold; it chills up every pore of the skin, and entirely stops the perspiration of such as are exposed to it. These blasts come only in the daytime, and always from the deserts. Water is the only known corrector or antidote against them; hence, coarse thick clothes, kept constantly wet, and hung up at the windows, or doors, greatly mitigate their violence. A house so built as to have no windows or doors towards the deserts, is an excellent protection against their pernicious effects. The hot land-winds constantly blow at Madras, and other places on the coast of Coromandel, at that season, from midnight till noon; the sea-breezes then begin, which relieve the difficulty in breathing and the obstructed perspiration which the former occasioned.

That the heat of these land-winds, as also of the sudden gusts which accompany them, proceed from large tracts of sand heated by the sun, is evident from the increased heat and suffocating quality of those winds, in proportion as the day advances, and as the heat of the season is increased. The opposite winds blowing from each side of the Balagate-mountains, are a farther proof of this. These mountains, running from north to south, divide the hither Peninsula of India into two unequal parts, and separate what is called the Malabar from the Coromandel coast. To the former they are very near, but at a great distance from the latter. The winds blowing from those hills are on the Malabar-coast always remarkably cool; but on the coast of Coromandel, in the months of April, May, June, and July, are extremely hot and suffocating, as they pass over a large tract of intermediate sand, heated during those months by an almost vertical sun. Hence the Malabar coast is always covered with an agreeable verdure; whereas the Coromandel-coast, during the continuance of these hot winds, seems a barren wilderness, nothing appearing green except the trees. On the contrary, the winds that pass over these sands after being wet with the rains, are the coldest which blow at Madras. Bottles of liquor inclosed in bags of coarse cloth, kept constantly wet, and suspended in the shade, where those hot winds may have access to them, become as cold as if they had been immersed in a solution of nitre; an effect owing undoubtedly to the constant evaporation of water from the surface. See Cold and Evaporation.

It is an observation of the natives on the coast of Coromandel, which is confirmed by the experience of many Europeans, that the longer the hot land-winds blow, the healthier are the ensuing months; these winds, as they express it, purifying the air. Are not the winds therefore the cause why the air on the coast of Coromandel, except during their continuance, is more healthy than in other parts of India where these winds do not blow? Does not this also suggest a very probable reason, why the plague in Egypt generally ceases in the beginning of June; the periodical hot winds which come from the deserts of Nubia and Ethiopia having then rendered the air of Egypt pure and wholesome? Many have ascribed that effect to the north-winds; as the plague not only ceases when they blow, but all infected goods, household-furniture, and wearing apparel, are then said to become entirely free from the contagion: these, however, cannot be the cause, as the most destructive plague is abated in its violence, if not wholly eradicated, before they set in. With equal propriety we may reject the opinion that the overflowing of the Nile is productive of that salutary effect, as the plague generally ceases before the increase of that river is perceptible.

Thus the plague, the greatest calamity which can afflict mankind, seems to be destroyed by these hot winds, which are otherwise so pernicious to animal and vegetable life. And although, during the continuance of these winds, the most fruitful fields wear the aspect of a parched desert, yet no sooner the rains fall, but vegetation is restored, the plants revive, and a beautiful verdure is again spread over the face of the country.

Having thus given an account of the signs of an unhealthy country, our author next proceeds to mention such employments as are particularly dangerous to Europeans on their first arrival. One of these is the cutting down of trees, shrubs, &c., or clearing the ground as it is called. Of the unhealthiness of this employment he gives two instances. At the conclusion of the late peace, the captain of a ship of war went on shore at the island of Dominica, with 12 of his men, to cut down the wood, and to clear a piece of ground which he intended to have purchased; but, in a few days, sickness obliged him to desist from this dangerous work; the captain and 11 of his men being seized with violent fevers, which terminated in obstinate intermittents, and of which several died. The survivors suffered so much in their constitutions, that, even after they came to England, the return of an east wind was apt to bring on a violent fit of the ague. The Ludlow-Caille, a ship of war of 40 guns, in a voyage to the coast of Guinea, also lost 25 of her men, at Sierra Leone, who were employed in cutting down wood for the ship. This is an occupation which has often proved destructive to Europeans in those climates, and in which they ought never to be employed, especially during the rainy season; there being numberless instances of white persons, when cutting down the woods at that season, who have been taken ill in the morning, and dead before night.

Another evil, less known, and less suspected, but no less dangerous, is the sending of Europeans in open boats after sunset, where the soil is swampy, or where there are great night-fogs. The single duty alone of fetching fresh-killed butcher's meat at night for the use of our ships companies in the East and West Indies, has destroyed every year several thousand seamen. In those parts of the world, butcher's meat must be brought on board at night immediately after it is killed; otherwise it will not be fit for use the next day; but a contract made with the natives to send it on board at that time, which might be done for a trifling sum, would be the means of preserving many useful lives. During the fickle season at Batavia, a boat belonging to the Medway, which attended on shore every night, was three times successively manned, not one having survived that service. They were all taken ill in the night, when on shore, or when returning on board; so that... Practice at length the officers were obliged to employ none but the natives on that business. Great numbers of men have perished from being employed in this manner at Bengal, where the European ships often anchor in the most unhealthy spots of the river; and even when the great night-fogs arise, after the rainy season, the men are often obliged to perform such night-services in boats. Now since it is so dangerous for Europeans in unhealthy countries, particularly during a season of sickness, to be exposed in an open boat to the foggy night-air, it must appear, that sending them unsheltered, in open boats, far up rivers, in unhealthy southern climates, for the sake of wood, water, trade, or other purposes, must be attended with the most destructive and fatal consequences.

Burying the dead in swampy countries is another occupation which has proved fatal to many, and which ought to be entrusted to negroes or the natives of the country. The effluvia from the ground when newly opened, whether from graves or ditches, are far more dangerous than from the same swampy soil when the surface is undisturbed; nay, in some places, it has been found almost certain death for an European to dig a grave, unless long seasoned to the country. In such a place, the attendance of friends at funerals ought to be dispensed with.

In all cases where it is practicable, the ships which visit these unhealthy countries should anchor at as great a distance as possible from shore; or if obliged to anchor near marshy grounds or swamps, especially during summer or in hot weather, and when the wind blows directly from thence, the gun-ports which would admit the noxious land-breeze ought to be kept shut, especially at night. Or if the ship rides with her head to the wind, a thick sail ought to be put upon the fore-mast, along which the smoke from the fire-place might be made constantly to play and ascend. If the sail should occasion a little smoke between decks, this inconvenience will be sufficiently compensated by its keeping off the direct stream of the swampy shore effluvia; which now being obliged to form a curve before they reach the more distant parts of the vessel, must needs be greatly diverted and scattered.

The best preservative against the mischievous impressions of a putrid fog, or of a marshy exhalation, is a cloe, sheltered, and covered place; such as the lower apartments in a ship, or a house in which there are no doors or windows facing the swamps. If in such places a fire is kept either at the doors and other inlets to a house, or in the chambers, as is practised in some unhealthy countries during the rainy or foggy season, it will prove an excellent and effectual protection against the injuries of a bad air. On board of ships also fires may be made at the hatchways; and of the good effects of this, we have the following example. When the Edgar, a ship of war of 60 guns, was upon the coast of Guinea in the year 1768, her men were very sickly, and many of them died: whereas it was observed, that in a sloop of war, which was constantly in company with her, few were taken ill, and not one died during the whole voyage. This could be ascribed to no other cause, but that in the sloop the fireplace for cooking victuals was on the same level with the deck where the men lay; and every morning when the fire was lighted, especially when there was but little wind, the smoke from the cook-room spread itself all over the ship, and particularly over those parts where the men lay; but from the construction of the fire-place of the Edgar, no smoke from it ever came between her decks.

Persons on board any ship whatever, are much more safe, and their situation is much preferable to that of those who make distant inland excursions in small boats upon the rivers, and who are for the most part ignorant of the cause of those maladies which destroy them. The intolerable heat at noon often obliges such persons to go in a manner half-naked; while a free and plentiful perspiration issues from every pore. A near approach to putrid swamps at this time is apt to produce an immediate sickness, vomiting, and afterwards a low nervous or malignant fever. But if they happen to pass them at night, or lie near them in an open boat, the air from those swamps is perceived to be quite chill and cold; in so much that warm thick clothing becomes absolutely requisite to guard the body against the impressions of so great an alteration in the air, and against its cold and inclement quality; for the effects of it then, even on the most healthy and vigorous constitution, is frequently a chilling cold fit of an ague, terminating in a fever with delirium, bilious vomitings, a flux, or even death itself.

But where such exposure becomes unavoidable, the only method is then to defend the body as much as possible against the pernicious miasmata with which the air abounds.—All those who are employed in cutting down woods, or in other laborious and dangerous services in hot climates, during the heat of the day ought to have their heads covered with a bladder dipped in vinegar, and to wash their mouths often with the same liquor; never to swallow their spittle, but rather to chew a little rhubarb or some other bitter and spit it out frequently; to stop their nostrils with a small bit of linen, or tow, dipped in camphorated vinegar; and to infuse some bark, garlic, and rhubarb, in brandy, of which a dram is to be taken, either by itself or diluted with water, morning and evening.

In the evening before sunset they should leave off work, and not return to their labour in the morning till the sun has dispersed the unwholesome dews and vapours. Those who must of necessity remain on shore, and sleep in dangerous places, must take care not to sleep upon the ground exposed to the dews, but in hammocks in a cloe tent, standing upon a dry land, gravel, or chalk, near the sea shore, and where there is no subterraneous water for at least four feet below the surface of the ground. The door of this tent should be made to open towards the sea; and the back part of it which receives the land breeze, must be well secured by double canvas, or covered with branches of trees. But in such circumstances, a hut, when it can be procured, is preferable to a tent, especially if it is well thatched, so as to prove a defence both against the excessive heat of the sun by day, and the noxious dews which fall at night. Here the men may be enjoined to smoke tobacco. When the air is thick, moist, and chill, the earth being overspread with cold dew, a constant fire must be kept in and about the tent or hut, as the most excellent means of purifying such unwholesome air, and of preserving the health There are three methods practised for purifying vessels after the men have been removed out of them. The first is by burning of tobacco. A quantity of tobacco is spread on several fires, made with such old pieces of rope as are called junk. These are dispersed into different places of the ship, and their heat and smoke afterwards closely confined below for a considerable time.—The second method is by charcoal fires strewed with brimstone. The heat and steam of these burning materials must also be long and close shut up; but, although this fume, properly applied, hath been experienced to purify most effectually tainted apartments, ships, clothes, &c. yet there are some kinds of vermin which it will not destroy, particularly lice.—The third method of purification is performed by the addition of arsenic to the materials of the second process, in the following manner. After carefully stopping up all the openings, and every small crevice of the ship, (as was also necessary in the preceding processes) a number of iron pots, properly secured, are to be placed in the hold, orloge, gun-deck, &c. Each of these are to contain a layer of charcoal at the bottom, then a layer of brimstone, and so alternately three or four layers of each, upon which the arsenic is to be sprinkled, and on the top of it some oakum dipped in tar is to be laid to serve as a match. The men, upon setting fire to the oakum, must speedily leave the place, shutting close the hatchway by which they came up.

From the known and experienced efficacy of these processes, it appears, that fire and smoke are the most powerful agents for annihilating infection; and, it may be presumed, even the plague itself. This is in some measure agreeable to what we learn from the ancient records of physic. But the preposterous use, or rather abuse, of fire on such occasions, has caused its effects to be disregarded by some, and to be suspected of mischief by others. The modern practice of burning large fires in the open air, in the streets, and about the walls of towns infected with the plague or other contagion, is founded on principles groundless and erroneous; and hath, therefore, been experienced not only unsuccessful, but hurtful. But though this must be allowed, it doth not thence by any means follow, that when once a house hath been infected and the patients removed from it, the doors and windows at the same time being shut, that such fires will then prove hurtful; or that, by this method of purification, all the seeds of contagion will not be effectually destroyed. Whenever, therefore, persons die of a spotted fever, a malignant sore throat, the small-pox, or any distemper found to be communicable from the sick to others, the corpse ought quickly after death to be removed into another room; that in which the person died should be well aired, by having the windows opened, till a charcoal-fire be kindled, with some rolls of sulphur upon it; after which, both doors and windows should be kept shut for a considerable time, not less than eight or ten hours, till the room be thoroughly smoked. In several ships, where there are the fairest opportunities of trying and judging things of this nature, the contagion of the small-pox has been entirely flopped by wood-fires, sprinkled with brimstone, kept burning and closely confined in the infected place. In a word, a judicious and proper application of fire and smoke is the best means for the destruction and utter extinction of Next to the smoke of wood, for purifying a tainted air, that of gun-powder is to be esteemed the best; and hath this further good property, that it is entirely inoffensive to the lungs. The cascara-bark, when burning, gives a most agreeable scent to the chamber of the sick; so is at least an elegant preservative, and may prevent bad smells from taking effect. The steam of camphorated vinegar warmed, is still more powerful for this purpose. But, besides correcting the ill quality of the air, and purifying the chamber, another good effect is produced from such steams and smoke as are inoffensive to the lungs. As soon as the vapour becomes dense, the nurses and patients become delirious of the admission of fresh air by the door or windows. Now it is certain, that the air in the chambers of the sick cannot be too often changed, provided the patient be well covered, and the curtains of his bed, if necessary, be drawn close. No argument is to forcible to obviate the danger of foul air in a room or ward, (occasioned by the obstinacy of nurses or relations,) as ordering it to be frequently fumigated or smoked: A practice more frequent in other countries than in this, but of great benefit to the sick.

Lastly, with regard to the method of purifying goods, moveables, clothes, &c. which are supposed to harbour infection, it must be observed, that the usual custom of only unpacking and exposing such materials to the open air, is in many instances insufficient to destroy the latent seeds of disease. It is certain indeed, that in most cases the contagious particles are more readily and fatally communicated from the clothes of a sick person, than from his body. The spreading abroad, therefore, of contaminated clothes to dry or to be aired, without a previous fumigation of them, may be of dangerous and fatal consequence. All such suspected substances should be first fumigated in a close place, and in the same manner as an infected chamber, after which they may be spread abroad and exposed to the air. In infectious diseases, especially fevers, the linen of the sick, or such clothes about them as will admit of being washed, ought never at first to be put in warm water, as it is dangerous to receive the steam that may hence arise. It is necessary to steep them first either in cold water, or in cold soap-les, for several hours, that the filth may be washed off.

We must now proceed to give an account of the method of cure, after these methods of preventing the infection from being received into the body have either been neglected or proved ineffectual. Here it is of the utmost importance to take the disease in the very beginning, before it hath time to corrupt the fluids to such a degree as to endanger life. In these slight degrees of infection, a vomit properly administered, especially if succeeded by a blister, never fails to remove the disorder, and prevent the fever which would otherwise unavoidably follow. Of this Dr Lind gives the following instances. A lady afflicted with the bilious cholick, had intolerably fetid discharges of corrupted matters upwards and downwards. A gentlewoman, only in passing the room, was immediately seized with a retching and sickness, which continued 24 hours. The nurse who attended, was suddenly seized with a giddiness and vomiting from the bad smell, which, as she expressed it, reached into her stomach. The vomiting became more severe at night, accompanied with a purging and frequent shiverings. By means of an emetic both evacuations were stopped; notwithstanding which, for some days afterwards, she continued to have frequent tremors, and a violent headache, with a low irregular pulse; and did not recover so soon as the patient.

Such slight degrees of infection have been often observed to be derived from patients of a gross habit of body, when labouring under inflammatory distempers, and even other complaints. A man was sent to Hafar Hospital, supposed to have a fever. He was furiously delirious, with a quick full pulse. Notwithstanding plentiful evacuations, this delirium continued for two months with short intervals; when the case was found to be plainly maniacal. A nurse, upon raising this person up in her arms, perceived an intolerably bad smell, and was instantly seized with shiverings, sickness, and head-ach. Finding herself very ill, she took a vomit in six hours afterwards, and passed the night in profuse sweats by means of a sudorific draught. Next morning the violence of the head-ach was but little abated; upon every attempt to move, she complained of a burning heat and pain in her forehead, and became giddy. Her inclination to drink was frequent, and her pulse low and quick. A blister was immediately applied to the back: as soon as the blister took effect, the head-ach and thirst entirely left her, and the pulse was calm. Next day she arose and was well.

Many similar instances of infection have been observed from putting the dead into their coffins. In particular, one man, who, from performing that duty to his messmate, was so ill, even after the operation of the vomit, as to require a blister. In the course of one week two nurses were infected by a person in the smallpox. Both were seized in like manner with shiverings, sickness, and head-ach; the one upon receiving the patient's breath, the other upon making his bed. In one, a pain darted into her breast; in the other, into the breast and in the small of the back. The complaints of the former were speedily removed by a vomit, though she continued to have irregular returns of shiverings for three days afterwards. But in the latter, though the head-ach, sickness, and rigors, were greatly abated by the vomit, yet a constant heat and thirst, with a low pulse, and a violent pain in the breast, indicated the necessity of applying a blister to the affected parts which next morning removed all her complaints.

A person is often immediately sensible of his having received an infection from the first attack: they generally compare the first impression to an earthy, disagreeable smell, reaching down, as they express it, into their stomach, as from a grave newly opened, but not quite so raw as the cadaverous flesh; and the effects of it, shivering and sickness, are instantaneous. It is a smell difficult to describe; but is well known to the nurses and attendants about the sick, as it usually accompanies fevers of extreme malignity, and, with the peculiar discharges from the blistered parts, may be reckoned among the most constant symptoms of a bad fever. Some compare the smell to that of rotten straw. It often resembles the disagreeable smell of a person labouring. labouring under the confluent small-pox at their turn, though not so strong. One person, on receiving the infection, was sensible of something like an electric shock through his body. But many are not sensible of any effect from an infection at first; and an infection from a fever will sometimes continue for many days, nay weeks, discovering itself chiefly by irregular shiverings, sometimes so severe as to oblige the patients to have recourse to their beds once or twice a day; sometimes every other day. Among a number thus affected, it also appears, that such as are put into unseasoned chambers, or have sat down on the cold ground, lain in raw damp apartments, &c. are immediately seized with a sickness at stomach, sometimes with a dangerous purging, and often with fevers accompanied with bad symptoms, which others have entirely escaped.

It now remains to consider the proper method of curing putrid fevers, on the supposition that the infection hath been allowed to operate till the blood becomes radically tainted, and of consequence the nervous system affected to such a degree, that its power cannot be restored by any of the simple medicines above-mentioned. Here all authors agree, that a change of air, when it can be effected, is absolutely necessary, and often contributes more towards the removing of the disease than all the medicines that can be exhibited. The utility of this change will appear from what hath been formerly said; and we shall only further allege one instance from Dr Lind, in which the effects of bad air appear to a degree almost incredible.

"It is remarkable," says he, "that in the last war, the English ships which touched at Batavia suffered more by the malignant and fatal diseases of that climate, than they did in any other part of India, if we except a fatal scurvy which once raged in that fleet at sea. Soon after the capture of Manila, the Falmosth, a ship of 50 guns, went to Batavia, where she remained from the latter end of July to the latter end of January; during which time she buried 100 soldiers of the 79th regiment, and 75 of the ships company; not one person in the ship having escaped a fit of sickness, except her commander Captain Breerton. The Panther, a ship of 60 guns, was there in the years 1762 and 1764; and both times during the rainy season. In the former of these years, she buried 70 of her men; and 92 of them were very ill when she left the place. In the year 1764, during a short stay, 25 of her men died. The Medway, which was in company with her, lost also a great number of men. Nor was the sickness at that time confined to the ships; the whole city afforded a scene of disease and death; streets crowded with funerals, bells tolling from morning to night, and horses jaded with dragging the dead in hearse to their graves. At that time a slight cut of the skin, the least scratch of a nail, or the most inconsiderable wound, turned quickly to a spreading putrid ulcer, which in 24 hours consumed the flesh even to the bone. This fact is so extraordinary, that, upon a single testimony, credit would hardly be given to it; yet on board the Medway and Panther they had the most fatal experience of it, and suffered much from it."

But where this change of air is impracticable or ineffectual, and where the fever hath already made some progress, Sir John Pringle generally took away some blood if the pulse was full. When the symptoms run high, a plentiful evacuation of that kind seemed indicated; yet it was observed that large bleedings generally did harm, by sinking the pulse, and affecting the head. Nor was a moderate bleeding to be repeated without caution; even those whose blood was fizzy, unless their lungs were inflamed, were the worse for a second bleeding. If the head only suffered, it was much safer to use leeches than to open a vein in the arm; but in the delirium with a sunk pulse, even leeches were hurtful. Many recovered without letting blood, but few who lost much of it.

Vomits also must be used with caution; for though they may be of use by way of prevention, yet in the advanced state of the disease, when the patient has all along complained of a sickness at stomach, they are evidently unsafe. Here the antiseptic quality of fixed air is of much use, and the neutral draughts given in the act of effervescence are generally attended with happy effects. Nay, clysters of fixed air itself have been found very serviceable. Even in very bad stages of the distemper, where a putrid and collusive looseness hath taken place, clysters of fixed air have been known to alleviate the symptoms. We must not, however, put too much confidence in medicines of this kind. Mild astringent cordials, especially the wine and Peruvian bark, are the only resources in these disorders. Concerning the former, Sir John Pringle observes, in the low state of these fevers, and in great sicknesses, which either come after unseasonable bleedings, or long want of nourishment, it was a most grateful and efficacious cordial, to which nothing was comparable. The common men had an allowance, from a quarter to half a pint in a day, of a strong kind, made into whey, or added to the panada which was their ordinary food. But to others out of the hospital, he usually prescribed Rhenish, or a small French wine, whereof some consumed near a quart per day, and part of that undiluted. Nay, so great was the virtue of wine in this stage of the fever, that several were known to recover from the lowest condition, when, refusing the bark on account of its taste, they took nothing but a little panada with wine and a volatile diaphoretic mixture every two or three hours by turns. Perhaps there is no rule more necessary in this state, than not to let the patient when low remain long without taking something cordial and nourishing; as many have been observed past recovery, by being suffered to pass a whole night without any support about the time of the crisis. In the advanced state of this fever the sick are remarkably low; and therefore Hoffman advises in such cases, that they should be constantly kept in bed, and not permitted even to sit up in it. In the last stage of this fever, as well as in that of the sea-scurvy, it would seem that the force of the heart was too small to convey the blood to the brain, except when the body is in an horizontal posture.

But, however necessary wine and the bark may be in the low stage of this fever, we must remember, that these remedies are to be administered only as antifeverics and supporters of the vis viva, without aiming at thoroughly raising the pulse or relieving the head, or at forcing a sweat by them before nature points that way, and which Sir John Pringle seldom observed before the 14th day. For though the patient may die before that time if he has been largely bled, or if the cordial... cordial medicines have been given him too freely, yet such means as our author made use of were not powerful enough to bring on a crisis sooner.

In the low state of the hospital-fever, a stupor was a constant attendant, which was very apt, in the evening, to change to a flight delirium. If this was all, as being in the common course, nothing was done. But if the delirium increased upon using wine, if the eyes looked wild or the voice became quick, there was reason to apprehend a phrenitis; and accordingly it was observed, that at such times all internal heating medicines aggravated the symptoms; and in these cases blisters were of the greatest service. Fomentations of vinegar and warm water for the feet, our author is of opinion, would answer better than either sinapis or blisters, provided they were long enough and often enough applied. In the inflammatory fevers, he has known these fomentations have little effect for the first hour, and yet succeed afterwards. For internal medicine, the bark was omitted for some time, but the patient was continued with an acidulated drink, viz. barley-water and vinegar; and treated also with camphire, pulvis contrayeria compositus, and nitre, as was usual in the beginning of the fever. If the delirium was of the low kind, a decoction of the bark and wine were the only remedies; for in no instance was the delirium perfectly removed till the time of the crisis. It must also be observed, that a delirium may arise in putrid fevers from two opposite errors; one from large and repeated bleedings, and the other from wine and the cordial medicines being taken too early. It appears therefore how nice the principles are that regard the cure; as neither a hot nor a cool regimen will answer with every patient, or in every state of the disease.

If a diarrhoea came on in the decline of the fever, it was moderated, but not suppressed, by adding an opiate to the usual medicines. For though the looseness may be considered as critical; yet as the sick were too low to bear evacuations, there was a necessity for restraining it in some measure; and it has often been observed, that when it has been treated in this manner, about the usual time of the crisis, the patient has fallen into a gentle sweat, which has carried off the disease. In the worst cases of this fever, and especially when it coincides with the dysentery, the stools are frequently bloody; in which dangerous state, if anything could be done, it was attempted by medicines of the same kind. In proportion to the putrid nature of the stools, opiates and astringents were used with the greater caution.

If the disease terminated in a suppuration upon one of the parotid glands (for the gland itself does not suppurate), the abscess was opened without waiting for a fluctuation, which might never happen; the pus being often here so viscid, that after it was ripe the part felt nearly as hard as if the suppuration had not begun.

Almost every patient, after the fever, complained of want of rest, frequently of a vertigo or confusion of the head, of a continuation of the deafness, or of other symptoms commonly called nervous. An opiate was then given at night; and in the day some strengthening medicines, such as the bark and the elixir of vitriol. In these cases, the bark was found not only to be the best strengthener, but the surest preservative against a return of the disease. For this last intention the convalescent was ordered about three drachms a day for six or seven days together; and afterwards, if he remained longer in the hospital, some smaller quantity daily. But if there was any appearance of a hectic fever from an inward abscess, the case was treated accordingly. Upon comparing some of the remaining symptoms of those who recovered, with the condition of the brain in those who died and were opened, our author was induced to think, that some part even of that substance might suppurate; and yet, the person recover.

Sometimes the patient falls into an irregular intermittent; which, if not of a hectic nature from an internal abscess, may proceed from neglecting to clear the prime vitæ. For it is easy to conceive, that after a long fever of such a putrid nature, often attended with languor of the bowels, the faeces may be so much accumulated, and so corrupted, as to occasion new disorders. In such cases, after proper evacuation by a purge, the bark was almost an infallible remedy.

XXVIII. The Yellow Fever, Sp. II.

Typhus isteroides, Sauv. sp. 7. Febris flavæ Indicæ Occidentalis, Warren. Malignant fever of Barbadoes, Hillary's Diseases of Barbadoes. Lining on the yellow fever of South Carolina, Edin. phys. and liter. Essays, vol. ii. Mackittrick de febre flavæ Indicæ Occidentalis, Edin. 1766.

Description. This is one of the most fatal diseases to which the inhabitants of warm climates are subject, and is the same with that called, from one of its worst symptoms, the black vomit, which is so terribly destructive in some of the warm parts of America, particularly at Carthagena. According to Dr Hillary, the yellow or putrid bilious fever most commonly seizes the patient at first with a faintness, then a sickness at stomach, accompanied mostly with a giddiness of the head; soon after with a slight chilliness and horror, very rarely with a rigor, which is soon followed by a violent heat and high fever, attended with acute darting pains in the head and back. A flushing in the face, with an inflamed redness and a burning heat in the eyes, great anxiety and oppression about the precordia, are the pathognomonic signs of the distemper; especially when attended with sickness at stomach, violent retchings, bilious yellow vomitings, with frequent sighing. The pulse is now generally very quick, high, soft, and sometimes throbbing, but never hard; in some it is very quick, soft, low, and oppressed; the respiration quick, full, and sometimes difficult; the skin very hot, and sometimes dry, though more frequently moist. Blood taken from the patient, even at the very beginning of the disease, is often of an exceeding florid red colour; much rarefied and thin, and without the least appearance of size; and the crustamentum, when it has stood till it is cold, will scarce cohere, but fluctuates; the serum is very yellow.

Most of the abovementioned symptoms continually increase, and are much aggravated; the retching and vomiting become almost incessant; the anxiety great, and sighing frequent; great restlessness; continual tossing; no ease in any posture; little sleep, and that distur- disturbed and uneasy, and without any refreshment to the sick: and when they are fainting, they turn yellow about the face and neck, instead of turning pale; and as the fainting goes off, they recover their natural colour. These symptoms generally continue to the third day, though sometimes not longer than the first or second, in others to the end of the fourth: the first shews the greater dissolution of the blood, and the greater malignity of the disease; the last, the contrary; which the improper manner of treating the disease sometimes hastens and increases, or the proper method retards. This may be called the first stadium of the disease, and generally ends on the third day.

Blood taken from the sick on the second or third day, is much more dissolved, the serum more yellow, and the coagulum florid, loose, scarce cohering, but undulates like fizzy water when shaken, and some- times has dark blackish spots on its surface, shewing a strong gangreneous diathesis.

About the third day, the pulse, which was quick and full before, now generally sinks greatly, and be- comes very low: though sometimes it remains very quick, yet in others it is not much quicker than when the patient is in health, but is always low; the vo- miting becomes almost incessant if not so before, and the matter thrown up is black; the patient then be- comes comatose, with interrupted deliria. The thirst in some is very great, in others but little; the pulse still low and quick, attended with cold clammy sweats, and sometimes with delirium. The eyes, which were inflamed and red before, and began to be of a more dusky colour, now turn yellow; and this yellowness also soon after appears round the mouth, eyes, temples, and neck, and in a short time diffuses itself all over the body. But this yellowness is so far from being always an encouraging prognostic, as some would have it, that it most commonly proves a mortal symptom. Sometimes indeed, though seldom, this suffusion of bile upon the surface has proved critical: but then it did not come on till the eighth or ninth day, nor ap- pear till the coma and all the other bad symptoms be- gan to abate; and then in proportion as the yellowness increases, all the bad symptoms decrease. But the case is most commonly quite the reverse; especially when the yellowness comes soon on: and then it is not only symptomatical, but others in the most fatal symp- toms of the disease, viz. a deep coma, a low, vermi- cular, and intermittent pulse, great hemorrhages from various parts of the body, a delirium with laborious and interrupted respiration, great anxiety, deep sigh- ing, restlessness, a subsultus tendinum, coldness of the extreme parts first, and then all over the body, a fal- tering of the speech, tremors, and convulsions, which are soon after followed by death. So that from the first appearance of the yellowness we may say the pa- tient is in the last stage of the disease, whether it ter- minates in death or recovery.

It has been observed, that in some strong sanguine constitutions, when the patients have not been bled to a sufficient quantity in the beginning of the disease, the pulse has continued full, strong, and rapid, but ne- ver hard; the face flushed, eyes inflamed; the tongue dry, with great thirst and heat, till the second or last stage of the fever is come on, when the pulse has suddenly sunk, and death soon after ensued. Yet in others, who seemed to be of a plethoric habit, the tongue has been moist all along, though they have been delirious most of the time, and the heat of their skin and the strength and quickness of their pulse have continued, after the first stage of the disease was over, pretty near to that of their natural state in health, till within a few hours of their death; and when they have had a coma on them, one who is not well ac- quainted with the nature of this disease would, from their pulse, heat, breathing, and other symptoms, have taken them to be in a natural sleep. Others, when the pulse has begun to sink, and the fatal period seem- ed to be just approaching, to the great surprise of all present have recovered their senses, sat up, and talk- ed pretty cheerfully for an hour or two, and in the midst of this seeming security have been suddenly seized with convulsions, which carried them off imme- diately.

In the latter stage of this fever, the blood is so at- enuated and dissolved, that we frequently see it flowing not only out of the nose and mouth, but from the eyes, and even through the pores of the skin; also great quantities of black, half-baked, or half-mortified blood, are frequently voided both by vomiting and by stool, with great quantities of yellow and blackish put- rid bile by the same ways; and the urine, which was before of a high icteritious colour, is now almost black, and is frequently mixed with a considerable quantity of half-dissolved blood. The pulse, which was much funk before, now becomes very low, unequal, and in- termittent; the breathing difficult and laborious; and the anxiety inexpressible: an oppression with a burn- ing heat about the precordia comes on, tho' the extre- mities are cold, and often covered with cold clam- my sweats: a constant delirium follows; and then a total loss of the outward senses as well as the judg- ment, with livid spots in many parts of the body, especially about the precordia; and sometimes gan- grenes in other parts of the body, which are very soon succeeded by death.

In a short time after death, the body appears much more full of livid, large, mortified spots, particularly about the precordia and hypochondres, especially the right; which parts seem, even from the first seizure, to be the principal seat of this terrible disease; and, upon opening the bodies of those who die of it, we generally find the gall-bladder and biliary ducts tur- gid, and filled with a putrid blackish bile; and the li- ver, stomach, and adjoining parts, full of livid or blackish mortified spots; and the whole corpse soon pu- trifies after death, and can be kept but a few hours above ground.

Dr Lind is of opinion, that the remarkable disso- lution of the blood, the violent hemorrhages, black- vomit, and the other symptoms which characterize the yellow fever, are only accidental appearances in the common fever of the West-Indies; that they are to be esteemed merely as adventitious, in the same manner as purple spots and bloody urine are in the small-pox, or as an hiccup in the dysentery: like these they only appear when the disease is attended with a high de- gree of malignity, and therefore always indicate great danger. This opinion he thinks is confirmed by an observation of Dr Wind's, that in 1750 the crew of a Dutch ship of war were distressed by the yellow fever, Practice fever, accompanied with the black vomit; but when the ship left the harbour, and changed the noxious land-air for one more healthy, the fever continued, but was not accompanied with the black vomit.

Diseases similar to this fever, our author informs us, may arise in any part of the world where the air is intensely hot and unwholesome; and therefore he treats as chimerical the notion of its being imported from one part of the world to another. An example of this happened at Cadiz in Spain, in the months of September and October 1764, when excessive heat, and want of rain for some months, gave rise to violent, epidemic, bilious disorders, resembling those of the West-Indies, of which 100 persons often died in a day. At this time the winds blew mostly from the south, and after sunset there fell an unusual and very heavy dew.

This disease began commonly with alternate slight chills and heats, nausea, pains of the head, back, loins, and at the pit of the stomach. These symptoms were often followed, in less than 24 hours, with violent retchings, and vomiting of a green or yellow bile, the smell of which was very offensive. Some threw up an humour as black as ink, and died soon after in violent convulsions and in a cold sweat. The pulse was sometimes sunk, sometimes quick, but often varying. After the first day, the surface of the body was generally either cold, or dry and parched. The head-ach and stupor often ended in a furious delirium, which quickly proved fatal. The dead bodies having been examined by order of the court of Madrid, the stomach, mesentery, and intestines, were found covered with gangrenous spots. The orifice of the stomach appeared to have been greatly affected, the spots upon it being ulcerated. The liver and lungs seemed to be putrid, both from their texture and colour. The stomach contained a quantity of an atrabilius liquor, which, when poured on the ground, produced a sensible effervescence; and, when mixed with spirit of vitriol, a violent ebullition ensued. The dead bodies so quickly turned putrid, that at the end of six hours their stench was intolerable; and, in some of them, worms were found already lodged in the stomach. His majesty's ship the Tweed being at that time in Cadiz bay, several of her men were taken ill when on shore, but by being carried on board all of them recovered. Neither did the black vomit, or any other deadly symptom of that fever, make its appearance in any of the ships.

It hath been a matter of much dispute, whether the yellow fever is of an infectious nature or not. Not long ago it became an object of consideration before the Right Hon. the Lords Commissioners of Trade and Plantations, where it was urged, among other reasons, for not removing the seat of government and justice in the island of Jamaica from Spanish Town to Kingston, that there was danger from Greenwich hospital, situated near Kingston, of an infection from the yellow fever being frequently communicated to that town. On this affair a physician was consulted, who had long practised in that island, and who gave it as his opinion, that from the yellow fever in that island there was no infection. This was the opinion not only of that gentleman, but of many others who had an opportunity of being well acquainted with this fever in Jamaica. Nevertheless Dr Lind gives a remarkable instance of its being of an infectious nature.—A gentleman dying at Barbadoes of a yellow fever, his wearing apparel and linen, packed up in a chest, were sent to his friends at Philadelphia; where, upon opening the chest, the family was taken ill; and the clothes being unluckily hung abroad to be aired, they presently diffused the contagion of the yellow fever over the whole town, by which 200 persons died. These contradictions, Dr Lind thinks, can only be reconciled by supposing the yellow fever in the West-Indies to be sometimes of an infectious nature, and sometimes not.

In the description of the same fever, as it appears in South-Carolina, by Dr Lining, there are several particulars considerably different from that by Dr Hillary. According to the former, people complained, for a day or two before the attack, of a head-ach, pain in the loins and extremities, especially in the knees and calves of the legs, loss of appetite, debility, and a spontaneous lassitude. Some, however, were seized suddenly, without any such previous symptoms. After a chillness and horror with which this disease generally invades, a fever succeeded. The pulse was very frequent, till near the termination of the fever, and was generally full, hard, and consequently strong: in some, it was small and hard; in others, soft and small; but in all these cases, it frequently varied in its fullness and hardness. Towards the termination of the fever, the pulse became smaller, harder, and less frequent. In some there was a remarkable throbbing in the carotids and in the hypochondria; in the latter of which it was sometimes so great, that it caused a constant tremulous motion of the abdomen. The heat generally did not exceed 102 degrees of Fahrenheit's thermometer; in some it was less; it varied frequently, and was commonly nearly equal in all parts, the heat about the precordia being seldom more intense than in the extremities when these were kept covered. In the first day of the disease, some had frequent returns of a sense of chillness, though there was not any abatement of their heat. In a few, there happened so great a remission of the heat for some hours, when at the same time the pulse was soft and less frequent, and the skin moist, that one from these circumstances might reasonably have hoped that the fever would only prove a remittent or intermittent. About the end of the second day, the heat began to abate. The skin was sometimes (though rarely) dry; but oftener, and indeed generally, it was moist, and disposed to sweat. On the first day, the sweating was commonly profuse and general; on the second day, it was more moderate; but on both these, there happened frequent and short remissions of the sweatings; at which times the febrile heat increased, and the patient became more uneasy. On the third day, the disposition to sweat was so much abated, that the skin was generally dry; only the forehead and backs of the hands continued moist. The respiration was by no means frequent or difficult; but was soon accelerated by motion, or the fatigue of drinking a cup of any liquid. The tongue was moist, rough, and white, even to its tip and edges. On the second day, its middle in some was brown. On the third day, the whitening and roughness of the tongue began to abate. The thirst in very few was great, A nausea, vomiting, or frequent retchings to vomit, especially after the exhibition of either medicines or food, came on generally the third day, as the fever began to lessen; or rather as the fulness of the pulse, heat, and disposition to sweat, began to abate. Some indeed, but very few, on the first day, had a vomiting, either bilious or phlegmatic. Very few complained of anxiety or oppression about the precordial or hypochondria, nor was there any tension or hardness about the latter. On the first day they generally dozed much, but were afterwards very watchful. Restlessness and almost continual jactations came on the second day. A great despondency attended the sick, and the strength was greatly prostrated from the first attack. The pain in the head, loins, &c. of which they had complained before the attack, were greatly increased, and in some the pain in the forehead was very acute and darting; but those pains went generally off the second day. The face was flushed; and the eyes were hot, inflamed, and unable to bear much light. On the first day, many of them at times were a little delirious, but afterwards not until the recess of the fever. The blood saved at venesection had not any inflammatory crust; in warm weather, it was florid like arterial blood, and continued in one soft homogeneous-like mass, without any separation of the serum after it was cold. When there was any separation, the crassamentum was of too lax a texture. The stools, after the first day, were fetid, inclined to a black colour, and were very rarely bilious, soft, or liquid, excepting when forced by art; for an obstinate costiveness attended the febrile state. The urine was discharged in a large quantity, was pale, sometimes limpid, and rarely of a higher than a straw colour, except when the weather was very warm, and then it was more saturated, of a deep colour, and discharged in smaller quantities. It had a large cloud, except when it was very pale or limpid; but more generally it had a copious white sediment, even on the first day of the fever. On the second day, the urine continued to be discharged very copiously; in some, it was then turbid, and deposited a more copious sediment than on the first day: this sediment was sometimes of a brownish colour; in which case it was generally followed by bloody urine, either about the end of the second or beginning of the third day. The colour and quantity of the urine, discharged in equal times, were remarkably variable, being now limpid, then of a deeper colour, now discharged in a larger, then in a smaller quantity; which could not be ascribed to any change made either in the quantity or quality of the drink, &c.

The fever accompanied with these symptoms terminated on the third day, or generally in less than 72 hours from the first attack, not by any assimilation or coction and excretion of the morbid matter: for if by the latter, there would have been some critical discharge by sweat, urine, stool, or otherwise, none of which happened; and if by the former, nothing then would have remained but great debility. This fever, however, did not terminate in either of these salutary ways, excepting in some, who were happy enough to have the disease conquered in the beginning by proper evacuations, and by keeping up a plentiful sweat, till the total solution of the fever, by proper mild diaphoretics and diluents. But those who had not that good fortune, however tranquil things might appear at this period, (as great debility, and a little yellowness in the white of the eyes, seemed then to be the chief complaint, excepting when the vomiting continued;) yet the face of affairs was quickly changed: for this period was soon succeeded by the second stadium; a state, though without any fever, much more terrible than the first: the symptoms in which were the following. The pulse, immediately after the recess of the fever, was very little more frequent than in health, but hard and small. However, though it continued small, it became, soon afterwards, slower and very soft; and this softness of the pulse remained as long as the pulse could be felt. In many, in this stage of the disease, the pulse gradually subsided, until it became scarce perceptible; and this notwithstanding all the means used to support and fill it; and when this was the case, the hecticous-like suffusion, the vomiting, delirium, restlessness, &c. increased to a great degree. In some, the pulse, after being exceedingly small and scarce perceptible, recovered considerably its fullness; but that favourable appearance was generally of but short continuance. The heat did not exceed the natural animal-heat; and when the pulse subsided, the skin became cold, and the face, breast and extremities acquired somewhat of a livid colour. The skin was dry when the weather was cold, but was moist and clammy when the weather was hot. The respiration was natural, or rather slow. The tongue was moist, and much cleaner than in the former stage; its tip and edges, as also the gums and lips, were of a more florid red colour than usual. Very few complained of thirst, though they had a great desire for cold liquors. The vomiting or reaching to vomit increased, and in some was so constant that neither medicines nor aliment of any kind were retained. Some vomited blood; others only what was last exhibited, mixed with phlegm; and others again had what is called the black vomit (a). The reaching to vomit continued a longer or shorter time according to the state of the pulse; for as that became fuller, and the heat greater, the reaching to vomit abated, and

(a) That which is called the black vomit, at first sight appears to be black; but on a more careful examination, it was observed that this colour proceeded from a great quantity of small flaky black substances which floated in the liquor thrown up by vomit; but the colour of this liquor was much the same with that which the patient had last drank, and was by no means black. Those black flaky substances are the bile mixed with, or adhering to, the mucus which lined the stomach. For, upon dissection of those who died of this disease, it was always observed that the mucus of the stomach was abraded, and the bile in its cysts was black and sometimes very viscid. In a lad who died of this disease in the beginning of the fourth day, and who was immediately opened, the bile was not only black, but had the consistence of thick venice-turpentine, and was exceedingly tough. On the inside of the stomach, there were several carbuncles or gangrenous specks. And in all those who were affected, and had died of this disease, the same appearances were not only always observed, but likewise the blood was very fluid, and the vessels of the viscera were much distended. The inquietude was very obstinate; and when they dozed, their slumber were but short and unrefreshing. There were some who were drowsy; but these always awaked, after the shortest slumber, with a great dejection of spirits and strength. The jaundices or restlessness were surprising: it was frequently scarce possible to keep the patients in bed; though, at the same time, they did not complain of any anxiety or uneasiness; but if asked how they did, the reply was, very well. The debility was so great, that, if the patient was raised erect in the bed, or, in some, if the head was only raised from the pillow, while a cup of drink was given, the pulse sunk immediately, and became sometimes so small, that it could scarce be felt; at this time, they became cold, as in a hibernation, but without the anterior-like skin: their skin became clammy, the delirium increased, their lips and skin, especially about the neck, face and extremities, together with their nails, acquired a livid colour. The delirium returned and increased; it was generally constant in those whose pulse was small and subsiding. The inflammation of the tunica conjunctiva or white of the eyes increased much, but without pain. A yellowness in the white of the eyes, if it did not appear before in the febrile state, became now very observable, and that icterous-like colour was soon diffused over the whole surface of the body, and was continually acquiring a deeper saffron-like colour. In some indeed no yellowness was observable, excepting in the white of the eyes, until a little before death, when it increased surprisingly quick, especially about the breast and neck. There were many small specks, not raised above the skin, which appeared very thick in the breast and neck, but less so in the extremities, and were of a scarlet, purple, or livid colour. In women the menstrua flowed, and sometimes excessively, though not at their regular period.

There was such a putrid dissolution of the blood in this stadium of the disease, that, besides the vomiting of blood formerly mentioned, and the bloody urine soon to be taken notice of, there were hemorrhages from the nose, mouth, ears, eyes, and from the parts which were blistered with cantharides. Nay, in the year 1739 or 1745, there was one or two instances of an hemorrhage from the skin, without any apparent puncture or loss of any part of the scarf-skin.

An obstinate coliciveness continued in some; in others, the stools were frequent and loose; in some, they were black, liquid, large, and greatly fatiguing; in others, when the stools were moderate, even though they were black, they gave great relief; in others, again, the stools nearly resembled tar in smoothness, tenacity, colour and consistence.

The urine was discharged in a large quantity, in proportion to the drink retained by the patient: it was pale if the patient was not yellow; but if yellow, then it was of a deep saffron-colour: in either case, it had a sediment, or at least a large cloud, which remained at the bottom of the glass; in some, it was very turbid; in others, it was bloody: and the quantity of blood discharged with the urine bore always some proportion to the state of the pulse; when that became fuller, the quantity of blood in the urine was diminished; when the pulse subsided, the bloody urine increased, and even returned after it had ceased some days, soon after the pulse became smaller. This stage of the disease continued sometimes seven or eight days before the patient died.

When this stadium of the disease terminated in health, it was by a recess or abatement of the vomiting, hemorrhagies, delirium, inquietude, jaundices, and icterous-like suffusion of the skin and white of the eyes; while, at the same time, the pulse became fuller, and the patient gained strength, which, after this disease, was very slowly. But when it terminated in death, those symptoms not only continued, but sooner or later increased in violence, and were succeeded with the following, which may be termed the third stadium of the disease, which quickly ended in death. The pulse, though soft, became exceedingly small and unequal; the extremities grew cold, clammy, and livid; the face and lips, in some, were flushed; in others, they were of a livid colour; the livid specks increased so fast, that in some the whole breast and neck appeared livid; the heart palpitated strongly; the heat about the precordia increased much; the respiration became difficult, with frequent sighing; the patient now became anxious, and extremely restless; the sweat flowed from the face, neck, and breast; blood flowed from the mouth, or nose, or ears, and in some from all those parts at once; the deglutition became difficult; the hiccoughs and fulguratus of the tendons came on, and were frequent; the patients trifled with their fingers, and picked the naps of the bed-clothes; they grew comatous, or were constantly delirious. In this terrible state, some continued eight, ten, or twelve hours before they died, even after they had been so long speechless, and without any perceptible pulsation of the arteries in the wrists; whereas, in all other acute diseases, after the pulse in the wrists ceases, death follows immediately. When the disease was very acute, violent convulsions seized the unhappy patient, and quickly brought this stadium to its fatal end. After death, the livid blotches increased fast, especially about the face, breast, and neck, and the putrefaction began very early, or rather increased very quickly.

This was the progress of this terrible disease through its several stadia. But in hot weather, and when the symptoms in the first stage were very violent, it passed through those stages with such precipitation, that there was but little opportunity of distinguishing its different stadia, the whole tragedy having been finished in less than 48 hours. It was remarkable, that, 1. The infection was increased by warm and lessened by cold weather. 2. The symptoms in the several stadia were more or less violent, according to the heat or coolness of the weather. In hot days, the symptoms were not only more violent, but in those who seemed, in moderate weather, to be on the recovery, or at least in no danger, the symptoms were all so greatly heightened, when the weather grew considerably warmer, as frequently to become fatal. In cool days, the symptoms were not only milder, but many, who were apparently in great danger in hot days, were saved from the jaws of death by the weather becoming happily cooler. 3. The disease was generally more fatal to those who lay... In those fevers, I have also seen the disease entirely confined to the heart and pericardium. In one who died the tenth day of the fever, without having been yellow, a quantity of pus and purulent crusts were found mixed with the water of the pericardium. The heart in different places was excoriated, and, together with the inside of the pericardium, was lined with a thick membranous cake, similar to that already mentioned on the lungs and pleura. In some places, this cake had a purulent, in others a gelatinous appearance, exactly resembling the coagulum of the blood. His complaints had been, a great oppression on the breast, and an extreme difficulty of breathing.

In a third person, who died on the thirteenth day of the fever, above two quarts of pus and purulent jelly were found in the cavity of the belly. The source of such an extraordinary quantity of matter was not from any preceding inflammation, nor any impotheum, that we could discover; but from innumerable ulcerations on the surface of the intestines, omentum, mesentery, and peritoneum. Neither did those ulcerations (or excoriations, as they rather appeared in several places) seem to be the primary fountains of the matter, but to have been occasioned by its acrimony.

This purulent appearance seems to arise merely from an extravasation of one of the component parts of the blood, the gluten or coagulable lymph, blood taken from persons in a fever, and frequently even from persons in perfect health, after standing in a clean vessel for a short time, commonly separates into three distinct portions; viz. the serum, or water of the blood, the red concreted mass, and a viscid pellicle termed the size, which spreads itself on the top of the red concretion. Some time ago, when making experiments with the blood taken from persons in the scurvy, I was surprised to find it often covered with that fizzy crust. This induced me to extend my experiments to large quantities of blood from different subjects, which I had opportunities of inspecting at once in so large a hospital. For this purpose I one morning ordered ten patients in the scurvy to be bled, taking two ounces from each. A larger quantity was taken, for its inspection, from two men in health. That day I had occasion to prefer the bleeding to a woman in labour, two hours before her delivery; to a girl of fifteen years of age afflicted with a lunacy proceeding from the chlorosis; to three patients in the rheumatism; and to a person labouring under an obstruction of the liver.

From a nice comparison, and an examination of the different blood, I found in general, that the more size there was on the top, and the thicker and more viscid this white pellicle showed itself, the concretion below it was of a more loose coherence. This was not to be observable when only some slight white streaks appeared on the top. But when much size had separated itself, the red mass became very soft at the bottom of the vessel, and less compact in its different parts, in proportion to their distance from the surface, towards which this whitish portion had ascended.

From this and from other experiments it appears, that this crust or pellicle is the natural gluten or cement of the blood, (called by some the coagulable lymph), which becomes strongly disposed, in certain circumstances and diseases, to separate itself. And whereas the serum and red concretion are easily incorporated together, it will be found, that this glue, after its separation, becomes immiscible with either. We have, by gentle drying, converted it into a perfectly tough elastic membrane; and, by the means of a small portion of the red mass being left adhering to it, into a substance resembling muscular flesh; and it is capable of undergoing various changes into corruption, in the same manner as either of these.

"Now, I can see no reason why this gluten, in its morbid state, may not separate itself from the circulating blood, and be deposited in the cavities of the body, as readily as the serum does in dropsies; the former having always a less disposition than the latter to incorporate with the mass.

"In dissecting persons who died of fevers in London and Minorca, and where no infection was suspected, appearances similar to these have also fallen under the inspection of those accurate anatomists Drs Hunter and Cleghorn. Hence it may be presumed very difficult to distinguish fevers that are produced by infection, from some others. I cannot, however, be induced to think, as those gentlemen seem to do, that these preternatural substances which were found in the cavities of the body are the consequence, but rather that they are the cause, of the inflammation and excoriations. I believe these substances to be at first diffused extravasated gluten, and conjecture their different states greatly to depend upon the different times at which they were deposited.

"I have remarked, in a variety of dead bodies, three different kinds of extravasation; these occurred in such as had died of the scurvy, the consumption, and of fevers. In the former of those diseases, red coagulated blood is found extravasated in almost all parts of the body, not only into the tela cellulosa, but into the bellies of the muscles, particularly of the legs and thighs, which often become quite stuffed, and even distorted, with large grumous masses. The intestines and mesentery are often spotted also with extravasated blood; and I have seen large ecchymoses on the stomach. Those appearances, at first sight, resembled so many distinct mortifications; and by this appearance some anatomists have been deceived; but, upon a nice examination, the texture of the parts is found to be sound and firm. There is likewise, in that disease, sometimes an extravasation of water, chiefly collected in, and always, when in the legs, confined to, the tela cellulosa.

"But whereas, in the limbs of scorbutic persons, it is extremely difficult to make a good dissection by reason of such quantities of extravasated blood that everywhere obstruct the operator; so, on the contrary, the lower extremities of those who have died consumptive, with swelled legs, are, of all other subjects, in the best state to afford a satisfactory view of the muscles. The water inclosed in their legs having infumated itself, by passing the tela cellulosa, into the spaces between the muscles, the muscles are easily separated from each other; and their several origins and insertions may be distinctly traced by means of their having been cleansed and washed by the water in the investing cellular membrane. Thus there are extravasations of three sorts; viz. first, the grumous mass in the scurvy; and this I have often remarked where no serum was observed. Secondly, The serum alone in anaerobic swellings. The third and last is what was taken notice of in those who died of fevers, being the gluten of the blood, accompanied for the most part with some serum; both of them altogether contained in the large cavities of the body.

"I conjecture, that in those fevers there is always an ulcerous or purulent disposition in the blood; and that this gluten, or coagulable lymph, is greatly diseased. I have frequently seen it have a true purulent appearance soon after it was drawn off, when the patient seemed not very ill.

"And I further conjecture, that the mischief often lies within the breast; as also that the great benefit derived from the very early application of blisters, in a great measure flows from so many ulcerations and vents being timely provided for the free discharge of those purulent and tainted particles from the body.

"If an infection depends, as many have imagined, on the admission of certain foreign particles into the blood, this gluten seems to be its more immediate seat, and to be primarily affected by it; and a discharge of this, as though by washing those particles out of the body, tends in a great measure to remove the disease.

"It is an observation of the best practical writers, that issues and fetors are most excellent preservatives against receiving an infection, nay, even that of the plague itself. And indeed a suppuration and plentiful discharge from a proper ulcer, whether produced by nature or by art, seems to open a channel the best appropriated for an exit out of the body to some of the most malignant poisons. Thus the most favourable crisis in the plague, and in most pestilential fevers, happens when nature excites tumours kindly suppurating in the groin or arm-pits, by whose beneficial and plentiful discharges the deadly poison is expelled from the constitution.

"I have observed it to be amongst the most certain characteristics of the worst fevers, that the blisters either do not rise and fill, or discharge such yellow, greenish, fetid, and highly offensive stuff, that even experienced nurses could give a pretty certain conjecture, from the blisters, of the different degrees of malignity in the fever. We have more than once endeavoured to conceal the bad state of some patients in the hospital; but a discovery was always made of their condition in the wash-house, from the linen sent there stained with the discharges from the blistered parts. And indeed a careful inspection of the state and discharge from the blisters, together with their effects, furnishes us, in those diseases, with some of the most certain diagnostics of their nature, and prognostics of their event."

Prognosis. This distemper, where it attacks with violence, is generally fatal; the prognosis therefore must be commonly unfavourable, and always uncertain; neither can any thing more be said on this subject, than that an abatement of the symptoms already enumerated affords a favourable prognostic, and an increase of them the contrary.

Cure. Cure. The cure of this terrible disease, according to Dr Hillary, is very easy and simple. His indications are, 1. To moderate the too great and rapid motion of the fluids, and abate the too great heat and violence of the fever in the two first days of the disease, as much and as safely as we can. 2. To evacuate and carry out of the body as much of the putrid bile and other humours, and as expeditiously and safely, as we possibly can. 3. To put a stop to the putrefactive disposition of the fluids, and to prevent the gangrene from coming on by suitable antiseptics.

The first indication is answered by bleeding, which, in the first stage of this fever, is absolutely necessary in some degree: the quantity to be taken away must be determined by the age and strength of the patient, the degree of plethora, fulness of the pulse, &c. When called in at the beginning, he orders 12, 14, 16, 18, or 20 ounces of blood to be taken away on the first or second day; and if the patient's pulse rises after the first bleeding, or if the fever still continue high and the pulse full, he repeats the bleeding once on the days above-mentioned. But bleeding a third time is seldom or never required; neither is bleeding on the third day almost ever required; and when it is performed on that day, it ought to be done with the greatest caution and judgment: neither should a vein be opened after the third day in this fever, unless some very extraordinary symptoms and circumstances require it; which seldom or never happen. On that day, indeed, the pulse generally sinks, and the blood is in such a dissolved state, that bleeding must be accounted highly pernicious. Nevertheless, it is indispensible necessary in the beginning of the distemper; and if omitted at that time, the violent heat and motion of the blood increase the putrefaction of the humours to such a degree as to bring on the fatal consequences much sooner than would otherwise have happened.

After bleeding, we come to the second indication of cure, namely, to evacuate as much of the bilious and putrid humours as soon and as safely as we can. The great irritation of the stomach, by the putrid bilious humours constantly attending this fever, with almost continual retchings and violent vomitings, seem to indicate the giving of an emetic; but the coats of the stomach are always observed to be so violently stimulated and irritated, and most commonly inflamed, by the acrimony of the putrefactive bile, that any emetic, even the most mild and gentle, given in the smallest dose, brings on an incessant vomiting, which continues, in spite of all remedies, till a mortification and death ensue. Instead of this, it is proper to give large draughts of warm water, which, without any additional stimulus to the coats of the stomach, evacuates its acid and putrid contents, commonly with great relief to the patient: the warm water also acts as an emollient foment to the inflamed coats of the stomach; and thus abates the inflammation, and prevents the gangrene and mortification from coming on.

After the patient has by this means vomited seven or eight times or oftener, and discharged a great quantity of yellow and blackish bilious matter as they often do, a grain or a grain and a half of Thebaic extract is given in order to procure some respite from the violent retching, vomiting, and anxiety. The person is desired to take nothing into his stomach for two hours after this, by which means it is seldom or never rejected; and thus all the symptoms are considerably abated; the retching and vomiting either totally cease or are very much lessened, so that medicines may now be exhibited which the stomach would not have retained before. These are cooling acid juleps, or other antiseptic remedies; but neither nitre nor any of its preparations will commonly be found to stay on the stomach; nor are the nitrous medicines, or even the common anti-emetic draughts, proper to be given in this disease, even though they should agree with the stomach, on account of their attenuating property.

If the patient has not a stool or two after drinking the warm water and vomiting, it is necessary to give a gentle purging clyster; and when six or eight hours rest have been obtained, a gentle antiphlogistic and antiseptic purge, in order to evacuate by stool as much of the bilious matter as we possibly can. Or if the patient has a purging before, which sometimes though very rarely happens, a dose of toasted rhubarb is given, and an antiseptic anodyne after it has operated to abate and check the too great purging, but not to stop it, as this evacuation has been always observed to be of service, provided it is not too violent.

After this indication is completely answered, the next is to exhibit such proper antiseptic medicines as may stop the putrefactive disposition of the fluids. Here the bark would seem to be the most proper remedy; but unluckily the stomachs of the patients in this disease are so much irritated, and so apt to reject every thing, that the bark cannot be retained in any form whatever. In this case Dr Percival recommends columbo-root, the infusion of which is found to be a powerful antiemetic and antiputrefactive medicine, and might perhaps so far alter the state of the stomach as to make it bear the bark. Our author, however, who was ignorant of the virtues of columbo, substituted the radix serpentinaria Virginiana with success. A slight infusion of this root not only sat easily on the stomach of the patients, but moderately raised the pulse and fever, both of which are now too low. The following receipt was found the most agreeable and efficacious:

Rad. serpentinum. 3i. Croc. Ang. 3i. M. et infunde vasa clausa in aqua bul. q. per horam unam ut col. 3vi. Adde aqua menth. simp. 3ii. Vin. Maderiens. 3iv. Syr. croc. vel syr. mecon. 3i. Elix. vitriol. acid. q. f. ad grat. acidi. sapor. Exhibe cochlear. duo vel tria singulis horis vel biihoris, vel sequi praecipue nata.

By the use of this medicine, and soft light nourishment taken in small quantities, the pulse is usually kept up and the distemper goes off. But if, after taking this a little while, we find that the pulse does not rise, but on the contrary that a coldness of the extreme parts comes on, the medicines must be made more warming, by increasing the quantity of the snake-root and saffron, or by adding vinum croceum, confectio cardiaca, or the like, but not by the use of volatile spirits and salts, which hurt by their stimulating and dissolving qualities. Blitters our author reproaches in the strongest terms, and affirms that he has seen the place where a blister was applied turned perfectly black and phaeolated; so that if the spine and end of the ribs... Practice ribs had not hindered, a large square passage would have been opened into the cavity of the thorax, had the patient lived a few hours after it.

At the same time that the strength of the patient is kept up by the medicines above-mentioned, or by others similar, he gave repeated gentle purgatives every second or third day, and sometimes, when the symptoms are very urgent, every day, for four or five days successively. But if proper methods be taken in the beginning of the disease, it is seldom that such a repetition of purging is necessary; and the Doctor gives the following remarkable instance of the efficacy of this method of treating the disease: "A young man about 24 years of age, surgeon to a Guinea ship, was brought into a house where I was visiting a patient; he was of a sanguine robust constitution, and a lover of spirituous liquors, and had been drunk three days and nights successively, and in that condition had run several races on the hot sea-shore, near noon, with the sailors, in the heat of the sun; and to complete his folly, lay the last night after that exercise, in the open air under a tamarind-tree all the night, where he was seized in the morning with all the symptoms of this fever, in the most violent manner that I have ever seen any one. In this condition he was brought to the house where I was; his retching and vomiting were so incessant, that he could not get time to say yes, or no, to the questions which I asked, without waiting some time for it; each time; his eyes were red and inflamed, attended with a burning heat, as usual in the beginning of this fever; and he had all the other symptoms which attend the first attack of this fever, in the most violent manner, which I need not repeat. I ordered 3xvi. of blood to be taken from him, which was very florid, thin, and much dissolved; and then directed him to drink warm water freely, and to vomit eight or ten times; and after that to take extract. Thebaic. gr. jfs. and take nothing for two hours after it. But I being gone, and he finding that he vomited with more ease, less sickness and retching, with the warm water, than he did before, and being much alarmed at his having this fever, he drank three gallons of the water, and brought up great quantities of yellow and blackish bilious matter with it, and washed his stomach effectually. He then took the extr. thebaic. and slept three or four hours after it; and the vomiting ceased: he took some panada, and four hours after that the purge of manna and tamarinds, &c. which gave him eight stools, and carried a good deal more of the putrid bilious matter off downwards; and got some rest after it: he then took of an antiseptic julep often, and light nourishment, a little acid, at the intervals; and repeated the purge on the third day, as directed. I being called out of the town, I did not see him till the fourth morning after; he said that he had followed my directions; and I found him free from the fever and all its symptoms, but weak and low, and his skin a little yellow, but much less so than usual, unless when the bilious matter is thus carried off. I ordered him to take elix. vitrioli acid. gut. lx. three or four times a-day for a few days, in an infusion of mint-leaves with a little snake-root, made as tea; which he did, and soon recovered perfectly well in seven or eight days time.

This patient being seized in so violent a manner, and recovering in so short a time, and so near to the practice rule which the elegant Celsus recommends, Cito, tutu, et jucunde, not only confirmed the above manner of reasoning on the cause and nature of this disease to be right, but made me determine to follow the same method as near as I possibly could ever since, and I must add, with the same good success also, when I am called so early on in the disease that I can strictly pursue it: which is too seldom the case; for in general the physician is not called in till the fourth or fifth day, or after, when the putrid acid bilious matter is a great part of it carried into the blood, which it has so dissolved and brought its whole mass into a colliquated, putrid, gangreneous state, that the best of methods, and the most efficacious medicines, however judiciously timed and applied, are precarious and uncertain; or sometimes it is so far advanced, that the ablest physician can do no more than tell the relations of the sick that it is too late, and that they can live but a few hours: for I know no disease in which the recovery of the patient so much depends upon the right or wrong method of treating it, at the very first attack or beginning of the disease, as this fever does: for by thus discharging and carrying the putrid, acrimonious, bilious matter, out of the body before much of it is carried into the blood, not only most of the bad symptoms which attend the second state of the fever are prevented from coming, but the hemorrhages, and the yellowness of the skin, &c. also, and the fever soon taken off too; for I have never seen any hemorrhage come on, and but little yellowness, or in some none, when they were thus treated.

And when the last stage of this fever is come on before we are called in, provided that it is not at the very latter end of it, I have always found that this method of gentle purging, whenever the before-mentioned symptoms indicate it, and a liberal use of the antiseptic medicines in the intervals, has been so successful, that I have seen but two patients that have died in this fever during the eight years past in which I treated it in this manner; and one of them was so weak that he could not take a spoonful of any thing, and so near his end that he died about two hours after without taking any medicine; and the other killed himself by drinking a gallon of cold water in less than three hours time, (after taking half an ounce of manna in the morning), which struck such a coldness into his whole body that he died; though I have visited several every year, and in some years a great many: therefore I take the liberty of recommending this method to others, and with it to be as successful to all."

To the genus of typhus also belong all those fevers attended with very profuse and debilitating sweats, and which have sometimes, not without good reason, been accounted plagues; such as the English sweating-sickness, Miliaris fudatoria, Sauv. sp. 5. Ephemera fudatoria, Sauv. sp. 7. Ephemera Britannica, Caius de ephem. Britan.

XXX. Synochus. Genus VI.

Synochus Sauv. gen. 81. Lin. 13. Lenta Lin. 14. Phrenitis Veg. 18. Febris continua putrida Boerh. 730.

This is a contagious distemper, being a complication XXXI. The Heptic Fever.

Hectica, Sauv. gen. 83. Lin. 24. Veg. 80. Sag. 684.

This disease is reckoned by Dr. Cullen to be merely symptomatic; as indeed seems very probable, seeing it always accompanies absorptions of pus into the blood from internal suppurations, or indeed from such as are external, provided they are very large or of a bad kind.

Description. The heptic, indeed the only proper description of this disorder we have, is that by Dr. Heberden. According to him, the appearance of the hectic fever is not unlike that of the genuine intermittent; from which, however, the disease is very different in its nature, as well as infinitely more dangerous. In the true intermittent, the three stages of cold, heat, and sweat, are far more distinctly marked, the whole fit is much longer, the period which it observes is more constant and regular, and the intermissions are more perfect than in the hectic fever. For in the latter, even in the clearest remission, there is usually a feverish quickness perceptible in the pulse, which seldom fails to exceed the utmost limit of a healthy one by at least ten strokes in a minute.

The chilliness of the hectic fever is sometimes succeeded by heat, and sometimes immediately by a sweat without any intermediate state of heat. The heat will sometimes come on without any remarkable chilliness preceding; and the chilliness has been observed to go off without being followed either by heat or sweat. The duration of these stages is seldom the same for three fits together; and as it is not uncommon for one of them to be wanting, the length of the whole fit must vary much more than in the true intermittent; but in general it is much shorter.

The hectic patient is little or nothing relieved by the coming on of the sweat; but is often as anxious and restless under it, as during the chilliness and heat. When the sweat is over, the fever will sometimes continue; and in the middle of the fever the chilliness will return; which is a most certain mark of this disease.

The hectic fever will return with great exactness, like an intermittent, for two or perhaps three fits; but Dr. Heberden informs us, that he does not remember ever to have known it keep the same period for four fits successively. The paroxysm will now and then keep off for ten or twelve days; and at other times, especially when the patient is very ill, it will return so frequently on the same day, that the chilliness of a new fit will follow immediately the sweat of the former. It is not unusual to have many threatenings of a slumbering return in the same day; and some degree of drowsiness is apt to attend the cessation of a fit.

The urine in a true intermittent is clear in the fit, and turbid in the intervals; but in the hectic fever it is liable to all kinds of irregularity. It will be equally clear or turbid in both stages; or turbid in the fit and clear in the intervals; and sometimes it will be, as in a true intermittent, clear during the fever, and thick at the going off.

Hectic patients often complain of pains like those of the rheumatism, which either affect by turns almost every part of the body, or else return constantly to the same part; which is often at a great distance from the seat of the principal disorder, and, as far as is known, without any peculiar connection with it. These pains are so violent in some patients, as to require a large quantity of opium. As far as Dr. Heberden has observed, they are more common, where the hectic arises from some ulcer open to the external air, as in cancers of the face, breast, &c. Joined with this fever, and arising probably from one common cause, he has been surprized to see swellings of the limbs, neck, or trunk of the body, rise up almost in an instant, as if the part was all at once grown fatter. These swellings are not painful, hard, or discoloured, and they continue for several hours.

Dr. Heberden has seen this fever attack those who seemed in tolerable health, in a sudden and violent manner, like a common inflammatory one; and like that, also, in a very short time bring them into imminent danger of their lives; after which it has begun to abate, and to afford hopes of a perfect recovery. But though the danger might be over for the present, and but little of a fever remain; yet that little has soon shewed, that it was kept up by some great mischief within, and, proving unconquerable by any remedies, has gradually undermined the health of the patient, and never ceased except with his life. This manner of its beginning, however, is extraordinary. It much oftener dissembles its strength at first; and creeps on so slowly, that the subjects of it, tho' they be not perfectly well, yet for some months hardly think themselves ill; complaining only of being sooner tired with exercise than usual, of want of appetite, and of falling away. But gentle as the symptoms may seem, if the pulse be quicker than ordinary, so as to have the artery to beat 90 times and perhaps 120 times in a minute, there is the greatest reason to be apprehensive of the event. In no disorder, perhaps, is the pulse of more use to guide our judgment than in the hectic fever: yet even here we must be upon our guard, and not trust entirely to this criterion; for one in about 20 patients, with all the worst signs of decay from some incurable cause, which irrefutably goes on to destroy his life, will shew not the smallest degree of quickness, nor any other irregularity of the pulse, to the day of his death.

Causes, &c. This fever will supervene whenever there is a great collection of matter formed in any part of the body; but it more particularly attends upon the inflammation of a seirrhouss gland, and even upon one that is slight and only just beginning; the fever growing worse in proportion as the gland becomes more inflamed, ulcerated, or gangrenous. And such is the lingering nature of those glandular disorders, that the first of those stages will continue for many months, and the second for some years.

If this seirrhouss inflammation be external, or in the lungs, or some of the abdominal viscera, where the disturbance of their functions plainly points out the seat of the disorder, no doubt can be entertained concerning the cause of the fever. But if the part affected be not obvious to the senses, and its precise functions be not known, the hectic, which is there only part of the train of another disease, may be mistaken for the primary or only one. Lying-in women, on account of the violence sustained in delivery, generally die of this fever. Women of the age of near 50 and upwards are particularly liable to it. For, upon the cessation of their natural discharge, the glands of the breasts, ovaries, or womb, too commonly begin to grow febrile, and proceed to be cancerous. Not only these, but the glandular parts of all the abdominal viscera, are disposed to be affected at this particular time, and to become the seats of incurable disorders.

The injuries done to the stomach and liver by hard drinking are attended with similar symptoms, and terminate in the same manner.

Dr Heberden observes, that the slightest wound by a fine pointed instrument is known upon some occasions to bring on the greatest disturbances, and the most alarming symptoms, nay even death itself. For not only the wounded part will swell and be painful, but by turns almost every part of the body; and very distant parts have been known to come even to suppuration. These symptoms are constantly accompanied with this irregular intermittent, which lasts as long as any of them remain.

Prognosis. This anomalous fever is never less dangerous than when it belongs to a kindly suppuration, into which all the diseased parts are melted down, and for which there is a proper outlet.

The symptoms and danger from some small punctures, with their concomitant fever, most frequently give way in a few days; though in some persons they have continued for two or three months, and in others have proved fatal.

The inflammation of internal febrile glands, or of those in the breasts, sometimes goes off, and the fever, which depended upon it, ceases; but it much oftener happens, that it proceeds to cancerous and gangrenous ulcers, and terminates only in death.

Cure. The same medicines are not likely always to suit a fever which, arising from very different causes, is attended with such a variety of symptoms. A mixture of asafoetida and opium has in some persons seemed singularly serviceable in this fever, when brought on by a small wound; but in most other cases the principal if not the sole attention of the physician must be employed in relieving the symptoms, by tempering the heat, by preventing both coliciveness and purging, by procuring sleep, and by checking the sweats. If, at the same time, continues Dr Heberden, he put the body into as good general health as may be, by air, exercise, and a proper course of mild diet, he can perhaps do nothing better than to leave all the rest to nature.

In some few fortunate patients, nature appears to have such resources, as may afford reason for entertaining hopes of cure, even in very bad cases. For some have recovered from this fever attended with every symptom of an abdominal viscus incurably diseased, after all probable methods of relief from art had been tried in vain, and after the flesh and strength were so exhausted as to leave scarce any hopes from nature. In those deplorable circumstances, there has arisen a swelling not far from the probable seat of the disorder, and yet without any discoverable communication with it. This swelling has come to an abscess; in consequence of which the pulse has soon returned to its natural state, as have also the appetite, flesh, and strength.

What nature has performed in those rare cases, Dr Heberden acquaints us, he has often endeavoured to imitate, by making issues or applying blisters near the seat of the disease; but he cannot say with the same success.

It seems at present, Dr Heberden observes, the opinion of many practitioners, that the gangrenes will be stopped, and suppuration become more kindly, by the use of bark; and therefore this remedy is always either advised or permitted in the irregular fever joined with suppurations and gangrenes. But he affirms he does not remember ever to have seen any good effect from the bark in this fever unattended with an apparent ulcer; and even in gangrenes it so often fails, that in successful cases, where it has been administered, there must be room for suspicion that the success was owing to another cause. Dr Heberden acknowledges at the same time, that he never saw any harm from the bark, in these, or indeed in any other cases, except a purging or sickness of no consequence, where it has happened to disagree with the stomach, or where the latter has been loaded by taking the medicine too fast, especially in dry boluses wrapped in wafer-paper.

In hectic illnesses, where all other means have proved ineffectual, a journey to Bath is usually proposed by the friends, and wished for by the sick; but Dr Heberden justly observes, that, besides the fatigue and many inconveniences of a journey to a dying person, the Bath waters are peculiarly hurtful in this fever, which they never fail to increase, and thereby aggravate the sufferings and hasten the death of the patient.

ORDER II. PHLEGMASIÆ.

Phlegmasiae membranofæ et parenchymatofæ, Sauv. Clas. III. Ord. I. II. Sag. 605. Morbi febriles phlogistici, Lin. Clas. III. Febrés continuee compotitae inflammatoriae, V. Morbi acuti febriles, Boerb. 770. Febrés inflammatoriae, Hoffm. II. 105. Junck. 61.

XXXI. PHLOGOSIS. Genus VIII. Sp. I. Phlegmone auctorum, Sauv. gen. 15. Lin. 39. Veg. 351. Inflammatio, Lin. 231. Boerb. 370. Junck. 20.

This disease is a synocha fever, accompanied with an inflammation of some particular part either external or internal, and consequently varies very much in its form and the degree of danger attending it, according to the situation and functions of the part affected with topical inflammation. To this species, therefore, belong the following diseases.

Furunculus, Sauv. gen. 18. Veg. 352. Terminthus, Veg. 381. Pupula, Lin. 275. Sauv. p. 6. Varus, Veg. 436. Lin. 269. Sauv. p. 7. Bacchia, Lin. 270. Gutta rosea, Sauv. gen. 4. Gutta rofacca, Veg. 437. Hordeolum, Sauv. gen. 27. Lin. 276. Veg. 434. Otalgia, Sauv. gen. 197. Lin. 44. Veg. 148. Dolor otalgicus, Hoffm. II. 336. Parulis, Veg. 362. For the cure of inflammations, Dr Collen lays down the following indications:

1. To remove the remote causes when they are evident and continue to operate. 2. To take off the phlogistic diathesis affecting the whole system, or the particular part. 3. To take off the spasm of the particular part by remedies applied to the whole system or to the part itself.

The means of removing the remote causes will readily occur, from considering the particular nature and circumstances of the different kinds. Acid matters must be removed, or their action must be prevented, by the application of demulcents. Compressing and over-stretching powers must be taken away; and, from their several circumstances, the means of doing so will be obvious.

The means of taking off the phlogistic diathesis of the system are the same with those already mentioned under the cure for synoche. The means of taking off the spasm also from the particular part, are much the same with those already mentioned. Only it is to be remembered, that topical bleedings, such as cupping with scarification, applying leeches, &c., are in this case much more indicated; and that some of the other remedies are to be directed more particularly to the part affected, as shall be more fully considered when we treat of those diseases attended with particular inflammations.

When a tendency to suppuration is perceived, the proper indication is to promote the production of perfect pus as much as possible. For this purpose various remedies, supposed to possess a specific power, have been proposed; but it does not appear that any of them are possessed of a virtue of this kind; and, in our author's opinion, all that can be done is to favour the suppuration by such applications as may support a moderate heat in the part, by some tenacity confine the perspiration, and by an emollient quality may weaken the cohesion of the teguments, and favour their erosion. As all abscesses are occasioned by the effusion of fluids, and as in the case of certain effusions a suppuration becomes not only unavoidable but desirable, it may be supposed that most of the means of procuring a resolution by diminishing the force of circulation, &c., ought to be avoided. But as we observe on the one hand, that a certain degree of increased impetus, or of the original symptoms of inflammation, is necessary to produce a proper suppuration; so it is then especially necessary to avoid those means of resolution which may diminish too much the force of circulation. And on the other hand, as the impetus of the blood, when violent, is found to prevent the proper suppuration; so, in such cases, though a tendency to suppuration may have begun, it may be proper to continue those means of resolution which moderate the force of the circulation. With respect to the opening of abscesses when completely formed, see the article Surgery.

When an inflammation has taken a tendency to gangrene, that event is to be prevented by every possible means; and these must be different according to the nature of the several causes: but after a gangrene has in some degree taken place, it can be cured only by the separation of the dead from the living parts. This in certain circumstances can be performed, and most properly, by the knife. In other cases it can be done by exciting a suppuratory inflammation on the verge of the living part, whereby its cohesion with the dead part may be every where broken off, so that the latter may fall off by itself. While this is doing it is proper to prevent the further putrefaction of the part, and its spreading wider. For this purpose various antiseptic applications have been proposed: but Dr Cullen is of opinion, that while the teguments are entire, these applications can hardly have any effect; and therefore, that the fundamental procedure must be to scarify the part so as to reach the living substance, and, by the wounds made there, to excite the suppuration required. By the same incisions also, we give access to antiseptics, which may both prevent the progress of the putrefaction in the dead, and excite the inflammation necessary on the verge of the living parts.

When the gangrene proceeds from the loss of tone, and when this communicated to the neighbouring parts prevents that inflammation which, as we have said, is requisite to the separation of the dead parts from the living, it will be necessary to obviate this loss of tone by tonic medicines given internally; and for this purpose the Peruvian bark has been found to be most effectual. But when the gangrene arises from the violence of inflammation, the bark may not only fail of proving a remedy, but may do harm: for its power as a tonic is especially suited to those cases of gangrene which proceed from an original loss of tone, as in the case of palsy and oedema; or in those cases where a loss of tone takes place while the original inflammatory symptoms are removed.

On the other hand, Mr Bell is of opinion, that incisions made with a view to admit the operation of antiseptic remedies in gangrene, as well as the remedies themselves, must be pernicious by reason of the irritation they occasion, and by the danger of wounding blood-vessels, nerves, tendons, &c., also by allowing a free passage for the putrefactive fluids into the parts not yet affected. And unless they are carried so deep as to reach the sound parts, applications of the antiseptic kind can never have any effect in answering the purpose for which they were intended. The same author also remarks, that all the advantages commonly observed from the great number of applications recommended for gangrene, are obtained with more ease, and generally too with more certainty, from the use of some gentle stimulating embrocation; which, by exciting a slight irritation upon the surface, especially when assisted by a free use of the bark, produces, for the most part, such a degree of inflammation as is wished for. With this view he has frequently known a weak solution of sal ammoniac, a drachm of the salt to two ounces of vinegar and six of water, form a mixture of a very proper strength for every purpose of this kind. But the degree of stimulus can easily be either increased or diminished according to circumstances, by using a larger or smaller proportion of the salt.

Whenever, either by the means recommended, or by a natural exertion of the system, a slight inflammation appears appears between the diseased and sound parts, we may in general, with tolerable certainty, expect, that in due time the parts will be separated; and when a full suppuration is once fairly established, there can be little doubt that the mortified parts will be soon and easily removed.

A complete separation being effected, the remaining sore is to be treated in the manner described under the article Surgery; with a proper attention, at the same time, to the support of the general system by the continuance of a nourishing diet, the bark, and such quantities of wine as may seem necessary.

With regard to the bark, however, it is proper to take notice of another case of mortification in which it is likewise unsuccessful, as well as in that attended with an high degree of inflammation; and that is, in those mortifications of the toes and feet, common in old people, or which arise from any cause increasing the rigidity of the vessels to such a degree as to prevent the motion of the fluids through them. In this case Mr Pott has discovered, that all kinds of warm applications are very unsuccessful; but that by the free use of opium, together with sedatives and relaxants externally applied, he has frequently seen the tumefaction of the feet and ankles subside, the skin recover its natural colour, and all the mortified parts separate in a very short time, leaving a clean sore. But as to scarifications, or any other attempt to separate artificially the mortified from the sound parts, he thinks them very prejudicial, by giving pain; which is generally of itself violent in this disease, and which seems to have a great share in producing the other evils.

The other terminations of inflammation either do not admit of any treatment, except that of preventing them by resolution, or properly belong to the article Surgery.

XXXII. Phlogosis Erythema. Sp. II.

Erythema, Sauv. gen. 11. Erysipelas auctorum, Veg. 343. Hieropyr. N. 344. Anthrax, Sauv. gen. 19. Lin. 272. Veg. 353. Carbo et carbunculus auctorum. Erythema gangrenosum, Sauv. sp. 7. Erythema a frigore. Erythema pernio, Sauv. sp. 4. Pernio, Lin. 259. Veg. 350. Erythema ambulio, Sauv. sp. 2. Erysipelas ambulio, Sauv. sp. 4. Combustura, Lin. 245. Combustio, Boerh. 476. Encausis, Veg. 347. Erythema ab acri alieno applicato. Erysipelas Chinense, Sauv. sp. 7. Erythema ab acri inquinillo. Erythema intertrigo, Sauv. sp. 5. Intertrigo, Lin. 247. Veg. 502. Erythema a compressione. Erythema paratrims, Sauv. sp. 6. Erythema a punctura, Sauv. sp. 9. Erysipelas a vespis, Sauv. sp. 19. Pyhydracia a vespis, Sauv. sp. 2. Erythema cum phlegmone. Erysipelas phlegmonodes auctorum.

Erythema cum edematose. Erysipelas symptomaticum, Sauv. sp. 6.

The word erythema doth not apply to any primary disease, but to a great number of those cutaneous inflammations denominated by another general term, viz. the erysipelas, or St Anthony's fire; and which being commonly symptomatic of some other inflammation or disorder, are to be removed only by removing the primary disease: the erythema is found scarcely to bear any kind of warm application to itself; and is very apt, if treated as a primary disease, to terminate in a gangrene of the part affected, or other disorder still more dangerous. The difference between the phlegmon or preceding species, and erythema, according to Dr Cullen, is, that, in the former, the inflammation seems particularly to affect the vessels on the internal surface of the skin, communicating with the lax adjacent cellular texture; whence a more copious effusion, and that too of serum convertible into pus, takes place. In the erythema the affection is of the vessels on the external surface of the skin communicating with the rete mucosum, which does not admit of any effusion but what separates the cuticle and gives occasion to the formation of a blister, while the smaller size of the vessels admits only of the effusion of a thin fluid very seldom convertible into pus.

For the cure of the fever attended with erythema, or erysipelas, see below; and for the external treatment of erythema, see the article Surgery.

XXXIII. OPHTHALMIA, or Inflammation of the Eyes. Genus VIII. Sp. I. 1. A. B. 2. Sp. II. 1. 2.

Ophthalmia, Sauv. gen. 196. Lin. 43. Veg. 341. Sag. 231. Funck. 24. Chemosis, Veg. 46. Ophthalmites, Veg. 47. Inflammatio oculorum, Hoffn. II. 165. Ophthalmia taraxis, Sauv. sp. 1. Ophthalmia humida, Sauv. sp. 8. Ophthalmia chemosis, Sauv. sp. 12. Ophthalmia erysipelasota, Sauv. sp. 7. Ophthalmia putulosa, Sauv. sp. 6. Ophthalmia phlyctenodes, Sauv. sp. 21. Ophthalmia choroides, Sauv. sp. 13. Ophthalmia tenebricosa, Sauv. sp. 10. Ophthalmia trachoma, Sauv. sp. 4. Ophthalmia ficca, Sauv. sp. 5. Ophthalmia angularis, Sauv. sp. 14. Ophthalmia tuberculoa, Sauv. sp. 3. Ophthalmia trichialis, Sauv. sp. 2. Ophthalmia cancroa, Sauv. sp. 15. Ophthalmia a synchia, Sauv. sp. 16. Ophthalmia a lagophthalmos, Sauv. sp. 17. Ophthalmia ab elecomate, Sauv. sp. 18. Ophthalmia ab unguie, Sauv. sp. 19. Ophthalmia a cornua fistula, Sauv. sp. 20. Ophthalmia uvea, Sauv. sp. 22. Ophthalmia metaftatica, Sauv. sp. 24. Ophthalmia scrophulosa, Sauv. sp. 9. Ophthalmia typhilitica, Sauv. sp. 11. Ophthalmia febricola, Sauv. sp. 23.

From reading this long list of distinctions which authors have invented in the ophthalmia, it is evident, that by far the greatest part of them are symptomatic, Practice or merely the consequences of other disorders present in the habit; and therefore the remedies must be directed towards the removal of these primary disorders; and when they are gone the ophthalmia will be removed of course. Dr Cullen observes, that the inflammation of the eye may be considered as of two kinds; according as it is seated in the membranes of the ball of the eye, when it is named ophthalmia membranarum; or as it is seated in the sebaceous glands placed in the tarsus, or edges of the eye-lids, in which case it may be termed ophthalmia tarfi*. These two kinds are very frequently connected together, as the one may excite the other; but they are still to be distinguished according as the one or the other may happen to be the primary affection.

1. The inflammation of the membranes of the eye affects especially, and most frequently, the adnata, and appears in a turgescence of its vessels; so that the red vessels which are naturally there, become not only increased in size, but many more appear than in a natural state. This turgescence of the vessels is attended with pain, especially upon the motion of the ball of the eye; and this irritation, like every other, applied to the surface of the eye, produces an effusion of tears from the lacrymal gland.

The inflammation commonly, and chiefly, affects the adnata spread on the anterior part of the bulb of the eye; but usually spreads also along the continuation of the adnata on the inside of the palpebrum; and as that is extended on the tarsus palpebrarum, the excretories of the sebaceous glands opening there are also frequently affected. When the affection of the adnata is considerable, it may be communicated to the subjacent membranes of the eye, and even to the retina itself, which thereby acquires so great sensibility, that every impression of light becomes painful. The inflammation of the membranes of the eye is in different degrees, according as the adnata is more or less affected, or according as the inflammation is either of the adnata alone, or of the subjacent membranes also; and upon these differences, different species have been established; but they seem all to differ only in degree, and are to be cured by the same remedies more or less employed.

The proximate cause of ophthalmia is not different from that of inflammation in general; and the different circumstances of ophthalmia may be explained by the difference of its remote causes, and by the different parts of the eye which it happens to affect; as may be understood from what has been already said. We shall therefore proceed to give an account of the method of cure.

The ophthalmia membranarum requires the remedies proper for inflammation in general; and when the deeper-seated membranes are affected, and especially when a pyrexia is present, large general bleedings may be necessary. But this last is seldom the case; and, for the most part, the ophthalmia is an affection purely local, accompanied with little or no pyrexia. General bleedings therefore have little effect upon it; and the cure is chiefly to be obtained by topical bleedings; that is, blood drawn from the vessels near the inflamed part; and opening the jugular vein, or the temporal artery, may be considered as in some measure of this kind. It is commonly sufficient to apply a number of leeches round the eye; and it is perhaps still better practice to draw blood by cupping and scarifying upon the temples. In many cases, the most effectual remedy is to scarify the internal surface of the inferior eye-lid, and to cut the turgid vessels upon the adnata itself.

Besides blood-letting, purging, as a remedy suited to inflammation in general, has been considered as peculiarly adapted to inflammation in any part of the head, and therefore to ophthalmia; and it is sometimes useful: but, for the reasons given before with respect to general bleeding, purging in the case of ophthalmia does not prove useful in any proportion to the evacuation excited.—For relaxing the spasm in the part, and taking off the determination of the fluids to it, blistering near the part has commonly been found useful.

Ophthalmia, as an external inflammation, admits of topical applications. All those, however, which increase the heat and relax the vessels of the part, prove hurtful; and the admission of cool air to the eye, and the application of cooling and astringent medicines, which at the same time do not produce irritation, prove useful. In the cure of this disorder indeed, all irritation must carefully be avoided, particularly that of light; and the only certain means of doing this is by keeping the patient in a very dark chamber.

2. In the ophthalmia tarfi, the same medicines may be necessary as are already recommended for the ophthalmia membranarum. However, as the ophthalmia tarfi may often depend upon an acrimony deposited in the sebaceous glands of the part, so it may require various internal remedies according to the variety of the acrimony in fault; for which we must refer to the consideration of scrophula, syphilis, or other diseases with which this ophthalmia may be connected; and where these shall not be evident, certain remedies more generally adapted to the evacuation of acrimony, such as mercury, may be employed. In the ophthalmia tarfi, it almost constantly happens that some ulcerations are formed on the tarsus. These require the application of mercury and copper, which alone may sometimes cure the whole affection; and they may be useful even when the disease depends upon a fault of the whole system.

Both in the ophthalmia membranarum, and in the ophthalmia tarfi, it is necessary to obviate that glueing together of the eye-lids which commonly happens in sleep; and which may be done by infusing a little of any mild unctuous medicine between the eye-lids before the patient shall go to sleep.

The slighter kinds of inflammations from the dust or the sun, may be removed by fomenting with warm milk and water, adding a small portion of brandy; and by anointing the borders of the eye-lids with unguentum tutte, or the like, at nights, especially when those parts are excoriated and sore. But in bad cases, after the inflammation has yielded a little to evacuations, the coagulum aluminaeum of the London dispensatory spread on lint, and applied at bed-time, has been found the best external remedy. Before the use of the latter, the solution of white vitriol is prescribed with advantage; and in violent pains it is of service to foment frequently with a decoction of white poppy-heads. Phrenitis, Sauv. gen. 101. Lin. 25. Sag. gen. 301. Boerh. 771. Hoffm. II. 131. Junck. 63.

Phrenitis, Veg. 45. Cephalitis, Sauv. gen. 109. Sag. gen. 310. Sphacelitis, Lin. 32. Phrenitis vera, Sauv. sp. 1. Boerh. 771. Phrenitis idiopathica, Junck. 63. Cephalalgia inflammatoria, Sauv. sp. 9. Cephalitis spontanea, Sauv. sp. 3. Cephalitis sirsis, Sauv. sp. 4. Sirialis, Veg. 34. Cephalitis Littiriana, Sauv. sp. 5.

Dr Cullen observes, that the true phrenitis, or inflammation of the membranes or substance of the brain, is very rare as an original disease; but, as a symptom of others, much more frequent; of which the following kinds are enumerated by different authors.

Phrenitis synochi pleuriticae, Sauv. sp. 2. Phrenitis synochi sanguinea, Sauv. sp. 4. Phrenitis calendura, Sauv. sp. 11. Phrenitis Indiae, Sauv. sp. 12. Cephalitis Ægyptiaca, Sauv. sp. 1. Cephalitis epidemica anno 1510, Sauv. sp. 6. Cephalitis verminosa, Sauv. sp. 7. Cephalitis cerebella, Sauv. sp. 8. Phrenitis miliaris, Sauv. sp. 3. Phrenitis variolosa, Sauv. sp. 5. Phrenitis morbillofa, Sauv. sp. 6. Phrenitis a plica, Sauv. sp. 8. Phrenitis aphrodisiaca, Sauv. sp. 9. Phrenitis a tarantismo, Sauv. sp. 14. Phrenitis hydrophobia, Sauv. sp. 15. Phrenitis a dolore, Sauv. sp. 13. Cephalitis traumatica, Sauv. sp. 2.

Description. The signs of an impending phrenzy are, Immoderate and continual watchings; or if any sleep is obtained, it is disturbed with dreams and gives no refreshment; acute and lasting pains, especially in the hind-part of the head and neck; little thirst; a great and slow respiration, as if proceeding from the bottom of the breast; the pulse sometimes small and slow, sometimes quick and frequent; a suppression of urine; and forgetfulness. The distemper when present may be known by the following signs: The veins of the head swell, and the temporal arteries throb much; the eyes are fixed, sparkled, and have a fierce aspect; the speech is incoherent, and the patient behaves very roughly to the bystanders, with furious attempts to get out of bed, not indeed continually, but returning as it were by paroxysms; the tongue is dry, rough, yellow, or black; there is a coldness of the external parts; a propensity to anger; chattering of the teeth; a trembling of the hands, with which the sick seem to be gathering something, and actually do gather the naps off the bed-clothes.

Causes of, and persons subject to, this disorder. People of a hot and bilious habit of body, and such as are of a passionate disposition, are apt to fall into a phrenzy. The same danger are those who use much spices, or are given to hot and spirituous liquors; who have been exposed more than usual to the sun, or obliged to undergo immoderate studies or watchings; who are subject to head-ache, or in whom some customary hemorrhages have been stopped; or the disease may arise from some injury offered to the head externally. Dr Pringle observes, that the phrenitis, when considered as an original disease, is apt to attack soldiers in the summer-season when they are exposed to the heat of the sun, and especially when asleep and in liquor. A symptomatic phrenzy is also more frequent in the army than elsewhere, on account of the violence done to all fevers when the sick are carried in waggons from the camp to an hospital, where the very noise or light alone would be sufficient, with more delicate natures, to raise a phrenzy.

Prognosis. Every kind of phrenzy, whether idiopathic or symptomatic, is attended with a high degree of danger; and, unless removed before the fourth day, a gangrene or sphacelus of the meninges readily takes place, and the patient dies delirious. The following are the most fatal symptoms: A continual and furious delirium, with watching; thin watery urine, white faces, the urine and stools running off involuntarily, or a total suppression of these excretions; a ready disposition to become stupid, or to faint; trembling, rigor, chattering of the teeth, convulsions, hiccup, coldness of the extremities, trembling of the tongue, shrill voice, a sudden cessation of pain, with apparent tranquility. The following are favourable: Sweats, apparently critical, breaking out; a seeming effort of nature to terminate the disease by a diarrhoea; a large haemorrhage from the nose; swellings of the glands behind the ears; hemorrhoids.

Cure. This is not different from the cure of inflammation in general; but here the most powerful remedies are to be immediately employed. Large and repeated bleedings are especially necessary; and these too taken from vessels as near as possible to the part affected. The opening the temporal artery has been recommended, and with some reason; but as the practice is attended with some inconveniences, perhaps the opening of the jugular veins may prove more effectual; with which, however, may be joined the drawing of blood from the temples by cupping and scarifying. It is also probable, that purging may be of more use in this than in some other inflammatory affections, as it may operate by revulsion. For the same purpose of revulsion, warm pediluvia are a remedy, but rather ambiguous. The taking off the force of the blood in the vessels of the head by an erect posture is generally useful. Blistering is also useful, but chiefly when applied near to the part affected. In short, every part of the antiphlogistic regimen is here necessary, and particularly the admission of cold air. Even cold substances applied to the head have been found useful; and the application of such refrigerants as vinegar is certainly proper. Opiates are hurtful in every inflammatory state of the brain. On the whole, however, it must be remarked, that practitioners are very uncertain with regard to the means proper to be used in this disease; and the more so, that the symptoms by which the disease is commonly judged to be present, appear sometimes without any internal inflammation; and on the other hand, affections have shown that the brain has been inflamed, where few of the peculiar symptoms of inflammation had appeared before. XXXV. The Inflammatory Quinsy, or Cynanche Tonfillaris. Sp. I.

Cynanche tonfillaris, Sauv. sp. 1. Angina inflammatoria (sp. 5), Boerh. 865.

Description. This is an inflammation of the mucous membrane of the fauces, affecting principally that congeries of mucous follicles which forms the tonsils; and from thence spreading along the velum and uvula, so as frequently to affect every part of the mucous membrane. The disease appears by some tumour and redness of the parts; is attended with a painful and difficult deglutition; a troublesome clamminess of the mouth and throat; a frequent, but difficult, excretion of mucus; and the whole is accompanied with pyrexia. The inflammation and tumour are commonly at first most considerable in one tonsil; and afterwards, abating in that, increase in the other. This disease is not contagious.

Causes of, and persons subject to, the disorder. This disease is commonly occasioned by cold externally applied, particularly about the neck. It affects especially the young and languid; and a disposition to it is often acquired by habit. It occurs especially in the spring and autumn, when vicissitudes of heat and cold frequently take place.

Prognosis. This species of quinsy terminates frequently by resolution, sometimes by suppuration, but hardly ever by gangrene; though in some cases sloughy spots appear on the fauces: the prognosis therefore is generally favourable.

Cure. Here some bleeding may be necessary; but large and general evacuations are seldom beneficial. The opening of the ranular veins seems to be an insignificant remedy, according to Dr. Cullen, but is recommended as efficacious by Sir John Pringle; and leeches set on the external fauces are serviceable. The inflammation may be often relieved by moderate astringents, and particularly by acids applied to the parts affected. In many cases, nothing has been found to give more relief than the vapour of warm water received into the fauces.

Besides these, blistering and rubefacient medicines are applied with success, as well as antiphlogistic purgatives; and every part of the antiphlogistic regimen is to be observed, except the application of cold. Sir John Pringle recommends a thick piece of flannel moistened with two parts of common sweet oil, and one of spirit-of-hartshorn, (or in a larger proportion, if the skin will bear it,) applied to the throat, and renewed once every four or five hours. By this means the neck, and sometimes the whole body, is put into a sweat, which, after bleeding, either carries off or lessens the inflammation. When the disease takes a tendency to suppuration, nothing will be more useful than the taking into the fauces the steams of warm water. When the abscess is attended with much swelling, if it break not spontaneously, it ought to be opened by a lancet; and this does not require much caution, as even the inflammatory state may be relieved by some scarification of the tonsils. Dr. Cullen has never seen any case requiring bronchotomy.

XXXVI. The malignant, putrid, or ulcerous sore Throat, Sp. II.

Cynanche maligna, Sauv. sp. 3. Cynanche ulcerosa, Sauv. var. a. Journ. de Med. 1758. Cynanche gangrenosa, Sauv. var. b. Journ. de Med. 1756.

Ulcera faucium et gutturis anginosa et lethalia, Hispanis Garrotillo, Lud. Mercat. consult. 24. Angina ulcerosa, Fothergill's Account of the ulcerous sore throat, edit. 1751. Huxham on the malignant ulcerous sore throat, from 1751 to 1753. Febris epidemica cum angina ulcerulosa, Douglas's Practical History, Bolton 1736. Angina epidemica, Russel, Occan. Natur. p. 105. Angina gangrenosa, Withering's Dissert. Inaug. Edinb. 1766. Angina suffocativa, Bard's Inquiry, New-York 1771. Angina maligna, Johnstone on the malignant Angina, Worcester 1779.

History and description. This distemper is not particularly described by the ancient physicians; though perhaps the Syrian and Egyptian ulcers mentioned by Aretaeus Cappadocx, and the pestilent ulcerated tonsils we read of in Aëtius Amiderus, were of this nature. Some of the scarlet fevers mentioned by Morton seem also to have approached near to it. In the beginning of the last century, a disease exactly similar to this is described by the physicians of that time, as raging with great violence and mortality in Spain and some parts of Italy; but no account of it was published in this country till the year 1748, when a very accurate one was drawn up by Dr. Fothergill, and in 1752 by Dr. Huxham. The latter observes, that this disease was preceded by long, cold, and wet seasons; by which probably the bodies of people were debilitated, and more apt to receive contagion, which possibly also might be produced by the stagnant and putrid waters.

The attack of this disease was very different in different persons. Sometimes a rigor, with fulness and soreness of the throat, and painful stiffness of the neck, were the first symptoms complained of. Sometimes alternate chills and heats, with some degree of giddiness, drowsiness, or head-ach, ushered in the distemper. It seized others with much more feverish symptoms; great pain of the head, back, and limbs; a vast oppression of the precordia, and continual sighing. Some grown persons went about for some days in a drooping state, with much uneasiness and anxiety, till at last they were obliged to take to their beds. Thus various was the disease, says our author, at the onset. But it commonly began with chills and heats, load and pain of the head, soreness of throat, and hoarseness; some cough, sickness at stomach, frequent vomiting and purging, in children especially, which were sometimes very severe; though a contrary state was more common to the adult. There was in all a very great dejection of spirits. spirits, very sudden weakness, great heaviness on the breast, and faintness, from the very beginning. The pulse in general was quick, small, and fluttering, though sometimes heavy and undulating. The urine was commonly pale, thin, and crude; however, in many grown persons, it was passed in small quantities, and high-colored, or like turbid whey. The eyes were heavy, reddish, and as it were weeping; the countenance very often full, flushed, and bloated, though sometimes pale, and sunk.

How flight forever the disorder might appear in the daytime, at night the symptoms became greatly aggravated, and the feverish habit very much increased, nay, sometimes a delirium came on the very first night; and this exacerbation constantly returned through the whole course of the disease. Indeed, when it was considerably on the decline, our author says he has been often pretty much surprised to find his patient had palled the whole night in a phrenzy, whom he had left tolerably cool and sedate in the day.

Some few hours after the seizure, and sometimes contemporary with it, a swelling and soreness of the throat was perceived, and the tonsils became very tumid and inflamed, and many times the parotid and maxillary glands swelled very much, and very suddenly, even at the very beginning; sometimes so much as even to threaten strangulation. The faucies also very soon appeared of a high florid red, or rather of a bright crimson, colour, very shining and glossy; and most commonly on the uvula, tonsils, velum palatinum, and back part of the pharynx, several whitish or ash-colored spots appeared scattered up and down, which oftentimes increased very fast, and soon covered one or both the tonsils, uvula, &c. those in the event proved floughs of superficial ulcers, (which sometimes, however, eat very deep into the parts). The tongue at this time, though only white and moist at the top, was very foul at the root, and covered with a thick yellowish or brown coat. The breath also now began to be very nauseous; which offensive smell increased hourly, and in some became at length intolerable, and that too sometimes even to the patients themselves.

The second or third day every symptom became much more aggravated, and the fever much more considerable; and those that had struggled with it tolerably well for thirty or forty hours, were forced to submit. The reflexions and anxiety greatly increased, as well as the difficulty in swallowing. The head was very giddy, pained, and loaded; there was generally more or less of a delirium; sometimes a pervigilium and perpetual phrenzy, though others lay very stupid, but often starting and muttering to themselves. The skin was very hot, dry, and rough; there was very rarely any disposition to sweat. The urine was pale, thin, crude; often yellowish and turbid. Sometimes a vomiting was urgent, and sometimes a very great looseness, in children particularly. The floughs were now much enlarged, and of a darker colour, and the surrounding parts tended much more to a livid hue. The breathing became much more difficult; with a kind of a rattling flector, as if the patient was actually strangling, the voice being exceeding hoarse and hollow, exactly resembling that from venereal ulcers in the faucies: this noise in speaking and breathing was so peculiar, that any person in the least conversant with the disease might easily know it by this odd noise; from whence indeed the Spanish physicians gave it the name of garotillo, expressing the noise such make as are strangling with a rope. Our author never observed in one of them the shrill, barking noise, that we frequently hear in inflammatory quinsies. The breath of all the diseased was very nauseous; of some insufferably fetid, especially in the advance of the distemper to a crisis; and many about the fourth or fifth day spit off a vast quantity of flinking, purulent mucus, tinged sometimes with blood; and sometimes the matter was quite livid, and of an abominable smell. The nostrils likewise in many were greatly inflamed and excoriated, continually dripping down a most sharp ichor, or fumious matter, so excessively acid, that it not only corroded the lips, cheeks, and hands of the children that laboured under the disease, but even the fingers and arms of the very nurses that attended them: as this ulceration of the nostrils came on, it commonly caused an almost incessant sneezing in the children; but few adults were affected with it, at least to any considerable degree. It was surprising what quantities of matter some children discharged this way, which they would often rub on their face, hands, and arms, and blister them all over. A sudden stoppage of this rheum from the mouth and nostrils actually choked several children; and some swallowed such quantities of it, as occasioned excoriations of the intestines, violent gripings, dysentery, &c. nay, even excoriations of the anus and buttocks. Not only the nostrils, faucies, &c. were greatly affected by this extremely sharp matter, but the wind-pipe itself was sometimes much corroded by it, and pieces of its internal membrane were spit up, with much blood and corruption; and the patients lingered on for a considerable time, and at length died tabid; though there were more frequent instances of its falling suddenly and violently on the lungs, and killing in a peripneumonic manner.

The Doctor was astonished sometimes to see several swallow with tolerable ease, though the tumour of the tonsils and throat, the quantity of thick mucus, and the rattling noise in breathing, were very terrible; which he thinks pretty clearly shews, that this malignant quinny was more from the acrimony and abundance of the humors than the violence of the inflammation.

Most commonly the angina came on before the exanthemata; but many times the cuticular eruption appeared before the sore-throat, and was sometimes very considerable, though there was little or no pain in the faucies: on the contrary, a very severe angina seized some patients, that had no manner of eruption; and yet, even in these cases, a very great itching and deliquamation of the skin sometimes ensued; but this was chiefly in grown persons, very rarely in children. In general, however, a very considerable efflorescence broke out on the surface of the body, particularly in children; and it most commonly happened the second, third, or fourth day: sometimes it was partial, sometimes it covered almost the whole body, though very seldom the face: sometimes it was of an erysipelasous kind; sometimes more pustular: the pustules frequently very eminent, and of a deep, fiery, red colour, colour, particularly on the breast and arms; but often- times they were very small, and might be better felt than seen, and gave a very odd kind of roughness to the skin. The colour of the efflorescence was com- monly of a crimson hue, or as if the skin had been smearred over with juice of raspberries, and this even to the fingers ends; and the skin appeared inflamed and swollen, as it were; the arms, hands, and fingers, were often evidently so, and very stiff, and somewhat pain- ful. This crimson colour of the skin seemed indeed peculiar to this disease. Though the eruption seldom failed of giving some manifest relief to the patient, as to anxiety, sickness at stomach, vomiting, purging, &c. yet there was observed an universal fiery eruption on some persons, without the least abatement of the symptoms, nay, almost every symptom seemed more ag- gravated, particularly the fever, load at breast, anxiety, delirium; and our author knew more than one or two patients die in the most raging phrenzy, covered with the most universal fiery rash he ever saw: so that, as in the highly confluent small-pox, it seemed only to denote the quantity of the disease, as he terms it.

He had under his care a young gentleman, about twelve years of age, whose tongue, fauces, and ton- sils, were as black as ink, and he swallowed with ex- treme difficulty; he continually spit off immense quan- tities of a black, fumous, and very fetid matter, for at least eight or ten days:—about the seventh day, his fever being somewhat abated, he fell into a bloody dysestery, though the bloody, fumous, fetid expe- ration still continued, with a most violent cough. He at length indeed got over it, to the very great surprise of every one that saw him. Now, in this pa- tient, a severe and universal a rash broke out upon him the second and third day; and the itching of his skin was so intolerable, that he tore it all over his body in a most shocking manner: yet this very great and timely eruption very little relieved his fever and phrenzy, or prevented the other dreadful symp- toms mentioned.

An early and kindly eruption, however, was most commonly a very good omen; and, when succeeded by a very copious deliquation of the cuticle, one of the most favourable symptoms that occurred; but when the eruption turned of a dusky or livid colour, or prema- turely or suddenly receded, every symptom grew wor- se, and the utmost danger impended, especially if purple, or black, spots appeared up and down, as sometimes happened; the urine grew limpid, and convulsions came on, or a fatal suffocation soon closed the tragedy.

The disease was generally at the height about the fifth or sixth day in young persons, in the elder not so soon; and the crisis many times was not till the eleventh or twelfth, and then very imperfect: some adults, however, were carried off in two or three days; the distemper either falling on the lungs, and killing in a peripneumonic manner, or on the brain; and the patient either died raving or comatose. In some, the disease brought on a very troublesome cough, puru- lent expectoration, hemoptoe, and hectic; in which they lingered on for several weeks, and then died tabid.

If a gentle easy sweat came on the third or fourth day; if the pulse became more slow, firm, and equal; if the sloughs of the fauces cast off in a kindly manner, and appeared at the bottom tolerably clean and florid; if the breathing was more soft and free, and some de- gree of vigour and quickness returned in the eyes; all was well, and a salutary crisis followed soon by a con- tinuance of the fever, and a turbid, subsiding, farina- ceous urine, a plentiful expectoration, and a very large deliquation of the cuticle. But if a rigor come on, and the exanthema suddenly disappeared or turned livid; if the pulse grew very small and quick, and the skin remained hot and parched as it were, the breath- ing more difficult, the eyes dead and glassy, the urine pale and limpid, a phrenzy or coma succeeded, with a coldish clammy sweat on the face or extremities; life was despaired of; especially if a singultus and choking- or gulping in the throat, attended with sudden, liquid, involuntary, livid stools, intolerably fetid. In some few patients our author observed, some time be- fore the fatal period, not only the face bloated, fallow, shining, and greasy as it were, but the whole neck vastly swollen, and of a cadaverous look; and even the whole body became in some degree oedematous; and the im- pression of a finger would remain fixed in a part, the skin not rising again as usual; an indication that the blood stagnated in the capillaries, and that the elasti- city of the fibres was quite lost.

Prognosis. This may be easily gathered from the above description. The malignant and putrid tendency of the disease is evident, and an increase of the symp- toms which arise from that putrefactive disposition of the body must give an unfavourable prognostic; as, on the contrary, a decrease of these, and an apparent increase of the vis viva, are favourable: in general, what is ob- served to be favourable in the nervous and putrid ma- lignant fevers, is also favourable in this, and vice versa.

Cure. In this the septic tendency of the disease is chiefly to be kept in view. The debility with which it is attended renders all evacuations by bleeding and purging improper, except in a few instances where the debility is less, and the inflammatory symptoms more considerable. The fauces are to be preserved from the effects of the acid matter poured out upon them, and are therefore to be frequently washed out by antiseptic gargles or injections; and the putrefactive state of the whole system should be guarded against and corrected by in- ternal antiseptics, especially by the Peruvian bark given in the beginning and continued through the course of the disease. Emetics, both by vomiting and naso- tting, prove useful. When any considerable tumour oc- curs, blisters applied externally will be of service, and in any case may be proper to moderate the inflammation.

XXXVII. Cynanche Trachealis, commonly called the Group. Sp. III.

Cynanche trachealis, Sauv. sp. 5. Cynanche laryngea auctorum, Eller de cogn. et cu- rand. morb. &c. 7. Anginae inflammatoriae sp. 1. Boerb. 801. Angina latens et difficilis, Dodon. obf. 18. Angina interna, Tulp. l. i. obf. 51. Angina pectoralis, Greg. Horfi. Obs. l. iii. obf. 1. Suffocatio stridula, Home on the Croup. Asthma infantum, Millar on the Asthma and Chil- cough. Asthma infantum spasmodicum, Ruff, Dissertation, Lon- London 1770.

Cynanche stridula, Crawford Dissert. Inaug. Edin. 1771.

Angina epidemica anno 1743. Melloy apud Rutty's History of the weather.

Morbus strangulatorius, Starr, Phil. Trans. no 495.

Morbus truculentus infantum, Françoys ad Viadrum et in vicinia grallans ann. 1758. C. a Bergen. A nova. N. C. tom. ii. p. 157.

Catarrhus suffocationis Barbadoensis ann. 1758. Hilary's Difcales of Barbadoes.

Angina inflammatoria infantum, Ruffel, Oecon. nat. p. 70.

Angina polyposa five membranacea Michaelis, Argentorati 1778, et auctores ab eo allegati.

The best description of this disease we have in Dr. Cullen's Practice of Physic. He informs us, that it consists in an inflammation of the glottis, larynx, or upper part of the trachea, whether it affect the membranes of these parts or the muscles adjoining. It may arise first in these parts, and continue to subsist in them alone; or it may come to affect these parts from the cynanche tonsillaris, or maligna, spreading into them.

In either way it has been a rare occurrence, and few instances of it have been marked and recorded by physicians. It is to be known by a peculiar croaking sound of the voice, by difficult respiration, with a sense of straitening about the larynx, and by a pyrexia attending it.

From the nature of these symptoms, and from the dissection of the bodies of persons who died of this disease, there is no doubt of its being of an inflammatory kind. It does not, however, always run the course of inflammatory affections; but frequently produces such an obstruction of the passage of the air, as suffocates, and thereby proves suddenly fatal.

If we judge rightly of the nature of this disease, it will be obvious, that the cure of it requires the most powerful remedies of inflammation to be employed upon the very first appearance of the symptoms. When a suffocation is threatened, whether any remedies can be employed to prevent it, we have not had experience to determine.

The accounts which books have hitherto given us of inflammations of the larynx, and the parts connected with it, amount to what we have now said; and the instances recorded have, almost all of them, happened in adult persons; but there is a peculiar affection of this kind happening to infants, which has been little taken notice of till lately. Dr. Home is the first who has given any distinct account of this disease; but, since he wrote, several other authors have taken notice of it, and have given different opinions concerning it.

This disease seldom attacks infants till after they have been weaned. After this period, the younger they are, the more they are liable to the disease. The frequency of it becomes less as children become more advanced; and there are no instances of children above 12 years of age being affected with it. It attacks children of the midland countries, as well as those who live near the sea. It does not appear to be contagious, and its attacks are frequently repeated in the same child. It is often manifestly the effect of cold applied to the body; and therefore appears most frequently in the winter and spring seasons. It very commonly comes on with the ordinary symptoms of a catarrh; but sometimes the peculiar symptoms of the disease show themselves at the very first.

These peculiar symptoms are the following: A hoarseness, with some shrillness and ringing sound, both in speaking and coughing, as if the noise came from a brazen tube. At the same time, there is a sense of pain about the larynx, some difficulty of respiration, with a whizzing sound in inspiration, as if the passage of the air were strained. The cough which attends it, is commonly dry; and if anything be spit up, it is a matter of a purulent appearance, and sometimes films resembling portions of a membrane. With all these symptoms, there is a frequency of pulse, a reflexion, and an uneasy sense of heat. When the internal surfaces are viewed, they are sometimes without any appearance of inflammation; but frequently a redness, and even swelling, appears; and sometimes there is an appearance of matter like to that rejected by coughing, together with the symptoms now described, and particularly with great difficulty of breathing, and a sense of strangling in the throat, by which the patient is sometimes suddenly taken off.

Many dissections have been made of infants who had died of this disease, and almost constantly there has appeared a preternatural membrane lining the whole internal surface of the upper part of the trachea, and extending in the same manner downwards into some of its ramifications. This preternatural membrane may be easily separated, and sometimes has been found separated in part, from the subjacent proper membrane of the trachea. This last is commonly found entire, that is, without any appearance of erosion or ulceration; but it frequently shows the vestiges of inflammation, and is covered by a matter resembling pus, like to that rejected by coughing; and very often a matter of the same kind is found in the bronchiae, sometimes in considerable quantity.

From the remote causes of this disease; from the catarrhal symptoms commonly attending it; from the pyrexia constantly present with it; from the same kind of preternatural membrane being found in the trachea when the cynanche maligna is communicated to it; and from the vestiges of inflammation on the trachea discovered upon dissection; we must conclude, that this disease consists in an inflammatory affection of the mucous membrane of the larynx and trachea, producing an exudation analogous to that found on the surface of inflamed viscera, and appearing partly in a membranous crust, and partly in a fluid resembling pus.

Though this disease consists in an inflammatory affection, it does not commonly end either in suppuration or gangrene. The troublesome circumstance of it seems to consist in a spasm of the muscles of the glottis, threatening suffocation.

When this disease terminates in health, it is by resolution of the inflammation, by a ceasing of the spasm of the glottis, by an expectoration of the matter exuding from the trachea, and of the crusts formed there, and frequently it ends without any expectoration, or at least with such only as attends an ordinary catarrh. When the disease ends fatally, it is by a suffocation seemingly depending upon a spasm affecting the glottis; but sometimes, probably, depending upon a quantity of matter filling the bronchus.

As we suppose the disease to be an inflammatory affection, so we attempt the cure of it by the usual remedies of inflammation, and which for the most part we have found effectual. Bleeding, both general and topical, has often given immediate relief, and, by being repeated, has entirely cured the disease. Blistering also, near to the part affected, has been found useful. Upon the first attack of the disease, vomiting, immediately after bleeding, seems to be of considerable use, and sometimes suddenly removes the disease. In every stage of the disease, the antiphlogistic regimen is necessary, and particularly the frequent use of laxative glysters. Tho' we suppose that a spasm affecting the glottis is often fatal in this disease, we have not found antispasmodic medicines to be of any use.

XXXVIII. Cynanche Pharyngea. Sp. IV. Cynanche pharyngea, Sauv. sp. 6. Eller de cogn. et cur. sec. 7. Angine inflammatorie sp. 4. Boerb. 804.

This is not materially different from the cynanche tonsillaris; only that the inflammation is said to begin in the pharynx, though Dr Cullen says he never knew an instance of it. The symptoms are almost the same, and the cure is precisely so with that of the cynanche tonsillaris.

XXXIX. Cynanche Parotidea. Sp. V. Cynanche parotidea, Sauv. sp. 14. Gallis Orellons et Ourles, Tillet Avis au peuple, no 116. Encyclopedie, au mot Orellons. Angina externa, Anglis the Mumps, Russel econ. natur. p. 114. Scotts the Branks. Catarrhus bellinfolans, Sauv. sp. 4. Osservazioni di Girof Gaspard, Venez. 1731. Osservazioni di Targ. Tozetti, Racolta ima, p. 176.

This is a disease well known to the vulgar, but little taken notice of by medical writers. It is often epidemic, and manifestly contagious. It comes on with the usual symptoms of pyrexia, which is soon after attended with a considerable tumour of the external fauces and neck. The swelling appears first as a glandular movable tumour at the corner of the lower jaw; but it soon becomes uniformly diffused over a great part of the neck, sometimes on one side only, but more commonly on both. The swelling continues to increase till the fourth day; but from that period it declines, and in a few days more goes off entirely. As the swelling of the fauces recedes, some tumour affects the testicles in the male sex, or the breasts in the female. These tumours are sometimes large, hard, and somewhat painful; but are seldom either very painful, or of long continuance. The pyrexia attending this disease is commonly slight, and goes off with the swelling of the fauces; but sometimes, when the swelling of the testicles does not succeed to that of the fauces, or when the one or the other has been suddenly repressed, the pyrexia becomes more considerable, is often attended with delirium, and has sometimes proved fatal.

As this disease commonly runs its course without either dangerous or troublesome symptoms, so it hardly requires any remedies. An antiphlogistic regimen, and avoiding cold, are all that will be commonly necessary. But when, upon the receding of the swellings, the pyrexia comes to be considerable, and threatens an affection of the brain, it will be proper, by warm fomentations, to bring back the swelling; and by vomiting, bleeding, or blistering, to obviate the consequences of its absence.

GENUS XL. PNEUMONIA.

Febris pneumonica, Hoffm. II. 136.

XL. Peripneumonia, Peripneumony, or Inflammation of the Lungs. Sp. I.

Peripneumonia, Sauv. gen. 112. Lin. 34. Vog. 51. Sag. gen. 311. Boerb. 820. Juncker 67. Peripneumonia pura five vera Auctorum, Sauv. sp. 1. Peripneumonia gastrica, Sauv. sp. 11. Morgagni de cauf. et fed. Epift. xx. art. 30, 31. Peripneumonia catarrhalis, Sauv. sp. 6. Peripneumonia notha, Sydenb. sect. 6. cap. 4. Boerb. 867. Morgagni de cauf. et fed. Epift. xii. 11—15. Peripneumonia putrida, Sauv. sp. 2. Peripneumonia ardens, Sauv. sp. 3. Peripneumonia maligna, Sauv. sp. 4. Peripneumonia typhodes, Sauv. sp. 5. Amphimerina peripneumonia, Sauv. sp. 15.

XLI. Pleuritis, the Pleurisy, or Inflammation of the Pleura. Sp. II.

Pleuritis, Sauv. gen. 103. Lin. 27. Vog. 56. Sag. gen. 303. Boerb. 875. Junck. 67. Paraphrenitis, Sauv. gen. 102. Lin. 26. Paraphrenitis, Vog. 55. Boerb. 907. Diaphragmitis, Sag. gen. 304. Pleuritis vera, Sauv. sp. 1. Boerb. 875. Verna principis morb. acut. pleuritis, i. i. cap. 2. 3. Zeviani della parapleuritide, cap. 3. Morgagni de cauf. et cauf. morb. Epift. xx. art. 56. xxi. 45. Wendt de pleuritide, apud Sandifort, thes. ii. Pleuritis pulmonis, Sauv. sp. 2. Zevian. dell.pleur. iii. 28, &c. Pleuripneumonia, pleuro-peripneumonia, peripneumo-pleuritis Auctorum. Baronius de pleuri-pneumonia. Ill. Halleri opuscul. patholog. obl. 13. Morgagni de cauf. et cauf. Epift. xx. and xxi. pafsim. Cleghorn, Minorca, p. 247. Triller de pleuritide, aph. 1, 2, 3. cap. i. 8. Huxham, Dissert. on pleuritis, &c. chap. i. Ill. Pringle, Dis. of the army. Pleuritis convulsiv. Sauv. sp. 13. Bianch. Hist. hep. vol. i. p. 234. Pleuritis hydrothoracica, Sauv. sp. 15. Morgagni de cauf. et fed. xx. 34. Pleuritis dorsalis, Sauv. sp. 3. Verna, p. iii. cap. 8. Pleuritis mediastini, Sauv. sp. 3. P. Sal. Div. de affect. part. cap. 6. Friend, Hist. med. de Avenzoare. Pleuritis mediastina, Vog. 52. Pleuritis pericardii, Sauv. sp. 5. Verna, p. iii. cap. 9. Parapleuritis, Zeviani della parapleuritide. Pleurodyne parapleuritis, Sauv. sp. 19. Paraphrenitis diaphragmatica, Sauv. sp. 1. De Haen. Rat. med. i. 7. iii. p. 31. Paraphrenesis pleuritica, Sauv. sp. 2. Paraphrenesis hepatica, Sauv. sp. 3.

Under the general head of Pneumonia, Dr. Cullen comprehends all inflammations of the thoracic viscera, or membrane lining the inside of that cavity; as the symptoms do not sufficiently distinguish the seat of the affection, nor does a difference in the situation of the affected place make any difference in the cure.

Description. Pneumonic inflammation, however various in the seat, always discovers itself by pyrexia, difficult breathing, cough, and pain in some part of the thorax. It almost always comes on with a cold stage, and is accompanied with the other symptoms of pyrexia; though in some few instances the pulse may not be more frequent, nor the heat of the body increased beyond what is natural. Sometimes the pyrexia is from the beginning accompanied with the other symptoms; but frequently is formed some hours before them, and particularly before the pain is felt. The pulse for the most part is frequent, full, strong, hard, and quick; but in a few instances, especially in the advanced state of the disease, it is weak, soft, and at the same time irregular. The difficulty of breathing is most considerable in inspiration, both because the lungs do not easily admit of a full dilatation, and because the dilatation increases the pain attending the disease. The difficulty of breathing is also greater when the patient is in one posture of the body rather than another. It is generally greater when he lies on the side affected; though sometimes the contrary happens. Very often the patient cannot lie easy upon either side, and can find ease only when lying on the back; and sometimes he cannot breathe easily, except when in somewhat of an erect posture. The cough, in different cases, is more or less urgent or painful. It is sometimes dry, or without any expectoration, especially in the beginning of the disease; but more commonly it is, even from the first, moist, and the matter spit up various both in consistence and colour, and frequently it is streaked with blood. The pain is also different in different cases, and felt in different parts of the thorax, but most frequently in one side. It has been said to affect the right side more frequently than the left; but this is uncertain, and we are sure that the left side has been very often affected. Sometimes it is felt as if it was under the sternum; sometimes in the back between the shoulders; and when in the sides, its place has been higher or lower, more forward or backward; but the place of all others most frequently affected is about the fifth or seventh rib, near the middle of its length, or a little more forward. The pain is often severe and pungent; but sometimes more dull and obtuse, with a sense of weight rather than of pain. It is most especially severe and pungent, when occupying the place last mentioned. For the most part it continues fixed in one part, but sometimes shoots from the side to the scapula on one hand, or to the sternum and clavicle of the other.

Dr. Cullen supposes that the disease is always seated, or at least begins, in some part of the pleura, taking that membrane in its greatest extent, as now commonly understood; that is, as covering not only the internal surface of the cavity of the thorax, but also as forming the mediastinum, and as extended over the pericardium, and over the whole surface of the lungs. But as the symptoms never clearly indicate where the seat of the disease is, there is but little foundation for the different names by which it hath been distinguished. The term pleurisy is improperly limited to that inflammation which begins in and chiefly affects the pleura costalis. This our author thinks is a rare occurrence; and that the pneumonia much more frequently begins in the pleura investing the lungs, producing all the symptoms which belong to what hath been called the pleuritis vera. The word peripneumony hath been applied to an inflammation beginning in the parenchyma, or cellular texture of the lungs, and having its seat chiefly there. But to our author it seems very doubtful if any acute inflammation of the lungs, or any disease which hath been called peripneumony, be of that kind. It seems probable, that every acute inflammation begins in membranous parts; and in every distention of persons dead of peripneumony, the external membrane of the lungs, or some part of the pleura, has appeared to have been considerably affected. An inflammation of the pleura covering the upper surface of the diaphragm, has been distinguished by the appellation of paraphrenitis, as supposed to be attended with the peculiar symptoms of delirium, visus sardonicus, and other convulsive motions: but it is certain, that an inflammation of that portion of the pleura, and affecting also even the muscular substance of the diaphragm, has often taken place without any of the symptoms abovementioned; and neither the distentions which have fallen under our author's observation, nor any accounts of distentions, support the opinion that an inflammation of the pleura covering the diaphragm is attended with delirium more commonly than any other pneumonic inflammation. It is to be observed, however, that though the inflammation may begin in one particular part of the pleura, the morbid affection is commonly communicated to the whole extent of the membrane.

The pneumonic inflammation, like others, may terminate by resolution, suppuration, or gangrene: but it has also a termination peculiar to itself; namely, when it is attended with an effusion of blood into the cellular texture of the lungs, which, soon interrupting the circulation of the blood through the vasa, produces a fatal suffocation. This indeed appears to be the most common termination of pneumonic inflammation when it ends fatally; for upon the distention of almost every person dead of this disease, it appears that such an effusion had happened. From the same distentions we learn, that pneumonic inflammation commonly produces an exudation from the internal surface of the pleura, which appears partly as a soft viscid crust, often of a compact membranous form covering every where the surface of the pleura, and particularly those parts where the lungs adhere to the pleura costalis, or mediastinum; and this crust seems always to be the cement of such adhesion. The same exudation shews itself also by a quantity of a serous fluid commonly found in the cavity of the thorax; and some exudation or effusion is usually found to have been made into the cavity of the pericardium. It seems likewise probable, that an effusion of this kind is sometimes made into the cavity of the bronchus; for, in some persons who have died after labouring under a pneumonic inflammation for a few days only, the bronchiae have been found filled with a considerable quantity of serous and thickish fluid, which must be considered rather as the effusion abovementioned, having had its thinner parts taken off by respiration, than as a pus so suddenly formed in the inflamed part. It is, however, not improbable, that this effusion, as well as that made into the cavities of the thorax and pericardium, may be a matter of the same kind with that which in other inflammations is poured into the cellular texture of the parts inflamed, and there converted into pus; but in the thorax and pericardium it does not always put on this appearance, because the crust covering the surface prevents the absorption of the thinner part. This absorption, however, may be compensated in the bronchiae, by the drying power of the air; and therefore the effusion into them may assume a more purulent appearance. In many cases of pneumonic inflammation, when the expectoration is very copious, it is difficult to suppose that the whole proceeds from the mucous follicles of the bronchiae, and it seems probable that a great part of it may come from the effused serous fluid just mentioned; and this too will account for the appearance of the expectoration being so often purulent. Perhaps the same thing will account for that purulent matter found in the bronchiae, which Mr de Haen says he had often observed when there was no ulceration in the lungs, and which he accounts for in a very strange manner, namely, by supposing a pus formed in the circulating blood.

Dr Cullen is of opinion, that the effusion into the bronchiae above-mentioned often concurs with the effusion of red blood into the cellular substance of the lungs to occasion the fatal suffocation which frequently terminates peripneumony: that the effusion of serum alone may have this effect: and that the serum poured out in a certain quantity, rather than any debility in the powers of expectoration, is the cause of that cessation of spitting which precedes the fatal event; for in many cases the expectoration has ceased, when no other symptoms of debility have appeared, and when, upon dissection, the bronchiae have been full of liquid matter. Nay, it is even probable, that in some cases such an effusion may take place without any symptoms of violent inflammation; and in other cases the effusion taking place may seem to remove the symptoms of inflammation which had appeared before, and thus account for those unexpected fatal terminations which have sometimes happened.

Pneumonic inflammation seldom terminates by resolution, without being attended with some evident evacuation. An hemorrhage from the nose happening on some of the first days of the disease has sometimes put an end to it; and it is said, that an evacuation from the hemorrhoidal veins, a bilious evacuation by stool, and an evacuation of urine with a copious sediment, have feverly had the same effect; but such occurrences have been rare. The evacuation most frequently attending, and seeming to have the greatest effect in promoting resolution, is an expectoration of a thick, white, or yellowish matter, a little streaked with blood, copious, and brought up without much or violent coughing. Very frequently the resolution of this disease is attended with, and perhaps produced by, a sweat which is warm, fluid, copious, over the whole body, and attended with an abatement of the frequency of the pulse, heat of the body, and other febrile symptoms.

Causes of, and persons subject to, the disorder. The remote cause of pneumonic inflammation is commonly cold applied to the body, obstructing perspiration, and determining to the lungs, while at the same time the lungs themselves are exposed to the action of cold. These circumstances operate chiefly when an inflammatory diathesis prevails in the system; and therefore upon persons of the greatest vigour, in cold climates, in the winter season, and particularly in the spring, when vicissitudes of heat and cold are frequent. This disease, however, may arise in any season when such varieties take place. Other remote causes also may have a share in producing this distemper; such as every means of obstructing, straining, or otherwise injuring, the pneumonic organs. The pneumonic inflammation has sometimes been so much an epidemic, that it hath been suspected of depending on a specific contagion; but Dr Cullen never met with an instance of its being contagious.

Prognosis. In pneumonic inflammations, a violent pyrexia is always dangerous. The danger, however, is chiefly denoted by the difficulty of breathing. When the patient can lie on one side only; when he can lie on neither side, but only on his back; when he cannot breathe with tolerable ease, except when the trunk of his body is erect; when even in this posture the breathing is very difficult, and attended with a turgescence and flushing of the face, with partial sweats about the head and neck, and an irregular pulse, these circumstances mark the difficulty of breathing in different degrees; and consequently, in proportion, the danger of the disease. A frequent violent cough, aggravating the pain, is always the symptom of an obstinate disease; and as the disease is seldom or never resolved without some expectoration, so a dry cough must always be an unfavourable symptom.

The proper characteristics of the expectoration have been already laid down; and though an expectoration which hath not these marks must indicate a doubtful state of the disease, yet the colour alone can give no certain prognostic. An acute pain, very much interrupting inspiration, is always the mark of a violent disease; but not of a more dangerous disease than an obtuse pain attended with very difficult respiration.

When the pains, which had at first affected one side only, shall afterwards spread into the other; or when, leaving the side first affected, they pass entirely into the other; these are always marks of a dangerous disease. A delirium coming on during a pneumonic inflammation is always a symptom denoting much danger.

When pneumonic disorders terminate fatally, it is on one or other of the days of the first week, from the third to the seventh. This is the most common case; but, in a few instances, death has happened at a later period. When the disease is violent, but admitting of resolution, this also happens frequently in the course of the first week; but in a more moderate disease the resolution is often put off to the second week. The disease generally suffers a remission on some of the days from the third to the seventh; which, however, may be often fallacious, as the disease sometimes returns again with as much violence as before; and in such a Practice case with great danger. Sometimes it disappears on the third day, while an erysipelas makes its appearance on some external part; and if this continues fixed, the pneumonic inflammation does not recur. If the disease continues beyond the 14th day, it will terminate in a suppuration, or PHthisis. The termination by gangrene is much more rare than has been imagined; and when it does occur, it is usually joined with the termination by effusion; the symptoms of the one being hardly distinguishable from those of the other.

Cure. This must proceed upon the general plan mentioned under SYNOCIA; but, on account of the importance of the part affected, the remedies must be employed early, and as fully as possible. Venefection is chiefly to be depended on; and may be done in either arm, as the surgeon finds most convenient; and the quantity taken away ought in general to be as large as the patient's strength will allow. The remission of pain, and the relief of respiration, during the flowing of the blood, may limit the quantity to be then drawn; but if these symptoms of relief do not appear, the bleeding should be continued till the symptoms of a beginning syncope come on. It is seldom that one bleeding, however large, will cure this disease; and though the pain and difficulty of breathing may be much relieved by the first bleeding, these symptoms commonly and after no long interval recur, often with as much violence as before. In this case the bleeding is to be repeated even on the same day, and perhaps to the same quantity as before. Sometimes the second bleeding may be larger than the first. There are persons who, by their constitution, are ready to faint even upon a small bleeding; and in such persons this may prevent the drawing so much blood at first as a pneumonic inflammation may require; but as the same persons are found to bear after bleedings better than the first, this allows the second and subsequent bleedings to be larger, and to such a quantity as the symptoms of the disease may seem to require.

Bleedings are to be repeated according to the state of the symptoms, and they will be more effectual when performed in the course of the first three days than afterwards; but they are not to be omitted though four days of the disease may already have elapsed. If the physician has not been called in time, or the first bleedings have not been sufficiently large, or even though they should have procured some remission, yet upon the return of the urgent symptoms, bleeding may be repeated at any time within the first fortnight, or even after that period, if a suppuration be not evident, or if after a seeming solution the disease shall have returned.

With respect to the quantity of blood which may be taken away with safety, no general rules can be given; as it must be very different according to the state of the disease, and the constitution of the patient. In an adult male of tolerable strength, a pound avoirdupois of blood is a full bleeding. Any quantity above 20 ounces is a large, and any quantity below 12 is a small, bleeding. An evacuation of four or five pounds, in the course of two or three days, is generally as much as such patients will bear; but if the intervals between the bleedings, and the whole of the time during which the bleedings have been employed, have been long, the quantity taken upon the whole may be greater.

When a large quantity of blood hath been taken from the arm, and it is doubtful if more can be taken in that manner with safety, some blood may still be taken by cupping and scarifying. This will especially be proper, when the recurrence of the pain, rather than the difficulty of breathing, becomes the urgent symptom; and then the cupping and scarification should be made as near as possible to the pained part.

An expectoration sometimes takes place very early in this disease; but if the symptoms continue urgent, the bleedings must be repeated notwithstanding the expectoration; but in a more advanced state, and when the symptoms have suffered a considerable remission, we may then trust the cure to the expectoration alone. It is not observed that bleeding, during the first days of the disease, stops expectoration; on the contrary, it hath been often found to promote it; and it is only in a more advanced state of the disease, when the patient has been already exhausted by large evacuations and a continuance of his illness, that bleeding seems to put a stop to expectoration; and even then, this stoppage seems not to take place to much from the powers of expectoration being weakened by bleeding, as by its favouring the serous effusion in the bronchus, already taken notice of.

Besides bleeding, every part of the antiphlogistic regimen ought here to be carefully employed: the patient must keep out of bed as much as he can bear; must have plenty of warm diluting drinks, impregnated with vegetable acids, accompanied with nitre or some other cooling neutral salt; and the belly also ought to be kept open by emollient glysters or cooling laxative medicines. Vomiting is dangerous; but it hath been found useful to exhibit emetics in nauseating doses, and in a somewhat advanced state of the disease these doses have been found the best means of promoting expectoration. Fomentations and poultices to the pained part have been found useful; but blistering is found to be much more effectual. A blister, however, ought not to be applied till at least one bleeding hath been premised, as venefection is less effectual when the irritation of a blister is present. If the disease is moderate, a blister may be applied immediately after the first bleeding; but in violent cases, where it may be presumed that a second bleeding may soon be necessary after the first, it will be proper to delay the blister till after the second bleeding, when it may be supposed that the irritation occasioned by the blister will be over before another bleeding becomes necessary. It may frequently be of use in this disease to repeat the blistering; and in that case the plasters should always be applied somewhere on the thorax, for when applied to more distant parts they have little effect. The keeping the blistered parts open, and making what is called a perpetual blister, has much less effect than a fresh blistering.

Many methods have been proposed for promoting expectoration, but none appear to be sufficiently effectual; and some of them, being acrid stimulant substances, are not very safe. The gums usually employed seem to be too heating; the squills less so; but they are not very powerful, and sometimes inconvenient, by the constant nausea they occasion. The volatile alkali may be of service as an expectorant, but it ought to be reserved for an advanced state of the disease. Mucilaginous and oily demulcents appear to be useful, by allaying that acrimony of the mucus which occasions too frequent coughing; and which coughing prevents the stagnation and thickening of the mucus, and thereby its becoming mild. The receiving the steams of warm water into the lungs, impregnated with vinegar, has often proved useful in promoting expectoration; and, for this purpose, the machine called the inhaler, lately invented by Mr Mudge surgeon at Plymouth, promises to be of great service*. But of all others, the antimonial emetics, given in nauseating doses, promise to be the most powerful for promoting expectoration. The kermes mineral hath been greatly recommended; but doth not seem to be more efficacious than emetic tartar or antimonial wine; and the dose of the kermes is much more uncertain than that of the others.

Though this disease often terminates by a spontaneous sweating, this evacuation ought not to be excited by art, unless with much caution. When, after some remission of the symptoms, spontaneous sweats arise, they may be encouraged; but it ought to be without much heat, and without stimulant medicines. If, however, the sweats be partial and clammy only, and a great difficulty of breathing still remain, it will be very dangerous to encourage them.

Physicians have differed much with regard to the use of opiates in pneumonic affections. It appears, however, that, in the beginning of the disease, and before bleeding and blistering have produced some remission of the pain and of the difficulty of breathing, opiates have a very bad tendency, by their increasing the difficulty of breathing and other inflammatory symptoms. But in a more advanced state of the disease, when the difficulty of breathing has abated, and when the urgent symptom is a cough, proving the chief cause of the continuance of pain and want of rest, opiates may be employed with great advantage and safety. The interruption of the expectoration which they seem to occasion, is for a short time only; and they seem often to promote it, as they occasion a stagnation of what was by frequent coughing diffused insensibly; and therefore give the appearance of what physicians have called concocted matter.

XLII. Vomica, or Abscess of the Lungs.

Vomica, Boerh. 835. Junck. 35. Pleurodyne vomica, Sauv. sp. 21.

This sometimes follows pneumonia, though the case is not frequent. The symptoms of it so much resemble the phthisis, that it can most properly be treated of under that head.

XLIII. Empyema.

This is another consequence of a pneumonia terminating unfavourably, and is occasioned by the effusion of a quantity of purulent matter into the cavity of the thorax, occasioning a lingering and painful disorder, very often incurable.

Description. The first sign of an empyema is a cessation of the pain in the breast, which before was continual: this is followed by a sensation of weight on the diaphragm; and a fluctuation of matter, sometimes making a noise that may be heard by the bystanders: the acute fever is changed into a hectic, with an exacerbation at night: a continual and troublesome dry cough remains. The respiration is exceedingly difficult, because the lungs are prevented by the matter from fully expanding themselves. The patient can lie easily on that side where the matter is effused, but not on the other, because then the weight of the matter on the mediastinum produces uneasiness. The more the hectic heat is augmented, the more is the body emaciated, and its strength decayed. In some there is danger of suffocation when they stoop down, which goes off when they alter that posture of the body; and in some there is a purulent spitting.—These symptoms are accompanied with great anxiety, palpitations of the heart, and faintings. Sometimes the patients have a sensation like a hot vapour ascending from the cavity of the thorax to their mouth. Others, in a more advanced state of the disease, have a putrid taste in the mouth. At the same time, profuse night-sweats waste the body, and greatly weaken the patients. The face at first grows red on that side where the matter lies, though sometimes there are only phlogoses; at last the Hippocratic face comes on, and the eyes become hollow. The pulse, especially on the affected side, is quick, but more frequently intermittent. Sometimes the nails are crooked, and pustules appear on the thorax; and frequently, according to the testimony of Hippocrates, the feet swell, and, on the affected side of the breast, there is an inflation and swelling of the skin.

Causes, &c. An empyema may arise either from the bursting of a vomica of the lungs, or from a suppuration taking place after the inflammatory stage of the pneumonia; or sometimes from a suppuration in the case of a quinny, when the inflammation had extended to the aspera arteria, from whence arises a kind of bloody spittle, and the patients are afflicted with an empyema, unless they die on the 7th day of the disease, according to the observation of Hippocrates. It may arise also from external violence, as wounds of the thorax, &c. blood extravasated, corrupted, or charged with pus. Like the vomica, it is a rare distemper, but may attack all those subject to pneumonia.

Prognosis. Very few recover after an empyema hath been once formed, especially if the operation of paracentesis hath been neglected. After this operation is performed, if a great quantity of bloody fetid pus is discharged, if the fever continues, and if the patient spits up a purulent, pale, frothy, livid, or green matter, with a decay of strength, there is no hope. But when a small quantity of pus, of a white colour, not very fetid, is discharged; when the fever and thirst presently cease, the appetite returns, and sweats of a good consistence are discharged, the strength also returning in some degree; there is then hope of a perfect recovery. If the matter is not dried up in seven weeks' time, the disease readily changes to a fistulous ulcer, which is very difficult to cure. An empyema affecting both sides of the thorax, is more dangerous than that which affects only one.

Cure. This consists in evacuating the purulent matter contained in the cavity of the thorax, which is best done by the operation of paracentesis. See the article Surgery. Afterwards the ulcer is to be treated with abstergent and consolidating medicines, and the same internal ones are to be given as in a Phthisis.

XLIV. XLIV. CARDITIS, or Inflammation of the Heart.

Gen. XIII.

Carditis, Sauv. gen. iii. Veg. 54. Pericarditis, Veg. 53. Carditis spontanea, Sauv. sp. i. Senac. Traité de Coeur, lib. iv. chap. 7. Meckel, Mem. de Berlin, 1756. Erysipelas pulmonis, Lommi. Observ. lib. ii.

Description. This disease is attended with all the symptoms of pneumonia, but in a higher degree; it is besides said to be accompanied with hydrophobic symptoms, fainting, palpitation of the heart, a seeming madness, sunk and irregular pulse, watery eyes, and a dejected countenance, with a dry and black tongue. On dissection, the heart and pericardium are found very much inflamed, and even ulcerated, with many polypous concretions.

Causes, &c. The same as in the pneumonia.

Prognosis. In the carditis the prognosis is more unfavourable than in the pneumonia; and indeed, unless the disease very quickly terminates, it must prove fatal, on account of the constant and violent motion of the heart, which exasperates the inflammation, and increases all the symptoms.

Cure. Here bleeding is necessary in as great a degree as the patient can possibly bear, together with blistering, and the antiphlogistic regimen likewise carried to a greater height than in the pneumonia; but the general method is the same as in other inflammatory diseases.

GENUS XIV. PERITONITIS, or Inflammation of the Peritoneum.

XLV. Inflammation of the Peritoneum properly so called. Sp. I.

Peritonitis, Veg. 62. Lieutad. Hist. anat. med. lib. i. obs. 3. Raynerius apud cand. lib. i. obs. 341. Morgagni. de fed. LVII. 20.

XLVI. Inflammation of the Peritoneum extended over the Omentum. Sp. II.

Epiploitis, Sauv. gen. 106. Sag. gen. 308. Omentitis, Veg. 61. Omenti inflammatio, Boerh. 958. et Ill. Van Swieten, Comm. Stork. An. Med. I. 132. Hulme on the puerperal fever.

XLVII. Inflammation of the Peritoneum stretched over the mesentery. Sp. III.

Mesenteritis, Veg. 60. Enteritis mesenterica, Sauv. sp. 4.

GENUS XV. GASTRITIS, or Inflammation of the Stomach.

XLVIII. The genuine Gastritis. A.

Gastritis legitima, Sauv. sp. i. Ettier. de cogn. et cur. morb. sect. xii. Haller, obf. 14. hist. 3. Lieut. Hist. anat. Med. lib. i. 74. Gastritis erysipelas, Sauv. sp. 4. Cardialgia inflammatoria, Sauv. sp. 13. Tralles, de opio, sect. ii. p. 231.

These diseases Dr Cullen hath thought proper to consider all under the general head of Gastritis, as there are no certain signs by which they may be distinguished from each other, and the method of cure must be the same in all.

Description. The inflammation of the stomach is attended with great heat and pain in the epigastric region, extreme anxiety, an almost continual and painful hiccup, with a most painful vomiting of everything taken into the stomach. Sometimes a temporary madness ensues; and there is an instance in the Edinburgh Medical Essays of the disorder being attended with an hydrophobia. The pulse is generally more sunk than in other inflammations, and the fever inclines to the nature of a typhus. The disorder is commonly of the remitting kind, and during the remissions the pulse frequently intermits. During the height of the disease, a mortal phrenzy frequently supervenes. The disease terminates on the fourth, seventh, ninth day, or from the eleventh to the fifteenth; and is more apt to end in a gangrene than pneumonic inflammations, and more frequently in a scirrhus than in an abscess.

Causes, &c. The inflammation of the stomach may arise from any acrid fluid taken into it; from a vehement passion; too large draughts of cold liquor, especially when the person is very hot; from a surfeit; a stoppage of perspiration; repulsion of the gout; opiates; inflammations of the neighbouring viscera; or from external injuries, such as wounds, contusions, &c.—It affects chiefly those of a plethoric habit, and hot bilious constitution.

Prognosis. This disease is always very dangerous, and the prognosis doubtful, which also must always be in proportion to the severity of the symptoms. A cessation of pain, coldness about the precordia, great debility, with a languid and intermitting pulse, with an abatement of the hiccup, denote a gangrene and speedy death. From the sensibility of the stomach also, and its great connection with the rest of the system, it must be obvious, that an inflammation of it, by whatever causes produced, may be attended with fatal consequences; particularly by the great debility it produces it may prove suddenly fatal, without running through the usual course of inflammations.—Its tendency to admit of resolution may be known by its having arisen from no violent cause, by the moderate state of the symptoms, and by a gradual remission of these symptoms in the course of the first or at most of the second week of the disease. The tendency to gangrene may be suspected from the symptoms continuing with unremitting violence notwithstanding the use of proper remedies, and a gangrene already begun may be known by the symptoms above-mentioned. The tendency to suppuration may be known by the symptoms continuing but in a moderate degree for more than one or two weeks, and by a considerable remission of the pain while a sense of weight and an anxiety still remain. When an abscess has been formed, the frequency of the pulse is at first abated; but soon after it increases with frequent cold shiverings, and an exacerbation in the afternoon and evening; followed by night-sweats, and other symptoms of hectic fever. These at length prove fatal, unless the abscess opens into the cavity of the stomach, the pus...

Cure. It appears from dissections, that the stomach may very often be inflamed when the characteristic marks of it have not appeared; and therefore we cannot lay down any general rules for the cure of this disease. When the symptoms appear in the manner above described, the cure is to be attempted by large and repeated bleedings employed early in the disease; and from these we are not to be deterred by the weakness of the pulse, for it has commonly become fuller and softer after the operation. A blister ought also to be applied to the region of the stomach; and the cure will be assisted by fomentations of the whole abdomen, and by frequent emollient and laxative glysters. The irritability of the stomach in this disease will admit of no medicines being thrown into it; and if any can be supposed necessary, they must be exhibited in glysters. Diluting drinks may be tried; but they must be of the very mildest kind, and given in very small quantities at a time. Opiates, in whatever manner exhibited, are very hurtful during the first days of the disease; but when the violence of the disease shall have abated, and when the pain and vomiting recur at intervals only, opiates given in glysters may frequently be employed with advantage. A tendency to gangrene in this disease is to be obviated only by the means just now mentioned; and when it does actually supervene, it admits of no remedy. A tendency to suppuration is to be obviated by the same means employed early in the disease. After a certain period it cannot be prevented by any means whatever; and, when actually begun, must be left to nature; the only thing that can be done by art being to avoid all irritation.

XLIX. The Erysipelasous Gastritis. B.

Description. This species of inflammation takes place in the stomach much more frequently than the former. From dissections it appears that the stomach has been often affected with inflammation, when neither pain nor fever had given any notice of it; and such is justly looked upon to have been of the erysipelasous kind. This kind of inflammation also is especially to be expected from acrimony of any kind applied to the stomach; and would certainly occur much more frequently, were not the interior surface of this organ commonly defended by mucus exuding in large quantity from the numerous follicles placed immediately under the villous coat. On many occasions, however, the exudation of mucus is prevented, or the liquid poured out is of a less viscid kind, so as to be less fitted to defend the subjacent nerves; and it is in such cases that acrid matters may readily produce an erysipelasous affection of the stomach.

In many cases, however, this kind of inflammation cannot be discovered, as it takes place without pain, pyrexia, or vomiting; but in some cases it may; namely, when it spreads into the oesophagus, and appears on the pharynx and on the whole internal surface of the mouth. When therefore an erysipelasous inflammation affects the mouth and fauces, and there shall be at the same time in the stomach an unusual sensibility to all acids, and also a frequent vomiting, there can be little doubt of the stomach's being affected in the same manner. Even when no inflammation appears in the fauces, if some degree of pain be felt in the stomach, if there be a want of appetite, an anxiety and frequent vomiting, an unusual sensibility with regard to acids, some thirst, and frequency of pulse, there will then be room to suspect an inflammation in the stomach; and such symptoms, after some time, have been known to discover their cause by the inflammation arising in the fauces or mouth. Inflammation of this kind is often disposed to pass from one place to another on the same surface, and, in doing so, to leave the place it had at first occupied. Such an inflammation hath been known to spread successively along the whole length of the alimentary canal; occasioning, when in the intestines, diarrhoea, and in the stomach vomitings; the diarrhoea ceasing when the vomitings came on, and the vomitings on the coming on of the diarrhoea.

Causes, &c. An erysipelasous inflammation may arise from acrid matters taken into the stomach; or from some internal causes not yet well known. It frequently occurs in putrid diseases, and in those recovering from fevers.

Cure. When the disease is occasioned by acrid matters taken internally, and these may be supposed still present in the stomach, they are to be washed out by drinking a large quantity of warm and mild medicines, and exciting vomiting. At the same time, if the nature of the acrimony, and its proper corrector be known, this should be thrown in; or if a specific corrector be not known, some general demulcents should be employed.

These measures, however, are more suited to prevent, than to cure inflammation after it has taken place. When this last may be supposed to have happened, if it be attended with a sense of heat, with pain and pyrexia, according to the degree of these symptoms, the measures proposed for the cure of the other kind are to be more or less employed. When an erysipelasous inflammation of the stomach hath arisen from internal causes, if pain and pyrexia occur, bleeding may be employed in persons not otherwise weakened; but in case of its occurring in putrid diseases, or where the patients are already debilitated, bleeding is inadmissible; all that can be done being to avoid irritation, and only throwing into the stomach what quantity of acids and acecent aliments it shall be found able to bear. In some conditions of the body in which this disease is apt to occur, the Peruvian bark and bitters may seem to be indicated; but an erysipelasous state of the stomach will seldom allow them to be used.

GENUS XIV. ENTERITIS, or Inflammation of the Intestines.

Enteritis, Sauv. gen. 105. Lin. 29. Veg. 57. Sag. gen. 307. Intestinorum inflammatio, Boerh. 959. Febris intestinorum inflammatoria ex mesenterio, Hoffm. II. 170.

I. The Acute Enteritis:

Enteritis illaca, Sauv. sp. 1. Enteritis colica, Sauv. sp. 2. Boerh. 963.

Description. This disease shews itself by a fixed pain in Practice in the abdomen, attended with fever, vomiting, and colic. The pain is often felt in different parts of the abdomen, but more frequently spreads over the whole, and is particularly violent about the navel.

Causes, &c. Inflammations of the intestines may arise from the same causes as those of the stomach; though commonly the former will more readily occur from cold applied to the lower extremities, or to the belly itself. It is also found supervening on the spasmodic colic, incarcerated hernia, and volvulus.

Prognosis. Inflammations of the intestines have the same terminations with those of the stomach, and the prognosis in both cases is much the same.

Cure. The cure of enteritis is in general the same with that of gastritis: but in the former there is commonly more access to the introduction of liquids, of acid, acetic, and other cooling remedies, and even of laxatives; but as a vomiting frequently attends the enteritis, care must be taken not to excite that vomiting by the quantity or quality of any thing thrown into the stomach. With regard to the suppuration and gangrene of the intestines following the enteritis, the same thing is to be understood as is mentioned under the Gastritis.

LI. Erysipelas Enteritis.

Concerning this nothing farther can be said, than what hath been already delivered concerning the gastritis.

LII. HEPATITIS, or Inflammation of the Liver. Genus XVII.

Hepatitis, Sauv. gen. 113. Lin. 35. Veg. 58. Sag. gen. 312. Boerh. 914. Hoffm. II. 14. Junck. 66.

Description. The inflammation of the liver is thought to be of two kinds, acute and chronic: but the latter very often does not discover itself except by an abscess found in the liver after death, and which is supposed to have been occasioned by some degree of inflammation; for this reason the chronic inflammation cannot be described, and we shall here only treat of the acute hepatitis.

The acute hepatitis is attended with considerable fever; a frequent, strong, and hard pulse; high coloured urine; an acute pain in the right hypochondrium, increased by pressing upon the part. The pain is very often in such a part of the side as to make it appear like a pleurisy; and frequently, like that, is increased on inspiration. The disease is also commonly attended with a cough, which is generally dry, but sometimes moist; and when the pain thus resembles a pleurisy, the patient cannot lie easily except upon the side affected. The pain is frequently extended to the clavicle, and to the top of the shoulder; and is attended sometimes with hiccup, and sometimes with vomiting. Some have added jaundice, or a yellowness of the eyes, to the symptoms of this distemper; but experience shows that it hath often occurred without any such symptom.

Causes, &c. The remote causes of hepatitis are not always to be discerned, and many have been assigned on a very uncertain foundation. It has been supposed that the disease may be an affection either of the extremities of the hepatic artery, or those of the vena portarum; but of the last there is no proof, nor is the supposition at all probable. The acute hepatitis seems rather to be an affection of the external membrane of the liver, and the chronic kind to be an affection of the parenchyma of that viscus. The acute disease may be seated either on the convex or concave surface of the liver; and in the former case a more pungent pain and hiccup may be produced, and the respiration is more considerably affected. In the latter there occurs less pain; and a vomiting is produced, commonly by some inflammation communicated to the stomach. The inflammation on the concave surface of the liver, may be readily communicated to the gall-bladder and biliary ducts: and this, perhaps, is the only case of idiopathic hepatitis attended with jaundice.

Prognosis. The inflammation of the liver, like others, may end by resolution, suppuration, or gangrene; and the tendency to the one or to the other of these events may be known from what has been already mentioned concerning the prognosis in gastritis. The resolution of hepatitis is often the consequence of, or is attended with, evacuations of different kinds. A hemorrhage, sometimes from the nose, and sometimes from the hemorrhoidal vessels, gives a solution of the disease. Sometimes the same thing is accomplished by a bilious diarrhoea; and sometimes the resolution is attended with sweating, and an evacuation of urine depositing a copious sediment. Sometimes it may be cured by an erysipelas appearing in some external part. When the disease hath ended in suppuration, the pus collected may be discharged by the biliary ducts; or, if the suppurated part does not adhere anywhere closely to the neighbouring parts, into the cavity of the abdomen: but if, during the first state of inflammation, the affected part of the liver shall have formed a close adhesion to some of the neighbouring parts, the discharge after suppuration may be various, according to the different seat of the abscess. When seated on the convex part of the liver, if the adhesion be to the peritoneum lining the common teguments, the pus may make its way through these, and be discharged outwardly: or if the adhesion shall have been to the diaphragm, the pus may penetrate through this, and into the cavity of the lungs; from whence it may be discharged by coughing. When the abscess is seated on the concave part of the liver, in consequence of adhesions, the pus may be discharged into the stomach or intestines; and into these last, either directly, or by the intervention of the biliary ducts. Upon a consideration of all these different circumstances therefore, together with the general principles of inflammation, must the prognosis of this disease be established.

Cure. For the cure of hepatitis, we must have recourse to the general means of removing other inflammatory disorders. Bleeding is to be used according to the degree of fever and pain. Blistering is to be applied: fomentations of the external parts, emollient glysters, gentle laxatives, diluents and refrigerants, are also useful. But when a suppuration has been formed, and the abscess points outwardly, the part must be opened, the pus evacuated, and the ulcer healed according to the ordinary methods in use for healing abscesses and ulcers in other parts. LII. SPLENITIS, or Inflammation of the Spleen.

Genus XVIII.

Splenitis, Sauv. gen. 114. Lin. 36. Veg. 59. Junck. 67. Sag. gen. 313. Licinis inflammatio, Boerh. 958. & Ill. Van Swieten Comm. Splenis phlegmonodæa, Sauv. sp. 1. Forsch. l. xx. obf. 5. 6. De Haan, apud Van Swieten, p. 958. Pleuritis splenica, Sauv. sp. 19. Splenalgia supporatio, Sauv. sp. 3.

Description. This disease, according to Juncker, comes on with a remarkable shivering, succeeded by a most intense heat and very great thirst; a pain and tumour are perceived in the left hypochondrium, and the paroxysms for the most part assume a quartan form. When the patients expose themselves for a little to the free air, their extremities immediately grow very cold. If an hemorrhage happens, the blood flows out of the left nostril. The other symptoms are the same with those of the hepatitis. Like the liver, it is also subject to a chronic inflammation, which often happens after agues, and is commonly called the ague cake.

Causes, &c. The causes of this distemper are in general the same with those of other inflammatory disorders; but those which determine the inflammation to that particular part more than another, are very much unknown. It attacks persons of a very plethoric and sanguine habit of body rather than others.

Prognosis. What hath been said of the inflammation of the liver applies also to that of the spleen, tho' the latter is less dangerous than the former. Here also a vomiting of black matter, which in other acute diseases is such a fatal omen, sometimes proves critical, according to the testimony of Juncker. Sometimes the hemorrhoids prove critical; but very often the inflammation terminates by scirrhus.

Cure. This is not at all different from what hath been already laid down concerning the hepatitis.

Genus XIX. NEPHRITIS, or Inflammation of the Kidneys.

Nephritis, Sauv. gen. 115. Lin. 37. Veg. 65. Sag. gen. 314.

LIII. The Genuine Nephritis.

Nephritis vera, Sauv. sp. 1.

Description. The nephritis has the same symptoms in common with other inflammations; but its distinguishing mark is the pain in the region of the kidney, which is sometimes obtuse, but sometimes pungent. The pain is not increased by the motion of the trunk of the body so much as a pain of the rheumatic kind affecting the same region. It may also frequently be distinguished by its shooting along the course of the ureter, and is frequently attended with a drawing up of the testicle, and a numbness of the limb on the side affected; though indeed these symptoms most commonly attend the inflammation arising from a calculus in the kidney or ureter. The disease is also attended with frequent vomiting, and often with colic pains and colic pains. The urine is most commonly of a deep red colour, and is voided frequently and in a small quantity at a time. In more violent cases the urine is commonly colourless.

Causes, &c. The remote causes of this disease may be various; as external contusion, violent or long-continued riding; strains of the muscles of the back-incumbent on the kidneys; various acids in the course of circulation conveyed to the kidney; and perhaps some other internal causes not yet well known: the most frequent is that of calculous matter obstructing the tubuli uriniferi, or calculi formed in the pelvis of the kidneys, and either sticking there or fallen into the ureter.

Prognosis. This is not different from that of other inflammatory diseases.

Cure. This is to be attempted by bleeding, external fomentation, frequent emollient glysters, antiphlogistic purgatives, and by the free use of mild and demulcent liquids. The use of blisters is scarce admissible, or at least will require great care to avoid any considerable absorption of the cantharides.

The other species of nephritis enumerated by authors are only symptomatic.

Genus XX. CYSTITIS, or Inflammation of the Bladder.

Cystitis, Sauv. gen. 108. Lin. 31. Veg. 66. Sag. gen. 309. Inflammatio velicæ, Hoffm. II. 157.

LIV. The Cystitis from Internal Causes.

Cystitis spontanea, Sauv. sp. 1.

LV. The Cystitis from External Causes.

Cystitis a cantharidibus, Sauv. sp. 2. Cystitis traumatica, Sauv. sp. 3.

The inflammation of the bladder from internal causes is a very rare distemper; and when it does at any time occur, is to be cured in the same manner with other inflammations, avoiding only the use of cantharides. When the disease arises from the internal use of these flies, camphire is recommended, besides other cooling medicines, and particularly cooling and emollient glysters.

LVI. HYSTERITIS, or Inflammation of the Uterus.

Genus XXI.

Hysteritis, Lin. 38. Veg. 63. Metritis, Sauv. gen. 107. Sag. gen. 315. Inflammatio et febris uterina, Hoffm. II. 156.

Description. This disease is often confounded with that called the puerperal or child-bed fever; but is very essentially distinct from it, as will be shown in its proper place. The inflammation of the uterus is often apt to terminate by gangrene: there is a pain in the head, with delirium; and the uterine region is so exceedingly tender, that it cannot bear the most gentle pressure without intolerable pain. When the fundus uteri is inflamed, there is great heat, throbbing, and pain, above the pubes; if its posterior part, the pain is more confined to the loins and rectum, with a tenesmus; if its anterior part, it shoots from thence towards the neck of the bladder, and is attended with a frequent irritation to make water, which is voided with difficulty; and if its sides or the ovaria are affected, the pains will then dart into the inside of the thighs. Causes, &c. Inflammations of the uterus, and indeed of the rest of the abdominal viscera, are very apt to take place in lying-in women; the reason of which seems to be the sudden change produced in the habit, and an alteration in the course of the circulating blood by the contraction of the uterus after delivery. The pressure of the gravid uterus being suddenly taken off from the aorta descendens after delivery, the resistance to the impulse of the blood passing through all the vessels derived from it, and distributed to the contiguous viscera, will be considerably lessened; it will therefore rush into those vessels with a force superior to their resistance; and, by putting them violently on the stretch, may occasion pain, inflammation, and fever. This contraction of the uterus also renders its vessels impervious to the blood which had freely passed through them for the service of the child during pregnancy; and consequently a much larger quantity will be thrown upon the contiguous parts, which will still add to their diffusion, and increase their tendency to inflammation.

Prognosis. An inflammation of the uterus generally may be expected to produce an obstruction of the lochia; but the fever produced seldom proves mortal, unless the inflammation is violent and ends in a gangrene.

Cure. This is to be attempted by the same general means already recommended, and the management of this disorder entirely coincides with that of the puerperal fever.

GENUS XXII. RHEUMATISMUS; the Rheumatism.

Rheumatismus, Sauv. gen. 185. Lin. 62. Veg. 138. Boerh. 1400. Junck. 19. Dolores rheumatici et arthritici, Hoffm. II. 317. Myofitis, Sag. gen. 301.

LVII. The Acute Rheumatism. Sp. I. Rheumatismus acutus, Sauv. sp. 1. Rheumatismus vulgaris, Sauv. sp. 2.

LVIII. The Lumbago, or Rheumatism in the Loins. Var. A. Lumbago rheumatica, Sauv. gen. 212. Sag. p. 1. Nephralgia rheumatica, Sauv. sp. 4.

LIX. The Sciatica, Ischias, or Hip-Gout. Var. B. Ischias rheumaticum, Sauv. 213. sp. 10.

LX. The Bastard Pleurisy. Var. C. Pleurodyne rheumatica, Sauv. gen. 148. sp. 3. Pleuritis spuria, Boerh. 878.

The other species, which are very numerous, are all symptomatic; as, Lumbago plethorica, Sauv. sp. 3. Ischias sanguineum, Sauv. sp. 2. Pleurodyne plethorica, Sauv. sp. 1. Rheumatismus hystericus, Sauv. sp. 7. Ischias hystericum, Sauv. sp. 3. Pleurodyne hysterica, Sauv. sp. 6. Rheumatismus saltatorius, Sauv. sp. 8. Pleurodyne flatulenta, Sauv. sp. 4. Pleurodyne a spasmate, Sauv. sp. 9. Rheumatismus scorbuticus, Sauv. sp. 4.

Lumbago scorbutica, Sauv. sp. 5. Pleurodyne scorbutica, Sauv. sp. 11. Ischias syphiliticum, Sauv. sp. 7. Pleurodyne veneres, Sauv. sp. 5. Lumbago sympathica, Sauv. sp. 13. a mesenterii glandulis induratis a pancreate tumido, purulentis, scirrhoso, putri ab induratis pyloro, vena cava, pancreate a rene scirrhoso, putrefacto ab abscessu circa venea cave bifurcationem a veribus intra renem. Lumbago a fabura, Sauv. sp. 8. Pleurodyne a cacochylia, Sauv. sp. 7. Rheumatismus saltatorius verminosus, Sauv. sp. 8. Ischias verminosum, Sauv. sp. 8. Pleurodyne verminosa, Sauv. sp. 2. Rheumatismus metallicus, Sauv. sp. 10. Lumbago a hydrothorace, Sauv. sp. 14. Lumbago pseudochuria, Sauv. sp. 16. Pleurodyne a rupto esophago, Sauv. sp. 20. Pleurodyne rachitica, Sauv. sp. 13. Ischias a sparganofi, Sauv. sp. 5. Pleurodyne catarrhalis, Sauv. sp. 14. Rheumatismus necrofosis, Sauv. sp. 14. Rheumatismus dorsalis, Sauv. sp. 11. Lumbago a satyriasis, Sauv. sp. 15. Rheumatismus febricosis, Sauv. sp. 9. Lumbago febrilis, Sauv. sp. 4. &c. &c.

Description. The rheumatism is particularly distinguished by pains affecting the joints, and for the most part the joints alone; but sometimes also the muscular parts. Very often they shoot along the course of the muscles from one joint to another, and are always much increased by the action of the muscles belonging to the joint or joints affected. The larger joints are those most frequently affected, such as the hip-joint and knees of the lower extremities, and the shoulders and elbows of the upper ones. The ankles and wrists are also frequently affected; but the smaller joints, such as those of the toes or fingers, seldom suffer. Sometimes the disease is confined to one part of the body, yet very frequently affects many parts of it; and then it begins with a cold stage, which is immediately succeeded by the other symptoms of pyrexia, and particularly by a frequent, full, and hard pulse. Sometimes the pyrexia is formed before any pains are perceived; but more commonly pains are felt in particular parts before any symptoms of pyrexia occur. When no pyrexia is present, the pain may be confined to one joint only; but when any considerable pyrexia takes place, though the pain may chiefly be felt in one joint, yet it seldom happens but that the pains affect several joints, often at the very same time, but for the most part shifting their place, and having abated in one joint become more violent in another. They do not commonly remain long in the same joint, but frequently shift from one to another, and sometimes return to joints formerly affected; and in this manner the disease often continues for a long time. The pyrexia hath an exacerbation every evening, and is most considerable during the night, when the pains also become more violent; and it is at the same time that the pains shift their place from one joint to another. These seem to be also increased during the night by the body. A joint, after having been for some time affected with pain, commonly becomes also affected with some swelling and redness, which is painful to the touch. It seldom happens that a swelling coming on does not take off the pain entirely, or secure the joint against a return of it. This disease is commonly attended with more or less sweating, which occurs early, but is seldom free or copious, and seldom either relieves from the pains or proves critical. The urine is high-coloured, and in the beginning without sediment. This, however, does not prove entirely critical, for the disease often continues long after such a sediment has appeared in the urine. The blood is always thin. The acute rheumatism differs from all other inflammatory diseases in not being liable to terminate in suppuration; this almost never happens; but the disease sometimes produces effusions of a transparent gelatinous fluid into the sheaths of the tendons; but if these effusions are frequent, it is certain that the liquor must very frequently be absorbed; for it very seldom happens, that considerable or permanent tumours have been produced, or such as required to be opened and to have the contained fluid evacuated. Such tumours, however, have sometimes occurred, and the opening made in them has produced ulcers very difficult to heal.

Sometimes the rheumatism will continue for several weeks; however, it seldom proves fatal, and it is rare that the pyrexia continues to be considerable for more than two or three weeks. While the pyrexia abates in its violence, if the pains of the joints continue, they are less violent; more limited in their place, being confined commonly to one or a few joints only; and are less ready to change their place.

Causes, &c. This disease is frequent in cold, and more uncommon in warm climates. It appears most frequently in autumn and spring; less frequently in winter, while the frost is constant; and very seldom during the heat of summer. It may, however, occur at any season, if vicissitudes of heat and cold be for the time frequent. For the most part, the acute rheumatism arises from the application of cold to the body when unusually warm; or when the cold is applied to one part of the body, whilst the other parts are kept warm; or lastly, when the application of the cold is long continued, as when moist or wet clothes are applied to any part of the body.—These causes may affect persons of all ages; but the rheumatism seldom appears either in very young or in elderly persons, and most commonly occurs from the age of puberty to that of 35. These causes may also affect persons of any constitution, but they most commonly affect those of a sanguine temperament.

With respect to the proximate cause of rheumatism, there have been various opinions. It has been imputed to a peculiar acrimony: of which, however, there is no evidence; and the consideration of the remote causes, the symptoms, and cure, render it very improbable. A disease of a rheumatic nature, however, may be occasioned by an acid matter applied to the nerves, as is evident from the tooth-ach, a rheumatic affection generally arising from a carious tooth. Pains arising from deep-seated suppurations may also resemble the rheumatism; and many cases have occurred in which such suppurations occasioned pains resembling the lumbago and sciatica; but from what hath been already said, it seems improbable that ever any rheumatic case should end in suppuration.

The proximate cause of rheumatism hath by many been supposed to be a lentor in the fluids obstructing the vessels of the part; but in the former part of this treatise, sufficient reasons have been already laid down for rejecting the doctrine of lentor. While we cannot therefore find either evidence or reason for supposing that the rheumatism depends on any change in the state of the fluids, we must conclude that the proximate cause of it is the same with that of other inflammations not depending upon a direct stimulus.

In the case of rheumatism, it is supposed that the most common remote cause of it, that is, cold applied, operates especially on the vessels of the joints, these being less covered by a cellular texture than those of the intermediate parts of the limbs. It is further supposed, that the application of cold produces a constriction of the extreme vessels, and at the same time an increase of tone or phlogistic diathesis in the course of them, from which arises an increased impetus of the blood, and at the same time a resistance to the free passage of it, and consequently inflammation and pain. It is also supposed, that the resistance formed excites the vis medicatrix to a further increase of the impetus of the blood; and to support this, a cold stage arises, a spasm is formed, and a pyrexia and phlogistic diathesis are produced in the whole system.

Hence the cause of rheumatism appears to be exactly analogous to that of inflammations depending on an increased influx of blood to a part while it is exposed to the action of cold. But there seems to be further in this disease some peculiar affection of the muscular fibres. These seem to be under some degree of rigidity; and therefore less easily admit of motion, and are pained upon the exertions of it. This also seems to be the affection which gives opportunity to the propagation of pains from one joint to another, and which are most severely felt in the extremities terminating in the joints, because beyond these the oscillations are not propagated. This affection of the muscular fibres explains the manner in which strains and spasms produce rheumatic affections; and, on the whole, shews, that with an inflammatory affection of the fanguiferous system, there is also in rheumatism a peculiar affection of the muscular fibres, which has a considerable share in producing the phenomena of the disease.

Cure. Here we must remember, that in the acute rheumatism there is an inflammatory affection of the parts, and a phlogistic diathesis of the whole system. The cure therefore requires, in the first place, an antiphlogistic regimen, and particularly a total abstinence from animal-food, and from all fermented or spirituous liquors; substituting a mild vegetable or milk diet, and the plentiful use of soft diluting liquors. On this principle, blood-letting is the chief remedy of acute rheumatism. The blood is to be drawn in large quantity; and the bleeding is to be repeated in proportion to the frequency, fulness, and hardness of the pulse, and the violence of the pain. For the most part, large and repeated bleedings during the first days...

Practice days of the disease seem to be necessary, and accordingly have been very much employed; but to this some bounds are to be set; for very profuse bleedings occasion a slow recovery, and, if not absolutely effectual, are ready to produce a chronic rheumatism.

To avoid that debility of the system which general bleedings are apt to occasion, the urgent symptom of pain may be often relieved by topical bleedings; and when any swelling or redness have come upon a joint, the pain may very certainly be relieved by topical bleedings; but as the pain and continuance of the disease seem to depend more upon the phlogistic diathesis of the whole system than upon the affection of particular parts, so topical bleedings will not supply the place of the general bleedings proposed above.

To take off the phlogistic diathesis prevailing in this disease, purging may be useful, if procured by medicines which do not stimulate the whole system, as neutral salts, and other medicines which have a refrigerant power. Purging, however, is not so useful as bleeding in removing phlogistic diathesis; and when the disease has become general and violent, frequent stools are inconvenient, and even hurtful, by the motion and pain which they occasion.

In this disease, external applications are of little service. Fomentations in the beginning of the disease rather aggravate than relieve the pains. The rubefacients and camphire are more effectual; but they generally only shift them from one part to another, and do not prove any cure of the general affection. Blistering may also be very effectual in removing the pain from a particular part; but will be of little use, except where the pains are much confined to a particular place.

The several remedies above-mentioned moderate the violence of the disease, and sometimes remove it entirely; but they sometimes fail, and leave the cure imperfect. The attempting a cure by large and repeated bleedings is attended with many inconveniences; and the most effectual and safe method of cure is, after some general bleedings for taking off, or at least diminishing, the phlogistic diathesis, to employ sweating conducted by the rules laid down when speaking of the cure of synochea. Opiates, except where they are directed to procure sweat, always prove hurtful in every stage of this disease. The Peruvian bark has been supposed a remedy in some cases; but it is seldom found useful, and is frequently hurtful. It seems only fit for those cases in which the phlogistic diathesis is much abated, and at the same time the exacerbations of the disease are manifestly periodical, with considerable remissions interposed. Calomel, and other preparations of mercury, have been recommended in some cases of the acute rheumatism; but Dr. Cullen is of opinion that they are only useful in cases approaching to the nature of the chronic kind.

LXI. ARTHRODYNA, or Chronic Rheumatism. Rheumatismus chronicus Auctorum.

Description. When the pyrexia attending the acute rheumatism hath ceased; when the swelling and redness of the joints are entirely gone, but pains still continue to affect certain joints, which remain stiff, feel uneasy upon motion, changes of weather, or in the night-time only; the disease is then called the chronic rheumatism, as it often continues for a very long time.

The limits between the acute and chronic rheumatism are not always exactly marked. When the pains are still ready to shift their place; when they are especially severe in the night-time; when, at the same time, they are attended with some degree of pyrexia, and with some swelling, and especially some redness, of the joints; the disease is to be considered as partaking of the nature of the acute rheumatism. But when there is no longer any degree of pyrexia remaining; when the pained joints are without redness; when they are cold and stiff; when they cannot easily be made to sweat; or when, while a free and warm sweat is brought out on the rest of the body, it is only clammy and cold on the pained joints; and when further, the pains of these are increased by cold, and relieved by heat, applied to them; the case is to be considered as that of a purely chronic rheumatism.

The chronic rheumatism may affect different joints; but is especially apt to affect those which are surrounded with many muscles, and those of which the muscles are employed in the most constant and vigorous exertions. Such is the case of the vertebrae of the loins, the affection of which is named lumbago; or of the hip joint, when the disease is named ischitis, or sciatica.

Violent strains and spasms occurring on sudden and somewhat violent exertions, bring on rheumatic affections, which at first partake of the acute, but very soon change into the nature of the chronic rheumatism.—Such are frequently the lumbago, and other affections, which seem to be more seated in the muscles than in the joints. The distinction of the rheumatic pains from those resembling them which occur in the siphylis and scurvy must be obvious, either from the seat of the pains, or from the concomitant symptoms peculiar to those diseases. The distinction of the rheumatism from the gout will be more fully understood from what is laid down in the following genus.

Causes, &c. The phenomena of the purely chronic rheumatism lead us to conclude, that its proximate cause is an atony both of the blood-vessels and of the muscular fibres of the part affected, together with such a degree of rigidity and contraction in the latter as frequently attend them in a state of atony.

Cure. From the view just now given of the proximate cause of chronic rheumatism, the indication of cure must be, to restore the activity and vigour of the vital principle in the part.—The remedies are either external or internal.

The external are, the supporting the heat of the part, by keeping it constantly covered with flannel; the increasing the heat of the part by external heat, applied either in a dry or humid form; the diligent use of the flesh brush, or other means of friction; the application of electricity in sparks or shocks; the application of cold water by affusion or immersion; the application of essential oils of the most warm and penetrating kind; the application of salt brine; and lastly, the employment either of exercise, of the part itself as far as it can easily bear, or by riding or other mode of gestation. The internal remedies are, 1. Large doses of essential oils drawn from resinous substances, such as turpentine. 2. Substances containing such oils, as gaiac. 3. Volatile alkaline salts. 4. These or other medicines directed to procure sweat; and, 5. Calomel, or some other preparation of mercury, in small doses, continued for some time. Besides these, there are several others recommended; as bleeding, general and topical; burning, blistering, and inflames; but these, to Dr. Cullen, seem only useful when the disease still partakes of the nature of the acute rheumatism.

LXII. ODONTALGIA, the Tooth Ache. G. XXIV.

Odontalgia, Sauv. gen. 198. Lin. 45. Vog. 145. Sag. gen. 157. Junc. 25.

Odontalgia sine rheumatismo odontalgicus, Hoffm. II. 330.

Odontalgia cariosa, Sauv. sp. 1.

Odontalgia ecorbutica, Sauv. sp. 4.

Odontalgia catarrhalis, Sauv. sp. 3.

Odontalgia arthritica, Sauv. sp. 6.

Odontalgia gravidarum, Sauv. sp. 2.

Odontalgia hysterica, Sauv. sp. 3.

Odontalgia stomachica, Sauv. sp. 9.

Description. This well-known disease makes its attack by a most violent pain in the teeth, most frequently in the molars, but more rarely in the incisors, reaching sometimes up to the eyes, and sometimes backward into the cavity of the ear. At the same time there is a manifest determination to the head, and a remarkable tension and inflation of the vessels takes place, not only in the parts next to that where the pain is seated, but over the whole head.

Causes, &c. The toothache is sometimes merely a rheumatic affection arising from cold, but more frequently from a carious tooth. It is also a symptom of pregnancy, and takes place in some nervous disorders; it may attack persons at any time of life, though it is most frequent in the young and plethoric.

Care. Many empirical remedies have been proposed for the cure of the tooth-ache, but none have in any degree answered the purpose. When the affection is purely rheumatic, blistering behind the ear will almost always remove it; but when it proceeds from a carious tooth, the pain is much more obstinate. In this case it hath been recommended to touch the pained part with a hot iron, or with oil of vitriol, in order to destroy the aching nerve; to hold strong spirits in the mouth; to put a drop of oil of cloves into the hollow of the tooth, or a pill of equal parts of opium and camphire. The Peruvian bark hath also been recommended, and perhaps with more justice, on account of its tonic and antiseptic powers; but very often all these remedies will fail, and the only infallible cure is to draw the tooth. See Surgery.

GENUS XXIV. PODAGRA, the Gout.

Podagra, Vog. 175. Boerh. 1254.

Febris podagraica, Vog. 69.

Arthritis, Sauv. gen. 183. Lin. 60. Vog. 139 Sag. gen. 142.

Dolor podagricus et arthriticus versus, Hoffm. II. 339.

Dolores arthritici, Hoffm. II. 317.

Afflictus spasico-arthritici, Junc. 46.

LXIII. The Regular Gout. Sp. II.

Arthritis podagra, Sauv. sp. 1.

Arthritis rachitalgica, Sauv. sp. 11.

Arthritis activa, Sauv. sp. 4.

LXIV. The Atonic Gout. Sp. II.

Arthritis melancholica, Sauv. sp. 6.

Arthritis hemalisis, Sauv. sp. 2.

Arthritis chlorotica, Sauv. sp. 5.

Arthritis asthmatica, Sauv. sp. 9.

LXV. The Retrocedent Gout.

LXVI. The Misplaced Gout.

Description. What we call a paroxysm of the gout is principally constituted by an inflammatory affection of some of the joints. This sometimes comes on suddenly, without any warning, but is generally preceded by several symptoms; such as the ceasing of a sweating which the feet had been commonly affected with before; an unusual coldness of the feet and legs; a frequent numbness, alternating with a sense of prickling along the whole of the lower extremities; frequent cramps of the muscles of the legs; and an unusual turbulence of the veins.

While these symptoms take place in the lower extremities, the body is affected with some degree of torpor and languor, and the functions of the stomach in particular are more or less disturbed. The appetite is diminished; and flatulence, or other symptoms of indigestion, are felt. These symptoms take place for several days, sometimes for a week or two, before a paroxysm comes on; but commonly, upon the day immediately preceding it, the appetite becomes greater than usual.

The circumstances of paroxysms are the following. They come on most commonly in the spring; and sooner or later, according as the vernal heat succeeds sooner or later to the winter's cold; and, perhaps, sooner or later also, according as the body may happen to be more or less exposed to vicissitudes of heat and cold.

The attacks are sometimes felt first in the evening, but more commonly about two or three o'clock of the morning. The paroxysm begins with a pain affecting one foot, most commonly in the ball or first joint of the great toe, but sometimes in other parts of the foot. With the coming on of this pain, there is commonly more or less of a cold shivering; which, as the pain increases, gradually ceases; and is succeeded by a hot stage of pyrexia, which continues for the same time with the pain itself. From the first attack, the pain becomes, by degrees, more violent, and continues in this state with great reflexions of the whole body till next midnight; after which it gradually relents; and, after it has continued for 24 hours from the commencement of the first attack, it commonly ceases very entirely; and, with the coming on of a gentle sweat, allows the patient to fall asleep. The patient, upon coming out of this sleep in the morning, finds the pained part affected with some redness and swelling, which, after having continued for some days, gradually abate.

When a paroxysm has thus come on, although the violent pain after 24 hours be considerably abated, the patient is not entirely relieved from it. For some days This doctrine, however ancient and general, appears to Dr Cullen very doubtful. For,

Firstly, there is no direct evidence of any morbid matter being present in persons disposed to the gout. There are no experiments or observations which show that the blood or other humours of gouty persons are in any respect different from those of others. Previous to attacks of the gout, there appear no marks of any morbid state of the fluids; for the disease generally attacks those persons who have enjoyed the most perfect health, and appear to be in that state when the disease comes on. At a certain period of the disease, a peculiar matter indeed appears in gouty persons; but this, which does not appear in every instance, and which appears only after the disease has subsided for a long time, seems manifestly to be the effect, not the cause, of the disease. Further, though there be certain acids which, taken into the body, seem to excite the gout, it is probable that these acids operate otherwise in exciting the disease, than by affording the material cause of it. In general, therefore, there is no proof of any morbid matter being the cause of the gout.

Secondly, the suppositions concerning the particular nature of the matter producing the gout, have been so various, and so contradictory to each other, as to allow us to conclude, that there is truly no proof of the existence of any of them. With respect to many of these suppositions, they are so inconsistent with chemical philosophy, and with the laws of the animal economy, that they must be entirely rejected.

Thirdly, the supposition of a morbid matter as the cause, is not consistent with the phenomena of the disease, particularly with its frequent and sudden translations from one part to another.

Fourthly, The supposition is further rendered improbable by this, that, if a morbid matter did exist, its operation should be similar in the several parts which it attacks: whereas it seems to be very different, being stimulant, and exciting inflammation, in the joints; but sedative, and destroying the tone, in the stomach: which, upon the supposition of particular matter acting in both cases, is not to be explained by any difference in the part affected.

Fifthly, Some facts alleged in proof of a morbid matter, are not sufficiently confirmed; such as those which would prove the disease to be contagious. There is, however, no proper evidence of this, the facts given being not only few, but exceptionable, and the negative observations innumerable.

Sixthly, Some arguments brought in favour of a morbid matter are founded upon a mistaken explanation. The disease has been supposed to depend upon a morbid matter, because it is hereditary. But the inference is not just: for most hereditary diseases do not depend upon any morbid matter, but upon a particular conformation of the structure of the body transmitted from the parent to the offspring; and this last appears to be particularly the case in the gout. It may be also observed, that hereditary diseases depending upon a morbid matter, appear always much more early in life than the gout commonly does.

Seventhly, The supposition of a morbid matter being the cause of the gout, has been hitherto useless, as it has not suggested any successful method of cure. Particular suppositions have often corrupted the practice, and have frequently led from those views which might have been useful, and from that practice which experience had approved. Further, though the supposition of a morbid matter has been generally received, it has been as generally neglected in practice. When the gout has affected the stomach, nobody thinks of correcting the matter supposed to be present there, but merely of restoring the tone of the moving fibres.

Eighthly, The supposition of a morbid matter is quite superfluous: for it explains nothing, without supposing that matter to produce a change in the state of the moving powers; and a change in the state of the moving powers, produced by other causes, explains every circumstance without the supposition of a morbid matter; and, to this purpose, it may be observed, that many of the causes exciting the gout, do not operate upon the state of the fluids, but directly and solely upon that of the moving powers.

Lastly, The supposition of a morbid matter is superfluous; because, without that, the disease can be explained in a manner more consistent with its phenomena, with the laws of the animal economy, and with the method of cure which experience has approved. We now proceed to give this explanation; but, before entering upon it, we must premise some general observations.

The first observation is, That the gout is a disease of the whole system, or depends upon a certain general conformation and state of the body, which manifestly appears from the facts above mentioned. But the general state of the system depends chiefly upon the state of its primary moving powers; and therefore the gout may be supposed to be an affection of these chiefly.

The second observation is, That the gout is manifestly an affection of the nervous system; in which the primary moving powers of the whole system are lodged. The occasional or exciting causes are almost all such as act directly upon the nerves and nervous system; and the greater part of the symptoms of the atonic or retrocedent gout are manifestly affections of the same system. This leads us to seek for an explanation of the whole of the disease in the laws of the nervous system, and particularly in the changes which may happen in the balance of its several parts.

The third observation is, That the stomach, which has so universal a consent with the rest of the system, is the internal part that is the most frequently, and often very considerably, affected by the gout. The paroxysms of the disease are commonly preceded by an affection of the stomach; many of the exciting causes act first upon the stomach, and the symptoms of the atonic and retrocedent gout are most commonly and chiefly affections of the same organ. This observation leads us to remark, that there is a balance subsisting between the state of the internal and that of the external parts; and, in particular, that the state of the stomach is connected with that of the external parts, so that the state of tone in the one may be communicated to the other.

These observations being premised, we shall now offer the following pathology of the gout.

In some persons there is a certain vigorous and pleasurable towards the cure of the gout by a regimen: and from what has been already observed, he is firmly persuaded, that any man who, early in life, will enter upon the constant practice of bodily labour, and of abstinence from animal-food, will be preserved entirely from the disease.

Whether there be any other means of radically curing the gout, the Doctor is not ready to determine. There are histories of cases of the gout, in which it is said, that by great emotions of mind, by wounds, and by other accidents, the symptoms have been suddenly relieved, and never again returned; but how far these accidental cures might be imitated by art, or would succeed in other cases, is at least extremely uncertain.

The practices proper and necessary in the treatment of the gout, are to be considered under two heads:

First, As they are to be employed in the intervals of paroxysms; or, secondly, As during the time of these. In the intervals of paroxysms, the indications are, to prevent altogether the return of paroxysms; or at least to render them less frequent, and more moderate. During the time of paroxysms, the indications are, to moderate the violence and shorten the duration of them as much as can be done with safety.

1. It has been already observed, that the gout may be entirely prevented by constant bodily exercise, and by a low diet; and Dr Cullen is of opinion, that this prevention may take place even in persons who have a hereditary disposition to the disease. Even when the disposition has discovered itself by several paroxysms of inflammatory gout, he is persuaded that labour and abstinence will absolutely prevent any returns of it for the rest of life. These, therefore, are the means of answering the first indication to be pursued in the intervals of paroxysms.

Exercise in persons disposed to the gout, is directed to two purposes. One of these is the strengthening of the tone of the extreme vessels; and the other, the guarding against a plethoric state. For the former, if exercise be employed early in life, and before intemperance has weakened the body, a very moderate degree of it will answer the purpose; and, for the latter, if abstinence be at the same time observed, little exercise will be necessary.

With respect to exercise, this in general is to be observed, that it should never be violent; for, if violent, it cannot be long continued, and must always endanger the bringing on an atony in proportion to the violence of the preceding exercise.

It is also to be observed, that the exercise of digestion, though considerable and constant, will not, if it be entirely without bodily exercise, answer the purpose in preventing the gout. For this end, therefore, the exercise must be in some measure that of the body; and must be moderate, but at the same time constant and continued through life.

In every case and circumstance of the gout in which the patient retains the use of his limbs, bodily exercise, in the intervals of paroxysms, will be always useful; and, in the beginnings of the disease, when the disposition to it is not yet strong, exercise may prevent a paroxysm which otherwise might have come on. In more advanced states of the disease, however, when there is some disposition to a paroxysm, much walking will bring it on; either as it weakens the tone of the lower lower extremities, or as it excites an inflammatory disposition in them; and thus it seems to be, that strains or contusions often bring on a paroxysm of the gout.

Abstinence, the other part of our regimen for preventing the gout, is of more difficult application. If an abstinence from animal food be entered upon early in life, while the vigour of the system is yet entire, our author has no doubt of its being both safe and effectual; but, if the motive for this diet shall not have occurred till the constitution hath been broken by intemperance, or by the decline of life, a low diet may then endanger the bringing on an atomic state.

Further, if a low diet be entered upon only in the decline of life, and be at the same time a very great change in the former manner of living, the withdrawing of an accustomed stimulus of the system may readily throw this into an atomic state.

The safety of an abstemious course may be greater or less according to the management of it. It is animal food which especially disposes to the plethoric and inflammatory state, and that food is to be therefore especially avoided; but, on the other hand, it is vegetable aliment of the lowest quality that is in danger of weakening the system too much by not affording sufficient nourishment, and more particularly of weakening the tone of the stomach by its acefacy. It is therefore a diet of a middle nature that is to be chosen; and milk is precisely of this kind, as containing both animal and vegetable matter.

As approaching to the nature of milk, and as being a vegetable matter containing the greatest portion of nourishment, the farinaceous foods are next to be chosen, and are the food most proper to be joined with milk.

With respect to drink, fermented liquors are useful only when they are joined with animal food, and that by their acefacy; and their stimulus is only necessary from custom. When, therefore, animal food is to be avoided, fermented liquors are unnecessary; and by increasing the acefacy of vegetables, these liquors may be hurtful. The stimulus of fermented, or spirituous liquors, is not necessary to the young and vigorous, and, when much employed, impairs the tone of the system. These liquors, therefore, are to be avoided, except so far as custom and the declining state of the system may have rendered them necessary.

For preventing or moderating the regular gout, water is the only proper drink.

With respect to an abstemious course, it has been supposed, that an abstinence from animal-food and fermented liquors, or the living upon milk and farinacea alone for the space of one year, might be sufficient for a radical cure of the gout: and it is possible that, at a certain period of life, in certain circumstances of the constitution, such a measure might answer the purpose.

But this is very doubtful; and it is more probable, that the abstinence must, in a great measure, be continued, and the milk-diet be persisted in, for the rest of life. It is well known, that several persons who had entered on an abstemious course, and had been thereby delivered from the gout, have however, upon returning to their former manner of full living, had the disease return upon them with as much violence as before, or in a more irregular and more dangerous form.

It has been alleged, that, for preventing the return of the gout, blood-letting, or scarifications of the feet, frequently repeated, and at stated times, may be practiced with advantage; but of this the Doctor has had no experience.

Exercise and abstinence are the means of avoiding the plethoric state which gives the disposition to the gout; and are therefore the means proposed for preventing the paroxysms, or at least for rendering them less frequent and more moderate. But many circumstances prevent the readiness necessary in pursuing these measures; and therefore, in such cases, unless great care be taken to avoid the exciting causes, the disease may frequently return; and, in many cases, the preventing of paroxysms is chiefly to be obtained by avoiding those exciting causes already enumerated.

A due attention in avoiding those several causes, will certainly prevent fits of the gout; and the taking care that those exciting causes be never applied in a great degree, will certainly render fits more moderate when they do come on. But, upon the whole, it will appear, that a strict attention to the whole conduct of life, is in this matter necessary; and therefore, when the predisposition has taken place, it will be extremely difficult to avoid the disease.

Dr. Cullen is firmly persuaded, that, by obviating the predisposition, and by avoiding the exciting causes, the gout may be entirely prevented; but, as the measures necessary for this purpose will, in most cases, be pursued with difficulty, and even with reluctance, men have been very desirous to find a medicine which might answer the purpose, without any restraint on their manner of living. To gratify this desire, physicians have proposed, and, to take advantage of it, empirics have feigned, many remedies, as we have already observed. Of what nature several of these remedies have been, it is difficult to say: but of those which are unknown, we conclude, from their having been only of temporary fame, and from their having soon fallen into neglect, that they have been either inert or pernicious, and therefore shall make no inquiry after them; and shall now remark only upon one or two known remedies for the gout which have been lately in vogue.

One of these is what has been named in England the Portland powder. This is not a new medicine, but is mentioned by Galen, and, with some little variation in its composition, has been mentioned by the writers of almost every age since that time. It appears to have been at times in fashion, and to have again fallen into neglect; and our author thinks that this last has been owing to its having been found to be, in many instances, pernicious. In every instance which the Doctor has known of its exhibition for the length of time prescribed, the persons who had taken it were indeed afterwards free from any inflammatory affection of the joints; but they were affected with many symptoms of the atomic gout; and all, soon after finishing their course of the medicine, have been attacked with apoplexy, asthma, or dropsy, which proved fatal.

Another remedy which has had the appearance of preventing the gout, is an alkali in various forms; such as the fixed alkali, both mild and caustic, lime-water, soap, and absorbent earths. Since it became common letting at the arm may be practised with advantage; but this practice cannot be repeated often with safety; because blood-letting not only weakens the tone of the system, but may also contribute to produce plethora. However, bleeding by leeches on the foot, and upon the inflamed part, may be practised and repeated with greater safety; and instances have been known of its having been practised with safety to moderate and shorten paroxysms; but how far it may be carried, we have not had experience enough to determine.

Besides blood-letting and the antiphlogistic regimen, it has been proposed to employ remedies for moderating the inflammatory spasm of the part affected, such as warm bathing and emollient poultices. These have sometimes been employed with advantage and safety; but, at other times, have been found to give occasion to a retrocession of the gout.

Blistering is a very effectual means of relieving and diffusing a paroxysm of the gout; but has also frequently had the effect of rendering it retrocedent. The stinging with nettles is analogous to blistering; and probably would be attended with the same danger. The burning with moxa, or other substances, is a remedy of the same kind; but, though not found hurtful, there are no sufficient evidences of its proving a radical cure.

Camphire, and some aromatic oils, have the power of allaying the pain, and of removing the inflammation from the part affected; but these remedies commonly make the inflammation only shift from one part to another, and therefore with the hazard of its falling upon a part where it may be more dangerous; and they have sometimes rendered the gout retrocedent.

From these reflections it will appear, that some danger must attend every external application to the parts affected during a paroxysm; and that therefore the common practice of committing the person to patience and flannel alone, is established upon the best foundation. Opiates give the most certain relief from pain; but, when given in the beginning of gouty paroxysms, occasion these to return with greater violence. When, however, the paroxysms shall have abated in their violence, but still continue to return, so as to occasion painful and restless nights, opiates may be then given with safety and advantage; especially in the case of persons advanced in life, and who have been often affected with the disease. When, after paroxysms have ceased, some swelling and stiffness shall remain in the joints, these symptoms are to be diffused by the diligent use of the flesh-brush. Purging immediately after a paroxysm, will be always employed with the hazard of bringing it on again.

Thus far of the regular gout. We now proceed to consider the management of the disease when it has become irregular.

1. In the atonic gout, the cure is to be accomplished by carefully avoiding all debilitating causes; and by employing, at the same time, the means of strengthening the system in general, and the stomach in particular.

For strengthening the system in general, Dr Cullen recommends frequent exercise on horseback, and moderate walking. Cold bathing also may answer the purpose; and may be safely employed, if it appear to be powerful in stimulating the system, and be not applied... For supporting the tone of the system in general, when threatened with atonic gout, some animal food ought to be employed, and the more acetic vegetables ought to be avoided. In the same case, some wine also may be necessary; but it should be in moderate quantity, and of the least acetic kinds; and if every kind of wine shall be found to increase the acidity of the stomach, ardent spirits and water must be employed.

For strengthening the stomach, bitters and the Peruvian bark may be employed; but care must be taken that they be not constantly employed for any great length of time.

The most effectual medicine for strengthening the stomach is iron, which may be employed under various preparations; but the best appears to be the rust in fine powder, which may be given in very large doses.

For supporting the tone of the stomach, aromatics may be employed; but should be used with caution, as the frequent and large use of them have an opposite effect; and they should therefore be given only in compliance with former habits, or for palliating present symptoms.

When the stomach happens to be liable to indigestion, gentle vomits may be frequently given, and proper laxatives should be always employed to obviate or to remove coliciveness.

In the atonic gout, or in persons liable to it, to guard against cold is especially necessary; and the most certain means of doing this, is by repairing to a warm climate during the winter-season. In the more violent cases, blistering the lower extremities may be useful; but that remedy should be avoided when any pain threatens the extremities. In persons liable to the atonic gout, issues may be established in the extremities, as in some measure a supplement to the disease.

2. A second case of the irregular gout, is the retrocedent.

When this affects the stomach and intestines, relief is to be instantly attempted by the free use of strong wines, joined with aromatics, and given warm; or, if these shall not prove powerful enough, ardent spirits must be employed, and are to be given in a large dose. In moderate attacks, ardent spirits, impregnated with garlic or with afa foetida, may be employed; or, even without the ardent spirits, a solution of afa foetida, with the volatile alkali, may answer the purpose. Opiates are often an effectual remedy; and may be joined with aromatics, as in the electurium thebicum; or they may be usefully joined with volatile alkali and camphire. Musk has likewise proved useful in this disease.

When the affection of the stomach is accompanied with vomiting, this may be encouraged, by taking draughts of warm wine, at first with water, and afterwards without it; having at length recourse, if necessary, to some of the remedies abovementioned, and particularly the opiates.

In like manner, if the intestines be affected with diarrhoea, this is to be at first encouraged by taking plentifully of weak broth; and when this shall have been done sufficiently, the tumult is to be quieted by opiates.

When the retrocedent gout shall affect the lungs, and produce asthma, this is to be cured by opiates, by antispasmodics, and perhaps by blistering on the back or breast.

When the gout, leaving the extremities, shall affect the head, and produce pain, vertigo, apoplexy, or palsy, our resources are very precarious. The most probable means of relief is, blistering the head; and, if the gout shall have receded very entirely from the extremities, blisters may be applied to these also. Together with these blisterings, aromatics, and the volatile alkali, may be thrown into the stomach.

3. The third case of the irregular gout is the misplaced; that is, when the inflammatory affection of the gout, instead of falling upon the extremities, falls upon some internal part. In this case, the disease is to be treated by blood-letting, and by such other remedies as would be proper in an idiopathic inflammation of the same parts.

Whether the translation so frequently made from the extremities to the kidneys, is to be considered as an instance of the misplaced gout, seems, as we have said before, uncertain; but our author is disposed to think it something different; and therefore is of opinion, that, in the nephralgia calcarea produced upon this occasion, the remedies of inflammation are to be employed no farther than they may be otherwise sometimes necessary in that disease, arising from other causes than the gout.

To this dissertation on the gout, taken from the works of our learned professor, we cannot help subjoining a very uncommon case published by Dr Samuel Pye in the London Medical Transactions, where the gout would seem to have been occasioned by a morbid matter, and to have been cured by the evacuation of it.

"Mr Major Rook, surgeon and apothecary in Upper Shadwell, of about 45 years of age, a sober, temperate man, of a good habit of body, accustomed to no disease but the gout; the returns of the fits whereof had never been more frequent than once in 12 or 14 months. About the month of June 1752, he was seized with a very severe paroxysm of the gout. As I had known some extraordinary effects, proceeding from a vegetable diet, in that distemper; particularly in one gentleman, who, by a total abstinence from all manner of food, except cow's milk, and that without bread, had cured himself of this disease; and who, at the time I mentioned the case to my friend, was in the 13th year of his milk-diet; I persuaded Mr Rook to try what vegetables would do for him: he readily complied, and entered upon it immediately, with a resolution, that, if it answered his expectoration, he would renounce fish and flesh for ever.

"But after the most religious abstinence from animal food, of every kind, for eleven weeks, being visited by a gentle attack in both feet, he returned immediately to his animal-food. This paroxysm continued but 48 hours; but in March 1753, was succeeded by a very severe one in both feet.

"The pain in his feet, heels, and ankles, increased with great violence, for about 10 or 12 days; till at length he was in the most extreme agonies; such as he had never felt before, and such as almost made him mad. In the height of this extremity, the pains (it is his own expression) from the feet, heels, and ankles, flew as quick as lightning directly to the calves of his legs;" but remaining there not half a minute, and not in the least abating of their extreme violence, (though the feet, heels, and ankles, were left entirely free from pain,) from the calves, after a short stay of about half a minute, the pains ascended with the same velocity as before to both the thighs, at the same time leaving the calves of the legs free from pain: from the thighs, in less than the space of one minute, and as quick as before, they arrived at the abdomen; and after giving the patient one most severe twitch in the bowels, they reached the stomach: here the pains and here the fit ended, upon the patient's vomiting up about a pint and a half of a green aqueous liquor, but so extremely corrosive, that he compared it to the strongest mineral acid.

"This extraordinary crisis happened at about two in the morning: immediately after this discharge he fell asleep, and slept till seven or eight, and waked perfectly easy in every part, no signs of the distemper remaining, but the swelling and tenderness of his feet; both of which went off gradually, so that in two days he was able to walk about his business.

"The next fit seized him in February 1754, in the common way; but was less violent than the former, and continued for about six weeks; during which time he had three increased paroxysms, or distinct smart fits, which held him about two hours each; in the last of which he had the same critical discharge, by vomiting of the same corrosive matter, preceded by the same uncommon symptoms as in the fit of 1753. But mending every hour, he was able the very next day to walk, and attend his patients, with more ease than after the first-mentioned fit; for the swelling abated much sooner, and in three days disappeared.

"I have said, that this last fit was attended with three distinct paroxysms, the last of which ended as above: yet to shew the disposition of nature, in this case, to throw off the offending humour in this her new way, it is remarkable, that, in the two first of these increased paroxysms of pain, the patient declared to me that he never had the least ease till he had vomited; but as there was no translation of the pain before these vomitings, there was none of that corrosive matter to be discharged; nothing but the common contents of the stomach was to be seen. These vomitings, however, procured the patient some ease; but the fit of the gout went on till the third paroxysm was over, which ended as has been related.

"As the crises in this case is uncommon, I must take notice of a symptom or two, which were no less extraordinary, in both these fits of the gout.

"A most profuse sweat attended the patient every morning, during the whole course of the fits; which was so very offensive, and at the same time his breath so uncommonly stinking, that neither the patient himself, nor those who waited on him, were ever sensible of the like.

"His linen was tinged as with saffron; and his urine very high coloured, of almost as deep a red as claret: but, upon the critical vomitings, every one of these symptoms disappeared with the disease.

"On the ninth of December 1755, he was attacked again in one foot. The symptoms, however, were so very mild, that he took no notice of them to his family, till the 12th: from that day the pain was aggravated, and the swelling greatly increased, by walking and riding in a coach. On the 17th it became extremely violent, particularly in the heel; when it instantaneously left the parts affected, and in the same manner and with equal velocity, (as in the two former fits,) it flew into the calves of his legs, thighs, and abdomen; and when it had reached the stomach, it caused him to vomit the same kind of corrosive acid as in the two former fits; and though the quantity was no more than a tea-spoonful, he became perfectly well in two days.

"The same symptoms of fetid urine, and offensive sweats, attended the patient in this short paroxysm, as in those of 1753 and 1754; the sweat continued but two nights, and the urine fetid only 48 hours.

"As Mr Rook had experienced so great and happy effects from the former critical vomitings, he was greatly disappointed upon finding the quantity evacuated to be very small; for which reason he immediately attempted to increase it, by drinking three pints of warm water (which was at hand), but in vain; for neither that, nor the use of his finger, could provoke to an evacuation, which was begun and finished by nature: for though the quantity evacuated was so very small, yet as it was equally corrosive, and produced the same effect, the discharge must be accounted as truly critical as the others were.

"During the first of these fits, in the year 1752, a hard tumour had appeared on the side of the metatarsus near the middle of the right foot, which continued till after the third critical vomiting; when it was resolved, and totally disappeared, upon the discharge of a viscid matter, like the white of an egg, with a few small chalk-stones from the end of the middle toe of the same foot. This discharge happened about four or five days before the patient was seized with a regular fit in April 1755. But it is to be remarked, that this last fit continued three or four weeks, and went off in the common way, without any of the critical discharges of vomiting, urine, or sweat; but left on one hand three, and on the other two, fingers loaded with chalk-stones; with this peculiar symptom, that when the weather was cold those fingers were affected with a most exquisite pain, which was always removed by heat.

"But not long after this last-mentioned fit, a large quantity of chalk-stones were extracted from the bottom of the left foot, near the ball of the great toe, and that from time to time for about three or four months. On the 19th of January 1756, (the wound occasioned by the chalk-stones being still open) he was seized with a fever, without any symptom of the gout: the fever went off on the third day, with the same kind of critical sweat and urine as always accompanied the acid vomitings in the forementioned fits. On the fourth day from the attack of the fever, a fit of the gout came on, with the common symptoms, in both feet; which continued with violence for about a week, with frequent retching and vomiting, but without bringing up more than the common contents of the stomach. At this time an uncommon itching in the bottom of the foot and ball of the great toe from whence the chalk-stones had been extracted, tormented the patient for five or six hours; upon his gently rubbing the part, he was very sensible of a fluctuation of Practice of some matter, which soon appeared to flow at first in small quantities from the open orifice in the ball of the toe; upon pressing the part, about a tea-cup full of a liquid chalky matter was collected. The next morning the patient made a large opening with an im- pithume knife, which produced more than half a pint of a bloody serous matter, full of chalk stones, which proved as truly critical as the vomitings of the corro- five acid did in the cases above-mentioned; for the orifice from whence the chalk-stones first issued, was very soon healed, and the gentleman continues in per- fect health."

LXIV. ARTHUOPROSIS, Genus XXV.

Lumbago psoadica, Sauv. sp. 6. Fordyce, Practice of Physic, P. II. p. 70. Lumbago apoplematoidea, Sauv. sp. 12. Lumbago ab arthrocose, Sauv. sp. 17. Ictias ex abscessu, Sauv. sp. 6. Morbus coxarius, De Haen, Rat. Med. Vol. I. c. xxxii.

This is a disease very much resembling the rheuma- tism; but differing both from it and the gout, in that it occasions suppurations, which they seldom or never do. It frequently, according to Sauvages, attacks the muscle psoas; and occasions excruciating pains, and then collections of matter.

The only cure is, if suppuration cannot be prevented, to lay open the part where the matter is contained, which would otherwise be absorbed, and occasion a fatal hectic.

ORDER III. EXANTHEMATA.

Exanthemata, Sag. Clas X. Phlegmasiae exanthematicae, Sauv. Clas III. Ord. I. Morbi exanthematici, Lin. Clas I. Ord. II. Febris exanthematica, Vog. Clas I. Ord. II.

GENUS XXVI. ERYSIPELAS, or St AN- THONY'S FIRE.

Erysipelas Sauv. gen. 97. Lin. 10. Sag. gen. 296. Febris erysipelacea, Vog. 68. Hoffm. 11. 98.

LXV. ERYSIPELAS with BLISTERS. Sp. I.

Erysipelas rosa, Sauv. sp. 1. Sennert de febr. lib. ii. c. 15. Febris erysipelatosa, Sydenham, sect. vi. cap. 5. Erysipelas typhodes, Sauv. sp. 2. Erysipelas petilens, Sauv. sp. 5. Erysipelas contagium, Sauv. sp. 9.

Description. The erysipelas of the face, where this affection very frequently appears, comes on with a cold shivering, and other symptoms of pyrexia. The hot stage of this is frequently attended with a confu- sion of the head, and some degree of delirium; and almost always with drowsiness, and perhaps coma. The pulse is always frequent, and commonly full and hard.—When these symptoms have continued for one, two, or at most three days, an erythema appears on some part of the face. This at first is of no great extent; but gradually spreads from the part it first occupied to the other parts of the face, till it has affected the whole; and frequently from the face it spreads over the hairy scalp, or descends on some part of the cheek. As the redness spreads, it commonly leaves, or at least is abated in the parts it had before occupied. All the parts which the redness affects are at the same time affected with some swelling, which continues for some time after the redness has abated. The whole face becomes considerably turgid; and the eye-lids are often so much swelled as entirely to shut up the eyes. When the redness and swelling have continued for some time, there commonly arise, sooner or later, blisters of a larger or smaller size on several parts of the face. These contain a thin colourless liquor, which sooner or later runs out. The surface of the skin, in the blistered places, sometimes becomes livid and blackish; but this seldom goes deeper, or discovers any degree of gangrene affecting the skin. On the parts of the face not affected with blisters, the cuticle suffers, towards the end of the disease, a considerable desquamation. Sometimes the tumour of the eye-lids ends in a suppuration.

The inflammation coming upon the face does not produce any remission of the fever which had before prevailed; and sometimes the fever increases with the spreading and increasing inflammation. The inflammation commonly continues for eight or ten days; and, for the same time, the fever and symptoms attending it also continue. In the progress of the disease, the delirium and coma attending it sometimes go on increaing, and the patient dies apoplectic on the seventh, ninth, or eleventh day of the disease. In such cases it has been commonly supposed, that the disease is translated from the external to the internal parts. But Dr Collen apprehends that the affection of the brain is merely a communication from the external affection, as this continues increasing at the same time with the internal. When the fatal event does not take place, the inflammation, after having affected the whole face, and perhaps the other external parts of the head, ceases, and with that the fever also; and, without any other crisis, the patient returns to his ordinary health. This disease is not commonly contagious; but as it may arise from an acrid matter externally applied, so it is possible that the disease may sometimes be communicated from one person to another. Persons who have once laboured under this disease are liable to return of it.

Prognosis. The event of this disease may be foreseen from the state of the symptoms which denote more or less the affection of the brain. If neither delirium nor coma come on, the disease is seldom attended with any danger; but when these symp- toms appear early in the disease, and are in a consider- able degree, the utmost danger is to be apprehended.

Care. The erysipelas of the face is to be cured much in the same manner as phlegmatic inflammations; by blood-letting, cooling purgatives, and by employing every part of the antiphlogistic regimen. The evacuations of blood-letting and purging are to be employed more or less, according to the urgency of symptoms; particularly those of the pyrexia, and of those which mark an affection of the brain. As the pyrexia continues, and often increases with the inflam- mation of the face, so the evacuations above-mentioned mentioned are to be employed at any time of the disease.

In this, as in other diseases of the head, it is proper to put the patient, as often as he can easily bear it, into somewhat of an erect posture; and as in this disease there is always an external affection, so various external applications have been proposed to be made to the part affected; but almost all of them are of doubtful effect.

An erysipelas frequently appears on other parts of the body besides the face, and such other erysipelatous inflammations frequently end in suppuration; but these cases are seldom dangerous. At coming on they are sometimes attended with drowsiness, and even with some delirium; but this seldom happens, and these symptoms do not continue after the inflammation is formed; and Dr Cullen does not remember to have seen an instance of the translation of an inflammation from the limbs to an internal part; and tho' these inflammations of the limbs be attended with pyrexia, they seldom require the same evacuations as the erysipelas of the face. It is probable, however, that this disease is sometimes attended with, or is the symptom of, a putrid fever; and in such cases the evacuations above-mentioned may be improper, and the use of the bark necessary; but our author remembers not to have seen any cases of this kind.

LXVI. ERYSPELAS with Phlycten. Sp. II.

Erysipelas zoster, Sauv. sp. 8. Zona; Anglis, The Shingles, Ruffel de tab. gland. p. 124. Hist. 35. Herpes Zoster, Sauv. sp. 9.

This differs from the former in no other way than in being attended with an eruption of phlyctene or small watery bladders on several parts of the body.—The method of cure is the same.

LXVII. PESTIS, the Plague. Gen. XXVII.

Petits, Sauv. gen. 91. Lin. 2. Junck. 78. Febris pestilentialis, Vog. 33. Hoffm. II. 93. Petits benigna, Sauv. sp. 2. Petits Massiliens, Clats III. Traité de la petite, p. 41. Ejusdem petitis, Cl. 5ta Traité, p. 228. Petits remittens, Sauv. sp. 9. Petits vulgaris, Sauv. sp. 1. Petits Massil. Cl. ii. Traité, p. 38. Ejud. Cl. iii. & iv. Traité, p. 225, &c. Waldschmidt. de pete Hollistica, apud Halleri Diff. Prad. tom. v. Chenot. de pete Transylvanica, 1755, 1759. De Haen, Rat. Med. pars xiv. Petits Egyptiaca, Sauv. sp. 11. Alpin. de Med. Egypt. Petits interna, Sauv. sp. 3. Pet. Massil. Cl. I. Traité, p. 37—224.

Description. Of this distemper Dr Cullen declines giving any particular history, because he never saw it; from the accounts of other authors, however, he is of opinion, that the circumstances peculiarly characteristic of it, especially of its more violent and dangerous states, are, 1. The great loss of strength in the animal functions, which often appears early in the disease. 2. The stupor, giddiness, and consequent flagging, which resembles drunkenness, or the headache and various delirium, all of them denote a great disorder in the functions of the brain. 3. Anxiety, palpitation, syncope, and especially the weakness and irregularity of the pulse, denote a considerable disturbance in the action of the heart. 4. Nausea and vomiting, particularly the vomiting of bile, which shows an accumulation of vitiated bile in the gall-bladder and biliary ducts, and from thence derived into the intestines and stomach; which denote a considerable spasm, and loss of tone in the extreme vessels on the surface of the body. 5. The buboes and carbuncles, which denote an acrimony prevailing in the fluids; and, lastly, The petechiae, hemorrhages, and colligative diarrhoea, which denote a putrefactive tendency prevailing in a great degree in the mass of blood.

To these characteristics of the plague enumerated by Dr Cullen, we shall add one mentioned by Sir John Pringle, which, though perhaps less frequent than the others, yet seems worthy of notice. It is this, That in the plague there is an extraordinary enlargement of the heart and liver. In nine dissections of bodies dead of the plague at Marseilles, this extraordinary enlargement of the heart is taken notice of in them all, and of the liver in seven of them. The account was sent to the Royal Society by M. Didier, one of the physicians to the king of France, and hath been published in the Philosophical Transactions. In the first case, the author takes notice, that "the heart was of an extraordinary bigness; and the liver was of double the natural size."—Case 2. The heart was of a prodigious bigness, and the liver much enlarged.—Case 3. The heart double the natural bigness.—Case 4. The heart was very large, and the liver was bigger and harder than ordinary.—Case 5. The heart was of a prodigious bigness.—Case 6. The heart was larger than in its natural state; the liver also was very large.—Case 7. The heart was of a prodigious size, and the liver was very large.—Case 8. The heart was much larger than natural, and the liver of a prodigious size.—Case 9. The heart was double the natural bigness, and the liver was larger than ordinary."

This preternatural enlargement Dr Pringle thinks is owing to the relaxation of the solid parts, by which means they become unable to resist the impetus of blood, and therefore are easily extended; as in the case of infancy, where the growth is remarkably quick. And a similar enlargement he takes notice of in the fevers, and other putrid diseases.

Causes, &c. From a consideration of the symptoms above-mentioned, Dr Cullen concludes, that the plague is owing to a specific contagion, often suddenly producing the most considerable debility in the nervous system or moving powers, and of a general putrefaction in the fluids.

Prevention. Here we must refer to all those methods of preventing and removing the incipient contagion of putrid fevers, which have been so fully enumerated. Dr Cullen is persuaded that the disease never arises in the northern parts of Europe, but in consequence of being imported from some other country. The magistrate's first care therefore ought to be to prevent the importation; and this may generally be done by a due attention to bills of health, and to the proper performance of quarantines.—With respect to the latter, he is of opinion, that the quarantines of persons persons may with safety be much less than 40 days; and if this were allowed, the execution of the quarantine would be more exact and certain, as the temptation to break it would be in a great measure avoided.

With respect to the quarantine of goods, it cannot be perfect unless the suspected goods be unpacked, duly ventilated, and other means be employed for correcting the infection they may carry; and if all this be properly done, it is probable that the time commonly prescribed for quarantine may be also shortened.

A second measure in the way of prevention is required, when an infection has reached and prevailed in any place, to prevent that infection from spreading into others. This can only be done by preventing the inhabitants or the goods of any infected place from going out of it, till they have undergone a proper quarantine.

The third measure, and which ought to be employed with great care, is, to prevent the infection from spreading among the inhabitants of a place in which it has arisen. And in this case, a great deal may be done by the magistrate, 1. By allowing as many of the inhabitants as are free from infection, and are not necessary to the service of the place, to go out of it. 2. By discharging all assemblies, or unnecessary intercourse of the people. 3. By ordering some necessary communications to be performed without contact. 4. By making such arrangements and provisions as may render it easy for the families remaining to shut themselves up in their own houses. 5. By allowing persons to quit houses where an infection appears, upon condition that they go into lazarettoes. 6. By ventilating, and purifying, and destroying, at the public expense, all infected goods. 7. By avoiding hospitals, and providing separate apartments for infected persons.

The fourth and last part of the business of prevention respects the conduct of persons necessarily remaining in infected places, especially those obliged to have some communication with persons infected. Those obliged to remain in places infected, but not to have any near communication with the sick, must avoid all near communication with other persons or their goods; and it is probable, that a small distance will serve, if, at the same time, there be no stream of air to carry the effluvia of persons or goods to some distance. Those who are obliged to have a near communication with the sick ought to avoid any of the debilitating causes which render the body susceptible of infection, as a spare diet, intemperance in drinking, excess in venery, cold, fear, or other depressing passions of the mind. A full diet of animal-food is also to be avoided, because it increases the irritability of the body, and favours the operation of contagion; and indigestion, whether from the quantity or quality of the food, contributes very much to the same.

Besides these, it is probable that the moderate use of wine and spirituous liquors, moderate exercise, and the cold bath, may be of use; tonic medicines also, of which the Peruvian bark is deservedly accounted the chief, may also be used with great probability of success. If anything is to be expected from antiseptics, Dr Cullen thinks camphire preferable to any other. In general, however, every one is to be indulged in the medicine of which he hath the best opinion, provided it is not evidently hurtful. Whether these be useful in preserving from the effects of contagion, Dr Cullen doth not determine.

Cure. Here, according to Dr Cullen, the indications are the same as in fever in general, but are not all equally important. The measures for moderating the violence of reaction, which operate by diminishing the action of the heart and arteries, have seldom any place here, excepting that the antiphlogistic regimen is generally proper. Some physicians have recommended bleeding, and Sydenham even seems to think it an effectual cure; but Dr Cullen thinks, that for the most part it is unnecessary, and in many cases might do much hurt. Purging has also been recommended; and in some degree it may be useful, in drawing off the putrefactive matter frequently present in the intestines; but a large evacuation this way may certainly be hurtful.

The moderating the violence of reaction, as far as it can be done, by taking off the spasm of the extreme vessels, is a measure of the utmost necessity in the cure of the plague; and the whole of the means formerly mentioned, as suited to this indication, are extremely proper. The giving an emetic, at the first approach of the disease, would probably be of great service; and it is probable, that, at some other periods of the disease, emetics might be useful, both by evacuating bile abounding in the alimentary canal, and by taking off the spasm of the extreme vessels.

From some principles with respect to fever in general, and with respect to the plague in particular, our author is of opinion, that after the exhibition of the first vomit, the body should be disposed to sweat; but this sweat should be raised only to a moderate degree, though it must be continued for 24 hours or more if the patient bears it easily. The sweating is to be excited and conducted according to the rules laid down under Synocha; and must be promoted by the plentiful use of diluents rendered more grateful by vegetable acids, or more powerful by being impregnated with some portion of neutral salts. To support the patient under the continuance of the sweat, a little weak broth, acidulated with the juice of lemons, may be given frequently, and sometimes a little wine if the heat of the body be not considerable. If sudorific medicines are judged necessary, opiates will be found most effectual and safe; but they should not be combined with aromatics, and probably may be more effectual if joined with a portion of emetics and of neutral salts. But if, notwithstanding the use of emetics and sudorifics in the beginning, the disease should still continue, the cure must turn upon the use of means for obviating debility and putrefaction; and for this purpose tonic medicines, especially the Peruvian bark, and cold drink, are the most proper. For the treatment of buboes and carbuncles, see the article Surgery.

Genus XXVIII. VARIOLA; the Small-Pox.

Variola, Sauv. gen. 92. Lin. 3. Seg. gen. 290. Febris variolosa, Veg. 35. Hoffm. II. 49. Variolae, Boerh. 1371. Junck. 76. LXVII. The Distinct Small-pox. Sp. I.

Variola discreta benigna, Sauv. sp. 2. Variolae regulares discretes, Sydenb. sect. iii. cap. 2. Variolae discretae simplices, Helvet. Obs. sp. 1. Variola discreta complicata, Sauv. sp. 2. Helvet. sp. 2. Variolae anomales, Sydenb. sect. iv. cap. 6. Variola discreta dytenteriodes, Sauv. sp. 4. Sydenb. sect. iv. cap. 1. Variola discreta vesicularis, Sauv. sp. 5. Variola discreta crystallina, Mead de variol. cap. 2. Variola discreta verrucosa, Sauv. sp. 6. Mead ibid. Variola discreta filiformis, Sauv. sp. 7. Freind Oper. p. 358. Variola discreta miliaris, Sauv. sp. 8. Helvet. Obs. sp. 3.

LXVIII. The Confluent Small-pox. Sp. II.

Variola confluenta, Sauv. sp. 9. Variolae regulares confluentes, ann. 1667. Sydenham. sect. iii. cap. 2. Variolae confluentes simplices, Helvet. Obs. sp. 1. Variola confluenta crystallina, Sauv. sp. 10. Variola japonica, Kempfer. Vesiculae Dive Barbarae, C. Pif. obs. 149. Variola confluenta maligna, Helvet. Obs. sp. 1. Variola confluenta coharentis, Sauv. sp. 11. Variola confluenta maligna, Helvet. sp. 2. Variola confluenta nigra, Sauv. sp. 12. Sydenham. sect. v. cap. 4. Variola confluenta maligna, Helvet. sp. 3. Variola sanguinea, Mead de variolis, cap. 2. Variola confluenta corymbosa, Sauv. sp. 13. Variola confluenta maligna, Helvet. sp. 4.

Description. In the distinct small-pox, the disease begins with a synoecia or inflammatory fever. It generally comes on about mid-day, with some symptoms of a cold stage, and commonly with a considerable languor and drowsiness. A hot stage is soon formed, and becomes more considerable on the second and third day. During this course children are liable to frequent startings from their slumber; and adults, if they are kept a-bed, are disposed to much sweating. On the third day, children are sometimes affected with one or two epileptic fits. Towards the end of the third day the eruption commonly appears, and gradually increases during the fourth; appearing first on the face, and successively on the inferior parts, so as to be completed over the whole body on the fifth day. From the third day the fever abates, and against the fifth it entirely ceases. The eruption appears first in small red spots hardly eminent, but by degrees rising into pimples. There are generally but few on the face; but, even when more numerous, they are separate and distinct from one another. On the fifth or sixth day, a small vesicle, containing an almost colourless fluid, appears on the top of each pimple. For two days these vesicles increase in breadth only, and there is a small hollow pit in their middle, so that they are not raised into spheroidal pustules till the eighth day. These pustules from their first formation continue to be surrounded with an exactly circular inflamed margin, which when they are numerous diffuses some inflammation over the neighbouring skin, so as to give somewhat of a damask-rose colour to the spaces between the pustules. As the pustules increase in size, the face swells considerably if they are numerous on it; and the eye-lids particularly are so much swelled, that the eyes are entirely shut. As the disease proceeds, the matter in the pustules becomes by degrees more opaque and white, and at length assumes a yellowish colour. On the eleventh day, the swelling of the face is abated, and the pustules seem quite full. On the top of each a darker spot appears; and at this place the pustule, on the eleventh day, or soon after, is spontaneously broken, and a portion of the matter oozes out; in consequence of which the pustule is shrivelled, and subsides; while the matter oozing out dries, and forms a crust upon its surface. Sometimes only a little of the matter oozes out, and what remains in the pustule becomes thick and even hard. After some days, both the crusts and the hardened pustules fall off, leaving the skin which they covered of a brownish red colour; nor doth it resume its natural colour till many days after. In some cases, where the matter of the pustules has been more liquid, the crusts formed by it are later in falling off, and the part they covered suffers some desquamation, which occasions a small hollow or pit in it.

On the legs and hands the matter is frequently absorbed; so that at the height of the disease, these pustules appear as empty as vesicles. On the tenth and eleventh days, as the swelling of the face subsides, a swelling arises in the hands and feet; but which again subsides as the pustules come to maturity. When the pustules on the face are numerous, some degree of pyrexia appears on the tenth and eleventh days, but disappears again after the pustules are fully ripened; or perhaps remains in a very slight degree till the pustules on the feet have finished their course; and it is seldom that any fever continues longer in the distinct small-pox. When the pustules are numerous on the face, upon the fifth or seventh day some uneasiness in the throat, with a hoarseness of the voice, comes on, and a thin liquid is poured out from the mouth. These symptoms increase with the swelling of the face; and the liquids of the mouth and throat becoming thicker are with difficulty thrown out; and there is at the same time some difficulty in swallowing, so that liquids taken in to be swallowed are frequently rejected or thrown out by the nose. But all these affections of the fauces are abated as the swelling of the face subsides.

In the confluent small-pox all the symptoms above-mentioned are much more severe. The eruptive fever particularly is more violent; the pulse is more frequent and more contracted, approaching to that state of pulse which is observed in typhus. The coma is more considerable, and there is frequently a delirium. Vomiting also frequently attends, especially at the beginning of the disease. In very young infants epileptic fits are sometimes frequent on the first days of the disease, and sometimes prove fatal before any eruption appears, or they usher in a very confluent and putrid small-pox. The eruption appears more early on the third day, and it is frequently preceded or accompanied with an erysipelasous efflorescence. Sometimes the eruption appears in clotters like the measles. When the eruption is completed, the Pimples are always more numerous upon the face, and at the same time smaller and less eminent. Upon the eruption the fever suffers some remission, but never goes off entirely; and after the fifth or sixth day it increases again, and continues to be considerable throughout the remaining part of the disease. The vesicles formed on the top of the pimples appear sooner; and while they increase in breadth, they do not retain a circular, but are every way of an irregular figure. Many of them run into one another, insomuch that very often the face is covered with one vesicle rather than with a number of pustules. The vesicles, as far as they are anyway separated, do not arise to a spheroidal form, but remain flat, and sometimes the whole of the face is of an even surface. When the pustules are in any measure separated, they are not bounded by an inflamed margin, but the part of the skin that is free from pustules is commonly pale and flaccid. The liquor that is in the pustules changes from a clear to an opaque appearance, and becomes whitish or brownish, but never acquires the yellow colour and thick consistence that appears in the distinct small-pox. The swelling of the face, which only sometimes attends the distinct small-pox, always attends the confluent kind; it also comes on more early, and arises to a greater height, but abates considerably on the tenth or eleventh day. At this time the pustules or vesicles break and shrivel; pouring out at the same time a liquor, which is formed into brown or black crusts, which do not fall off for a long time after. Those of the face, in falling off, leave the skin subject to a desquamation, which pretty certainly produces pittings. On the other parts of the body the pustules of the confluent small-pox are more distinct than on the face; but never acquire the same maturity and consistence of pus as in the properly distinct kind. The salivation, which sometimes only attends the distinct small-pox, very constantly attends the confluent; and both the salivation and the affection of the fauces above-mentioned, are, especially in adults, in a higher degree. In infants a diarrhoea comes frequently in place of a salivation.

In this kind of small-pox there is often a very considerable putrefaction of the fluids, as appears from petechiae, serous vesicles, under which the skin shows a disposition to gangrene, and from bloody urine or other hemorrhages; all of which symptoms frequently attend this disease. In the confluent small-pox also, the fever, which had only suffered a remission from the eruption to the maturation, at or immediately after this period is frequently renewed again with considerable violence. This is what has been called the secondary fever, and is of various duration and event.

Causes, &c. It is evident that the small-pox is originally produced by a contagion; and that this contagion is a ferment with respect to the fluids of the human body, which assimilates a great part of them to its own nature; and it is probable, that the quantity thus assimilated is, in proportion to their several bulks, nearly the same in different persons. This quantity passes again out of the body, partly by insensible perspiration, and partly by being deposited in pustules; but if the quantities generated be nearly equal, the quantities passing out of the body the two ways above-mentioned are very unequal in different persons. The causes which determine more of the variolous matter to pass by perspiration, or to form pustules, are probably certain circumstances of the skin, which determine more or less of the variolous matter to stick in it, or to pass freely through it. The circumstance of the skin which seems to determine the variolous matter to stick in it, is a certain state of inflammation depending much on the heat of it: thus we have many instances of parts of the body, from being more heated, having a greater number of pustules than other parts. Thus parts covered with plasters, especially those of the stimulant kind, have more pustules than others. Certain circumstances also, such as adult age, and full living, determining to a phlogistic diathesis, seem to produce a greater number of pustules, and vice versa. It is therefore probable, that an inflammatory state of the whole system, and more particularly of the skin, gives occasion to a greater number of pustules; and the causes of this may produce most of the other circumstances of the confluent small-pox, such as the time of eruption, the continuance of the fever, the effusion of a more putrefactive matter and less fit to be converted into pus, together with the form and other circumstances of the pustules.

Prognosis. The more exactly the disease retains the form of the distinct kind, it is the safer; and the more completely the disease takes the form of the confluent kind, it is the more dangerous. It is only when the distinct kind shows a great number of pustules on the face or otherwise, by fever or putrefaction, approaching to the circumstances of the confluent, that the distinct kind is attended with any danger.

In the confluent kind the danger is always very considerable; and the more violent and permanent the fever is, the greater the danger; and especially in proportion to the increase of the symptoms of putrefaction. When the putrid disposition is very great, the disease sometimes proves fatal before the eighth day; but in most cases death happens on the eleventh, and sometimes not till the fourteenth or seventeenth day.

Though the small-pox may not prove immediately fatal, the more violent kinds are often followed by a morbid state of the body, sometimes of very dangerous event. These consequences, according to Dr Cullen, may be imputed sometimes to an acrid matter produced by the preceding disease, and deposited in different parts; and sometimes to an inflammatory diathesis produced and determined to particular parts of the body.

Cure. The art of medicine hath never yet afforded a method of preventing the eruption of the small-pox after the contagion is received; all that can be done is, to render the disease more mild, which is generally effected by inoculation. It is not to be supposed that the mere giving of the infection artificially could make any difference in the nature of the disease, was it not that certain precautions are commonly used in the case of those who are inoculated, which cannot be used in the case of those who receive them naturally. These measures, according to Dr Cullen, are chiefly the following:

1. The choosing for the subject of inoculation persons otherwise free from disease, and not liable from their age or otherwise to any incidental disease. 2. The choosing that time of life which is most favourable to a mild disease.

3. The choosing for the practice a season most favourable to a mild disease.

4. The preparing the person to be inoculated, by enjoining abstinence from animal-food for some time before inoculation.

5. The preparing the person by courses of mercurial and antimonial medicines.

6. The taking care at the time of inoculation to avoid cold, intemperance, fear, or other circumstances which might aggravate the future disease.

7. After these preparations and precautions, the choosing a fit matter to be employed in inoculation, by taking it from a person of a sound constitution, and free from any disease, or suspicion of it; by taking it from a person who has had the small-pox of the most benign kind; and lastly, by taking the matter from such person as soon as it has appeared in the pustules, either on the part inoculated, or on other parts of the body.

8. The introducing, by inoculation, but a small portion of the contagious matter.

9. After inoculation, the continuing of the vegetable diet, and the employment of mercurial and antimonial medicines, and at the same time employing frequent purging.

10. Both before and after inoculation, taking care to avoid external heat, either from the sun, artificial fires, warm chambers, much clothing, or being much in bed; and, on the contrary, exposing the person to a free and cool air.

11. Upon the appearance of the eruptive fever, the rendering that moderate by the employment of purgatives; by the use of cooling and antiseptic acids; and especially by exposing the person frequently to a cool, and even a cold air, at the same time giving freely of cold drink.

12. After the eruption, the continuing the application of cold air, and the use of purgatives, during the course of the disease, till the pustules are fully ripened.

On these measures Dr Cullen observes, that, as the common infection may often seize persons under a diseased state, which may render the small-pox more violent, it is evident that inoculation must have a great advantage by avoiding such concurrence. But as the avoiding of this may in the mean time frequently leave persons exposed to the common infection, it is well worth while to inquire what are the diseased states which should refrain from the practice of inoculation. This is not yet sufficiently ascertained: for it hath been observed, that the small-pox has often occurred with a diseased state of the body, without being thereby rendered more violent; and it hath also been observed, that some diseases of the skin are equally innocent. Our author is of opinion, that they are diseases of the febrile kind, or such ailments as induce or aggravate a febrile state, that especially give the concurrence which is most dangerous with the small-pox. He is also of opinion, that though a person be in a diseased state, if that state be of uncertain nature and effect, and at the same time the small-pox are very common in the neighbourhood, so that it must be extremely difficult to guard against the common infection, it will always be safer to give the small-pox by inoculation than to leave the person to take them by the common infection.

Though inoculation hath been practised with safety upon persons of all ages, yet there is reason to conclude, that adults are more liable to a violent disease than persons of younger years. At the same time it is observed, that children, in the time of their first dentition, are liable, from the irritation of that, to have the small-pox rendered more violent; and that infants, before the time of dentition, upon receiving the contagion of the small-pox are liable to be afflicted with epileptic fits, which frequently prove fatal. Hence it is evident, that though circumstances may admit and approve of inoculation at any age, yet for the most part it will be advantageous to choose persons after the first dentition is over, and before the time of puberty. The operation of inoculation may be performed at any season of the year; yet as it is certain that the cold of winter may increase the inflammatory, and the heats of summer increase the putrefactive state of the small-pox, it is highly probable that inoculation may have some advantage from avoiding the extremes either of cold or heat.

As the use of animal-food may increase both the inflammatory and putrefactive state of the human body, so it must render persons, in receiving the contagion of the small-pox, less secure against a violent disease; and therefore inoculation may derive some advantage by enjoining abstinence from animal-food for some time before the operation is performed: but Dr Cullen is of opinion, that a longer time is necessary than what is commonly prescribed.

Mercurial and antimonial preparations may have some effect in determining to a more free perspiration, and therefore may be of some use in preparing a person for the small-pox; but there are many observations which render their use doubtful. The quantity of both these medicines, particularly the antimony, commonly employed, is too inconsiderable to have any effects. Mercurials indeed have been often employed more freely; but even their salutary effects have not been evident, and they have sometimes been evidently productive of mischief. It is therefore much to be doubted, whether inoculation really derives any benefit from these preparatory courses or not.

It has been often observed, in the case of almost all contagions, that cold, intemperance, fear, and some other circumstances, concurring with the application of the contagion, have greatly aggravated the future disease; it must undoubtedly be the same in the case of the small-pox: and it is certain that inoculation must derive a great advantage, perhaps its principal one, from avoiding the concurrences above-mentioned.

It has commonly been supposed, that inoculation derives some advantage from the choice of the matter employed in it; but it is very doubtful if any choice be here necessary, or can be of any benefit in determining the state of the disease. It is not indeed probable that there is any difference of contagion producing the small-pox; for there are innumerable instances of the contagion arising from a person who labours under the distinct small-pox producing the confluent kind, and the contrary. Since the practice of inoculation hath been introduced, it hath also been observed,

Practice observed, that the same variolous matter would in one person produce the distinct, and in another the confluent small-pox. It is therefore highly probable, that the difference of the small-pox does not depend upon any difference of the contagion, but upon some difference in the state of the persons to whom it is applied, or in the state of certain circumstances concurring with the application of the contagion.

Some have supposed, that inoculation has an advantage over the natural infection, by introducing only a small portion of contagious matter into the body; but this is by no means well ascertained. It is not known what quantity of contagion is introduced into the body by the common infection of the small-pox; and it is probable the quantity is not great; nor, though it were larger than that thrown in by inoculation, is it certain what the effects would be. A certain quantity of ferment may be necessary to excite fermentation in a given mass; but when that quantity is given, the fermentation and assimilation are extended to the whole mass; and we do not find that a greater quantity than is just necessary, either increases the activity of the fermentation, or more certainly secures the assimilation of the whole. In the case of the small-pox, a considerable difference in the quantity of the contagion introduced, hath not shewn any effects in modifying the disease.

Purging has the effect of diminishing the activity of the sanguiferous system, and of obviating the inflammatory state of it; and therefore it is probable, that the frequent use of cooling purgatives gives a considerable advantage to the practice of inoculation; and probably this is also obtained by diminishing the determination to the skin. It seems also probable, that mercurials and antimonials are useful only as they make part of the purging course.

It is probable that the state of the small-pox depends very much upon the state of the eruptive fever, and particularly in avoiding the inflammatory state of the skin; and therefore it is also probable, that the measures taken for moderating the eruptive fever, and inflammatory state of the skin, afford the greatest improvement which has been made in the practice of inoculation. The tendency of purging, and the use of acids to this purpose, is sufficiently obvious; and upon the same grounds we should suppose that blood-letting might be useful; but probably this has been omitted, and perhaps other remedies might be so, since we have found a more powerful and effectual one in the application of cold air and the use of cold drink.

It hath been the practice of inoculators to continue the use of purgatives and the application of cold air after the eruption; but it cannot be said to give any particular advantages to inoculation, and the employment of purgatives seems often to have led to an abuse. When the state of the eruption is determined, when the number of pustules is very small, and the fever hath entirely ceased, the safety of the disease may be said to be ascertained, and further remedies absolutely superfluous; in such cases therefore the use of purgatives is unnecessary, and may be hurtful.

It remains now only to consider the treatment of the small-pox, when the symptoms shall be violent, as may sometimes happen, even after inoculation and every remedy and precaution have been used. The cause of this is not ascertained, but it seems to be a patrificent tendency of the fluids. When therefore, from the prevailing of small-pox as an epidemic, and more especially when it is known that a person not formerly affected with the disease has been exposed to the infection, if such person should be attacked with the symptoms of fever, there can be little doubt that it is the fever of the small-pox, and therefore he is to be treated in every respect as if he had received the disease by inoculation. He is to be freely exposed to cool air, to be purged, and to have cooling acids given liberally. If these measures moderate the fever, nothing more is necessary; but if the nature of the fever be uncertain; or if, with suspicions of the small-pox, the fever be violent; or even if, knowing the distemper to be the small-pox, the measures above-mentioned do not moderate the fever sufficiently; venefaction will be proper; and more especially if the person be an adult, of a plethoric habit, and accustomed to full living. In the same circumstances it will always be proper to give a vomit; which is useful in the beginning of all fevers, and especially in this, where a determination to the stomach appears by pain and spontaneous vomiting.

It frequently happens, especially in infants, that, during the eruptive fever of the small-pox, convulsions occur. Of these, if only one or two fits appear on the evening preceding the eruption, they give a prognostic of a mild disease, and require no remedy; but if they occur more early, are violent, and frequently repeated, they are very dangerous, and require a speedy remedy; and here bleeding and blistering are of no service, the only effectual medicine is an opiate given in a large dose.

These are the remedies necessary during the eruptive fever; and if, upon the eruption, the pustules on the face are distinct, and their number few, the disease requires no further remedies. But when, upon the eruption, the number of pimples on the face is considerable, when they are not distinct; and especially if, upon the fifth day, the fever does not suffer a considerable remission; the disease still requires a great deal of attention.

If, after the eruption, the fever shall still continue, the avoiding of heat and the continuing to expose the body to a cool air will still be proper. If the fever is considerable, with a full hard pulse, in an adult person, a bleeding will be necessary, and more certainly a cooling purgative; but it will be seldom necessary to repeat the bleeding, as a loss of strength very soon comes on; but the repetition of a purgative, or the frequent use of laxative glysters, is commonly advantageous.

When a loss of strength, with other marks of a patrificent tendency of the fluids, appears, the Peruvian bark must be given in substance, and in large quantity. In the same case, the use of acids and of nitre is advantageous, and commonly it is proper also to give wine very freely. From the fifth day of the disease throughout the whole course of it, it is proper to give an opiate once or twice a day; taking care at the same time to obviate collinevity, by purgatives or by laxative glysters. From the eighth to the eleventh day of a violent disease, it will be proper to lay on blisters. that greater liberties may be taken than were formerly judged admissible. Persons afflicted with various chronic complaints, of scrophulous, scorbutic, and arthritic habits; persons of unwieldy corpulency, and of intemperate, irregular lives; have all passed through this disease with as much facility as the most temperate, healthy, and regular. But those who labour under any acute or critical disease, or its effects, are obviously unfit and improper subjects. So likewise are those in whom are evident marks of corrosive acrimonious humours, or who have an evident debility of the whole frame from inanition or any other cause. All such require to be treated in a particular manner previous to the introduction of this disease. Constitutions disposed to frequent returns of intermittent fevers, seem likewise justly exceptionable; especially as the preparatory regimen may in some habits increase this tendency. Baron Dimsdale, however, has known instances of severeague-fits attacking persons between the infection of the matter and the eruption of the pox, and even during maturation, when the Peruvian bark has been given liberally and with much success; the principal benefits, in the mean time, suffering no injury or interruption.

Among the circumstances generally considered as more or less propitious to inoculation, the season of the year has been reckoned a matter of some importance. Spring and autumn have been generally recommended, as being the most temperate seasons; the cold of winter, and the summer-heats, having been judged unfavourable for this purpose. But the Baron remarks, that experience does not justify those opinions; for, according to the best observation he has been able to make, inoculated persons have generally had more pustules in spring than at any other time of the year; and epidemic diseases being commonly most frequent in autumn, especially fluxes, intermittents, and ulcerated sore throats (all which are liable to mix more or less with the small-pox), the autumn, upon this account, does not seem to be the most favourable season in general.

Our author's opinion is, that considering the surprising and indisputable benefits arising at all times to patients in the small-pox, from the free admission of fresh cool air and evacuations, we may safely inoculate at all seasons, provided care be taken to screen the patients as much as possible from heat in summer, and to prevent them from keeping themselves too warm and too much shut up, as they are naturally disposed to do, from the weather in winter. When seasons, however, are marked with any peculiar epidemics, of such a kind especially as may render a mild disease more untractable, it may perhaps be most prudent not to inoculate while such diseases are prevalent.

In directing the preparatory regimen, Baron Dimsdale principally aims at the following points, viz. To reduce the patient, if in high health, to a lower and more secure state; to strengthen the constitution, if too low; to correct what appears vitiated; and to clear the stomach and bowels, as much as may be, from all crudities and their effects. With this view he orders such of his patients as constitute the first class abovementioned, and who are by much the majority, to live in the following manner: To abstain from all animal food, including broths, also butter and cheese; and and from all fermented liquors, excepting small beer, which is allowed sparingly; and from all spices, and whatever is endured with a manifest heating quality.

The diet is to consist of pudding, gruel, fago, milk, rice-milk, fruit-pies, greens, roots, and vegetables of any of the kinds in season, prepared or raw. Eggs, though not to be eaten alone, are allowed in puddings, and butter in pye-crust. The patients are to be careful that they do not eat such a quantity as to overload their stomachs, even of this kind of food. Tea, coffee, or chocolate, are permitted for breakfast, to those who choose or are accustomed to them.

In this manner they are to proceed about nine or ten days before the operation; during which period, at nearly equal distances, they are directed to take three doses of the following powder, either made into pills or mixed with a little syrup or jelly, at bedtime, and a dose of Glauber's salt dissolved in thin water-gruel, each succeeding morning.

The powder is composed of eight grains of calomel, the same quantity of the compound powder of crab's-claws, and one eighth part of a grain of emetic tartar. Instead of the latter, Baron Dimidale has sometimes substituted two grains of precipitated sulphur of antimony. In order to facilitate the division of the doses, a large quantity is prepared at once, and great care taken that the several ingredients be well mixed.

This quantity is usually sufficient for a healthy strong man; and the dose must be lessened for women or children, according to their age and strength, as well as for persons advanced in years.

The first dose is generally ordered at the commencement of the course; the second, three or four days after; and the third about the eighth or ninth day. The Baron chooses to inoculate the day after the last dose has been taken. On the days of purging, broths are allowed, and the patients are directed to abstain from unprepared vegetables.

What has been said concerning the preparation, must be considered as proper only for the young or middle-aged, in a good state of health: but among those who are delirious of inoculation are often found tender, delicate, and weakly women; men of bad stamina, valetudinarians by constitution, by illness, or intemperance; also aged persons, and children; and for all such a very different treatment must be directed. Here a milder course of medicine, rather of the alternative than purgative kind, is preferable; and in many instances, an indulgence in some light animal-food, with a glass or two of wine in case of lowfever, is not only allowable, but necessary to support a proper degree of strength, especially in advanced age.

Children whose bowels are often tender, and ought not to be ruffled by strong purges, yet require a mild mercurial, and bear it well. Besides emptying the bowels of crudities, it is a good security against worms and their effects, which sometimes produce very alarming and even fatal disorders.

Inattention to the particular state of health of those who are entering upon the preparatory course, has been productive of great mischief. This is chiefly observable respecting the indescreet use of mercurials, by which a salivation has often been raised, to the risque of impairing good constitutions, and the ruin of such as were previously weak and infirm. The di-

stinctions and treatment necessary, will be obvious to those who are acquainted with the animal-economy and medical practice.

The time of menstruation has generally been the guide in respect to the inoculation of women, that the whole of the disease might be over within the menstrual period. Baron Dimidale informs us, that he observes this rule, when he can choose his time without any inconvenience, and he inoculates soon after the evacuation ceases; though he has no reason to decline performing the operation at any time.

Women with child have likewise been inoculated, and done well; but the state of pregnancy seems unfavourable to the process, which ought therefore not to be hazarded without some urgent reason. Baron Dimidale has not inoculated any woman whom he knew to be pregnant; but on some who concealed their pregnancy he has performed the operation, without producing a miscarriage, the hope of which event, he suspects, had rendered them desirous of the process. One of those had a child born nine weeks after inoculation, at the full time, with distinct marks of the disease, though the mother had very few eruptions.

The manner most usually practised in this country for communicating the small-pox by inoculation, has of late been the following: A thread is drawn through a ripe pustule, and well moistened with matter. A piece of this thread is introduced into a superficial incision made in one or both arms, near the part where issues are usually fixed; and being covered with a plaster, is there left for a day or two.

Very different methods of inoculation, however, are pursued; two of which Baron Dimidale has frequently practised and describes; but he informs us, that the following has proved so invariably successful, as to induce him to give it the preference.

The patient to be infected being in the same house, and, if no objection is made to it, in the same room, with one who has the disease, a little of the variolous matter is taken from the place of infection, if the subject be under inoculation; or a pustule, if in the natural way, on the point of a lancet, so that both sides of the point are moistened.

With this lancet an incision is made in that part of the arm where issues are usually placed, deep enough to pass thro' the scarf-skin, and just to touch the skin itself; and in length as short as possible, not more than one eighth of an inch.

The little wound being then stretched open between the finger and thumb of the operator, the incision is moistened with the matter, by gently touching it with the flat side of the infected lancet. This operation is generally performed in both arms, and sometimes in two places in one arm, a little distant from each other. For as Baron Dimidale has not observed any inconvenience from two or three incisions, he seldom trusts to one; that neither he nor his patient may be under any doubt about the success of the operation from its being performed in one place only.

Baron Dimidale has also tried the following method, with the same success as that above described; but he does not so much approve of it, because he has been credibly informed that it has sometimes failed in the practice of others. A lancet being moistened with the variolous fluid in the same manner as in the other, because the application of either plaster or unguent, as is the usual practice, will occasion an inflammation on some skins; and, in all, tend to disfigure the natural appearance of the incision, and prevent our forming a proper judgment of the progress of the infection.

If neither an inoculated patient be at hand, nor any one in the neighbourhood has a distinct kind of the natural disease, a thread may be used as in the common manner, provided it be very recently infected; but Baron Dimfdale is of opinion, that the thread ought to be used as soon as possible after being charged with infecting matter.

The following method of introducing the disease has likewise been found effectual: Dip the point of a lancet in various matter; let it be held in the air till it is dry; after which it may be put up and kept in the common case, without any farther care. With this prepared lancet raise the scarf-skin obliquely, and keep the lancet a little time in motion between the two skins, that part of the matter may be mixed with the animal-juices; then withdraw the lancet, and leave the incision uncovered as before.

A due attention to the progress of infection, discoverable by the part where the operation was performed, is a necessary circumstance; because a just prognostic may thence be sometimes formed of the future state of the distemper, and indications may be taken from the different appearances on the arm, that will enable us to prevent inconveniences.

Our author observes, that the former method of covering the place of incision with a platter, and continuing upon it dressings of one sort or other, prevented much useful information of this kind. They precluded any judgment by the touch, and sometimes rendered that by the eye equivocal.

The day after the operation is performed, though it takes effect, little alteration is discoverable. On the second day, if the part be viewed with a lens, there generally appears a kind of orange-coloured stain about the incision, and the surrounding skin seems to contract. At this time Baron Dimfdale usually gives the following medicine at going to bed, either mixed with a little of any kind of jelly, or more frequently made into a pill.

Calomel, and compound powder of crabs-claws, of each three grains; emetic tartar, one-tenth of a grain.

A quantity of this medicine should be carefully prepared at once, in order to make the division more exact.

On the fourth or fifth day, upon applying the finger, a hardness is perceptible to the touch. The patient feels an itching on the part, which appears slightly inflamed; and under a kind of vesication is seen a little clear fluid, the part resembling a superficial burn. About the sixth, most commonly some pain and stiffness is felt in the axilla; a circumstance which not only foretells the near approach of the eruptive symptoms, but is a sign of a favourable progress of the disease. Sometimes on the seventh, oftener on the eighth day, symptoms of the eruptive fever appear; such as slight remitting pains in the head and back, succeeded by transient shiverings and alternate heats, which continue in a greater or less degree till the eruption be perfected. At this time also it is usual for the pa- Practice patient to complain of a very disagreeable taste in his mouth, the breath is always fetid, and there ensues a smell peculiar to the variolous eruptive fever.

The inflammation in the arms at this time spreads fast; and, upon viewing it with a good glass, the incision for the most part appears surrounded with an infinite number of small confluent pustules, which increase in size and extent as the disease advances. On the tenth or eleventh day, a circular or oval efflorescence is usually discovered surrounding the incision, and extending sometimes near half round the arm, but more frequently about the size of a shilling; and being under the cuticle, is smooth to the touch and not painful. This appearance also is favorable. It accompanies eruption; every disagreeable symptom ceases; and at the same time it certainly indicates the whole affair to be over, the pain and stiffness in the axilla also going off.

The feverish symptoms are for the most part so mild, as seldom to require any assistance, except a repetition of the same medicine that was directed on the second night after the operation; and next morning the following laxative draught should be given, to procure three or four stools.

Infusion of senna two ounces, manna half an ounce, tincture of jalap two drachms.

These are given as soon as the eruptive symptoms are perceptible, if they seem to indicate any uncommon degree of vehemence.

It has been observed that by attending to the progress of infection, we may in general be able to prognosticate with some degree of certainty the issue of the distemper. Particular incidents will ever happen, but not sufficient to invalidate the propriety of general rules.

If the appearances already described are observed early, a very favourable event may be expected; but it happens in some cases, that the success of the inoculation is barely perceptible, the colour about the wound remaining pale, instead of changing to red or inflamed; the edges of the incision spread but little, they remain almost entirely flat, and are attended neither with itching nor uneasiness of any kind. Nay, sometimes on the fifth, and even the sixth day, the alteration is so little as to render it doubtful whether the infection has taken place.

When matters are in this state, the appearance is unfavourable, implying a late and more untoward disease: To prevent which, Baron Dimfdale directs the powder or pill to be taken every night; and in case it fails to operate by stool, or there be the least disposition to coliciveness, an ounce of Glauber's salts, or more commonly the laxative draught already mentioned, is given in the morning, once or twice, as the case may require. This course forwards the inflammation, which is always a desirable circumstance; it being constantly observed, that an early progress on the arm, and an early commencement of the eruptive complaints, portend that the distemper will be mild and favourable; and on the contrary, when both are late, the symptoms are usually more irregular and unfavourable.

The management recommended by Baron Dimfdale at the period of eruption differing essentially from that of former practitioners, and being a matter of great importance, he gives the following explicit directions on this head, advising that they may be pursued with firmness and moderation.

Instead of the patient being confined to his bed or his room, when the symptoms of the eruptive fever come on, he is directed, as soon as the purging medicine has operated, to keep abroad, as much as he can bear, in the open air, be it ever so cold; always taking care not to stand still, but to walk about moderately while abroad. He is also directed, if thirsty, to drink cold water.

Baron Dimfdale observes, that this treatment seems as hard at first to the patients as it must appear singular to those who are unacquainted with such practice; but the effects are so salutary, so constantly confirmed by experience, and an easy progress through every stage of the disease depends so much upon it, that he admits of no exception, unless the weather be extremely severe and the constitution very delicate. He adds, it is indubitably true, that, in the few instances where the symptoms of eruption have run very high, the patients being averse to any motion, and fearing the cold as the greatest evil; yet when, under those circumstances, he has persuaded them to rise out of bed, and go out of doors, though led sometimes by two assistants, and has allowed them to drink as much cold water as they chose, they have not suffered the least unfavourable accident; on the contrary, after they have been prevailed upon to comply with those directions, they find their spirits revived; an inclination for nourishment returns; they rest well; a gentle sweat succeeds, accompanied with a favourable eruption; and the fever seems to be entirely extinguished.

In general, the complaints in this state are very moderate, and attended with so little illness that the patient eats and sleeps well the whole time. A few pustules appear, sometimes equally disposed; sometimes the inflammations on the arms spread, and are surrounded with a few pustules, which gradually advance to maturity; during which time, for the most part, the eruption proceeds kindly, and there is much more difficulty to restrain the patients within due bounds, and prevent their mixing with the public, thereby spreading the infection, than there was at first to prevail upon them to go abroad. During this time medicine is seldom wanted; the cool air seems the best cordial; and if any uncommon languor happens, a basin of small broth, or a glass of wine, is allowed in the day, or some white-wine whey at bed-time; which are indeed at any time allowed to tender, aged, or weakly persons.

With those exceptions, the patients are hitherto kept very scrupulously to the diet at first directed. But after the eruption is completed, they are, if occasion requires, indulged in a little well-boiled meat of the lightest kind, as chicken, veal, or mutton.

The above-mentioned regimen, the cooling alternative purges, and the free use of cool air at the season of eruption, almost universally prevent either alarming symptoms or a large crop of pustules. Baron Dimfdale has seen a few with such a quantity of pustules, though distinct, that he has neither advised nor allowed them to go out of the house. But the generality of his patients, when the eruptions are few, amuse This practice, however, the Baron neither enjoins, nor maintains to be necessary; but he has not been able to observe that any inconvenience has arisen from it. He also informs us, that, how strange soever it may appear, those who are most adventurous, seem to enjoy better spirits, and are more free from complaints, than others who are inclined to keep within doors.

Those who have the disease in the slightest manner first described, viz. without any appearance of eruption but on the inoculated part, are soon permitted to go about their usual affairs: and many instances have happened of very industrious poor men, who have immediately returned to their daily labour, with a caution not to intermix with those who have not had the distemper, for fear of spreading it; and with injunctions to take, two or three times, of the purge already directed, or as many doses of Glauber's salts. Those who have the disease in a greater degree, are confined somewhat longer; and, if there be the least disposition to colliquation, a very mild laxative is now and then exhibited; as the progress to maturation appears rather to be advanced than retarded by such means.

When the maturation is completed, and there is nothing farther to fear from the distemper, Baron Dimidale allows his patients gradually to change their course of diet, from the perfectly cooling kind, to one a little more generous; recommending strictly to all a return to their ordinary animal-diet, with much caution and restraint upon their appetites, both in respect of food and fermented liquors.

He observes it is not often that we are under a necessity of making any application to the part where the insertion of the variolous matter was made. It most commonly heals up, and is covered with a scab, about the time when, in a natural way, all the pox would have been dried up. But in some cases the incisions continue to discharge a purulent matter a longer time. In these instances it is sufficient to cover the part with the white cerate, or any other mild emollient substance, which may at once prevent the linen from adhering to the sore, and defend it from the air. As in these cases the part remains unhealed from some peculiar cause in the habit, it will be necessary to give gentle purgatives, and proper alternatives, as particular exigencies may require.

After describing the usual progress of the small-pox from inoculation, Baron Dimidale remarks that there are frequent deviations from this course, which may embarrass an inexperienced practitioner, and create a real difficulty, as well as apprehensions of danger. He therefore proceeds to relate the means for removing those symptoms, and the doubts respecting the event.

The symptom he first notices, and which, though it very rarely happens, sometimes gives much trouble, is great sickness, accompanied with vomiting, in the eruptive state of the disease. For this complaint it is always necessary in the first place to clear the stomach; which may be effected, either by ordering the patient to drink plentifully of warm liquids to promote vomiting; or perhaps more properly, by giving to an adult one grain of emetic tartar, mixed with tea grains of compound powder of crabs-claws; taking care to diminish the dose for very young and weak subjects.

This usually throws off some bilious matter by vomit, sometimes procures stools, or occasions a moderate sweat, and generally administers relief. If, however, no stools should follow from this medicine, and the sickness should remain, a gentle laxative almost certainly procures a respite, and the appearance of the eruption entirely removes the complaint.

Another deviation, of yet greater consequence, which sometimes happens towards the time of the eruption, and is often, though not always, accompanied with great sickness, is an erysipelasous efflorescence. If this shows itself on the skin partially, and here and there in patches, it is not very alarming, and soon wears off. But sometimes the whole surface of the body is covered with a rash intimately mixed with the variolous eruption, and so much resembling the most malignant kind of confluent small-pox as scarcely to be distinguished from it. In some such cases, accompanied with pustules and livid spots, Baron Dimidale has been much alarmed; not being able by inspection only, though assisted by glasses, to determine whether what he saw was an inoffensive rash, or tokens of the greatest malignity. Very strict attention, however, has enabled him to distinguish the difference clearly; and for assailing others in such a discrimination, he makes the following remarks.

The real and essential difference is to be gathered from the concomitant symptoms. In the erysipelasous or variolous rash, there is not so much fever, nor is the reflexness or pain of the head or loins so considerable; neither is there that general prostration of strength; all which are usual attendants on a confluent small-pox, especially when accompanied with such putrid appearances.

Besides, upon a careful examination, there may sometimes be discerned a few distinct pustules, larger than the rest, mixed with the rash, which are the real smallpox. In those cases the patients are ordered to refrain from cold water, or anything cold; and to keep within doors, but not in bed. If any sickness yet remains, a little white-wine whey, or other temperate cordial, is advised; and this method has been found generally successful, as to prevent any alarming complaint. After two or three days, the skin changes from a florid to a dusky colour, a few distinct pustules remain, and advance properly to maturation, without any farther trouble ensuing from this formidable appearance.

This rash has often been mistaken for the confluence it so much resembles; and has afforded occasion for some practitioners, either ignorantly or disingenuously, to pretend, that, after a very copious eruption of the confluent pox, they can by a specific medicine discharge the greater part of the pustules, leaving only as many distinct ones as may satisfy the patient that he has the disease.

Baron Dimidale informs us, that rashes of the kind above described frequently happen during the preparation (whether owing to the regimen, or medicine, or both, he does not determine), and cause the operation to be postponed. But he has observed, that in such cases they are apt to return at the time of the eruption of the small-pox. In general, as has been already said, the symptoms which precede eruption commence at the end of the seventh or on the eighth day inclusive from the operation; but it often happens that they appear much sooner, and sometimes much later than this period. Baron Dimsdale has seen some cases in which the disease has come on so suddenly after infection, and with so little complaint or uneasiness, that the whole affair has been terminated, purges taken, and the patient returned home perfectly well, in a week; before others, inoculated at the same time, from the same patient, and under the same circumstances, have begun to complain.

In this case, the inoculated part shews early certain marks of infection, sometimes on the very next day, or the day after, when the incision will often appear considerably inflamed and elevated. The patient about this time frequently makes some of the following complaints, viz. chillness, itchings, and slight pricking pains in the part, and sometimes on the shoulder; giddiness, drowsiness, and a slight head-ach, sometimes attended with a feverish heat, but often without any. The account themselves give of their feelings is, in some, as if they had drank too much, and in others, as if they had caught a cold. Those complaints seldom last 24 hours, often not so long, and with frequent intermissions; never, so far as our author remembers, rising to a degree that requires confinement. During the continuance of those complaints, the inflammation of the arm advances apace, and feels hard to the touch; but upon their wearing off, the inflamed appearances gradually diminish, and the part dries to a common small scab; the skin, that was before red, turns livid, and the disease entirely vanishes. In some instances, those symptoms attack much later; even on the seventh or eighth day, when an eruption might be expected in consequence of them, yet none appears; but the arm gets well very soon, and the disease is at an end.

In this irregular sort of the disorder there have, however, been some examples where a few eruptions have appeared, and probably in consequence of the inoculation: yet the pustules have not looked like the true pox, neither have they matured like them, nor lasted longer than three days; about which time, for the most part, they have dried away.

When this irregular kind of the disease first occurred in Baron Dimsdale's practice, he was in doubt whether the patients were quite secure from any future attacks of the distemper. In order to be satisfied of this point, he inoculated them a second time, causing them to associate with persons in every stage of the disease, and to try all other means of catching the infection. This method has been practised with the generality of such patients ever since, yet without a single instance of its producing any disorder. Baron Dimsdale, therefore, now makes no scruple of pronouncing them perfectly safe; and experience has enabled him to foretell, for the most part, in two or three days after the operation, whether the disease will pass in this flight manner.

Upon the second inoculation, however, the incited parts are uncommonly inflamed for a day or two, just in the same manner as has in numerous instances been observed, as well in those who, though certain of hav- While the common or old methods prevailed of conducting inoculation, the patients, particularly children, after passing through the disease in a very favourable manner, were frequently liable to abscesses in the axilla and other parts, tedious ophthalmies, and troublesome ulcerations in the place of infection; which though they could not be foreseen nor prevented, yet often gave more pain and vexation to the patients, and trouble to the operator, than the disease itself had done. But on inquiry into the state of those who have been treated in the cool way, or according to the new method, Baron Dimidale affirms, that in more than 1500 there has been only one who has had so much as a boil in the axilla; and this was a child who had in the same arm an issue, which was at that time dried up. He has seen only two very small superficial boils in others near the place of infection; and those seemed to be occasioned rather by an irritation from the discharge, than by any other cause, and were all soon healed with very little trouble.

In a few instances also, there has been a slough in the incised part, which has caused a sore of short duration; but not one instance of an ulcer of any continuance. Such little breakings out too, and scabs, as frequently succeed the mild natural small-pox, sometimes, though rarely, happen to those inoculated in the new way; and, as they are of little consequence, are generally cured by the same method of a few gentle purges.

In regard to ophthalmies from this kind of practice, Baron Dimidale has never known an instance of one truly deserving that name. The coats of the eye have been a little inflamed in a very few, but they soon became clear, without any means used for that purpose. He knows but two cases where he thought the inflammation great enough to require bleeding; and not one where a blister was necessary. Those complaints, therefore, which were formerly so frequent and troublesome, seem to be much reduced by the new method, the great utility of which is now universally acknowledged.

LXIX. Varicella, the Chicken-Pox. Gen. XXIX.

Varicella, Vog. 42. Variola lymphatica, Saxv. sp. 1. Anglis, The Chicken-Pox, Edin. Med. Essays, vol. ii. art. 2. near the end. Heberden, Med. Transac. art. 17.

This is a very slight disease; and is attended with so little danger, that it would not merit any notice, if it were not apt to be confounded with the small-pox; and thus give occasion to an opinion that a person might have the small-pox twice in his life; or they are apt to deceive into a false security those who have never had the small-pox, and make them believe that they are safe, when in reality they are not. These pox break out in many, according to Dr. Heberden, without any illness or previous sign; in others they are preceded by a little degree of chilliness, languor, cough, broken sleep, wandering pains, loss of appetite, and feverishness for three days.

In some patients they make their first appearance on the back, but this perhaps is not constant. Most of them are of the common size of the small-pox, but some are less. Our author never saw them confluent, nor very numerous. The greatest number was about 12 in the face, and 200 hundred over the rest of the body.

On the first day of the eruption they are reddish. On the second day there is at the top of most of them a very small bladder, about the size of a millet-seed. This is sometimes full of a watery and colourless, sometimes of a yellowish liquor, contained between the cuticle and skin. On the second, or, at the farthest, on the third day from the beginning of the eruption, as many of these poxes as are not broken seem arrived at their full maturity; and those, which are fullest of that yellow liquor, very much resemble what the genuine small-pox are on the fifth or sixth day, especially where there happens to be a larger space than ordinary occupied by the extravasated serum. It happens to most of them, either on the first day that this little bladder arises, or on the day after, that its tender cuticle is burst by the accidental rubbing of the clothes, or by the patient's hands to allay the itching, which attends this eruption. A thin scab is then formed at the top of the pock, and the swelling of the other part abates, without its ever being turned into pus, as it is in the small-pox. Some few escape being burst; and the little drop of liquor contained in the vesicle at the top of them, grows yellow and thick, and dries into a scab. On the fifth day of the eruption they are almost all dried and covered with a slight crust. The inflammation of these poxes is very small; and the contents of them do not seem to be owing to suppuration, as in the small-pox, but rather to what is extravasated under the cuticle by the serous vellus of the skin, as in a common blister. No wonder, therefore, that this liquor appears so soon as on the second day; and that, upon the cuticle being broken, it is presently succeeded by a slight scab: hence too, as the true skin is so little affected, no mark or scar is likely to be left, unless in one or two poxes, where, either by being accidentally much fretted, or by some extraordinary sharpness of the contents, a little ulcer is formed in the skin.

The patients scarce suffer anything throughout the whole progress of this illness, except some languor of strength and spirits and appetite, all which is probably owing to the confining of themselves to their chamber.

Two children were taken ill of the chicken-pox, whose mother chose to be with them, though she had never had this illness. Upon the eighth or ninth day after the pox were at their height in the children, the mother fell ill of this distemper then beginning to shew itself. In this instance the infection lay in the body much about the same time that it is known to do in the small-pox.

Remedies are not likely to be much wanted in a disease attended with hardly any inconvenience, and which in so short a time is certainly cured of itself.

The principal marks by which the chicken-pox may be distinguished from the small-pox are,

1. The appearance, on the second or third day from the eruption, of that vesicle full of serum upon the top of the pock.

2. The crust, which covers the pox on the fifth day; at which time those of the small-pox are not at the height of their suppuration.

Foreign medical writers hardly ever mention the

Description. This disease begins with a cold stage, which is soon followed with a hot, with the ordinary symptoms of thirst, heat, anorexia, anxiety, sickness, and vomiting; and these are more or less considerable in different cases. Sometimes from the beginning, the fever is sharp and violent; often, for the first two days, it is obscure and inconsiderable; but always becomes violent before the eruption, which commonly happens on the fourth day. This eruptive fever, from the beginning of it, is always attended with hoarseness, a frequent hoarse dry cough, and frequently with some difficulty of breathing. At the same time, the eyelids are somewhat swollen; the eyes are a little inflamed, and pour out tears; and, with this, there is a coryza, and frequent sneezing. For the most part, a constant drowsiness attends the beginning of this disease. The eruption, as we have said, commonly appears upon the fourth day, first on the face, and successively on the lower parts of the body. It appears first in small red points; but, soon after, a number of these appear in clusters, which do not arise in visible pimples, but, by the touch, are found to be a little prominent. This is the case on the face; but, in other parts of the body, the prominence, or roughness, is hardly to be perceived. On the face, the eruption retains its redness, or has it increased for two days; but, on the third, the vivid redness is changed to a brownish red; and, in a day or two more, the eruption entirely disappears, while a mucous desquamation takes place. During the whole time of the eruption, the face is somewhat turgid, but seldom considerably swollen. Sometimes, after the eruption has appeared, the fever ceases entirely; but this is seldom the case; and more commonly the fever continues or is increased after the eruption, and does not cease till after the desquamation. Even then the fever does not always cease, but continues with various duration and effect. Though the fever happens to cease upon the eruption's taking place, it is common for the cough to continue till after the desquamation, and sometimes much longer. In all cases, while the fever continues, the cough also continues, generally with an increase of the difficulty of breathing; and both of these symptoms sometimes arise to a degree which denotes a pneumonic affection. This may arise at any period of the disease; but very often it does not come on till after the desquamation of the eruption.

After the same period, also, a diarrhoea frequently comes on, and continues for some time.

It is common for measles, even when they have not been of a violent kind, to be followed by inflammatory affections, particularly ophthalmia and phthisis. If the blood be drawn from a vein in the measles, with the circumstances necessary to favour the separation of the gluten, this always appears separated, and lying on the surface of the craftamentum, as in inflammatory diseases. For the most part, the measles, even when violent, are without any putrid tendency; but in some cases, such a tendency appears both in the course of the disease, and especially after the ordinary course of it is finished. See Dr. Watson, in London Med. Obf. vol. iv. art. 11.

Cause. The measles are occasioned by some kind of contagion, the nature of which is not understood; and which, like the former, affects a person only once Prognosis. From the description of this distemper already given, it appears that the measles are attended with a catarrhal affection, and by an inflammatory diathesis to a considerable degree; and therefore the danger of them is to be apprehended chiefly from the coming on of a pneumonic inflammation.

Cure. From the consideration mentioned in the prognosis, it will be obvious, that the remedies especially necessary are those which may obviate and diminish the inflammatory diathesis; and therefore, in a particular manner, blood-letting. This remedy may be employed at any time in the course of the disease, or after the ordinary course of it is finished. It is to be employed more or less, according to the urgency of the symptoms of fever, cough, and dyspnea; and generally may be employed very freely. But, as the symptoms of pneumonic inflammation seldom come on during the eruptive fever; and, as this is sometimes violent, immediately before the eruption, though a sufficiently mild disease be to follow; bleeding is seldom very necessary during the eruptive fever, and may often be deferred for the times of greater danger which are perhaps to follow.

In all cases of measles, where there are no marks of putrefaction, and where there is no reason, from the known nature of the epidemic, to apprehend putrefaction, bleeding is the remedy to be depended upon; but assistance may also be drawn from cooling purgatives; and particularly from blistering on the sides, or between the shoulders. The dry cough may be alleviated by the large use of demulcent pectorals, mucilaginous, oily, or sweet. It may, however, be observed, with respect to these demulcents, that they are not so powerful in involving and correcting the acrimony of the mafs of blood as has been imagined; and that their chief operation is by besmearing the faucies, and thereby defending them from the irritation of acids, either arising from the lungs, or distilling from the head. For moderating and quieting the cough in this disease, opiates certainly prove the most effectual means, whenever they can be safely employed. In the measles, in which an inflammatory state prevails in a considerable degree, opiates may be supposed to be inadmissible; and, in those cases in which a high degree of pyrexia and dyspnea show either the presence, or at least the danger, of pneumonic inflammation, opiates might be very hurtful; but, in cases in which the dyspnea is not considerable, and in which bleeding, to obviate or abate the inflammatory state, has been duly employed; in such cases, while the cough and watchfulness are the urgent symptoms, opiates may be safely exhibited, and with great advantage. In all the exanthemata, there is an acrimony diffused over the system, which gives a considerable irritation; and, for obviating the effects of this, opiates are useful, and always proper, when no particular contra-indication prevails.

When the deflagration of the measles is finished, though then there should be no disorder remaining, physicians have thought it necessary to purge the patient several times, with a view to draw off the dregs of this disease, that is, a portion of the morbid matter which is supposed to remain long in the body. Dr Cullen doth not reject this supposition; but, at the same time, cannot believe that the remains of the morbid matter, diffused over the whole mass of blood, can be wholly drawn off by purging; and therefore thinks, that, to avoid the consequence of the measles, it is not the drawing off the morbid matter which we need to study, so much as to obviate and remove the inflammatory state of the system which had been induced by the disease. With this last view, indeed, purging may still be a proper remedy; but bleeding, in proportion to the symptoms of inflammatory disposition, is still more so.

From our late experience of the use of cold air in the eruptive fever of the small pox, some physicians have been of opinion that the practice may be transferred to the measles; but we have not yet had experience to determine this. We are certain, that external heat may be very hurtful in the measles, as in most other inflammatory diseases; and, therefore, that the body ought to be kept in a moderate temperature during the whole course of the measles: but how far, at any period of the disease, cold air may be applied with safety, we are uncertain. Analogy, though so often the resource of physicians, is frequently fallacious; and further, though the analogy with the small-pox might lead to the application of cold air during the eruptive fever of the measles, the analogy with catarrh seems to be against the practice. When the eruption is upon the skin, we have had many instances of cold air making it disappear, and thereby producing much disorder in the system; and we have also had frequent instances of this disorder's being removed by restoring the heat of the body, and thereby again bringing out the eruption.

Upwards of 20 years ago, inoculation for the measles was proposed, and practised in several instances with success, by Dr Home of Edinburgh. His method of communicating the infection was, by applying, to an incision in each arm, cotton moistened with the blood of a patient labouring under the measles. But the contagion hath since been artificially induced by means of lint wet with the tears which flow from the eyes in the first stage of this disorder. Thus, it is said, the foreheads of the eyes was mitigated, the cough abated, and the fever rendered less severe. But the practice was never much in fashion, and now is scarce ever heard of.

LXXV. The MILIARY FEVER. Genus XXXI.

Miliaria, Lin. 7. Miliaris, Sauv. gen. 95. Sag. gen. 295. Febris miliaris, Vog. 37. Febris purpurata rubra et alba miliaris, Hoffm. II. 68. Febris purpurea seu miliaris, Funck. 75. Germanis der Friel. God. Welsch, Hist. Med. de novo puerperarum morbo, qui der Friel dicatur, Lips. 1655. Hamilton, de febr. miliar. 1710. Fatonius, de febr. mil. 1747. Allioni de miliar. 1758. Fordyce, de febr. mil. 1748. Fijfer, de febr. mil. 1767. De Haen, de divit. febr. 1760, et in Ratio med. passio. Matt. Collin ad Baldinger de miliar. 1764. Miliaris benigna, Sauv. sp. 1. Miliaris maligna, Sauv. sp. 2. Miliaris recidivans, Sauv. sp. 3. Miliaris Germanica, Sauv. sp. 5. Miliaris Boia, Sauv. sp. a. Miliaris Britannica, Sauv. sp. f. Miliaris nova febris, Sydenb. Sched. monit. Sauv. sp. d. Miliaris sudatoria, Sauv. sp. c. Miliaris nautica, Sauv. sp. g. Miliaris purpurata, Sauv. sp. b. Miliaris lactea, Sauv. sp. c. Miliaris puerperarum, Sauv. sp. k. Miliaris scorbutica, Sauv. sp. l. Miliaris critica, Sauv. sp. b.

History and Description. This disease is said to have been unknown to the ancients, and that it appeared for the first time in Saxony about the middle of the last century. It is said to have since spread from thence into all the other countries of Europe; and, since the period mentioned, to have appeared in many countries in which it had never appeared before.

From the time of its having been first taken notice of, it has been described and treated of by many different writers; and by all of them, till very lately, has been considered as a peculiar idiopathic disease. It is said to have been constantly attended with peculiar symptoms. It comes on with a cold stage, which is often considerable. The hot stage, which follows, is attended with great anxiety, and frequent sighing. The heat of the body becomes great, and soon produces profuse sweating, preceded, however, with a sense of pricking, as of pin-points in the skin; and the sweat is of a peculiar rank and disagreeable odour. The eruption appears sooner or later in different persons, but at no determined period of the disease. It seldom or never appears upon the face; but appears first upon the neck and breast, and from thence often spreads over the whole body.

The eruption named miliary is said to be of two kinds; the one named the red, the other the white miliary. The former, which in English is strictly named a rubis, is commonly allowed to be a symptomatic affection; and, as the latter is the only one that has any pretensions to be considered as an idiopathic disease, it is this only that we shall more particularly describe and treat of in this chapter.

What is then called the white miliary eruption, appears at first like the red, in very small red pimples, for the most part distinct, but sometimes clustered together. Their little prominence is better distinguished by the finger than by the eye. Soon after the appearance of this eruption, and, at least, on the second day, a small vesicle appears upon the top of the pimples. At first the vesicle is whey-coloured; but soon becomes white, and stands out like a little globule on the top of the pimple. In two or three days, these globules break, or are rubbed off; and are succeeded by small crusts, which soon after fall off in small scales. While one set of pimples take this course, another set arise to run the same, so that the disease often continues upon the skin for many days together. Sometimes when one crop of this eruption has disappeared, another, after some interval, is produced. And, it has been further observed, that, in some persons, there is such a disposition to this disease, that they have been affected with it several times in the course of their lives.

This disease is said to affect both sexes, and persons of all ages and constitutions; but it has been observed at all times to affect especially, and most frequently, lying-in women.

It is often accompanied with violent symptoms, and has frequently proved fatal. The symptoms, however, attending it are very various; and they are, upon occasion, every one attending febrile diseases; but no symptom, or concourse of symptoms, are steadily the same in different persons, so as to give any specific character to the disease. When the disease is violent, the most common symptoms are phrenetic, comatose, and convulsive affections, which are also symptoms of all fevers treated by a very warm regimen.

While there is such a variety of symptoms appearing in this disease, it is not to be expected that any one particular method of cure can be proposed; and, accordingly, we find in different writers different methods and remedies prescribed; frequent disputes about the most proper; and those received and practised by some, opposed and deserted by others.

It appears, however, to Dr Cullen, very improbable that this was really a new disease, when it was first considered as such. There are very clear traces of it in authors who wrote long before that period; and though there were not, we know that ancient descriptions were inaccurate and imperfect, particularly with respect to cutaneous affections; and we know very well that those affections which commonly appeared as symptomatic only, were commonly neglected, or confounded together under a general appellation.

The antecedent symptoms of anxiety, sighing, and pricking of the skin, which have been spoken of as peculiar to this disease, are, however, common to many others; and, perhaps, to all those in which sweatings are forced out by a warm regimen. Of the symptoms said to be concomitant of this eruption, there are none which can be said to be constant and peculiar but that of sweating. This, indeed, always precedes and accompanies the eruption; and, while the miliary eruption attends many different diseases, it never, however, appears in any of these, but after sweating; and in persons labouring under the same diseases it does not appear, if in such persons sweating is avoided. It is, therefore, probable, that the eruption is the effect of sweatings; and that it is the effect of a matter not before prevailing in the mass of blood, but generated under particular circumstances in the skin itself. That it depends upon particular circumstances of the skin, appears further from hence, that the eruption seldom or never appears upon the face, although it affects the whole of the body besides; and that it comes upon those places especially which are more closely covered; and that it can be brought out upon particular places by external applications.

It is to be observed, that this eruptive disease differs from the other exanthemata in many circumstances; in its not being contagious, and therefore never epidemic; in this the eruption appears at no determined period of the disease; that the eruption has no determined duration; that successive eruptions frequently appear in the course of the same fever, and that such eruptions frequently recur in the course of the same person's life. All this renders it very probable, that in the miliary fever, the morbid matter is not a sub- sisting contagion communicated to the blood, and thence, in consequence of fever and assimilation, thrown out upon the surface of the body, but a mat- ter occasionally produced in the skin itself by sweating.

This conclusion is further rendered probable from hence, that, while the miliary eruption has no symp- toms or concourse of symptoms peculiar to itself, it, upon occasion, accompanies almost every febrile dis- ease, whether inflammatory or putrid, if these happen to be attended with sweating; and from thence it may be presumed, that the miliary eruption is a sympto- matic affection only, produced in the manner we have said.

But, as this symptomatic affection does not always accompany every instance of sweating, it may be pro- per to inquire, what are the circumstances which espe- cially determine this eruption to appear? And to this our author gives no full and proper answer. He can- not say that there is any one circumstance which in all cases gives occasion to this eruption; nor can he say what different causes, in different cases, may give oc- casion to it. There is only one observation that can be made to the purpose of this inquiry; and it is, that these persons sweating, under febrile diseases, are espe- cially liable to the miliary eruption, who have been previously weakened by large evacuations, particu- larly of blood. This will explain why it happens to ly- ing-in-women more frequently than to any other per- sons; and to confirm this explanation, he has obser- ved, that the eruption has happened to other women, though not in child-bed, but who had been much sub- jected to a frequent and copious menstruation, and to an almost constant flux of blood. He has also observed it to have happened to men in fevers, after wounds from which they had suffered a great loss of blood.

Further, that this eruption is produced by a certain state of debility, will appear probable, from its so of- ten attending fevers of the putrid kind, which are al- ways attended with great debility. It is true, that it also sometimes attends inflammatory diseases, when it may not be accounted for in the same manner; but he believes it may be observed, that it especially attends those inflammatory diseases in which the sweats have been long protracted, or frequently repeated, and which have thereby produced a debility, and perhaps a debilitating putrid diathesis.

It appears so clearly that this eruption is always a symptomatic and febrile affection, that our author is persuaded it may be, in most cases, prevented mere- ly by avoiding sweats. Spontaneous sweatings, in the beginning of diseases, are very rarely critical; and all sweatings, not evidently critical, should be pre- vented; and the promoting them, by increasing exter- nal heat, is commonly very pernicious. Even critical sweats should hardly be encouraged by such means. If, therefore, spontaneous sweats arise, they are to be checked by the coolness of the chamber; by the light- ness and looseness of the bed-cloths; by the persons laying out their arms and hands; and by their taking cold drinks; and in this way our author thinks he has frequently prevented miliary eruptions, which were otherwise likely to have appeared, particularly in lying- in-women.

But it may happen, when these precautions have been neglected, or from other circumstances, that a mi- linary eruption does not actually appear; and the ques- tion will then be put, how the case is to be treated? It is a question of consequence; as our author believes that the matter here generated is often of a virulent kind; it is often the offspring of putrefaction; and, when treated by increasing the external heat of the body, it seems to acquire a virulence which produces those symptoms mentioned above, and proves certainly fatal.

It has been an unhappy opinion with most physi- cians, that eruptive diseases were ready to be hurt by cold; and that it was therefore necessary to cover up the body very closely, and thereby increase the ex- ternal heat. We now know that this is a mistaken op- inion; that increasing the external heat of the body is very generally mischievous; and that several eruptions not only admit, but require the application of cold air. He is persuaded, therefore, that the practice which formerly prevailed in the case of miliary eruptions, of covering up the body close, and both by external means and internal remedies encouraging the sweat- ings which accompany this eruption, was highly per- nicious, and commonly fatal. He is therefore of opin- ion, that even when a miliary eruption has appeared, in all cases in which the sweating is not manifestly cri- tical, we should employ all the several means of stop- ping the sweating that are mentioned above; and he has sometimes had occasion to observe, that even the admission of cool air was safe and useful.

This is, in general, the treatment of miliary erup- tions: but at the same time, the remedies suited to the primary disease are to be employed; and therefore, when the eruption happens to accompany inflamma- tory affections, and the fulness and hardness of the pulse or other symptoms shew an inflammatory state present, the case is to be treated by blood-letting, purgings, and other antiphlogistic remedies.

Upon the other hand, when the miliary eruption attends diseases, in which debility and putrefaction prevail, it will be proper to avoid all evacuations, and to employ tonic and antiseptic remedies, particularly the Peruvian bark, cold drink, and cold air.

We shall conclude this subject with observing, that the venerable octogenarian practitioner, Dr. Fischer, when treating of this subject, in laying down the in- dications of cure, has given this as one of them: "Excretionis peripheriae non primariam habere ra- tionem."

GENUS XXXII. SCARLATINA. The Scarlet Fever.

Scarlatina, Sauv. gen. 98. Vog. 39. Sag. 294. Funck. 75.

LXXVI. The Mild Scarlet Fever. Sp. I. Scarlatina febris, Sauv. fp. 1. Sydenham, sect. vi. cap. 2.

LXXVII. The Scarlet Fever with Ulcerated Sore Throat. Sp. II. Scarlatina anginosa. Withering on the Scarlet Fever.

The mild scarlet fever is described by Syden- ham, who tells us that he can scarce account it a disease; and indeed nothing more seems to be ne- cessary cessary in the treatment of it than an antiphlogistic regimen, avoiding the application of cold air and cold drink. The disease however sometimes rages epidemically, and is attended with very alarming symptoms, bearing no small resemblance to the cynanche maligna, in which case it is called scarlatina anginosa.—The best description of this distemper hath been published by Dr Withering in the year 1778. This disease made its appearance, we are told, at Birmingham and the neighbouring villages, about the middle of May 1778. It continued in all its force and frequency to the end of October; varying, however, in some of its symptoms, as the air grew colder. In the beginning of November it was rarely met with; but towards the middle of that month, when the air became warmer, it increased again, and in some measure resumed those appearances it possessed in the summer-months, but which it had lost during the cold winds in October.

It affected children more than adults; but seldom occurred in the former under two years of age, or in the latter when once they had passed their fifteenth year.

Description. With various general symptoms of fever, the patient at first complains of a dejection of spirits, a flight forenses or rather stiffness in the neck, with a sense of straitness in the muscles of the neck and shoulders, as if they were bound with chords. The second day of the fever this soreness in the throat increases, and the patients find a difficulty in swallowing; but the difficulty seems less occasioned by the pain excited in the attempt, or by the straitness of the passage, than by an inability to throw the necessary muscles into action. The skin feels hot and dry, but not hard; and the patients experience frequent, small, pungent pains, as if touched with the point of a needle. The breath is hot and burning to the lips, and thirst makes them wish to drink; but the tendency to sickness, and the exertions necessary in deglutition, are so unpleasant, that they seldom care to drink much at a time. They have much uneasiness also from want of rest during the night. In the morning of the third day, the face, neck, and breast, appear redder than usual; in a few hours this redness becomes universal; and increases to such a degree of intensity, that the face, body, and limbs, resemble a boiled lobster in colour, and are evidently swollen. Upon pressure the redness vanishes, but soon returns again. The skin is smooth to the touch, nor is there the least appearance of pimples or pustules. The eyes and nostrils partake more or less of the general redness; and in proportion to the intensity of this colour in the eyes, the tendency to delirium prevails.

Things continue in nearly this state for two or three days longer, when the intense scarlet gradually abates, a brown colour succeeds, and the skin becoming rough, peels off in small scales. The tumefaction subsides at the same time, and the patients gradually recover their strength and appetite.

During the whole course of the disease, the pulse is quick, small, and uncommonly feeble; the urine small in quantity; the sub-maxillary glands somewhat enlarged and painful to the touch. The velum pendulum palati, the uvula, the tonsils, and gullet, as far as the eye can reach, partake of the general redness and tumefaction; but although collections of thick mucus, greatly resembling the specks or sloughs in the putrid sore throat, sometimes occur, yet these are easily washed off, and real ulcerations of those parts were never observed.

These are the most usual appearances of this disorder; but it too frequently assumes a much more fatal form. In some children the delirium commences in a few hours after the first attack; the skin is intensely hot; the scarlet colour appears on the first or second day, and they die very early on the third. Others again, who survive this rapid termination, instead of recovering, as is usual, about the time the skin begins to get its natural colour, fall into a kind of lingering, and die at last in the course of six or eight weeks.

In adults, circular livid spots, were frequently observed about the breast, knees, and elbows; also large blotches of red, and others of white intermixed, and often changing places.

In the month of October, when the air becomes colder, the scarlet colour of the skin was both less frequent and less permanent. Many patients had no appearance of it at all; whilst others, especially adults, had a few minute red pimples, crowned with white pellucid heads. The inside of the throat was considerably tumefied; its colour a dull red, sometimes tending to a livid. The pulse beat in general 130 or 140 strokes in a minute; was small, but hard, and sometimes sufficiently so to justify the opening of a vein; and the blood thus taken away, in every instance when cool, appeared fizzy, and the whole frameamentum firm.

Happy would it be, our author observes, if the baneful influence of this disorder terminated with the febrile symptoms. But in ten or fifteen days from the cessation of the fever, and when a complete recovery might be expected, another train of symptoms occur, which at last frequently terminate fatally. The patients, after a few days amendment, feel something that prevents their farther approach to health; an unaccountable languor and debility prevails, a stiffness in the limbs, an accelerated pulse, disturbed sleep, distaste to food, and a scarcity of urine. These symptoms, we are told, are soon succeeded by swellings of a real dropical nature, forming sometimes an anaeroma, and on other occasions an abscess.

Dr Withering, after examining the accounts given of this disease by different authors, proceeds to the diagnosis. It may be distinguished, he observes, from the petechial fever, by the eruption in the latter appearing seldom before the fourth day, by the regularity and distinctness of the spots, and by its principally occupying the neck, the back, and the loins. On the other hand, in the scarlet fever, the eruption generally appears about the third day; consists either of broad blotches, or else one continued redness, which spreads over the face and the whole body.

In the fever called purpura, the pustules are prominent, keep their colour under pressure, and never appear early in the disease; whereas in the scarlet fever, the eruption appears more early, is not prominent, but perfectly smooth to the touch, and becomes quite white under pressure.

Although Although the purple fever and scarlatina may be connected by some general cause, yet our author takes occasion to observe, that they cannot be mere modifications of the same eruption: for examples occur, he says, of the same person being first seized with one of these disorders, and afterwards with the other; but he never met with an instance of the same person having the scarlet fever twice; and he believes it to be as great an improbability as a repetition of the small-pox.

This disorder is particularly distinguished from the measles, we are told, by the want of that cough, watery eye, and running at the nose, which are known to be the predominant symptoms in the early state of the measles, but are never known to exist in the scarlatina.

From the erysipelas, this disease is distinguishable, by the limited seat of the former, together with its not being contagious.

The ulcerated sore throat, however, is more difficult to distinguish from this disease than any other; and yet the distinction is a matter of the greatest importance, as the method of treatment, we are told, ought to be extremely different.—But although, in a number of circumstances, these two diseases bear a very great resemblance, yet, with a little attention, the one may in general be distinguished from the other. From Dr Fothergill's account of the sore throat attended with ulcers, our author has made out the following characteristic circumstances of the two diseases, contrasted to one another.

| Scarlatina Anginosa. | Angina Gangrenosa. | |---------------------|--------------------| | Season. Summer . . . Autumn. | Season. Spring . . Winter. | | Air. Hot . . Dry. | Air. Warm . . Moist. | | Places. High . . Dry . . Gravelly. | Places. Clole . . Low . . Damp . . Marshy. | | Subject. Vigorous. Both sexes alike. Robust in most danger . . . | Subject. Delicate . . Women and female Children. Robust adults not in danger. | | Skin. Full scarlet . . . smooth . . If pimply, the pimples white at the top . . Always dry and hot. | Skin. Red tinge . . pimply . . The pimples redder than the interstices . . bedewed with sweat towards morning. | | Eyes. Shining, equable, intense redness, rarely watery. | Eyes. Inflamed and watery, or sunk and dead. | | Throat. In summer, tonsils, &c. little tumefied; no slough . . In autumn, more swollen. Integuments separating . . Sloughs white. | Throat. Tonsils, &c. considerably swelled and ulcerated . . Sloughs dark brown. | | Breath. Very hot, but not fetid. | Breath. Offensive to the patients and assistants. | | Voice. In summer, natural. | Voice. Flat and Rattling. | | Bowels. Regular at the accesion. | Bowels. Purging at the accesion. | | Blood. Buffy . . Firm. | Blood. Florid . . Tender. | | Termination. The 3d, 5th, 8th, or 11th day. | Termination. No stated period. | | Nature. Inflammatory. | Nature. Putrid. |

It is not pretended, our author remarks, that all the above contrasted symptoms will be met with in every case. It is enough, he observes, that some of them appear; and that if conjoined, with the consideration of the prevailing constitution, they enable us to direct that mode of treatment which will most contribute to the relief of the sick.

Causes. Our author affirms that the immediate cause of this disease is a poison of a peculiar kind, communicable by contagion.

1. That this poison first takes possession of the mucous membrane lining the fauces and the nose; and either by its action upon the secretory glands, or upon the mucus itself, assimilates that mucus to its own nature.

2. That it is from this beginning, and from this only, that it spreads to the stomach, &c. and at length acts upon the system at large.

3. That its first action upon the nerves, is of a sedative or debilitating nature.

4. That in consequence of certain laws of the nervous system, when the debilitating effects operate upon the sensorium commune, a reaction takes place; and that this reaction is, ceteris paribus, proportioned to the debilitating power.

5. That, in consequence of this reaction of the nervous system, the vibratory motion of the capillary blood-vessels dependent thereon is greatly increased; an unusually large quantity of blood is accumulated in those vessels; the heart and large blood-vessels are deprived of their customary proportion; and hence, though stimulated to more frequent contraction, the pulse must necessarily be feeble.

6. That as violent exertions are followed by debility, upon the cessation of the fever, the capillary vessels, which had acted with such unusual violence, are left in a state of extreme debility, and are long in recovering their tone; hence it is that so many patients afterwards become dropsical.

Our author now proceeds to the consideration of the different remedies, which either are at present in common use, or have been recommended as proper in this disease.

Cure. Blood-letting has been recommended by authors; but such was the state of the pulse in this disorder, at least during the summer-months, that it was not in any instance thought advisable to take away blood. In some cases, indeed, where the fiery redness of the eyes seemed to demand the use of leeches, they were had recourse to, but never with any advantage. In the harvest months, when the pulse was more firm, and when suffocation seemed to be threatened from the swelling in the fauces, blood-letting was sometimes advised, but still with less advantage than one would have expected in almost any other situation.

Vomiting.] This, our author observes, seems to be the remedy of nature; and he is surprised how it should have been omitted by several authors, who have gone before him. Vomiting, he says, most amply fulfils the indications arising both from a consideration of the cause and of the effects; and a liberal use of the remedy he holds forth as the true foundation for successful practice in scarlet-fever and sore-throat. His common form of emetic is a combination of tartar emetic. Purging.] The action of purgatives is considered by our author as altogether repugnant to the curative indications in this disease; for the poison, as formerly remarked, being received into the system by the fauces, the operation of a purge, instead of discharging it, can only promote its diffusion along the alimentary canal; and in fact, we are told, that when even a spontaneous purging supervenes in this disease, the patients sink so amazingly fast, that it is not within the reach of art to support them.

Sudorifics. Cordials. Alexipharmics.] None of these remedies were found beneficial. With respect to cordials, our author observes, that although they seem to be indicated by the great loss of strength and feeble pulse, yet the certain consequence of their use always was, an increase of restlessness, of the delirium, and of the heat.

Diuretics.] These were found very beneficial. The vegetable fixed alkali is recommended as the most proper article of this kind; a dram or two may be easily swallowed every 24 hours, by giving a small quantity in every thing the patient drinks.

Peruvian bark.] No medicine, we are told, ever had a fairer trial in any disease than the Peruvian bark had in this epidemic; for the feeble pulse, great prostration of strength, with here and there a livid spot, were thought to be such undeniable evidences of a putrid tendency, that the bark was poured down not with a sparing hand. But this was only at first; for these livid spots and the sloughs in the throat being found to be the effects of inflammation instead of putrefaction, and the bark instead of diminishing, rather increasing these symptoms, it was at last entirely laid aside.

Upon the same principles that the bark was prescribed, fixable air was at first likewise advised, but with no evident effects either one way or another. Dulcified acids were also had recourse to, but with no advantage.

Opiates.] These, although recommended by some authors for the removal of inquietude and watchfulness, yet in this epidemic, instead of effecting these purposes, always increased the distress of the patient.

Blisters.] In the summer appearance of the disease, blisters were universally detrimental; they never failed to hasten the delirium; and if the case was of the worst kind, they too often confirmed its fatal tendency. In the autumnal season, when the inflammation was less generally diffused through the body, they were less detrimental, but did not even here produce any beneficial effects.

Injected gargles of contrayerva decoction, sweetened with oxymel of squills, &c. were found very beneficial in bringing always large quantities of viscid ropy fluff from the fauces.

The immersion of the feet and legs in warm water, although it did no harm, yet did not either procure sleep or abate the delirium, as it frequently does in other kinds of fever.

As in summer it was found difficult to keep the patients sufficiently cool, they were ordered to lie upon a mattress instead of a feather-bed; a free circulation of air was kept up; and where the patient's strength would admit of it, they were ordered frequently out of doors. Animal food and fermented liquors were denied them, and nothing allowed but tea, coffee, chocolate, milk and water, gruel, barley-water, and such articles.

With respect to the dropsical disorder which so frequently succeeds to this complaint, it was never observed, our author remarks, when the preceding symptoms had been properly treated.

When called upon to patients in the dropsical state, our author commences his practice by a dose of calomel at night, and a purgative in the morning. When a febrile pulse attended the other symptoms, emetics were useful, as well as the saline draughts and other neutral salts. When great debility, comafose or peripneumonic symptoms occurred, blisters were found very serviceable; but when dropsical symptoms were the principal cause of complaint, small doses of rhubarb and calomel are advised; recourse was also had to diluted solutions of fixed alkalies, squills, Seltzer waters, and other diuretics.

When the urine flows freely, steel and other tonics are recommended; together with gentle exercise, high-seasoned foods, wine, and the wearing of flannel in contact with the skin.

Our author concludes his essay with an enumeration of several cases, treated according to the principles above laid down. The successful termination of these cases demonstrates the propriety of the practice which he has recommended.

LXXVIII. URTICARIA, the NETTLE-RASH.

Genus XXXIII.

Febris urticata, Vog. 40. Uredo, Lin. 8. Purpura urticata, Funck. 75. Scarlatina urticata, Sauv. sp. 2. Erysipelatis species altera, Sydenham, sect. vi. cap. 6. Febris scarlatina, et febris urticata, Meyser, Mal. des armées, 291 et seq.

Description. This disease has its English name from the resemblance of its eruption to that made by the stinging of nettles. These little elevations upon the skin in the nettle-rash often appear instantaneously, especially if the skin be rubbed or scratched, and seldom stay many hours in the same place, and sometimes not many minutes. No part of the body is exempt from them; and where many of them rise together, and continue an hour or two, the parts are often considerably swelled; which particularly happens in the face, arms, and hands. These eruptions will continue to infect the skin, sometimes in one place and sometimes in another, for one or two hours at a time, two or three times every day, or perhaps for the greatest part of the 24 hours.—In some persons they last only a few days, in others many months; nay, sometimes the disease hath lasted for two years, with very short intervals, or even for seven or ten years.

But though the eruption of the urticaria resembles, as already observed, that produced by the stinging of nettles, it is sometimes accompanied with long wheals, produce something like this effect on the parts which they touch, and undoubtedly from the same cause.

Dr Heberden asks, Is it impossible that the nettle-rash should arise from the same causes, or from others similar, which we miss by looking too deeply for them in the blood and humours? Such, says he, may have been its origin in some instances, where it has lasted only a few days; but where this affection hath continued for some years, in persons who change their linen every day, and who bathe frequently all the time, it can hardly be ascribed to such an external cause. Our author has observed it frequently to arise from cantharides: but though it hath continued many weeks after the removal of the blister, yet it might be suspected that this arose from the fine spicula of the cantharides sticking all this time about the skin; it being customary to strew much of the dry powder of the cantharides over the blister-plaster, whence it may readily be carried to other parts of the body. But it is certain that similar effects will sometimes follow the internal use of wild valerian root, or the eating of fish not sufficiently dressed; mussels, shrimps, and even honey, and the kernels of fruits, will also sometimes produce symptoms of a similar kind. But whatever be its cause, Dr Heberden never saw any reason to suppose that the nettle-rash had in any way vitiated the humours to such a degree as to require the use of internal remedies; and if the itching could be certainly and expeditiously allayed, there would be no occasion for any farther cure. The Doctor concludes this history of the disorder with a case communicated to him by Dr Monsey, physician of Chelsea-college, and in which the disease appeared with uncommon violence.

W. A., aged near 30, of a thin spare habit, was seized with a disorder attended with symptoms of a very uncommon kind. Whenever he went into the air, if the sun shined bright, he was seized with a tickling of his flesh on those parts exposed to the sun; this tickling, by his continuing in the air, increased to a violent itching, attended with great heat and pain: the skin would then be almost as red as vermillion, and thicken like leather; and this remained till he went out of the open air, and then abated in about 15 or 20 minutes. This happened only when the sun was above the horizon; at other times he was what he called quite well.—But it was not owing to the heat of the sun; for the sun in winter affected him full as much, if not more, and the heat of the fire had no such effect. Thus he was confined to the house for ten years. He tried several hospitals, and had advice from many physicians, without the least abatement of his complaints. At last it was agreed by a consultation of physicians, that he should try dipping in salt-water; which he did at Yarmouth for 13 weeks, without any visible amendment. One hot day, having pulled off his clothes and gone into the sea in the middle of the day, the heat diffused itself so violently all over his body, that, by the time he had put on his clothes, his eye-sight began to fail, and he was compelled to lie down upon the ground to save himself from falling. The moment he lay down, the faintness went off; upon this he got up again; but had no sooner arisen, than he found himself in the former condition: he therefore Practice therefore lay down again, and immediately recovered. He continued alternately getting up and lying down, till the disorder began to be exhausted, which was in about half an hour; and he was frequently obliged to have recourse to the same expedient.

Having at last accidentally met with Dr Monsey, this physician questioned him concerning the cause of the disorder; but nothing could be guessed at, excepting that the patient owned he had one winter lived entirely upon bullock's liver and porter, from inability to purchase better victuals. A comrade lived with him at that time, on the same provisions; and he also was affected in a similar manner, though in a less degree, and had recovered. This patient was then first put upon a course of Dover's sweating powder without any effect, and afterwards tried a course of nitrous ones with the same bad success. At last Dr Monsey determined to try the effect of mercury, which happily proved effectual in removing this obstinate and uncommon distemper. The patient began with taking five grains of calomel for three nights running, and a cathartic next morning. In this course he went on for near a fortnight, at the end of which he found himself very sensibly relieved. This encouraged him to go on rather too boldly, by which means a slight salivation ensued; however, that went off soon, and in about six weeks he was quite well.—Some time after, he was threatened with a return of his disorder; but this was effectually relieved by a dose of calomel, which he had afterwards occasion to repeat for the same reason, and with the same success; but at last the disorder seemed to be radically cured, by his having no further symptoms of a relapse.

LXXIX. PEMPHIGUS. Gen. XXXIV.

Pemphigus, Sauv. gen. 93. Sag. 291. Morta, Lin. 1. Febris bulbosa, Veg. 41. Pemphigus major, Sauv. sp. 1. Exanthemata serosa, C. Pijn. Obf. 150. Febris pemphygedes, Ephem. Germ. D. I. A. viii. Obf. 56. Pemphigus caffrensis, Sauv. sp. 2. Febris synches, cum vesiculis per pectus et collum sparsis, Morton App. ad Exerc. II. Pemphigus Helveticus, Sauv. sp. 3. Langhans in Act. Helvet. vol. ii. p. 260. et in Beschreibung des Siementhals, Zurich 1753.

This is a very rare disease, insomuch that Dr Culen declares he never saw it. He declines taking the descriptions of foreign physicians; we shall therefore content ourselves with giving an instance of this very uncommon distemper, as it was observed in the infirmary at Aberdeen.—A private soldier of the 73d regiment, aged eighteen years, formerly a pedlar, and naturally of a healthy constitution, was received into the hospital at Aberdeen on the 25th of April. About twenty days before that, he had been seized with the measles when in the country; and, in marching to town, on the second day of their eruption, he was exposed to cold; upon which they suddenly disappeared.

Having arrived at Aberdeen, he was quartered in a damp, ill-aired, under-ground apartment. He then complained of sickness at stomach, great oppression about the precordia, head-ach, lassitude, and weariness, on the least exertion; with stiffness and rigidity of his knees and other joints. The surgeon of the regiment visited him: he was purged, but with little benefit. About ten days before, he observed on the inside of his thighs a number of very small, distinct, red spots, a little elevated above the surface of the skin, and much resembling the first appearance of small-pox. This eruption gradually spread itself over his whole body, and the pustules continued every day to increase in size.

Upon being received into the hospital, he complained of head-ach, sickness at stomach, oppression about the precordia, thirst, sore throat, with difficulty of swallowing; his tongue was foul, his skin felt hot and feverish; pulse from 110 to 120, rather depressed; belly colicive; eyes dull and languid, but without delirium. The whole surface of his skin was interspersed with vesicles, or phlyctane, of the size of an ordinary walnut; many of them were larger, especially on the arms and breast. In the interstices, between the vesicles, the appearance of the skin was natural, nor was there any redness round their base; the distance from one to another was from half an inch to a handbreadth or more. In some places two or three were joined together, like the pustules in the confluent smallpox. A few vesicles had burst of themselves, and formed a whitish scab or crust. These were mostly on the neck and face; others showed a tolerably laudable pus. However, by far the greatest number were perfectly entire, turgid, and of a bluish colour. Upon opening them it was evident, that the cuticle elevated above the cutis, and diffused with a thin, yellowish, semipellucid serum, formed this appearance. Nor was the surface of the cutis ulcerated, or livid; but of a red florid colour, as when the cuticle is separated by a blister, or superficial burning. No other person laboured under a similar disease, either in the part of the country from which he came, or when he resided in Aberdeen.

This case was treated in the following manner. The largest of the vesicles were shipped, and dressed with unguent, e lap. calaminarii. In the evening he was vomited with a solution of tartar emetic, given in small quantities and at intervals. This also procured two loose stools. And he was ordered for drink, water-gruel acidulated with lemon-juice.

April 16. He still complained of sickness, some oppression about his breast, and sore throat; he had slept little during the night; his tongue was foul and blackish; his skin, however, was not so hot as the preceding day; his urine was high-coloured, but had the appearance of separation; his pulse 90, and soft; most of the fores on the trunk of the body looked clean. Others, particularly where the vesicles were confluent, seemed beginning to ulcerate, and to have a bluish sublivid appearance. They were dressed afresh with cerate, and he was ordered the following medicines:

B. Decoet. Cort. Peruvian. 3vi. Vini rubr. Lusitan. 3iii. M. Hujus mixture capiat 3i. tertia qua que horæ.

His acidulated drink was continued; and on account of the very offensive smell on approaching near him, some vinegar was placed in a basin before the bed, and sprinkled on the floor; and the room was kept "April 17. His sores looked tolerably clean, unless on his arms and thighs; where they were livid, a little ulcerated, and discharged a bloody ichor.

"His head-ach, sicknesses, &c. were mostly gone; his tongue was rather cleaner; pulse 68, and soft. As the decoction of the bark sat easily on his stomach, the following prescription was ordered:

R. Pulv. subtill. Cort. Peruv. 3i. Vini rubri Lusitan. Aque fontan. 2i 3i. M. ft. Haust. tercia quaque hora repetend.

The acidulated drink was continued, and fresh dressings applied to the sores.

"April 18. The little ulcers in his arms and thighs still discharged a bloody ichor, and looked ill; his other complaints were better; pulse 82. The bark had not nauseated him, and it was continued as well as his former drink.

"April 19. His sores looked greatly cleaner and better; the fever was gone, his pulse natural, and he had no complaint but weakness and a troublesome itching of the skin: The Peruvian bark, &c. were continued.

"April 20. Some of the ulcers still poured forth a bloody ichor; most of them, however, looked well, and had begun to heal—fever gone—medicines continued.

"From the 21st April, he went on gaining strength, and his sores appeared to heal fast; he was delirious to take only four doses every day; and by the 27th his sores, &c. were totally dried up—he had no complaint—was dismissed cured."

LXXX. APHTHA, the THRUSH. Genus XXXV.

Aphtha, Sauv. gen. 100. Lin. 9. Sag. 298. Boerh. 978. Hoffm. II. 478. Junck. 137.

Febris aphthosa, Vog. 44.

The only idiopathic species is the thrush to which infants are subject; (Aphtha lactucinae, Sauv. sp. 1.)

The aphthae are whitish or ash-coloured pustules, invading the uvula, faucies, palate, tonsils, inside of the cheeks, gums, tongue, and lips. They for the most part begin at the uvula, sending forth a glutinous mucus, and the pustules covering all or the greatest number of the parts above-mentioned with a thick whitish crust adhering most tenaciously. This crust doth not induce an ejection on the parts on which it lies by eating into them, but comes off in whole pieces after the pustules have arrived at maturity. This will often happen in a short time, so that the throat and internal parts of the mouth are frequently observed to be clean which a few hours before were wholly covered with white crusts. Neither is this disease confined to the throat and faucies, but is said to affect the oesophagus, stomach, and all parts of the alimentary canal. Of this indeed there is no other proof, than that, after a great difficulty of swallowing, there is sometimes an immense quantity of aphtha evacuated by stool and vomit, such as the mouth could not be thought capable of containing.

Causes, &c. The aphthous fever seems to be produced by cold and moisture, as it is found only in the northern countries, and especially in marshy places; and in them the aphtha often appear without any fever at all.

Prognosis. There is no symptom by which the coming out of aphtha can be foretold, tho' they are common in many fevers; but they themselves are in general a bad symptom, and always signify a very tedious disorder: the danger denoted by them is in proportion to the difficulty of deglutition; and a diarrhoea accompanying them is likewise bad. This indeed generally carries off old people when they become affected with aphtha. The dark-coloured aphtha also are much more dangerous than such as are of a brown or other dark colour; but it is a good sign when the appetite returns, and the dark-coloured ones are succeeded by others of a whiter colour. Neither are those which are unaccompanied with fever so dangerous as the other kind.

Cure. As the aphthae are seldom a primary disease, we must generally endeavour to remove the disorder upon which they depend, after which they will fall off; but in the mean time we are not to neglect applications to the aphtha themselves, such as detergent and softening gargles made of the decoction of figs, with the addition of honey of roses, a little vinegar, and some tincture of myrrh: in those ulcerated aphtha which appear in the malignant sore throat, Mr Penrose recommends the vitrum antimonii ceratum.

ORDER IV. HÆMORRHAGIÆ; HAEMORRHAGES.

Hæmorrhagia, Vog. Clas. II. Ord. I. Hoffm. II. 194. Junck. 5.

Sanguifluxus, Sauv. Clas. IX. Ord. I. Sag. Clas V. Order I.

LXXXI. EPISTAXIS, or BLEEDING at the Nose. Genus XXXVIII.

Hæmorrhagia, Sauv. gen. 239. Lin. 173. Sag. gen. 174.

Hæmorrhagia narium, Hoffm. II. 196. Junck. 6.

Hæmorrhagia plethorica, Sauv. sp. 2. Hoffm. II. 198.

The other species enumerated by authors are all symptomatic.

Description. The milder species of this hemorrhage comes on more frequently in summer than in winter, and for the most part without giving any warning, or being attended with the least inconvenience; but the less benign kind is preceded by several remarkable symptoms. These are, congestions of the blood sometimes in one part and sometimes in another, and which are often very troublesome in the sides of the head; there is a redness of the cheeks; an inflation of the face; and the vessels of the neck and temples; a tinnitus aurium; a heavy pain of the eyes, with a prominence, dryness, and sparks; there is a vertiginous affection of the head; with an itching of the nostrils, and a sense of weight, especially about the root of the nose. In some the sleep is disturbed with dreams about blood, fire, &c. Frequently the belly is colicive, there is a diminution of the quantity of urine, a suppression of sweat, coldness of the lower extremities, and tensions of the hypochondria, especially the right one.

Causes, &c. This hemorrhage may occur at any time of life; but most commonly happens to young persons, owing to the peculiar state of the system at at that time. Sometimes, however, it happens after the age and during the state of manhood, at which time it is to be imputed to a plethoric state of the system; to a determination of the blood, by habit, to the vessels of the nose; or to the particular weaknesses of these vessels.

In all these cases the disease may be considered as an arterial hemorrhage, and depending upon an arterial plethora; but it sometimes occurs in the decline of life, and may then be considered as the sign of a venous plethora in the vessels of the head. It often happens at any period of life in certain febrile diseases, which are altogether or partly of an inflammatory nature, and which show a particular determination of the blood to the vessels of the head. As by this evacuation the diseases are often removed, it may on these occasions be deemed truly critical. It happens to persons of every constitution and temperament; but most frequently to the plethoric and languine, and more commonly to men than women.

Prognosis. In young people, the bleeding at the nose may be considered as a slight disease, and scarcely worth notice. But, even in young persons, when it recurs very frequently and in great quantity, it is alarming; and is to be considered as a mark of an arterial plethora, which in the decline of life may give the blood a determination to parts from which the hemorrhage would be more dangerous. And this will require more particular attention as the marks of plethora and congestion preceding the hemorrhage are more considerable, and as the flowing of the blood is attended with a more considerable degree of febrile disorder. These consequences are more especially to be dreaded, when the epistaxis happens to persons after their age, returning frequently and violently. Even in the decline of life, however, it may be considered as in itself very salutary; but at the same time it is a mark of a dangerous state of the system, i.e., of a strong tendency to a venous plethora in the head, and hath accordingly been often followed by apoplexy, palsy, &c. When it happens in febrile diseases, and is in pretty large quantity, it may be generally considered as critical and salutary; but it is very apt to be too profuse, and thus become dangerous. It sometimes occurs during the eruptive fever of some exanthemata, and is in such cases sometimes salutary; but if these exanthemata be accompanied with any putrid tendency, this hemorrhage, as well as artificial blood-letting, may have very bad tendency.

Cure. Though this disease has been generally thought very slight, Dr Cullen is of opinion that it should seldom be left to the conduct of nature; and that in all cases it should be moderated by keeping the patient in cool air, by giving cold drink, by keeping the body and head erect, by avoiding any blowing of the nose, speaking, or other irritation; and if the blood has flowed for some time without showing any tendency to stop, we are to attempt the suppression of the hemorrhage by pressing the nostril from which the blood flows, washing the face with cold water, or applying this to some other parts of the body. These measures he judges to be proper even on the first attacks, and in young persons where the disease is the least hazardous; but these measures will still be more requisite if the disease frequently recurs without any external violence; if the returns happen to persons disposed to a plethoric habit; and more particularly if the signs of plethora appear in the foregoing symptoms.

When the bleeding is so profuse that the pulse becomes weak and the face pale, every means must be used to put a stop to it, and that whether the patient is young or old. Besides those methods above mentioned, we must use astringents both internal and external; but the latter are the most powerful, and the choice of these may be left to the surgeon. The internal astringents are either vegetable or fossil; but the vegetable astringents are seldom powerful in the cure of any hemorrhages except those of the alimentary canal. The fossil astringents are more powerful, but differ considerably in strength from one another. The chalybeates appear to have little strength; the preparations of lead are more powerful; but cannot be employed, on account of their pernicious qualities, unless in cases of the utmost danger. The tinctura saturnina, or antiphtisica, is a medicine of very little efficacy, either from the small quantity of lead it contains, or from the particular state in which it is. The safest and at the same time the most powerful astringent seems to be alum.

For suppressing this and other hemorrhages, many superstitious remedies and charms have been used, and said to have been employed with success. This has probably been owing to the mistake of the bystanders, who have supposed that the spontaneous cessation of the hemorrhage was owing to their remedy. At the same time Dr Cullen is of opinion, that such remedies have sometimes been useful, by impressing the mind with horror or dread. Opiates have sometimes proved successful in removing hemorrhages; and when the fulness and inflammatory diathesis of the system have been previously taken off by bleeding, they may, in Dr Cullen's opinion, be used with safety and advantage. Ligatures have been applied upon the limbs, for retarding the return of the venous blood from the extremities; but their use seems to be ambiguous. In the case of profuse hemorrhages, no care is to be taken to prevent the patient from fainting, as this is often the most certain means of stopping them.

GENUS XXXVIII. HÆMOPTYSIS, or Spitting of Blood

Hæmoptysis, Sauv. gen. 240. Lin. 179. Vog. 84. Sag. gen. 175. Junc. 8. Hæmoptoe, Boerh. 1198. Sanguinis fluxus ex pulmonibus, Hoffm. II. 202.

LXXXII. Hæmoptysis from Plethora. Sp. I.

LXXXIII. Hæmoptysis, from External Violence.

Sp. II.

Hæmoptysis accidentalis, Sauv. sp. I. Hæmoptysis habitualis, Sauv. sp. II. Hæmoptysis traumatica, Sauv. sp. II.

LXXXIV. Hæmoptysis with Phthisis. Sp. III.

Hæmoptysis phthisica, Sauv. sp. II. Hæmoptysis ex tuberculo pulmonum, Sauv. sp. II.

LXXXV. LXXXV. The Calculous Hemoptysis. Sp. IV. Hemoptysis calculosa, Sauv. sp. 14.

LXXXVI. The Vicarious Hemoptysis. Sp. V. Hemoptysis catamenialis, Sauv. sp. 4. Hemoptysis periodica, Sauv. sp. 5.

Description. The hemoptysis commonly begins with a sense of weight and anxiety in the chest, some uneasiness in breathing, pain of the breast or other parts of the thorax, and some sense of heat under the sternum; and very often it is preceded by a saltish taste in the mouth. Immediately before the appearance of blood, a degree of irritation is felt at the top of the larynx. The person attempts to relieve this by hawking, which brings up a little florid and somewhat frothy blood. The irritation returns; and in the same manner blood of a similar kind is brought up, with some noise in the wind-pipe, as of air passing through a fluid. Sometimes, however, at the very first, the blood comes up with coughing, or at least somewhat of coughing accompanies the hawking above-mentioned.

The blood is sometimes at first in very small quantity, and soon disappears; but in other cases, especially when it frequently recurs, it is in greater quantity, and often continues to appear at times for several days together. It is sometimes profuse, but rarely in such quantity as either by its excess or by a sudden suffocation to prove immediately mortal.

It is not always easy to discover whether the blood evacuated by the mouth proceeds from the internal surface of the mouth itself, from the faucies or adjoining cavities of the nose, from the stomach, or from the lungs. It is, however, very necessary to distinguish the different cases, and for this Dr Cullen offers the following considerations.

1. When the blood proceeds from some part of the internal surface of the mouth, it comes out without any hawking or coughing; and generally, upon inspection, the cause is evident.

2. When blood proceeds from the faucies, or adjoining cavities of the nose, it may be brought out by hawking, and sometimes by coughing. In this case there may be a doubt concerning its real source, and the patient may be allowed to please himself with the thoughts that the blood doth not come from the lungs. But the physician must remember that the lungs are much more frequently the source of an hemoptysis than the faucies. The latter seldom happens but to persons who have before been liable to an hemorrhage from the nose, or to some evident cause of erosion; and in most cases, by looking into the faucies, the dilution of the blood from thence will be perceived.

3. When blood proceeds from the lungs, the manner in which it is brought up will commonly show from whence it comes; but independent of that, it may also be known from the causes of hemoptysis from the lungs, to be afterwards mentioned, having preceded.

4. When vomiting accompanies the throwing out of blood from the mouth, we may generally know the source from whence it proceeds, by considering that blood does not proceed so frequently from the stomach as from the lungs; that blood proceeding from the stomach commonly appears in greater quantity than from the lungs. The pulmonary blood also is usually of a florid colour, and mixed with a little frothy mucus only; but the blood from the stomach is of a darker colour, more grumous, and mixed with the other contents of the stomach. The coughing or vomiting, as the one or the other happens first to arise, may sometimes point out the source of the blood; and this hath also its peculiar antecedent signs and causes.

Causes, &c. An hemoptysis may be produced at any time of life by external violence; and, in adult persons, while the arterial plethora prevails in the system, i.e. from the age of 16 to 35, an hemoptysis may at any time be produced merely by a plethoric state of the lungs. More frequently, however, it arises from a faulty proportion between the capacity of the lungs and that of the rest of the body. Thus it is often an hereditary disease, which implies a peculiar and faulty conformation.

This disease especially happens to persons who discover the smaller capacity of their lungs by the narrowness of their chest, and by the prominence of their shoulders; which last is a mark of their having been long liable to a difficulty of respiration. In such cases, too, the disease very frequently happens to persons of sanguine temperament, in whom particularly the arterial plethora prevails. It happens also to persons of a slender delicate make, of which a long neck is a mark; to persons of much sensibility and irritability, and therefore of quick parts; to persons who have formerly been liable to hemorrhages from the nose; to those who have suffered a suppression of any usual hemorrhage, the most frequent instance of which is in females, who have suffered a suppression of their menstrual flux; and lastly, to persons who have suffered the amputation of any considerable limb.

All this constitutes the predisposing cause of hemoptysis; and the disease may happen merely from the predisposing cause arising to a considerable height. But in those who are already predisposed, it is often brought on by the concurrence of various occasional and exciting causes. One of these, and perhaps a frequent one, is external heat; which, even when in no great degree, brings on the disease in spring, and the beginning of summer, while the heat rarifies the blood more than it relaxes the solids, which had before been contracted by the cold of winter. Another exciting cause is a sudden diminution of the weight of the atmosphere, especially when concurring with any effort in bodily exercise. The effort too, alone, may often be the exciting cause in those who are already predisposed; and more particularly any violent exercise of respiration. In the predisposed, also, the disease may be occasioned by any degree of external violence.

Prognosis. The hemoptysis may sometimes be no more dangerous than a hemorrhage from the nose; as when it happens to females in consequence of a suppression of their menstres; when, without any marks of predisposition, it arises from external violence; or, from whatever cause arising, when it leaves no cough, dyspnea, or other affection of the lungs, behind it. But, even in these cases, a danger may arise from too large a wound being made in the vessels of the lungs, from any quantity of red blood being left to stagnate in the cavity of the bronchia, and particularly from any determination termination of the blood being made into the vessels of the lungs, which by renewing the hemorrhage may have these consequences.

Cure. On this subject Dr Cullen differs from those who prescribe chalybeates and the Peruvian bark in the cure of hemoptysis. Both of these, he observes, contribute to increase the phlogistic diathesis then prevailing in the system, and the hemoptysis from predisposition is always accompanied with such a diathesis. Instead of these, therefore, he recommends blood-letting in greater or smaller quantity, and more or less frequently repeated as the symptoms shall direct. At the same time cooling purgatives are to be employed, and every part of the antiphlogistic regimen is to be strictly enjoined. In the London Medical Observations, the use of nitre is greatly recommended by Dr Dickson, to whom its efficacy was made known by Dr Letherland, physician to St Thomas's hospital. The most commodious method of exhibiting it he found was in an electuary. Four ounces of conserve of roses were made into an electuary with half an ounce of nitre; of which the bulk of a large nutmeg was directed to be given, four, six, or eight times a day, according to the urgency of the case. The good effects of this, our author tells us, have often astonished him; and when given early in the disease, he says he can depend as much upon it for the cure of an hemoptysis, as on the bark for the cure of an intermittent. He agrees with Dr Cullen, however, that in those cases where there is any hardness in the pulse, and which almost always happens, there is a necessity for venesection. A cool regimen, and quiet of body and mind, are certainly useful; but Dr Cullen observes, that some kinds of gaitation, such as sailing, and travelling in an easy carriage on smooth roads, have often proved a remedy. When the cough is very troublesome, it is absolutely necessary to exhibit frequently a small dose of an opiate. Dr Dickson also informs us, that the nitre joined with spermaceti, or palu. e tragacanth. comp., has produced equally good effects with the electuary above-mentioned; in the composition of which the Doctor at first considered the conserve only as a vehicle for the nitre, though he means not to intimate that the former is totally destitute of efficacy.

PHTHISIS, or Consumption of the Lungs.

Phthisis, Sauv. gen. 276. Lin. 208. Veg. 319. Sag. 101. Funck. 33. Phthisis pulmonis, Boerh. 1196. Affecio phthisica, five tabes pulmonalis, Hoffm. II. 284.

LXXXVII. The Incipient Phthisis, with an expectoration of Pur. Sp. I.

Phthisis incipiens, Morton. Physiolog. L. II. cap. 3. Phthisis sicca, Sauv. sp. 1.

LXXXVIII. The Confirmed Phthisis with an expectoration of Pur. Sp. II.

Phthisis confirmata auctiorum. Phthisis humida, Sauv. sp. 2.

Sometimes, notwithstanding all the care we can take, the hemoptysis will degenerate into a phthisis pulmonalis, or consumption of the lungs; and sometimes an hemoptysis will be the consequence of this dangerous disorder. It hath been indeed supposed, that an ulceration of the lungs, or phthisis, was the natural and almost necessary consequence of an hemoptysis; but, according to Dr Cullen, this is in general a mistake; for there are many instances of an hemoptysis from external violence without being followed by any ulceration. The same thing hath often been observed where the hemoptysis arose from an internal cause; and this not only in young persons, when the disease returned for several times, but when it has often recurred during the course of a long life; and it may easily be conceived, that a rupture of the vessels of the lungs, as well as of the vessels of the nose, may be sometimes healed. The causes of phthisis, therefore, Dr Cullen reduces to five heads. 1. An hemoptysis. 2. A suppuration of the lungs in consequence of a pneumonia. 3. A catarrh. 4. An asthma; and, 5. Tubercles.

1. When a phthisis arises from an hemoptysis, it is probable that it is occasioned by particular circumstances; and what these circumstances are, may not always be easily known. It is possible, that merely the degree of rupture, or frequently repeated rupture, preventing the wound from healing, may occasion an ulcer; or it is possible, that red blood effused, and not brought up entirely by coughing, may, by stagnating in the bronchiae, become acrid, and erode the parts. But these hypotheses are not supported by any certain evidence; and from many observations we are led to think, that several other circumstances must concur in producing the disease from hemoptysis.

2. The second cause of an ulceration of the lungs to be considered, is a suppuration formed in consequence of pneumonia. When a pneumonia, with symptoms neither very violent nor very slight, has continued for many days, it is to be feared it will end in a suppuration; but this is not to be determined by the number of days; for, not only after the fourth, but even after the tenth day, there have been examples of a pneumonia ending by a resolution; and if the disease has suffered some intermission, and again recurred, there may be instances of a resolution happening at a much later period from the beginning of the disease than that just now mentioned. But, if a moderate disease, in spite of proper remedies employed, be protracted to the 14th day without any considerable remission, a suppuration is pretty certainly to be expected; and it will be more certain still, if no signs of resolution have appeared, or if an expectoration which had appeared shall have again ceased, and the difficulty of breathing has continued or increased while the other symptoms have been rather abated.

That in a pneumonia, the effusion is made which may lay the foundation of a suppuration, we conclude from the difficulty of breathing becoming greater when the patient is in a horizontal posture, or when the patient can lie more easily on the affected side. That, in such cases, a suppuration has actually begun, we conclude from the patient's being frequently affected with slight cold shiverings, and with a sense of cold felt sometimes in one sometimes in another part of the body. We form the same conclusion also from the state of the pulse, which is commonly less frequent and softer, but sometimes quicker than before. That a suppuration is already formed, we conclude from there being a considerable A considerable remission of the pain which had before subsided; while at the same time the cough and especially the dyspnea continue, and are rather increased. At the same time the frequency of the pulse is rather increased, the feverish state suffers considerable exacerbations every evening, and by degrees a hectic in all its circumstances comes to be formed.

In this state of symptoms, we conclude very confidently, that an abscess, or, as it is called, a somica, is formed in some part of the pleura, and most frequently in that portion of it involving the lungs. Here purulent matter frequently remains for some time, as if inclosed in a cyst; but commonly not long before it comes to be either absorbed and transferred to some other part of the body, or breaks through into the cavity of the lungs, or into that of the thorax. In the latter case it produces the disease called empyema; but it is when the matter is poured into the cavity of the bronchus that it properly constitutes the phthisis pulmonalis. In the case of empyema, the chief circumstances of a phthisis are indeed also present; but we shall here consider only that case in which the abscess of the lungs gives occasion to a purulent expectoration.

An abscess of the lungs in consequence of pneumonia, is not always followed by a phthisis: for sometimes a hectic fever is not formed; the matter poured into the bronchus is a proper and benign pus, which frequently is coughed up very readily, and spit out; and though this purulent expectoration should continue for some time, if it be without hectic, the ulcer soon heals, and every morbid symptom disappears. This has so frequently happened, that we may conclude, that neither the access of the air, nor the constant motion of the lungs, will prevent an ulcer of these parts from healing if the matter of it be well-conditioned. An abscess of the lungs, therefore, does not necessarily produce the phthisis pulmonalis; and if it is followed by such a disease, it must be in consequence of particular circumstances which corrupt the purulent matter produced, render it unsuitable to the healing of the ulcer, and at the same time make it afford an acrimony, which, absorbed, produces a hectic and its consequences.

The corruption of the matter of such abscesses may be owing to several causes; as, 1. That the matter effused during the inflammation had not been a pure serum fit to be converted into a laudable pus, but had been joined with other matters which prevented that, and gave a considerable acrimony to the whole; Or, 2. That the matter effused and converted into pus, merely by long stagnation in a somica, or by its connection with an empyema, had been so corrupted as to become unfit for the purpose of pus in the healing of the ulcer. These seem to be possible causes of the corruption of matter in abscesses, so as to make it the occasion of a phthisis in persons otherwise sound; but it is probable that a pneumonic abscess especially produces phthisis when it happens to persons previously disposed to that disease, and therefore only as concurring with some other causes of it.

3. The third cause supposed to produce a phthisis is a catarrh; which, in many cases, seems in length of time to have the expectoration of mucus proper to it gradually changed to an expectoration of pus; and at the same time, by the addition of a hectic fever, the disease, which was at first a pure catarrh, is changed into a phthisis. But this supposition is not easily to be admitted. The catarrh is properly an affection of the mucous glands of the trachea and bronchus; analogous to the coryza and less violent kinds of cynanche tonsillaris, which very seldom end in suppuration. And although a catarrh should be disposed to do so, the ulcer produced might readily heal up, as it does in the case of a cynanche tonsillaris; and therefore should not produce a phthisis.

Further, the catarrh, as purely the effect of cold, is generally a mild disease as well as of short duration; and, according to Dr Cullen, there are at most but very few of the numerous cases of it, which can be said to have ended in a phthisis. In all these cases in which this seems to have happened, he thinks it probable that the persons affected were peculiarly predisposed to phthisis; and the beginning of phthisis so often resembles a catarrh, that it may have been mistaken for such a disease. It often happens also to increase the fallacy, that the application of cold, which is the most frequent cause of catarrh, is also frequently the exciting cause of the cough, which proves to be the beginning of a phthisis.

Many physicians have supposed that an acrimony of the fluids eroding some of the vessels of the lungs is a frequent cause of ulceration and phthisis; but this appears to Dr Cullen to be a mere supposition. He acknowledges, that in many cases an acrimony subsisting in some part of the fluids is the cause of the disease; but observes that it is at the same time probable, that this acrimony operates by producing tubercles, rather than by any direct erosion.

A phthisis, indeed, most commonly arises from tubercles. Dr Simmons informs us, that he has had opportunities of inspecting the bodies of several people who died in this way, and never found them totally absent. He hath likewise seen them in subjects of different ages, who had been troubled with no symptoms of an affection of the breast during their lifetime. In these, however, they were small, and few in number. This proves that they may exist without inconvenience till they begin to disturb the functions of the lungs by their size and number; or till some degree of inflammation is excited, either by accidental causes, or by certain changes that take place within their substance; for as yet we know but little of their true nature. These little tumours vary in their consistence; in some they are composed of a pulpy substance, and in others approach more to the nature of scirrhus. They are most commonly formed in consequence of a certain constitutional predisposition; but whatever is capable of occasioning a morbid irritability of the lungs seems to be capable of generating them. Thus the spasmodic asthma frequently ends in tubercles and consumption; and it is not unusual for millers, stone-cutters, and others, to die consumptive, from their being so constantly exposed to dust, which in these cases probably acts by producing similar concretions; and Dr Kirkland observes, that scythe-grinders are subject to a disease of the lungs, from particles of sand mixing with iron dust, which among themselves they call the grinders' rot. Tubercles likewise often have their source from a seropulous acrimony; and some eminent physicians have supposed that the generality of pulmonary consumptions are of This notion, however, they have carried too far: they have probably been misled by these tuberculous concretions which, without good reason, have been supposed to be diseased glands, and of course analogous to the glandular affections we meet with in the scrophula. Tubercles may likewise sometimes be owing to the sudden repulsion of cutaneous eruptions, or of the matter of exanthemata, &c., or to other causes.

The persons who are most liable to consumption are those of a fair complexion, fine and soft skin, florid cheeks, and a slender make; with high cheek-bones, hollow temples, long neck, shoulders standing out like wings, narrow chest, and a remarkable prominence of the processes of the os sacrum. To these marks we may add, that of sound teeth, which, as the disease advances, usually become of a milky white colour, and more or less transparent. Of those who are carried off by this disease, Dr Simmons asserts, the greater number will be found never to have had a carious tooth.

Persons of the above description often remain for a long time without feeling any other inconvenience than some oppression at the breast in moist weather, or in hot apartments. Their breathing is easily hurried, sometimes by the slightest motion; and they become languid, paler, and thinner. All this while, however, they feel no heat or painful sensation in the breast. As the evil increases, the patient begins to be attacked with a slight, frequent, and dry cough, which is most troublesome in the night-time. This, however, by proper care, is often relieved; and the patient remains in this state for a considerable time, and even for many years, if he is sensible of his danger, and careful to guard against it by a suitable manner of living. More commonly, however, we find the cough increasing, and sometimes accompanied with more or less of catarrh. This is usually ascribed to cold; but too generally neglected, till the disease becomes alarming by its obstinacy and its effects. This may be considered as the beginning, or first period, of the disease. During this stage, the cough is sometimes dry from the first; and sometimes, when it sets in in the form of a catarrh, is attended with more or less expectoration of mucus.

When the cough sets in in the form of a catarrh, and appears to be occasioned by an increased secretion of a thin salivous mucus irritating the membrane of the trachea, all judicious practitioners agree in recommending an attention to regimen, the free use of diluting liquors, bland emulsions, small doses of nitre, the taking away a few ounces of blood if there be much inflammation, the inhaling the steams of warm water, and the occasional use of such a dose of elixir paregoricum as will be sufficient to allay the irritation of the bronchiae, and to promote a gentle moisture on the skin. These methods will generally be found to be efficacious, especially if the patient's chamber is of a moderate temperature, and he carefully avoids exposure to a cold, damp, or raw air, till the complaint is removed. In cases in which the cough has been obstinate, and the inflammatory symptoms considerable, Dr Simmons has often experienced the great advantages of the warm bath, the heat of which did not exceed 92°. When this is had recourse to, the patient should remain in it only a very few minutes, and go soon afterwards to bed; but not with a view to force a sweat by an increased weight of bed-clothes, as is too often injudiciously practised.

Patients of a consumptive habit, who have had an attack of this kind at the beginning of winter, are particularly liable to a return of the complaint during the continuance of the cold season, on the slightest occasion and with greater violence. A relapse is therefore to be carefully guarded against; and nothing will be found to do this more effectually than the use of focks and a flannel under-waistcoat. The use of flannel has been condemned by several medical writers as increasing the insensible perspiration; but in the present case, to say nothing of some others in which it may be useful, it will in general be found to have the best effects. It will prevent a too great determination to the lungs, and should not be left off till the approach of summer. In some few instances in which flannel was found to have a disagreeable effect, a piece of dainty, worn over the breast next the skin, prevented the return of colds and coughs in persons of a delicate habit, who had before been liable to them on the slightest occasions. In these cases, circumstances that are seemingly of the most trifling nature become of importance.

Sometimes the cough is occasioned by an immediate inflammation of some part of the lungs, from some of the usual causes of inflammation; and when this happens no time is to be lost in removing it. To do this will perhaps require more than one bleeding, together with a strict attention to a cooling plan of diet, diluting drinks, the inhalation of warm steams, and, if convenient, the use of the warm bath; but above all, the speedy application of a large blister as near as may be to the supposed seat of the inflammation. The cough, in this case, will often remain after the original complaint is abated. A prudent use of opiates at bed-time, joined to gum ammoniacum, will then generally be useful as a sedative and antispasmodic.

In this, as well as in the catarrhal cough just now mentioned, many practitioners are too eager to administer the Peruvian bark, with the view, as they term it, of bracing up the patient: but this never fails to increase the cough, and of course to do great and very often irreparable mischief.

And here it will not be foreign to our subject to observe, that a symptomatic cough, which has its rise not from catarrh, or from an immediate inflammation of the lungs, but from their sympathy with the stomach, has sometimes laid the foundation of phthisis, from its having been mistaken, and of course improperly treated. It seems to be owing to a redundancy or vitiated state of the bile, or to some affection of the stomach, which it is perhaps not easy to define. It is sometimes a concomitant of other bilious symptoms; and when this happens to be the case, it cannot easily be mistaken; but we sometimes find it occurring singly, and in general attacking persons of a sedentary life. Dr Stoll of Vienna, who has noticed this cough, has very properly given it the name of tussis stomacchica. This complaint is so far from being relieved by bleeding, that it constantly grows worse after it, especially if the evacuation is in any considerable quantity. The oily remedies seldom fail to exacerbate Practice asperate this cough, which at first is dry, frequent, and often extremely violent, but which seldom fails to give way to one or two gentle pikes, and the occasional use of mild purges. The cough, as in other cases, often continues from habit after the cause that gave rise to it has been removed, and may then be checked by opiates.

When the disease has been neglected, or our attempts to remove it in the beginning have failed, both of which circumstances but too frequently happen, the patient begins to complain of a foreness, and of slight lancinating pains shooting through the breast, sometimes in the direction of the mediastinum, and sometimes confined chiefly to one side. The foreness is pretty constant, and much increased by the cough. The pain in the side often prevents the patient from lying on the side affected; and this inability of lying, except on one side, frequently occurs even when no such pain is felt. In this stage of the disease, flushing heats are felt in the palms of the hand and soles of the feet; the breathing is short and laborious; and it is not long before the patient begins to expectorate a thin and frothy phlegm, at first in small quantities, coughed up with difficulty and foreness, and now and then streaked with blood; this may be considered as the inflammatory period of the disease, to which succeeds the suppurative stage. In the latter, the expectoration becomes more copious and purulent, the breath proportionably offensive, and the exacerbations of the hectic more considerable: an increased quickness of the pulse comes on about the middle of the day; but the most considerable paroxysm of the fever is at night, and at first continues till towards morning, commonly till three or four o'clock, when it terminates in a sweat, which usually begins upon the breast. As the disease advances, these sweats become more profuse, and sometimes come on almost as soon as the pulse begins to quicken, but without affording any relief to the patient. During the exacerbations, we observe a circumscribed redness of the cheeks, while the rest of the face is pale, and appears as if it were not clean washed. The costiveness that commonly accompanies the beginning of the disease is usually succeeded by a diarrhoea; the spitting of lemons, and all the purulent matter seems to be carried downwards. The wasting of the fat and the loss of nourishment occasion the nails to curve inwards, the hair to fall off, and the eyes to sink in their sockets. In the mean time, the legs commonly swell; till at length death closes a scene which is melancholy to all but the patient himself, who in general continues sensible to the last moment, and even then indulges a vain hope of prolonging a miserable existence. In some cases, and that not unfrequently, a delirium comes on towards the close of the disease.

The hectic fever that attends this and some other chronic diseases, is evidently the effect of acrimony, and most commonly of pus absorbed and carried into the circulation. The nature of this acrimony, and the different irritability of different patients, are probably the sources of the variety we observe in fevers of this denomination; a variety which is doubtless much greater than we are aware of. Thus we find that the matter of the small-pox excites a fever of this kind; but this secondary fever, as it is called, differs from the hectic attendant on consumptions; nor does the latter correspond with that which sometimes accompanies the suppuration of a cancerous ulcer. In the pulmonary consumption, or at least in the third stage of it, the fever induced is truly of the putrid kind, and has been well denominated *febris hectica putrida* by the judicious Morton, who considers it as being combined with a peripneumonic or inflammatory fever, which recurs as often as fresh tubercles begin to inflame. For although we have named one period of the disease the inflammatory, and another the suppurative period, yet we are not to suppose that the latter is exempt from inflammation. While matter is poured into the bronchies, or absorbed and carried into the system from one part of the lungs, other parts are in a crude state of inflammation, or advancing towards suppuration; so that, on examining the lungs of persons who die consumptive, we find some tubercles that are small and just formed, some that are large and full of matter, and others that are in a state of ulceration. This easily accounts for the occasional combination of inflammatory symptoms with those of the putrid hectic. When the matter absorbed is a laudable pus, as in the case of a plos abscess, we find the form of the hectic differing from either of those we have mentioned.

Cure. In these different periods of the disease, the curative indications are sufficiently obvious. To prevent the formation of fresh tubercles; to obviate the inflammation of those already formed; to promote their resolution; to allay morbid irritability, the cough, and other troublesome symptoms; and, above all, to check the tendency to hectic,—are the views that every rational physician proposes to himself in the treatment of the genuine consumption. We know of no medicines that can exert their specific effects upon the lungs by dissolving tuberculous concretions; nor is it probable, from what we know of the animal economy, that any such will ever be discovered. Yet medicines that operate in a general manner upon the system, may, by promoting absorption, and diminishing the determination to the lungs, tend to disperse tubercles, or to prevent their formation. There are not wanting instances of wonderful recoveries in cases where the evil was supposed to be beyond the power of physic; and in some, where nature was left to herself; so that a physician who has observed the various and powerful resources nature has within herself, will be very cautious how he asserts that a disease is incurable.

The most formidable effects of ulcerated lungs are the absorption and consequent hectic. It seems evident, that, in many cases, death is brought on by this, rather than by the lungs themselves being rendered unfit for the purposes of respiration. So that if we can obviate the effects of the absorption, diminish the preternatural determination to the lungs, and fulfil the other general indications just now mentioned, we may very often enable nature to recover herself. It may be alleged indeed, that the physician's art has hitherto proved very unsuccessful in these cases; but may not this be owing to the remedies that are adopted being very often such as are inimical to the cure?

The bark is, perhaps, the most commonly employed of any, and often confided in as an ultimate resource in these cases. But besides this, the elixir of vitriol, The balsams, and frequent bleedings, have each had their partizans. The use of blisters and issues, opiates, a milk and vegetable diet, exercise, and change of air, are pretty generally recommended by all. Concerning the bark, Default* long ago observed, that it had been productive of great mischief in consumptive cases; and Dr. Fothergill, in a paper lately published Med. Obf. by him † on this subject, very judiciously remarks, that the bark is so far from curing the disease arising from disordered lungs, that, according to the best of his observations, it not only takes up that time which might probably have been better employed in the use of other medicines, but for the most part aggravates the disease beyond remedy. Indeed it will be found by every attentive observer, that whenever pus, or any kind of matter excites an hectic, by being absorbed and carried into the circulation, the bark will never fail to exacerbate the complaint, especially if it is accompanied with any degree of inflammatory diathesis, unless the matter has a free outlet from the system; as in the case of abscesses, for instance, in which we often find the bark productive of excellent effects. It is likewise well known to be used as a tonic, to obviate the effects of fluor albus, or any other immoderate evacuation in delicate persons, which, by enfeebling the system, very often lays the foundation of phthisis: but the moment we have reason to suspect that the lungs are ulcerated, it ought to be laid aside; and in the genuine tuberculous consumption, it is at all times inadmissible.

Dr. Fothergill, however, observes, that there are two causes of consumptions, which often produce symptoms so similar to those of the genuine phthisis, as sometimes to have led him to make use of the bark in apparent tendencies to a genuine pulmonary consumption with advantage.

One of these causes is, the sucking of children longer than is consistent with the mother's ability. This case frequently occurs among the middling and lower classes of females of constitutions naturally delicate and tender. In such a state of weakness, some slight cold brings on a cough, which increases gradually, till at length it produces the true pulmonary consumption. Here the bark, given early, in moderate doses, and merely as a tonic remedy, is often of excellent use.

Another cause is, any weakening discharge, either from abscesses, the greater operations of surgery, a copious and constant fluor albus, or similar enfeebled evacuations. That the bark is, for the most part, of use in these cases, when the lungs are not inflamed, is indubitable; and if they are so affected, but not beyond a certain degree, it is also efficacious in preventing the progress of the consumption.

In phthisical complaints succeeding such situations, a prudent trial of the bark seems necessary. Small doses of the decoction, either alone, or joined with the saline mixture or such other additions as the physician thinks proper, may be given. But if the breath becomes more tight and oppressed, the cough dry, the pulse more quick and hard, and especially if slight transitory pains or stitches about the thorax are more frequently complained of, a perseverance in the use of the bark will increase the disease. If such also should be the appearances in the progress of the dif-

ease, or, from whatever cause, if the bark is accompanied with such effects, the use of it ought to be withheld.

If, on the other hand, no pain, tightness, or oppression, is perceived, and there appears a manifest abatement of the symptoms, it will be advisable to proceed. The administration of this medicine, however, requires a judicious observer; and it ought neither to be given in the early inflammatory stage of this disease, nor be continued in any subsequent period, if it produces the effects above mentioned.

By its tonic virtues it will often enable nature to conquer many difficulties. In confirmation of this remark, Dr. Fothergill farther observes, that he has seen it of use in promoting expectoration, when this became deficient from want of strength towards the end of peripneumonic fevers; but that it stops this discharge, changes slight wandering pains into such as are fixed, and increases them with all their consequences, in a variety of cases.

The elixir of vitriol is often exhibited in consumptive cases, with no less propriety than the bark. This medicine, from its stringency, is obviously improper in the inflammatory state of the disease. But in the latter stage, when a general tendency to putrefaction takes place, it is serviceable in resisting the effect; it restrains the colligative sweats; and if the lungs are not injured past repair, it is allowed to be a very useful auxiliary.

Various are the opinions concerning the efficacy of Bristol-water in this disease. The experienced author last mentioned informs us, that he has seen many persons recover from pulmonary diseases after drinking these waters, whose cure seemed to be doubtful from any other process; and he thinks this circumstance, added to the general reputation of Bristol-waters in phthisical cases, affords sufficient inducement to recommend the trial of them in the early stage of such complaints. It is, however, before the approach of a confirmed phthisis that patients ought to repair to Bristol; otherwise a journey thither will not only be without benefit, but may even prove detrimental.

Some have imagined, that the journey, a better air, change of situation and of objects, have contributed to the patient's recovery; and these may doubtless be of advantage. It seems, however, that the water drank fresh at the pump, actually contains principles conducive to the recovery of patients affected with phthisical complaints. It seems to possess a slight calcareous hypotonicity, and perhaps the air it contains may also have an antiseptic quality. On the whole, it appears to be an efficacious medicine, and is often found of remarkable benefit to consumptive patients.

Change of air, sometimes even from good to bad, is of great consequence in all chronic diseases of the lungs. In consumptive cases, however, the air of all large cities is found to be particularly injurious.

A sea-voyage has been much recommended in the cure of this disease. The benefit of exercise has also been strongly urged by many writers; but, however salutary when properly used, it certainly ought to be regulated with discretion. Dr. Dickson declares himself of opinion, that riding on horseback in consumptive cases is most commonly hurtful, without such regulations as in general have been little regard- For instance, he has known a person who, by a ride of an hour or two in the morning, was very much recruited, and who, at another time, in the afternoon and evening, without undergoing more bodily motion, has returned faint and languid, and apparently worse. This observation on the same person has been so frequently made, as to point out clearly the times when this exercise shall not do hurt in consumptive cases. In this disease, the pulse, however calm in the morning, becomes more frequent in the afternoon and night; attended with heat and other feverish symptoms. Exercise therefore, at this time, can only add to the mischief of the fever. For this reason he prudently recommends to all hectic persons, especially those who shall travel to distant places on account of a better air, or the benefit expected from any particular water, that their travelling should be slow, confined to a very few hours, and only in the morning.

Horse-exercise, however, seems to be chiefly beneficial in those cases where consumption is a secondary disease. For example, in the nervous atrophy; in the hypochondriacal consumption; or when it is the effect of long-continued intermittents, or of congestions in any of the abdominal viscera; or in a word, whenever the consumption is not attended with an inflamed or ulcerated state of the lungs; long journeys on horseback will be beneficial. Such a practice may likewise be highly useful in obviating an attack of phthisis, or in carrying off a dry hulky cough in a person of a consumptive habit, when there is reason to suppose that no tubercles are as yet formed. On the other hand, in the confirmed phthisis, when the lungs are inflamed or ulcerated, much or violent exercise will be improper; and there have been instances where the death of the patient was evidently accelerated by it. The exercise therefore should be gentle, proportioned to the strength of the patient, and employed only in the morning. In fine weather, an easy open carriage is perhaps the most eligible, not only on account of its being open to the air, but because it affords that kind of agitation which is most wanted in these cases. For if we consider the different modes of exercise, we shall find that walking, though the best exercise in health, as it employs the most muscles, is the worst for the sickly, who should have the benefit of exercise without fatigue. Riding on horseback agitates the viscera more than walking, and is therefore preferable to it in many chronic diseases; but when a preternatural determination to the lungs has taken place, it will be liable to increase the evil, and may likewise be hurtful by the fatigue that attends it. For these reasons it will be prudent to begin with a carriage; and if the patient gains strength, and the disease abates, recourse may afterwards be had to horse-exercise.

The gentle motion of a coach has been often found of great utility in pulmonary complaints. Its efficacy seems to depend chiefly on its increasing the determination to the surface of the body. The nausea which this motion excites in some persons is an effect of this increased determination. It has therefore been found beneficial in hemoptysis; and Dr Simmons mentions the case of a lady, who, after trying various remedies to no purpose, was cured of this complaint by travelling several hundred miles through different parts of England in her own coach. At first, whenever she tarried three or four days in any place, the disorder began to return again; but at length by persevering in her journeys, it gradually went off. Default, who practised at Bordeaux about 40 years ago, tells us, he sent several consumptive patients to Bareges, and with good success; but that in these cases his reliance was not so much upon the Bareges waters, as upon the motion of the carriage and the change of air in a journey of more than 100 leagues.

It is now pretty generally acknowledged, that the good effects of sea-voyages in consumptive cases depend more upon the constant and uniform motion of the ship, than upon any particular impregnation of the sea-air; although this from its coolness may likewise be of great use, especially in the hot months, when sea-voyages are generally undertaken by consumptive patients. The ancients were no strangers to this remedy; and amongst the Romans it was no unusual thing for consumptive patients to sail to Egypt. Pliny observes, that this was done not for the sake of the climate, but merely on account of the length of the voyage.

Many of our English physicians have recommended a voyage to Lisbon in these cases. When this is done, the proper season of the year should be carefully attended to. Dr Simmons knew a gentleman who went thither with symptoms of incipient phthisis, and who experienced some relief during the course of the voyage; but happening to arrive at Lisbon at the beginning of the rainy season, the disease was soon greatly increased, and terminated fatally.

The best adapted diet in consumptive cases, is milk, particularly that of asses. It may however be remarked, that there are constitutions in which this salutary nutriment seem to disagree. A propensity to generate bile, or too strong a disposition to ascendency from a weakness of the digestive organs, both merit attention. Whey, either from cows or goats milk, appears to be more suitable in the former case; and for correcting acidity, lime-water may be added to the milk. The method of adding rum or brandy to asses or cows milk, should be used with great caution: for when added beyond a certain quantity, as is often the case, they not only coagulate the milk, but heat the body; by which means the former disagrees with the patient, and the spirit augments the disease.

In consumptive cases, Dr Simmons observes, that the patient's taste should be consulted; and says that a moderate use of animal-food, where the salted and high-seasoned kinds are avoided, is not to be denied. Shellfish, particularly oysters, are useful, as well as snails swallowed whole, or boiled in milk.

Repeated bleedings, in small quantities, are considered in consumptive cases as highly advantageous; and in particular circumstances they undoubtedly are so; for instance, when the constitution apparently abounds with blood; when the fluid drawn off is extremely viscid; when there is much pain in the breast; and when venesection is followed by an abatement of every symptom. In these cases, bleeding is certainly proper, and ought to be repeated so long as it seems to be attended with advantage. In very delicate constitutions, however, where the pulse is quick, with

PRACTICE some degree of fulness, and the blood last drawn considerably fizzy, it may not prove equally serviceable.

It deserves to be remarked, that the inflammatory appearance of the blood is not alone a sufficient reason for bleeding; but, in determining the propriety of this evacuation, all other circumstances should be considered; such as the patient's age, strength, habit, and the state of the disease.

A remark which has been judiciously made by Dr Fothergill, ought not to be omitted in the account of this disease. It is, that young delicate females, from the age of 15 or 16, and upwards, are often subject to consumptions. When the disease has advanced considerably, the menstruation, if they have made their appearance, most generally cease. This alarms their female friends, and they call upon the physician to use his utmost endeavours for restoring the discharge; believing the cessation of it to be the immediate cause of the phthisical complaint. Induced by their solicitations, medicines have sometimes been administered, that, without obtaining this end, have tended to aggravate the distemper. This deficiency is often of no real disadvantage in those cases; and in many the evacuation would prove injurious, by diminishing the strength, which is already too much impaired. Even small bleedings at the regular periods, have often done more harm than good. A sudden suppression may require bleeding; but when the evacuation fails through want of strength, and from poverty of blood, the renewal of it increases the disease.

Besides these remedies, Dr Simmons strongly recommends a frequent repetition of vomits. Many physicians have supposed that where there is any increased determination to the lungs, vomits do mischief; but our author is persuaded, that instead of augmenting they diminish this determination; and that much good may be expected from a prudent use of this remedy, than which none has a more general or powerful effect on the system. If any remedy is capable of dispersing a tubercle, he believes it to be vomits. The affections of the liver, that sometimes accompany pulmonary complaints, give way to repeated emetics sooner than to any other remedy. In several cases where the cough and the matter expectorated, the flushing heats, loss of appetite, and other symptoms, threatened the most fatal event; the complaints were greatly relieved, and in others wholly removed, by the frequent use of emetics. Other suitable remedies were indeed employed at the same time; but the relief the patients generally experienced after the emetic, was a sufficient proof of its salutary operation. By this, however, our author does not mean that vomits will be useful in every period of the disease, or in every patient. In general, it will be found that the earlier in the disease emetics are had recourse to, the more likely they will be to do good and the less likely to do harm. The cases in which this may be reckoned improper, are commonly those in which the disease is rapid in its progress; or in that stage of it, when there is great debility, with profuse colliquiative sweats.

In these cases, when an emetic has been administered twice a-week, and the cough is mitigated, the expectoration facilitated, and the other symptoms relieved, both the patient and the physician will be encouraged to proceed, and to repeat the vomit every other day, or even every day, for several days together, as our author has sometimes done when the good effects of it were obvious.

The choice of emetics to be employed in these cases is by no means a matter of indifference. Carduus tea, chamomile tea, warm water, and others that act by their bulk, and by exciting nausea, relax the tone of the stomach when they are frequently repeated, and of course will be improper. More active emetics are therefore to be preferred; and here some of the preparations of antimony might naturally be thought of. But the operation of these is not confined to the stomach. They produce evacuations by stool, and a disposition to sweat; and are therefore improper in the pulmonary hectic. The mildness and excellence of ipecacuanha as an emetic, are well known; but in these cases Dr Simmons hath often employed the blue vitriol, concerning the effects of which we meet with some groundless assertions in several medical books. Its operation is confined to the stomach; it acts instantaneously, and its alacrity seems to obviate the relaxation that is commonly supposed to attend the frequent use of emetics. In two cases he experienced its good effects, after vomits of ipecacuanha had been given ineffectually. It should be administered in the morning, and in the following manner:

Let the patient first swallow about half a pint of water, and immediately afterwards the vitriol dissolved in a cupful of water. The dose of it must be adapted to the age and other circumstances of the patient, and may be varied from two grains to ten, fifteen, or twenty. As some persons are much more easily puked than others, it will be prudent to begin with a small dose: not that any dangerous effects will be produced by a large one, for the whole of the medicine is instantly rejected; but if the nausea is violent and of long continuance, the patient may perhaps be discouraged from repeating it. In general, the moment the emetic has reached the stomach it is thrown up again. The patient must then swallow another half pint of water, which is likewise speedily rejected; and this is commonly sufficient to remove the nausea.

Dr Marryat, in his New Practice of Physic, prescribes with great freedom what he calls the dry vomit, from its being directed to be taken without drinking. This medicine consists of blue vitriol and the emetic tartar; but its good effects have not yet been ascertained by other practitioners.

Besides the use of internal remedies in pulmonary affections, physicians have often prescribed the steams of resinous and balsamic substances to be conveyed into the lungs. The vapour of dulcified spirit of vitriol, dropt into warm water, has likewise been used in these cases, and is advertised as a nostrum under the name of ether. The inhaling of fixed air has also been spoken of as an useful practice. Dr Simmons hath seen all of these methods tried at different times; but without being able to perceive any real advantages from them in the suppurative stage of the disease; where they might be expected to be of the greatest use; and in the beginning he hath often found the two first to be too stimulating. He therefore Part II.

Practice preferred the simple vapour of warm water, and hath experienced its excellent effects in several instances: but when the complaint has made any considerable progress, its utility is less obvious; and when the patients have been much weakened, he hath seen it bring on profuse sweats, especially when used in bed, and therefore generally recommended it to be used in the daytime. Formerly he made use of a fumigating machine, described in the gentleman's magazine for 1748, in which the air, inspired by the patient, is made to pass through hot water, by means of a tube that communicates with the external air, and with the bottom of the vessel; but we have now a more elegant, and (on account of the valve and mouth-piece) a more useful instrument of this kind, invented by the ingenious Mr Mudge. See Inhaler.

Another remedy recommended by some as a specific in consumptions, is the earth-bath. Van Swieten, in his Commentaries on Boerhaave, tells us, from the information of a person of credit, that in some parts of Spain they have a method of curing the phthisis pulmonalis by the use of this remedy; and he quotes the celebrated Solano de Luque in confirmation of this practice. Solano speaks of the banos de tierra, or earth-baths, as a very old and common remedy in Granada and some parts of Andalusia, in cases of hectic fever and consumptions; and relates several instances of their good effects in his own practice. The method he adopted on these occasions was as follows: He chose a spot of ground on which no plants had been sown, and there he made a hole large and deep enough to admit the patient up to the chin. The interstices of the pit were then carefully filled up with the fresh mould, so that the earth might everywhere come in contact with the patient's body. In this situation the patient was suffered to remain till he began to shiver or felt himself uneasy; and during the whole process, Solano occasionally administered food or some cordial medicine. The patient was then taken out, and, after being wrapped in a linen cloth, was placed upon a mattress, and two hours afterwards his whole body was rubbed with an ointment composed of the leaves of the folium nigrum and hog's lard. He observes, that a new pit must be made every time the operation is repeated; and advises the use of these baths only from the end of May to the end of October. Dr Fouquet, an ingenious French physician, has tried this remedy in two cases. In one, a confirmed phthisis, he was unsuccessful; but the remedy had not a fair trial. The patient, a man 30 years of age, had been for several months afflicted with cough, hectic fever, and profuse colliquative sweats. He was first put into the earth in the month of June; but soon complained of an uneasy oppression at his stomach, and was removed at the end of seven minutes. The second time he was able to remain in it half an hour, and when taken out was treated in the way prescribed by Solano. In this manner the baths were repeated five times, and the patient was evidently relieved; but having conceived a dislike to the process, he refused to submit to any further trials, and died some months afterwards. In the second case he was more fortunate: the patient, a girl 11 years of age, had been for three months troubled with a cough brought on by the measles, which was at length attended with a purulent expectoration, hectic fever, and night-sweats. She began the use of the earth-bath in August, and repeated it eight times in the space of 20 days. At the end of that time the fever and disposition to sweat had entirely ceased, and by the use of the common remedies the patient was perfectly restored. A physician at Warsaw has likewise prescribed the earth-bath with good success in cases of hectic fever. The Spaniards confine it entirely to such cases; but in some other parts of the world we find a similar method employed as a remedy for other diseases, and particularly for the scurvy. Dr Priestley observes, that the Indians, he has been told, have a custom of burying their patients labouring under putrid diseases, up to the chin in fresh mould, which is also known to take off the恶or from flesh-meat beginning to putrefy. The rancidity of a ham may likewise be corrected by burying it for a few hours in the earth. The efficacy of this remedy in the sea-scurvy has frequently been experienced by the crews of our East India ships. See below.

Solano, who is fond of philosophizing in his writings, is of opinion, that the earth applied in this way absorbs the morbid taint from the system; but does it not seem more probable, that the effluvia of the earth, by being absorbed and carried into the circulation, correct the morbid state of the fluids, and thus are equally useful in the sea-scurvy and in the pulmonary hectic? That the earth when moistened does emit a grateful odour is a fact generally known; and Baglivi long ago gave his testimony in favour of the grateful effects of the effluvia of fresh earth. He ascribes these good effects to the nitre it contains.

With regard to the drains, such as blisters, issues, and setons, that are so frequently recommended in pulmonary complaints, there is less danger of abuse from them, than from the practice of venesection. The discharge they excite is not calculated to weaken the patient much; and the relief they have so often been found to afford, is a sufficient reason for giving them a trial. Blisters, as is well known, act in a twofold manner; by obviating spasm, and producing revulsion: Issues and setons act chiefly in the latter of these two ways; and, in this respect, their effects, though less sudden and less powerful at first, are more durable from the continuance of the discharge they occasion. It is perhaps hardly necessary to remark, that, if much service is to be expected from either of these remedies, they should be applied early in the disease. The ingenious Mr Mudge, who experienced the good effects of a large scapular issue on his own person, very properly observes, that the discharge in these cases ought to be considerable enough to be felt. But it is seldom possible for us to prevail on the delicate persons, who are most frequently the victims of this disease, to submit to the application of a cauthe between the shoulders. The discharge produced by a seton is by no means inconsiderable; and as in these cases there is generally some inflammatory itch, some part of the breast that is more painful or more affected by a deep inspiration than the rest, a seton in the side, as near as can be to the seat of the inflammation, will be an useful auxiliary. Our author has seen it evidently of great use in several cases.

GENUS GENUS XL. HÆMORRHOIS, the Hemorrhods of Piles.

Hæmorrhois, Sauv. gen. 217. Lin. 192. Sag. gen. 182. Hæmorrhoidalis fluxus, Hoffm. 219. Hæmorrhoides, Junck. 11. and 12. Leucorrhois, Vog. 112.

LXXXIX. The External Bloody Piles. Sp. I. Var. A. Hæmorrhois moderata, Sauv. sp. 1. Hæmorrhoides ordinatae, Junck. 11. Hæmorrhoides nimiae, Junck. 11. Hæmorrhois inmodica, Sauv. sp. 2. Hæmorrhoides excedentes, Alberti. de hæmorrhoid. p. 179. Hæmorrhois polyposa, Sauv. sp. 3.

XC. Mucous Piles. Sp. I. Var. B. Hæmorrhoides decolorate, albe, et mucide, Junck. 13. Alberti, p. 248.

XCI. The Piles from a Procedentia Ani. Sp. II. Hæmorrhois ab exanis, Sauv. sp. 4.

XCII. The Running Piles. Sp. II. XCIII. The Blind Piles. Sp. IV.

Hæmorrhoides cæca, Junck. 12. Alberti p. 274.

Description. The discharge of blood from small tumours on the verge of the anus constitutes what is called the hæmorrhoids or piles. They are distinguished into the external and internal, according to the situation of the tumours, either without or within the anus. Sometimes, however, these tumours appear without discharging any blood; and in this case they are called the hæmorrhoides cæca or blind piles. Sometimes the disease appears without the verge of the anus in distinct separate tumours; but frequently only one tumid ring appears, seeming as it were the anus pushed without the body. Sometimes these tumours appear without any previous disorder of the body; but more frequently, before the blood begins to flow, and sometimes even before the tumours are formed, various affections are perceived in different parts of the body; as head-ach, vertigo, stupor, difficulty of breathing, sickness, colic pains, pain of the back and loins, and frequently a considerable degree of pyrexia; while along with these symptoms there is a sense of fullness, heat, itching, and pain, in and about the anus. Sometimes the disease is preceded by a serous discharge from the anus; and sometimes this serous discharge, accompanied with swelling, seems to come in place of the discharge of blood, and to relieve the above-mentioned disorders of the system. This serous discharge hath therefore been named the hæmorrhoeis alba.

In this disease the quantity of blood discharged is different upon different occasions. Sometimes it flows only when the person goes to stool, and commonly follows the discharge of faeces. In other cases it flows without any discharge of faeces; and then generally in consequence of the disorders above-mentioned, when it is also commonly in larger quantity.

This is often very considerable; and, by the repetition, so great, that we could hardly suppose the body to bear it but with the hazard of life. Indeed, though rarely, it has been so great as to prove suddenly fatal, as probably was the case with Arius and Copernicus.—These considerable discharges occur especially to persons who have been frequently liable to the disease. They often induce great debility, and frequently a leucophlegmatia or dropy which proves fatal. Sometimes the tumours and discharges of blood in this disease recur exactly at stated periods. In the decline of life it frequently happens, that the hemorrhoidal flux, formerly frequent, ceases to flow; and in that case it generally happens that the persons are affected with apoplexy or palsy. Sometimes hemorrhoidal tumours are affected with inflammation, which ends in suppuration and gives occasion to the formation of fistulous ulcers in those parts.

The hemorrhoidal tumours have often been considered as varices or dilatations of the veins; and in some cases various dilatations have appeared upon dissection. These, however, do not appear; and Dr Cullen is of opinion that they are usually formed by an effusion of blood into the cellular texture of the intestine near to its extremity. When recently formed they contain fluid blood, but after they remain for some time they are usually of a firmer consistence.

Causes, &c. It would seem probable, that the hemorrhoidal tumours are produced by some interruption of the free return of the blood from the rectum, by which a rupture of the extremities of the veins is occasioned. But considering that the hemorrhage occurring here is often preceded by pain, inflammation, and a febrile state, and with many other symptoms which shew a connection of the topical affection with the state of the whole system, it is probable that the interruption of the venous blood produces a considerable resistance to the motion of the venous blood through the arteries, and consequently that the discharge of blood is commonly from the latter. Some have thought, that a difference of the hæmorrhoids, and of its effects upon the system, might arise from the difference of the hæmorrhoidal vessels from whence the blood issued. But Dr Cullen is of opinion, that we can scarce ever distinguish the vessels from which the blood flows; and that the frequent inoculations of both arteries and veins belonging to the lower extremity of the rectum, will render the effects of the hemorrhage much the same, from whatever source it proceeds.

With regard to the hæmorrhoids, however, the author is of opinion, that they are, for the most part, merely a topical affection. They take place before the period of life at which a venous plethora happens. They happen to females, in whom a venous plethora determined to the hæmorrhoidal vessels cannot be supposed; and they happen to both sexes, and to persons of all ages, from causes which do not affect the system, and are manifestly suited to produce a topical affection only.

These causes are, in the first place, the frequent voiding of hard and bulky faeces, which, by their long stagnation in the rectum, and especially when voided, must necessarily press upon the veins of it, and interrupt interrupt the course of the blood in them. For this reason the disease so frequently happens to those who are habitually constive. From the same causes, the disease happens frequently to those who are subject to a prolapsus ani. In voiding the faeces, it almost always happens that the internal coat of the rectum is more or less protruded; and, during this protrusion, it sometimes happens that the sphincter ani is contracted; in consequence of this, a strong constriction is made, which preventing the fallen-out gut from being replaced, and at the same time preventing the return of blood from it, occasions a considerable swelling, and the formation of a tumid ring round the anus.

Upon the sphincter's being a little relaxed, as it is immediately after its strong contraction, the portion of the gut which had fallen out is commonly taken into the body again; but by the frequent repetition of the accident, the size and fulness of the ring formed by the prolapsed intestine is much increased. It is therefore more slowly and difficultly replaced; and in this consists the chief uneasiness of hemorrhoidal persons. As the internal edge of this ring is necessarily divided by clefts, the whole often puts on the appearance of a number of distinct swellings; and it also frequently happens, that some portions of it are more considerably swelled, become more protuberant, and form those small tumours more strictly called hemorrhoids or piles.

From considering that the pressure of the faeces, and other causes interrupting the return of venous blood from the lower extremity of the rectum, may operate a good deal higher up than that extremity, we may understand how tumours may be formed within the anus; and probably it also happens, that some of the tumours formed without the anus may continue when taken within the body, and even be increased by the causes just mentioned. Thus may the production of internal piles be explained, which, on account of their situation and bulk, are not protruded on the person's going to stool, and are therefore more painful.

The production of piles is particularly illustrated by this, that pregnant women are frequently affected with the disease.—This is to be accounted for, partly by the pressure of the uterus upon the rectum, and partly by the constive habit to which pregnant women are liable. Dr Cullen hath known many instances of piles happening for the first time during the state of pregnancy; and there are few women who have born children, that are afterwards entirely free from piles.—Purgatives also, especially those of the more acrid kind, and particularly aloetis, are apt to produce the piles, when frequently used; and as they stimulate particularly the great guts, they may be justly reckoned among the exciting causes of this disease.

Prognosis. Though the hemorrhoids are commonly, as we have said, to be esteemed a topical disease, they may, by frequent repetition, become habitual and connected with the whole system; and this will more readily happen in persons who have been once affected with the disease, if they are frequently exposed to a renewal of the causes which occasioned it. It happens also to persons much exposed to a con-

Vol. VI. this case some other measures must also be used. It is especially proper to guard against a plethoric state of the body; and therefore to avoid a sedentary life, full diet, and intemperance in the use of strong liquor, which in all cases of hemorrhage is of the most pernicious consequence.

Exercise of all kinds is of great service in obviating and removing a plethoric state of the body; but upon occasion of the hemorrhoidal flux, when this is immediately to come on, both walking and riding, as increasing the determination of the blood into the hemorrhoidal vessels, are to be avoided. At other times, when no such determination is already formed, these modes of exercise may be very properly employed.

Another method of removing plethora is by cold bathing; but this must be employed with caution. When the hemorrhoidal flux is approaching, it may be dangerous to divert it; but during the intervals of the disease, cold bathing may be employed with safety and advantage; and in those who are liable to a prolapsus ani, the frequent washing of the anus with cold water may be useful.

When the flux has actually come on, we are to moderate it as much as possible, by causing the patient lie in a horizontal posture on a hard bed; by avoiding exercise in an erect posture, using a cool diet, and avoiding external heat. But with respect to the further cure of this disease, we must observe, that there are only two cases in which it is common for hemorrhoidal persons to call for medical assistance. The one is, when the affection is accompanied with much pain; and the other, when the piles are accompanied with excessive bleeding. In the first case, we must consider whether the piles are external or internal. The pain of the external piles happens especially when a considerable protrusion of the rectum has happened; and while it remains unreduced, it is strangled by the contraction of the sphincter; and at the same time no bleeding happens to take off the swelling of the protruded portion of the intestine; and sometimes an inflammation supervenes, which greatly aggravates the pain. In this case, emollient fomentations and poultices are sometimes of service, but the application of leeches is generally to be preferred.

In case of excessive bleeding, we are on all occasions to endeavour to moderate the flux, even where the disease has occurred as a critical discharge; for if the primary disease shall be entirely and radically cured, the preventing any return of the hemorrhoids seems entirely safe and proper. It is only when the disease arises from a plethoric habit, and from a stagnation of blood in the hypochondriac region; or when, though originally topical, it hath by frequent repetition become habitual, and has thereby acquired a connection with the system, that any doubt can arise about curing it entirely. In any of these cases, however, Dr Cullen is of opinion that it will be proper to moderate the bleeding, lest, by its continuance or repetition, the plethoric state of the body, and the particular determination of the blood into the hemorrhoidal vessels, be increased, and the return of the disease be too much favoured. Dr Stahl is of opinion, that the hemorrhoidal flux is never to be accounted excessive excepting when it occasions great debility or leucophlegma-

GENUS XLI. MENORRHAGIA, or Immoderate Flow of the Menses.

Menorrhagia, Sauv. 244. Lin. 202. Veg. 96. Metrorrhagia, Sag. gen. 179. Uteri hemorrhagia, Hoffm. II. 224. Hemorrhagia uterina, Junk. 14. Leucorrhea, Sauv. gen. 267. Lin. 201. Veg. 119. Sag. gen. 202. Cachexia uterina, five flor albus, Hoffm. III. 348. Flor albus, Junk. 133. Abortus, Sauv. gen. 245. Lin. 204, Sag. gen. 180. Junk. 92. Abortio, Veg. 97. Flor uterini sanguinis, Boerh. 1303. Convulsio uteri, five abortus, Hoffm. III. 176.

XCII. The Immoderate Flow of the Menses, properly so called. Sp. I.

Menorrhagia immodica, Sauv. sp. 3. Menorrhagia stillatitia, Sauv. sp. 2.

Description. The quantity of the menstrual flux is different in different women, and likewise in the same woman at different times. An unusual quantity therefore is not always to be considered as morbid; but when a larger flow of the menses has been preceded by head-ache, giddiness, or dyspnea; has been ushered in by a cold stage, and is attended with much pain of the back and loins, with a frequent pulse, heat and thirst; it may then be considered as preternaturally large. On the other hand, when the face becomes pale, the pulse weak, an unusual debility is felt in exercise, and the breathing is hurried by little labour; when the back becomes pained from any continuance in an erect posture, when the extremities become frequently cold, and when at night the feet appear affected with edematous swelling; from all these symptoms we may conclude, that the flow of the menses hath been immoderate, and has already induced a dangerous state of debility.—The debility, induced in this case, often appears also by affections of the stomach, an anorexia, and other symptoms of dyspepsia; by a palpitation of the heart, and frequent faintings; by a weakness of mind, liable to strong emotions from flight causes, especially those presented by surprise. A flow of the menses attended with barrenness in married women, may generally be considered Generally, also, that flow of the menses may be considered as immoderate, which is preceded and followed by a leucorrhoea.

Causes, &c. The proximate cause of the menorrhagia is either the effort of the uterine vessels prematurely increased, or a preternatural laxity of the extremities of the uterine arteries.—The remote causes may be, 1. Those which increase the plethoric state of the uterine vessels; as a full and nourishing diet, much strong liquor, and frequent intoxication. 2. Those which determine the blood more copiously and forcibly into the uterine vessels; as violent straining of the whole body; violent shocks from falls; strokes or contusions on the lower belly; violent exercise, particularly in dancing; and violent passions of the mind. 3. Those which particularly irritate the vessels of the uterus; as excess in venery; the exercise of venery in the time of menstruation; a collyve habit, giving occasion to violent straining at stool; and cold applied to the feet. 4. Those which have forcibly overstrained the extremities of the uterine vessels; as frequent abortions, frequent child-bearing without nursing, and difficult tedious labours. Or, lastly, those which induce a general laxity; as living much in warm chambers, and drinking much of warm enervating liquors, such as tea, coffee, &c.

Cure. The treatment and cure of the menorrhagia, must be different, according to the different causes of the disease.

In all cases, the first attention ought to be given to avoiding the remote causes, whenever that can be done; and by such attention the disease may be often entirely cured. When the remote causes cannot be avoided, or when the avoiding them has been neglected, and a copious menstruation has come on, it should be moderated as much as possible, by abstaining from all exercise at the coming on or during the continuance of the menstruation; by avoiding even an erect posture as much as possible; by shunning external heat, and therefore warm chambers and soft beds; by using a light and cool diet; by taking cold drinks, at least as far as former habits will allow; by avoiding venery; by obviating coiffements, or removing it by laxatives which give little stimulus. The sex are commonly negligent, either in avoiding the remote causes, or in moderating the first beginnings of this disease. It is by such neglect that it so frequently becomes violent and of difficult cure; and the frequent repetition of a copious menstruation may be considered as a cause of great laxity in the extreme vessels of the uterus.

When the coming on of the menstruation has been preceded by some disorder in other parts of the body, and is accompanied with pains of the back, somewhat like parturient pains, with febrile symptoms, and when at the same time the flow seems to be copious, a bleeding at the arm may be proper, but is not often necessary; and it will in most cases be sufficient to employ, with great attention and diligence, those means already mentioned for moderating the discharge.

When the immoderate flow of the menses shall seem to be owing to a laxity of the vessels of the uterus, as may be concluded from the general debility and laxity of the person's habit; from the remote causes that have occasioned the disease; from the absence of the symptoms which denote increased action in the vessels of the uterus; from the frequent recurrence of the disease; and particularly from this, that the person in the intervals of menstruation is liable to a leucorrhoea: in such a case, the disease is to be treated, not only by employing all the means above-mentioned for moderating the hemorrhagy, but also by avoiding all irritation; every irritation having the greater effect in proportion as the vessels are more lax and yielding. If, in such a case of laxity, it shall appear that some degree of irritation concurs, opiates may be employed to moderate the discharge; but in using these much caution is requisite. If, notwithstanding these measures having been taken, the discharge shall prove very large, astringents, both external and internal, may be employed. In such cases, Dr. Cullen asks, May small doses of emetics be of service?

When the menorrhagia depends on the laxity of the uterine vessels, it will be proper, in the intervals of menstruation, to employ tonic remedies; as cold bathing, and chalybeates. The exercises of gestation also may be very useful, both for strengthening the whole system, and for taking off the determination of the blood to the internal parts.

These remedies may be employed in all cases of menorrhagia, from whatever cause it may have proceeded, if it shall have already induced a considerable degree of debility in the body.

XCIII. Abortion. Sp. II.

Menorrhagia gravidarum, Sauv. sp. 6. Abortus effluxio, Sauv. sp. 1. a. Abortus subtrimestris. b. Abortus sobremeltris. c. Abortus octimeltris. Abortus ab uteri laxitate, Sauv. sp. 2.

XCIV. Immoderate Flux of the Lochia. Sp. III.

Menorrhagia lochialis, Sauv. sp. 8. For the description, treatment, and cure, of these two last diseases, see the article MIDWIFERY.

XCV. Immoderate Flow of the Menses from some Local Disorder. Sp. IV.

Menorrhagia ex hysteroptosi, Sauv. sp. 5. Menorrhagia ulcerosa, Sauv. sp. 9.

XCV. The Leucorrhoea, Fluor Albus, or Whites. Sp.V. and VI.

Leucorrhoea, G. ut supra. Menorrhagia decolor, Sauv. sp. 7. Leucorrhoea Americana, Sauv. sp. 5. Leucorrhoea Indica, Sauv. sp. 6. Leucorrhoea Nabothi, Sauv. sp. 9. Leucorrhoea gravidarum, Sauv. sp. 8.

Description. The fluor albus, female weakness, or whites, as commonly called, is a disease of the womb and its contiguous parts; from which a pale coloured, greenish or yellow fluid is discharged, attended with loss of strength, pain in the loins, bad digestion, and Causes, &c. The quantity, colour, and consistence of the discharge chiefly depend upon the time of its duration, the patient's habit of body, and the nature of the cause by which it was produced. Taking cold, strong liquor, immoderate heat and moisture, or violent exercise, are all observed to produce a bad effect, as to its quantity and quality.

Weakly women of lax solids, who have had many children, and long laboured under ill health, are of all others the most subject to this disagreeable disease; from which they unfortunately suffer more severe penance than others, as the nicest sensations are often connected with such a delicacy of bodily frame as subjects them to it.

In Holland it is very frequent, and in a manner peculiar to the place, from the dampness of its situation; the surrounding air being so overcharged with moisture as to relax the body, stop perspiration, and throw it upon the bowels, or womb; producing in the first, a diarrhoea or flux; in the last, the fluor albus or female weakness.

The discharge proceeds from the vessels subservient to menstruation; because, in delicate habits, where those vessels are weak, and consequently remain too long uncontracted, the fluor albus sometimes immediately follows the menses, and goes off by degrees as they gradually close. It also comes from the mucous glands of the womb, as is particularly evident in very young females of eight and ten years old; in whom, though very rarely, it has been observed, and where it must then necessarily have escaped from those parts; for the uterine vessels are not sufficiently enlarged for its passage at so early a period.

Sometimes, as in women with child, it proceeds from the passage to the womb, and not from the womb itself; which, during pregnancy, is closely sealed up, so that nothing can pass from thence till the time of labour. The application of those instruments called pessaries, from the pain and irritation they occasion, are also apt to bring on this discharge. Hence we may conclude, that this disease may happen although the blood is in a pure state. Here the fault seems to be placed in the vessels or strainers, by which the fluids are vitiated and changed from their natural qualities.

The fluor albus has been supposed to supply the want of the menses; because, where the first prevails, the last is generally either irregular, or totally wanting; but it might more properly be said, that the presence of the fluor albus, which is a preternatural evacuation, occasions the absence of that which is natural; as is evident from the return of the menses after the fluor albus has been taken away. Indeed, when this discharge appears about the age of 13 or 14, and returns once a month, with symptoms like those of the menses, then it may be deemed strictly natural, and therefore ought not to be stopped.

Prognosis. The fluor albus may be distinguished into two kinds. The first arises from a simple weakness, or the relaxation of the solids; which may either be general, where the whole bodily system is enervated and unstrung; or partial, where the womb only is thus affected, in consequence of hard labour, frequent miscarriages, a suppression or immoderate quantity of the menses, or a sprain of the back or loins.

In the first case, the discharge being generally mild, may be safely taken away. In the second, it may proceed from a vitiated, or impure blood, where the body, from thence, is loaded with gouts humours, which nature for her own security and relief thus endeavours to carry off. In such cases, the discharge is often of a reddish colour, like that from old ulcerous sores; being sometimes so sharp as to excoriate the contiguous parts, and occasion a smarting and heat of urine.

A deep-seated, darting pain, with a forcing down, attending such a discharge, is a very dangerous and alarming sign, and indicates an ulceration or cancerous state of the womb. This malignant state of the disease, if of long continuance, is extremely difficult of cure; and disposes the patient to barrenness, a bearing down, the dropy, or a consumption.

Cure, &c. The causes of those two kinds of this disease being different, so they will require a very different method of cure. To answer this intention; in the first case, nothing will be more proper than nourishing simple food, such as veal broths, jellies, fresh eggs, and milk diet. The acid fruits will also be proper; and the patient may take a restorative, strengthening infusion, which will give firmness to the body, and assist the weakened fibres of the womb in returning to their natural state.

The same method may be used with success, where the fluor albus follows the menses, as already observed.

The Tunbridge or Spa waters may be drank at the same time; and if necessary, an infusion of green tea, or pure smith's forge-water, may be used with a womb-frying as an injection twice a day. Should the disease prove uncommonly obstinate; the patient may go into the cold bath every other day; and also drink lime-water with milk, which will expedite the cure, and prevent a relapse. A volatile liniment, and afterwards a strengthening plaster, may be applied to the small of the back.

By way of caution, she should abstain from the moderate use of tea; and be removed into a dry clear air; or if she is obliged to remain in one less proper, she may apply the flesh-brush, and wear a flannel shift next her skin, impregnated with the fumes of burning frankincense, or any of the grateful aromatic gums. Cold spring-water pumped on the loins, or a blistering plaster applied to the bottom of the spine or back, are both very powerful in their effects, and have sometimes succeeded after other remedies had been tried in vain.

In the second sort of the disease, where the discharge is sharp and of long standing, it would be extremely dangerous to suppress it suddenly, either by astringents internally taken, or applied as injections, until the blood is freed from its impurities by proper purgatives, and otherwise corrected by such medicines as not only carry off the sharp scorbustic farts and putrid juices, but also impart to it that soft balmy quality of which it had been deprived.

A purging potion may be taken twice a week, and in the intervals an alterative pill night and morning. After this course has been continued a fortnight or three weeks, she may begin with the strengthening, bitter infusion, or other tonic, in the quantity of a tea- The same sort of food and regimen will here be proper as in the first kind of the disease. The patient should abstain from malt liquors, and drink rice-water, in each pint of which half an ounce of gum arabic has been dissolved; or if she is weak, and of a cold bloated habit of body, a little French brandy may be added occasionally.

When she begins to take the bitter infusion, it will be proper to use the Tonbridge or Pyrmont water for common drink; but if those cannot conveniently be had, the artificial Spa water, impregnated with iron and fixed air*, will make an excellent substitute. If it should render her costive, and occasion the headache; she may deftly, and drink imperial water or a little fennel-tea sweetened with manna, till those complaints are removed.

In short, as this is a malady of the most disagreeable kind, which, by long continuance or neglect, becomes difficult of cure, and often produces an ulceration of the womb, bearing down, barrenness, a dropsy, or consumption; it were to be wished, that women, on such occasions, would be more attentive to their own safety, by using all possible means, in due time, to prevent those disorders.

Dr Leake says he has attended more patients labouring under the fluor albus in the autumn than at any other season of the year, especially when the weather was uncommonly moist and cold: most of them were cured by change of diet, an increased perspiration, and the proper use of Peruvian bark with aromatics. He observed, that several about this time who escaped the disorder, were visited with bad colds, a diffusion of rheum on the throat, or a diarrhoea, which were removed by a similar treatment.

As women are sometimes connected with those who do not conscientiously regard their safety, it is a circumstance of the utmost consequence to distinguish a fresh venereal infection from the fluor albus or whiter; for, if the first is mistaken for the last, and is either neglected or treated accordingly, the disorder may unfortunately end in a confirmed ulcer or pox.

The following signs will best inform the patient whether there is occasion for her doubts or not.

A fresh infection, called gonorrhoea, is malignant and inflammatory; the fluor albus most commonly arises from relaxation and bodily weaknesses; and therefore, the remedies proper in the first disorder would render the last more violent, by locking up and confining the infectious matter.

In the gonorrhoea, the discharge chiefly proceeds from the parts contiguous to the urinary passage, and continues whilst the menses flow; but in the fluor albus, it is supplied from the cavity of the womb and its passage, and then the menses are seldom regular.

In the gonorrhoea, an itching, inflammation, and heat of urine, are the fore-runners of the discharge; the orifice of the urinary passage is prominent and painful, and the patient is affected with a frequent irritation to make water. In the fluor albus, pains in the loins, and loss of strength, attend the discharge; and if any inflammation or heat of urine follow, they happen in a less degree, and only after a long continuance of the discharge, which, becoming sharp and acrimonious, excoriates the surrounding parts.

In the gonorrhoea, the discharge suddenly appears without any evident cause; but in the fluor albus, it comes on more slowly, and is often produced by irregularities of the menses, frequent abortion, sprains, or long-continued illness.

In the gonorrhoea, the discharge is greenish or yellow, less in quantity, and not attended with the same symptoms of weakness. In the fluor albus, it is often of the same colour, especially in bad habits of body, and after long continuance; but is usually more offensive, and redundant in quantity.

All the other kinds of hemorrhage enumerated by medical writers, are by Dr Cullen reckoned to be symptomatic; as,

Stomacae, Sauv. gen. 241. Lin. 175. Vog. 85. Sag. gen. 176. Species: Scorbutica, Purulenta, &c.

Hæmatemesis, Sauv. gen. 242. Lin. 184. Vog. 89. gen. 177. Species: Pletorica, Catamenialis, Scorbutica, &c.

Hæmaturia, Sauv. gen. 233. Lin. 198. Vog. 92. Sag. gen. 178. Species: Purulenta, Calculosa, Hæmorrhoidalis, &c.

ORDER V. PROFLUVIA.

Genus XLII. The CATARRH.

Catarrhus, Sauv. gen. 186. Vog. 98. Sag. gen. 145. Coryza, Lin. 174. Vog. 100. Sag. gen. 196. Rheuma, Sauv. gen. 142. Tullis, Sauv. gen. 142. Lin. 155. Vog. 205. Sag. gen. 245. 255. Junck. 30. Tullis catarrhalis et rheumatica, Hoffm. III. 109.

XCVII. Catarrh from Cold. Sp. I.

Catarrhus benignus, Sauv. sp. 1. Catarrhus petecorous, Sauv. sp. 6. Coryza catarrhalis, Sauv. sp. 1. Coryza phlegmatorrhagia, Sauv. sp. 2. Salmuth. Obf. cent. 1. 37. Junck. 28. Morgagni de fed. xiv. 21. Coryza febricola, Sauv. sp. 6. Tullis catarrhalis, Sauv. sp. 1. N. Rosen Diff. apud Haller, Disput. Pract. tom. II. Rheuma catarrhale, Sauv. sp. 1. Amphimerina catarrhalis, Sauv. sp. 2. Amphimerina tulliculosa, Sauv. sp. 13. Cephalalgia catarrhalis, Sauv. sp. 10.

Catarrh from Contagion. Sp. II.

Catarrhus epidemicus, Sauv. sp. 3. Rheuma epidemicum, Sauv. sp. 2. Synocha catarrhalis, Sauv. sp. 5.

There are several symptomatic species: as, Catarrhus Rubicolosus; Tullis Varioloïda, Verminosa, Calculosa, Phthisica, Hysterica, a Dentitione, Gravidarium, Metallicorum, &c.

Description. The catarrh is an increased excretion of Practical writers and nosologists have distinguished the disease by different appellations, according as it happens to affect those different parts of the mucous membrane, the one part more or less than the other; but Dr Cullen is of opinion that the disease in those different parts is always of the same nature, and proceeds from the same cause in the one as in the other. Very commonly indeed those different parts are affected at the same time; and therefore there is little room for the distinction mentioned. The disease has been frequently treated of under the title of *tussis*, or cough; and a cough, indeed, always attends the chief form of catarrh, that is, the increased excretion from the bronchiae; but it is so often also a symptom of many other affections, which are very different from one another, that it is improperly used as a generic title.

The disease generally begins with some difficulty of breathing through the nose, and with a sense of some fulness stopping up that passage. This again is often attended with some dull pain and a sense of weight in the forehead, as well as a stiffness in the motion of the eyes. These feelings, sometimes at their very first beginning, and always soon after, are attended with the distillation of a thin fluid from the nose, and sometimes from the eyes; and these fluids are often found to be somewhat acrid, both by their taste and by their fretting the parts over which they pass. These symptoms constitute the coryza and gravel of authors, and are commonly attended with a sense of lassitude over the whole body. Sometimes cold shiverings are felt; at least the body is more sensible than usual to the coldness of the air; and with all this the pulse is more frequent than ordinary, especially in the evenings.

These symptoms have seldom continued long before they are accompanied with some hoarseness, and a sense of roughness and foreboding in the trachea, with some difficulty of breathing, expressed by a sense of straitness in the chest, and with a cough which seems to arise from some irritation felt at the glottis. This cough is generally at first dry and painful, occasioning pains about the chest, and more especially in the breast; sometimes, together with these symptoms, pains resembling those of the rheumatism are felt in several parts of the body, particularly about the neck and head. With all these symptoms, the appetite is impaired, some thirst arises, and a feverish lassitude is felt all over the body. These symptoms mark the height and violence of the disease; but commonly it does not continue long. By degrees the cough becomes attended with a more copious excretion of mucus; which is at first thin, but gradually becoming thicker, is brought up with less frequent and less laborious coughing. The hoarseness and foreboding of the trachea are also relieved or removed; and the febrile symptoms abating, the expectoration becomes again less, and the cough less frequent, till at length they cease altogether.

Such is generally the course of this disease, neither tedious nor dangerous; but it is sometimes in both respects otherwise. The body affected with catarrh seems to be more than usually liable to be affected by cold air; and if the body affected with catarrh be exposed to cold, the disease, which seemed to be yielding, is often brought back with greater violence than before, and is rendered not only more tedious than otherwise it would be, but also more dangerous by the supervening of other diseases. Some degree of the cynanche tonsillaris often accompanies the catarrh; and when this is aggravated by a fresh application of cold, the cynanche also becomes more violent and dangerous from the cough, which is present at the same time. When a catarrh has been occasioned by a violent cause, when it has been aggravated by improper management, and especially when it has been rendered more violent by fresh and repeated applications of cold, it often passes into a pneumonic inflammation, attended with the utmost danger.

Unless, however, such accidents as those happen, a catarrh, in sound persons not far advanced in life, is always a slight and safe disease; but, in persons of a phthisical disposition, a catarrh may readily produce a hemoptysis, or perhaps form tubercles in the lungs; and, more certainly in persons who have tubercles already formed in the lungs, an accidental catarrh may occasion the inflammation of these tubercles, and in consequence produce a phthisis pulmonalis.

In elderly persons, a catarrh sometimes proves a dangerous disease. Many persons, as they advance in life, and especially after they have arrived at old age, have the natural mucus of the lungs poured out in greater quantity, and requiring a frequent expectoration. If, therefore, a catarrh happen to such persons, and increase the afflux of fluids to the lungs, with some degree of inflammation, it may produce the peripneumonia notha, which in such cases is very often fatal.

Cause, &c. The proximate cause of catarrh seems to be an increased afflux of fluids to the mucous membrane of the nose, fauces, and bronchiae, along with some degree of inflammation affecting the same. The latter circumstance is confirmed by this, that, in the case of catarrh, the blood drawn from a vein commonly exhibits the same inflammatory crust which appears in the case of phlegmasia. The remote cause of catarrh is most commonly cold applied to the body. This application of cold producing catarrh is generally evident and observed; and Dr Cullen is of opinion that it would always be so, were men acquainted with and attentive to the circumstances which determine cold to act upon the body.

The application of cold which occasions a catarrh, probably operates by stopping the perspiration usually made by the skin, and which is therefore determined to the mucous membrane of the parts above-mentioned. As a part of the weight which the body daily loses by insensible evacuation, is owing to an exhalation from the lungs, there is probably a connection between this exhalation and the cutaneous respiration, so that the one may be increased according as the other is diminished; and therefore we may understand how the diminution of cutaneous perspiration, by the application of cold, may increase the afflux of fluids to the lungs, and thereby produce a catarrh.

Dr Cullen observes that there are some observations of Dr James Keil which may render this matter doubtful; but says there is a fallacy in those observations. The evident effects of cold in producing coryza, coryza, leave the matter, in general, without doubt; and there are several other observations which shew a connection between the lungs and the surface of the body.

Whether from the suppression of perspiration, a catarrh be produced merely by an increased afflux of fluids, or whether further the matter of perspiration be at the same time determined to the mucous glands, and there excites a particular irritation, may be uncertain; but our author thinks the latter supposition is most probable.

Although, in the case of a common catarrh, which is in many instances sporadic, it may be doubtful whether any morbid matter be applied to the mucous glands; we are, however, certain that the symptoms of a catarrh do frequently depend upon such a matter being applied to these glands, as appears from the case of measles, chincough, and especially from the frequent occurrence of contagious and epidemical catarrh.

The phenomena of contagious catarrhs have been much the same with those of the others; and the disease has always been particularly remarkable for this, that it has been the most widely and generally spreading epidemic known. It has seldom appeared in any one country of Europe, without appearing successively in every different part of it; and, in some instances, it has been also transferred to America, and has been spread there in like manner, so far as we have had opportunities of being informed.

The catarrh from contagion appears with nearly the same symptoms as those above-mentioned. It seems often to come on in consequence of the application of cold. It comes on with more cold shivering than the catarrh arising from cold alone; and the former does also not only sooner show febrile symptoms, but to a more considerable degree. Accordingly, it more speedily runs its course, which is commonly finished in a few days. It sometimes ends by a spontaneous sweat; and this, in some persons, produces a milky eruption. It is, however, the febrile state of this disease especially, that is finished in a few days; for the cough and other catarrhal symptoms do frequently continue longer, and often when they appear to be going off they are renewed by any fresh application of cold.

Prognosis. Considering the number of persons who are affected with catarrh, of either the one species or the other, and escape from it quickly without any hurt, it may be allowed to be a disease very free from danger; but it is not always to be treated as such, for in some persons it is accompanied with pneumonic inflammation. In the phthisically disposed, it often accelerates the coming on of phthisis; and in elderly persons it often proves fatal in the manner we have explained above.

Cure. The cure of catarrh is nearly the same, whether it proceeds from cold or contagion; only in the latter case remedies are commonly more necessary than in the former. In the cases of a moderate disease, it is commonly sufficient to avoid cold, or to abstain from animal-food for some days, or perhaps for the same time to lie a-bed, and, by taking frequently some mild and diluent drink, a little warmed, to promote a very gentle sweat, and after this to take care to return very gradually only to the use of the free air. When the disease is more violent, not only the antiphlogistic regimen, exactly observed, but various remedies also, become necessary. To take off the phlogistic diathesis, which always attends this disease, blood-letting, more or less, according as the symptoms shall require, is the proper remedy. After blood-letting for restoring the determination of the fluids to the surface of the body, and at the same time for expediting the secretion of mucus in the lungs, which may take off the inflammation of its membrane, vomiting is the most effectual means. For the last-mentioned purpose, it has been supposed that squills, gum-ammoniac, the volatile alkali, and some other medicines, might be useful; but their efficacy has never been found considerable: and if squills have ever been very useful, it seems to have been rather by their emetic than by their expectorant powers. When the inflammatory affections of the lungs seem to be considerable, it is proper, besides blood-letting, to apply blisters to the back or sides.

As a cough is often the most troublesome circumstance of this disease, so demulcents may be employed to alleviate it. But after the inflammatory symptoms are much abated, if the cough still remains, opiates afford the most effectual means of relieving it; and, in the circumstances just now mentioned, they may be very safely employed. After the inflammatory and febrile states of this disease are very much gone, the most effectual means of dissolving all remains of the catarrhal affection, is by some exercise of generation diligently employed.

Besides the remedies above-mentioned, Mr Mudge, in a treatise on this disease, recommends the steam of warm water as a most efficacious and safe remedy for a catarrh, and which indeed he seems to consider as little less than infallible. The method of breathing in these steams is described under the word Inhaler; but he gives a caution to people in health, who may accidentally see his machine, not to make the experiment of breathing through cold water with it, or they will be almost certain of catching a severe cold with it. His directions for those troubled with the catarrh are as follow:

"In the evening, a little before bed-time, the patient, if of adult age, is to take three drachms, or as many tea-spoonfuls, of elixir paragoricum, in a glass of water: if the subject is younger, for instance, under five years old, one tea-spoonful; or within that and ten years, two. [Each tea-spoonful contains somewhat less than one quarter of a grain of opium.] About three quarters of an hour after, the patient should go to bed, and, being covered warm, the inhaler three parts filled with water nearly boiling, (which, from the coldness of the metal, and the time it ordinarily takes before it is used by the patient, will be of a proper degree of warmth,) and being wrapped up in a napkin, but so that the valve in the cover is not obstructed by it, is to be placed at the arm-pit, and the bed clothes being drawn up and over it close to the throat, the tube is to be applied to the mouth, and the patient should inspire and expire through it about twenty minutes or half an hour.

"It is very evident, as the whole act of respiration is..." Practice is performed through the machine, that in inspiration the lungs will be filled with air which will be hot, and loaded with vapour, by passing through the body of water; and in expiration, all that was contained in the lungs will, by mixing with the steam on the surface of the water, be forced thro' the valve in the cover, and settle on the surface of the body under the bed-cloths.

"The great use of this particular construction of the inhaler is this. First, as there is no necessity, at the end of every inspiration, to remove the tube from the mouth, in order to expire from the lungs the vapour which had been received into them, this machine may therefore be used with as much ease by children as older people. And, secondly, as a feverish habit frequently accompanies the disorder, the valve in that respect also is of the utmost importance: for a sweat, or at least a free perspiration, not only relieves the patient from the restless anxiety of a hot, dry, and sometimes parched skin, but is also, of all others, the most eligible evacuation for removing the fever; and it will be generally found, that, after the inhaler so constructed hath been used a few minutes, the warm vapour under the cloaths will, by settling upon the trunk, produce a sweat, which will gradually extend itself to the legs and feet.

"In a catarrhous fever, or any feverish habit attending this cough, it would be proper to take a draught of warm thin whey a few minutes before the inhaler is used; and after the process is over, the sweat which it has produced may be continued by occasional small draughts of weak warm whey or barley-water. The sweating is by no means so necessary to the cure of the catarrhous cough, as that the success of the inhaler against that complaint at all depends upon it; yet I cannot help once more remarking, that when this disorder happens to be accompanied with a feverish habit, the advantages of this particular construction will be very important.

"After this respiratory process is over, the patient usually passes the night without the least interruption from the cough, and feels no farther molestation from it than once or twice in the morning to throw off the trifling leakage which, unperceived, had dripped into the bronchiae and vesicles during the night; the thinner parts of which being evaporated, what remains is soon got rid of with a very gentle effort.

"I cannot, however, take leave of this part of my subject, without pointedly observing, that if the patient means not to be disappointed by my assurances or his own expectations, it is essentially necessary that the following remarks, with regard to the time and manner of using this process, should be strictly attended to.

"First, That as tender valetudinary people are but too well acquainted with the first notices of the disorder, the remedy must, or ought to be, used the same evening; which will, in an ordinary seizure, be attended with an immediate cure: but if the soreness of the respiratory organs, or the petulance of the cough, shew the cold which has been contracted to have been very severe, the inhaler, without the opiate, should be again repeated for the same time the next morning.

"Secondly, if the use of the inhaler, &c. is delayed till the second night, it will be always right to repeat it again the next morning without the opiate, but with it if the seizure has been violent.

"And, lastly, if the cough is of some days standing, it will be always necessary to employ both parts of the process at night and the succeeding morning, as the first simple inflammatory mischief is now most probably aggravated by an additional one of a chronic tendency.

"But if, through the want of a timely application, or a total neglect of this or any other remedy, the cough should continue to harass the patient, it is particularly in delicate and tender constitutions, of the utmost consequence to attempt the removal of it as soon as possible, before any floating acrimony in the constitution (from the perpetual irritation) receives an habitual determination to an organ so essential to life as the lungs.

"If the patient expectorates with ease and freedom a thick and well-digested inoffensive phlegm, there is generally but little doubt of his spitting off the disorder, with common care, in a few days; and till that is accomplished, a proper dose of elixir paregoricum for a few successive nights will be found very useful in suppressing the fatiguing irritation and ineffectual cough, occasioned by a matter which, dripping in the early state of the disease into the bronchiae during the night, is commonly at that time too thin to be discharged by those convulsive efforts.

"If, however, notwithstanding a free and copious expectoration, the cough should still continue, and the discharge, instead of removing the complaint, should itself, by becoming a disease, be a greater expense than the constitution can well support, it is possible that a tender patient may spit off his life through a weak relaxed pair of lungs, without the least appearance of purulence, or any suspicion of suppuration. In those circumstances, besides, as was mentioned before, increasing the general perspiration by the salutary friction of a flannel waistcoat, change of situation, and more especially long journeys on horseback, conducted as much as possible through a thin, sharp, dry air, will seldom fail of removing the complaint.

"But, on the contrary, if the cough should, at the same time that it is petulant and fatiguing to the breast, continue dry, hulky, and without expectoration; provided there is reason to hope that no tubercles are forming, or yet actually formed, there is not perhaps a more efficacious remedy for it than half a drachm of gum ammoniacum, with 18 or 20 drops of laudanum, made into pills, and taken at bedtime, and occasionally repeated. This excellent remedy Sir John Pringle did me the honour to communicate to me; and I have accordingly found it, in a great many instances, amazingly successful, and generally very expeditiously so; for it seldom fails to produce an expectoration, and to abate the distressing fatigue of the cough. In those circumstances I have likewise found the common remedy of 3s or 9j of half fulph. anat. taken twice a-day, in a little powdered sugar or any other vehicle, a very efficacious one. I have also, many times, known a salutary revulsion made from the lungs by the simple application of a large plaster, about five or six inches diameter, of pix Burgund. between the shoulders; for the perspirable matter, which is locked up under it, becomes so sharp and acid, that in a few days XCV. DYSENTERIA, the Dysentery. Genus XLIII.

Dysenteria, Sauv. gen. 248. Lin. 191. Vog. 107. Sag. 183. Hoffm. III. 151. Franck. 76.

Description. The dysentery is a disease in which the patient has frequent stools, accompanied with much griping, and followed by a tenesmus. The stools, though frequent, are generally in small quantity; and the matter voided is chiefly mucus, sometimes mixed with blood. At the same time, the natural feces seldom appear; and, when they do, it is generally in a compact and hardened form.—This disease occurs especially in summer and autumn, at the same time with autumnal, intermittent, and remittent fevers; and with these it is often complicated. It comes on sometimes with cold shiverings, and other symptoms of pyrexia; but more commonly the symptoms of the topical affection appear first. The belly is swollen, with an unusual flatulence in the bowels. Sometimes, though more rarely, some degree of diarrhea is the first appearance. In most cases, the disease begins with griping, and a frequent inclination to go to stool. In indulging this, little is voided, but some tenesmus attends it. By degrees the stools become more frequent, the griping more severe, and the tenesmus more considerable. With these symptoms there is a loss of appetite, and frequently sickness, nausea, and vomiting, also affecting the patient. At the same time there is always more or less of pyrexia present. It is sometimes of the remittent kind, and observes a tertian period. Sometimes the pyrexia is manifestly inflammatory, and very often of a putrid kind. These febrile states continue to accompany the disease during its whole course, especially when it terminates soon in a fatal manner. In other cases, the febrile state almost entirely disappears, while the proper dysenteric symptoms remain for a long time after.

In the course of the disease, whether for a shorter or a longer time, the matter voided by stool is very various. Sometimes it is merely a mucous matter, without any blood, exhibiting that disease which is named by some the morbus mucosus, and by others the dysenteria alba. For the most part, however, the mucus discharged is more or less mixed with blood. This sometimes appears only in streaks amongst the mucus; but at other times is more copious, tinging the whole; and upon some occasions a pure and unmixed blood is voided in considerable quantity. In other respects, the matter voided is variously changed in colour and consistence, and is commonly of a strong and unusually fetid odour. It is probable, that sometimes a genuine pus is voided, and frequently a putrid fæces, proceeding from gangrenous parts. There are very often mixed with the liquid matter, some films of a membranous appearance, and frequently some small masses of a seemingly sebaceous matter. While the stools voiding these various matters are, in many instances, exceedingly frequent, it is seldom that natural feces appear in them; and when they do appear, it is, as we have said, in the form of feyballs, that is, in somewhat hardened, separate balls. When these are voided, whether by the efforts of nature or as solicited by art, they procure a remission of all the symptoms, and more especially of the frequent stools, griping, and tenesmus.

Accompanied with these circumstances, the disease proceeds for a longer or a shorter time. When the pyrexia attending it is of a violent inflammatory kind, and more especially when it is of a very putrid nature, the disease often terminates fatally in a very few days, with all the marks of a supervening gangrene. When the febrile state is more moderate, or disappears altogether, the disease is often protracted for weeks, and even for months; but, even then, after a various duration, it often terminates fatally, and generally in consequence of a return and considerable aggravation of the inflammatory and putrid states. In some cases, the disease ceases spontaneously; the frequency of stools, the griping, and tenesmus, gradually diminishing, while natural stools return. In other cases, the disease, with moderate symptoms, continues long, and ends in a diarrhoea, sometimes accompanied with lienteric symptoms.

Causes, &c. The remote causes of this disease have been variously judged of. It generally arises in summer or autumn, after considerable heats have prevailed for some time, and especially after very warm and at the same time very dry states of the weather; and the disease is much more frequent in warm, than in cooler climates. It happens, therefore, in the same circumstances and seasons which considerably affect the state of the bile in the human body; but the cholera is often without any dysenteric symptoms, and copious discharges of bile have been found to relieve the symptoms of dysentery: so that it is difficult to determine what connection the disease has with the state of the bile. It has been observed, that the effluvia from very putrid animal-substances readily affect the alimentary canal, and, upon occasion, they certainly produce a diarrhoea; but whether they ever produce a genuine dysentery, is not certain.

The dysentery does often manifestly arise from the application of cold, but the disease is always contagious; and, by the propagation of such contagion, independent of cold, or other exciting causes, it becomes epidemic in camps and other places. It is, therefore, to be doubted if the application of cold ever produces the disease, unless where the specific contagion has been previously received into the body; and, upon the whole, it is probable that a specific contagion is to be considered as always the remote cause of this disease.

Whether this contagion, like many others, be of a permanent nature, and only shows its effects in certain circumstances which render it active, or if it be occasionally produced, we cannot determine. Neither, if the latter supposition be received, can we say by what means it may be generated. As little do we know any thing of its nature, considered in itself; or at most, only this, that, in common with many other contagions, it is very often somewhat of a putrid nature, and capable of inducing a putrefactive tendency in the human body. This, however, does not at all explain the peculiar effect of inducing those symptoms which properly and essentially constitute the disease of dysentery. Of these symptoms the proximate cause is still obscure. The common opinion has been, that the disease depends upon an acrid matter thrown upon or somehow generated in the intestines, exciting their peristaltic motion, and thereby producing the frequent stools which occur in this disease. But this supposition cannot be admitted; for, in all the instances known, of acrid substances applied to the intestines, and producing frequent stools, they at the same time produce copious stools, as might be expected from acrid substances applied to any length of the intestines. This, however, is not the case in dysentery, in which the stools, however frequent, are generally in very small quantity, and such as may be supposed to proceed from the lower parts of the rectum only. With respect to the superior portions of the intestines, and particularly those of the colon, it is probable they are under a preternatural and considerable degree of constriction: for, as we have said above, the natural faeces are seldom voided; and when they are, it is in a form which gives reason to suppose they have been long retained in the cells of the colon, and consequently that the colon had been affected with a preternatural constriction. This is confirmed by almost all the dissections which have been made of the bodies of dysenteric patients; in which, when gangrene had not entirely destroyed the texture and form of the parts, considerable portions of the great guts have been found affected with a very considerable constriction.

The proximate cause of dysentery, or at least the chief part of the proximate cause, seems to consist in a preternatural constriction of the colon, occasioning, at the same time, those spasmodic efforts which are felt in severe gripings, and which efforts, propagated downwards to the rectum, occasion there the frequent mucous stools and tenesmus. But, whether this explanation shall be admitted or not, it will still remain certain, that hardened faeces, retained in the colon, are the cause of the griping, frequent stools, and tenesmus: for the evacuation of these faeces, whether by nature or by art, gives relief from the symptoms mentioned; and it will be more fully and usefully confirmed by this, that the most immediate and successful cure of dysentery is obtained by an early and constant attention to the preventing the constriction, and the frequent stagnation of faeces in the colon.

Cure. The most eminent of our late practitioners, and of greatest experience in this disease, seem to be of opinion, that it is to be cured most effectually by purging, assiduously employed. The means may be various: but the most gentle laxatives are usually sufficient; and, as the medicine must be frequently repeated, these are the most safe, the more especially as an inflammatory state so frequently accompanies the disease. Whatever laxatives produce an evacuation of natural faeces, and a consequent remission of the symptoms, will be sufficient to effectuate the cure. But, if the gentle laxatives shall not produce the evacuation now mentioned, somewhat more powerful must be employed; and Dr Cullen hath found nothing more proper or convenient than tartar emetic, given in small doses, and at such intervals as may determine their operation to be chiefly by stool. Rhubarb, so frequently employed, is, in several respects, amongst the most unfit purgatives.

Vomiting has been held a principal remedy in this disease; and may be usefully employed in the beginning of the disease, with a view to both the state of the stomach and of the fever: but it is not necessary to repeat it often; and, unless the emetics employed operate also by stool, they are of little service. Ipecacuanha is by no means a specific; and it proves only useful when so managed as to operate chiefly by stool.

For relieving the constriction of the colon, and evacuating the retained faeces, glysters may sometimes be useful; but they are seldom so effectual as laxatives, given by the mouth; and acid glysters, if they be not effectual in evacuating the colon, may prove hurtful by stimulating the rectum too much.

The frequent and severe griping attending this disease, leads almost necessarily to the use of opiates; and they are very effectual for the purpose of relieving from the gripes; but, by occasioning an interruption of the action of the small guts, they favour the constriction of the colon, and thereby aggravate the disease; and if, at the same time, the use of them supercede in any measure the employing purgatives, it is doing much mischief; and the neglect of purging seems to be the only thing which renders the use of opiates very necessary.

When the gripes are both frequent and severe, they may sometimes be relieved by the employment of fencupium, or by a fomentation of the abdomen continued for some time. In the same case, the pains may be relieved, and the constriction of the colon may be taken off, by blisters applied to the lower belly.

At the beginning of this disease, when the fever is any way considerable, blood-letting, in patients of tolerable vigour, may be proper and necessary; and, when the pulse is full and hard, with other symptoms of an inflammatory disposition, blood-letting ought to be repeated. But, as the fever attending dysentery is often of a putrid kind, or does, in the course of the disease, become soon of that nature, blood-letting must be cautiously employed.

From our account of the nature of this disease, it will be sufficiently obvious, that the use of astringents in the beginning of it must be absolutely pernicious. Whether an acrid matter be the original cause of the dysentery may be uncertain; but, from the indigestion, and the stagnation of fluids, which attend the disease, we may suppose that some acid matters are constantly present in the stomach and intestines, and therefore that demulcents may be always usefully employed. At the same time, from this consideration that mild oily matters thrown into the intestines in considerable quantity always prove laxative, Dr Cullen is of opinion that the oleaginous demulcents are the most useful.

As this disease is so often of an inflammatory or of a putrid nature, it is evident that the diet employed in it should be vegetable and aseptic. Milk, in its entire state, is of doubtful quality in many cases; but some portion of the cream is often allowable, and whey is always proper.—In the first stages of the disease, the sweet and subacid fruits are allowable, and even proper. It is in the more advanced stages only that any morbid acidity seems to prevail in the stomach, and to require some reserve in the use of acids. At the beginning of the disease, absorbents seem to be superfluous; and, by their attritional and septic powers, they may be hurtful.

When this disease is complicated with an intermittent, and is protracted from that circumstance chiefly, it is to be treated as an intermittent, by administering the Peruvian bark, which in the earlier periods of the disease is hardly to be admitted.

**Class II. Neuroses.**

**Order I. Comata.**

*Comata, Sauv. Clas. VI. Ord. II. Sag. Clas IX. Ord. V.*

*Soporofii, Lin. Clas VI. Ord. II.*

*Adynamiae, Vog. Clas VI.*

*Nervorum resolutiones, Hoffm. III. 194.*

*Affectus soporofii, Hoffm. III. 209.*

*Motuum vitalium defectus, Junck. 114.*

**Genus XLIV. Apoplexy.**

*Apoplexia, Sauv. gen. 182. Lin. 101. Vog. 229. Boerh. 1007. Junck. 117. Sag. gen. 288. Wepser. Hist. apoplecticorum.*

*Carus, Sauv. gen. 181. Lin. 100. Vog. 231. Boerh. 1045. Sag. gen. 287.*

*Cataphora, Sauv. gen. 180. Lin. 99. Vog. 232. Boerh. 1048. Sag. gen. 286.*

*Coma, Vog. 232. Boerh. 1048.*

*Haemorrhagia cerebri, Hoffm. II. 240.*

To this genus also Dr Cullen reckons the following diseases to belong.

*Catalepsis, Sauv. gen. 176. Lin. 129. Vog. 230.*

*Sag. gen. 281. Boerh. 1036. Junck. 44.*

*Affectus cerebri spasmodico-eclitaticus, Hoffm. III. 44.*

*Ecclisis, Sauv. gen. 177. Vog. 333. Sag. gen. 283.*

The following he reckons symptomatic.

*Typhomania, Sauv. gen. 178. Lin. 97. Vog. 23. Sag. gen. 284.*

*Lethargus, Sauv. gen. 179. Lin. 98. Vog. 22. Sag. gen. 285.*

**XCVI. The Sanguineous Apoplexy. Sp. I.**

*Description. In this disease the patients fall suddenly down, and are deprived of all sense and voluntary motion, but without convulsions. A giddiness of the head, noise in the ears, coruscations before the eyes, and redness of the face, usually precede. The distinguishing symptom of the disease is a deep sleep, attended with violent snorting; if anything is put into the mouth, it is returned through the nose; nor can anything be swallowed without shutting the nostrils; and even when this is done, the person is in the utmost danger of suffocation. Sometimes apoplectic patients will open their eyes after having taken a large dose of an emetic; but if they show no sign of sense, there is not the least hope of their recovery. Sometimes the apoplexy terminates in a hemiplegia; in which case it comes on with a distortion of the mouth towards the sound side, a drawing of the tongue the same way, and stammering of the speech. Distortions sometimes show a rupture of some vessels of the meninges, or of the brain itself; though sometimes, if we may believe Dr Willis, no defect is to be observed either in the cerebrum or cerebellum.*

*Causae, &c. The general cause of a sanguineous apoplexy is a plethoric habit of body, with a determination to the head. The disease therefore may be brought on by whatever violently urges on the circulation of the blood; such as surfeits, intoxication, violent passions of the mind, immoderate exercise, &c. It takes place, however, for the most part, when the venous plethora hath subsided for a considerable time in the system. For that reason it commonly does not attack people till past the age of 60; and that whether the patients are corpulent and have a short neck, or whether they are of a lean habit of body. Till people are past the age of childhood, apoplexy never happens.*

*Prognosis. This disease very often kills at its first attack; and few survive a repetition of the fit; so that those who make mention of people who have survived several attacks of the apoplexy, have probably mistaken the epilepsy for it. In no disease is the prognosis more fatal; since those who seem to be recovering from a fit, are frequently and suddenly carried off by its return, without either warning of its approach, or possibility of preventing it. The good signs are when the disease apparently wears off, and the patient evidently begins to recover; the bad ones are when all the symptoms continue and increase.*

*Cure. This is to be attempted, in the first place, by large and repeated bleedings; after which, the same remedies are to be used as in the serous apo- XCVII. The Serous Apoplexy. Sp. II.

Apoplexia pituitosa, Sauv. sp. 7. Apoplexia serosa, Preysinger, sp. 4. Morg. de causis, &c. IV. LX. Carus a hydrocephalo, Sauv. sp. 16. Cataphora hydrocephalica, Sauv. sp. 6. Cataphora somnolenta, Sauv. sp. 1. Lethargus literarum, Sauv. sp. 7. Van Swieten in Aphor. 1010. 2 y and 3 n.

Description. In this species the pulse is weak, the face pale, and there is a diminution of the natural heat. On dissection, the ventricles of the brain are found to contain a larger quantity of fluid than they ought; the other symptoms are the same as in the former.

Causes, &c. This may arise from any thing which induces a debilitated state of the body, such as depressing passions of the mind, much study, watching, &c. It may also be brought on by a too plentiful use of diluting, acidulated drinks. It doth not, however, follow, that the extravasated serum above-mentioned in the ventricles of the brain is always the cause of the disease, since the animal-humours are very frequently observed to ooze out in plenty through the coats of the containing vessels after death, though no extravasation took place during life.

Prognosis. This species is equally fatal with the other; and what hath been said of the prognostics of the sanguineous, may also be said of that of the serous apoplexy.

Cure. In this species venefication can scarcely be admitted: acid purgatives, emetics, and stimulating clysters, are recommended to carry off the superabundant serum; but in bodies already debilitated, they may perhaps be liable to the same exceptions with venefication itself. Volatile salts, cephalic elixirs, and cordials, are also prescribed; and in case of a hemiplegia supervening, the cure is to be attempted by apertent pittans, cathartics, and sudorifics; gentle exercise, as riding in a carriage; with such stimulating medicines as are proper in a palsy. See below.

XCVIII. Hydrocephalic Apoplexy, or Dropsy of the Brain. Sp. III.

Hydrocephalus interior, Sauv. sp. 1. Hydrocephalus internus, Whytt's works, pag. 725. London Med. Obs. vol. iv. art. 3, 6, and 25. Gaudelius de hydrocephalo, apud Sandifort Theaur. vol. ii. Hydrocephalus acutus, Quin, Diff. de hydrocephalo, 1779. Athenia a hydrocephalo, Sauv. sp. 3.

History and description. This disease has been accurately treated within these few years by several eminent physicians, particularly the late Dr Whytt, Dr Fothergill, and Dr Watson; who concur in opinion with respect to the seat of the complaint, the most of its symptoms, and its general fatality. Out of twenty patients that had fallen under Dr Whytt's observation, he candidly owns that he had been so fortunate as to cure only one who laboured under the characteristic symptoms of the hydrocephalus; and he suspects that those who imagine they have been more successful, had mistaken another distemper for this. It is by all supposed to consist in a dropsy of the ventricles of the brain; and this opinion is fully established by dissections. It is observed to happen more commonly to healthy, active, lively children; than to those of a different disposition.

Dr Whytt supposes that the commencement of this disease is obscure; that it is generally some months in forming; and that, after some obvious urgent symptoms render assistance necessary, it continues some weeks before its fatal termination. This, in general, differs from what has hitherto been observed by Dr Fothergill; the latter informing us, that he has seen children, who, from all appearance, were healthy and active, seized with this distemper, and carried off in about fourteen days. He has seldom been able to trace the commencement of it above three weeks.

Though the hydrocephalus be most incident to children, it has been sometimes observed in adults; as appears from a case related by Dr Huck, and from some others.

Those who are seized with this distemper, usually complain first of a pain in some part below the head; most commonly about the nape of the neck and shoulders; often in the legs; and sometimes, but more rarely, in the arms. The pain is not uniformly acute, nor always fixed to one place; and sometimes does not affect the limbs. In the latter case, the head and stomach have been found to be most disordered; so that when the pain occupied the limbs, the sickness or head-ach was less considerable; and when the head became the seat of the complaint, the pain in the limbs was seldom or never mentioned. Some had very violent sicknesses and violent head-aches, alternately. From being perfectly well and sportive, some were in a few hours seized with those pains in the limbs, or with sickness, or head-ach, in a slight degree, commonly after dinner; but some were observed to droop a few days before they complained of any local indisposition. In this manner they continued three, four, or five days, more or less, as the children were healthy and vigorous. They then commonly complain of an acute deep-seated pain in the head, extending across the forehead from temple to temple; of which, and a sickness, they alternately complain in short and affecting exclamations; doing a little in the intervals, breathing irregularly, and sighing much while awake. Sometimes their sighs, for the space of a few minutes, are incessant.

As the disease advances, the pulse becomes slower and irregular, the strokes being made both with unequal force and in unequal times, till within a day or two of the fatal termination of the disorder, when it becomes exceeding quick; the breathing being at the same time deep, irregular, and laborious. After the first access, which is often attended with feverish heats, especially towards evening, the heat of the body is for the most part temperate, till at last it keeps pace with the increasing quickness of the pulse. The head and precordia are always hot from the first attack. The sleeps are short and disturbed, sometimes interrupted by watchfulness; besides which there are startings, the pupils of the eyes are much dilated, and during sleep great part of the white of them is... The patients are averse to light, unwilling to be disturbed for any purpose, and can bear no posture but that of lying horizontally. One or both hands are most commonly about their heads. The urine and stools come away insensibly. At length the eyelids become paralytic; great heat accompanied with sweat overspreads the whole body; respiration is rendered totally suspitious; the pulse increase in its trembling undulations beyond the possibility of counting, till the vital motions entirely cease; and sometimes a spasm concludes the scene.

Many of the symptoms above enumerated are so common to worm cases, teething, and other irritating causes, that it is difficult to fix upon any which particularly characterize this disease. The most peculiar seem to be the pains in the limbs, with sickness and incessant head-ach; which, though frequent in other diseases of children, are neither so uniformly nor so constantly attendant as in this. Another circumstance observed to be familiar, if not peculiar to this distemper, is, that the patients are not only costive, but it is likewise with the greatest difficulty that stools can be procured. These are generally of a very dark greenish colour, with an oiliness or a glairy bile, rather than the slime which accompanies worms; and they are, for the most part, extremely offensive. No positive conclusion can be drawn from the appearance of the urine; it being various, in different subjects, both in its colour and contents, according to the quantity of liquor they drink, and the time between the discharges of the urine. From their unwillingness to be moved, they often retain their water twelve or fifteen hours, and sometimes longer. In complaints arising from worms, and in dentition, spasms are more frequent than in this disorder. Children subject to fits are sometimes seized with them a few days before they die. Sometimes these continue twenty-four hours incessantly, and till they expire.

Causes. The causes of internal hydrocephalus are very much unknown, though some suppose it to proceed from a rupture of some of the lymphatic vessels of the brain. In many cases it seems to be hereditary; and as it attacks children rather than adults, it would seem to be occasioned by a laxity, rather than a rupture, of the vessels.

Prognosis and Cure. Till very lately this disorder was reckoned totally incurable; but now it is found that mercury, if applied in time, will remove every symptom. This remedy was first thought of by Dr Percival of Manchester, afterwards by Dr Dobson of Liverpool, and its efficacy is now ascertained beyond a doubt. The method of exhibiting this medicine in order to effect a cure, as well as the utility of other medicines, will fully appear from the following cases.

CASE I. By Dr Percival.

"September 4, 1777. Master H., a child at the breast, aged seven months, has laboured about a fortnight under a slow irregular fever. His eyes have been now and then a little distorted; he has been affected with some degree of stupor; his gums have been inflamed and tender; and his mouth uncommonly dry. No tooth has yet made its appearance. An emetic has been administered; a blister applied to his back; and his belly has been kept soluble by repeated small doses of magnesia. During the action of the blister, he was thought to be much better, but he soon relapsed into his former state.

"About three o'clock this morning, he was convulsed; at nine, I saw him; and, from his countenance, instantly suspected a dropy of the brain. The symptoms confirmed my apprehensions. His skin was hot; yet his pulse beat only 78 strokes in a minute, which were irregular. The pupils of his eyes were considerably, but unequally, dilated; nor did they contract much when a lighted candle was suddenly held before them. He often squinted, especially with the right eye, and seemed to take no notice of any objects around him. He refused the breast, and food swallowed till the lips and tongue had been stimulated with a feather. During several days past, he had been frequently observed to rub the end of his nose when his hand was at liberty; and, notwithstanding his stupor, he had been uncommonly watchful. I examined his head, and found a manifest tumour of the bregma, which had never before been noticed. Convinced by all these circumstances that the child laboured under the hydrocephalus internus, and that he was now in the second stage of that disorder, I directed ten grains of the anguinum mercuriale nitidus to be rubbed into his thighs every three hours, till the mouth should be affected, and a tea-spoonful of the following mixture to be given whenever the convulsive symptoms recurred.

R. Salli ammon. vol. ii. Succi Lemon. 3vi. Myschopt. mucilagine gum. Arabic foliat. gr. vi. Saech. alb. q. f. ad gratiam. M.

"Small blisters were applied on each side of the head, just below the bregma; and a folded rag, frequently moistened with brandy, was laid upon the tumour, to promote absorption. An emetic had been given early in the morning, by which a large quantity of bile was discharged; and a vesicatory had also been applied to his leg.

"September 5, nine o'clock. The child has had frequent convulsions in the night; his right eye is much distorted; and it has been remarked, that he seldom moves the right-hand. The pulse beat 120 strokes in a minute. Two scruples of the mercurial ointment have been used, and he has taken five grains of musk. A large discharge of serum has been produced by the blisters. Five o'clock, P.M. The tumour of the head is sensibly diminished; the child's mouth is now moist, and often filled with saliva; and his tongue appears to be swollen. His pulse beat 146 strokes in a minute. I directed another blister to be applied to the head.

"September 6. His convulsions have been much slighter; his eye is frequently distorted; and the pupils of each are more contracted. The tumor is considerably abated; the child seems to take some notice, distinguishes taste, and swallows freely. The musk has been continued; and half a dram more of the mercurial ointment has been consumed. A clyster was injected last night, but ineffectually; I therefore prescribed a grain of jalap, mixed with an equal quantity of sugar, to be given every three hours, till a motion to stool succeeded.

"September 7. The child has passed the night more..." more comfortably, but not free from convulsions. His head has sweated profusely, and the blisters have run much. The tumour of the bregma is considerably reduced. The jalap operated gently last night, and the mercurial unction has been twice repeated. There is an evident mitigation of all the symptoms.

"September 8. About eleven o'clock last night, the child was attacked with severe convulsions, which recurred frequently till six o'clock this morning. He had had a short sleep, and is now composed. His pulse beats 140 strokes in a minute; his heat is moderate; and his skin soft and perspirable. The mercurial ointment has been again used; but, tho' his gums and tongue are sore and very moist, his breath is not offensive. I directed a grain of calomel to be immediately given, to procure a stool; and a blister to be applied to the occiput.

"September 10. He has passed two nights almost entirely free from convulsions. Ten grains of the mercurial ointment have been again rubbed into his thighs. The dose of calomel occasioned three very offensive stools; and directions are given to repeat it, as he is again colicive. The blister applied to the occiput, like the others, has produced a very copious discharge. The tumour of the head is now scarcely perceptible. Pulse 120.

"September 12. At 12 o'clock last night, the convulsions recurred with greater violence than ever, and still continue. Two teeth have almost protruded through the upper, and the same number through the lower gum. Pulse 160, tremulous and irregular. I directed that the child should be immediately put into a warm bath, and that the following remedies should be administered,

B. Infus. rad. valer. fortissimi 3ii. Asefetid. electa 3i. M. f. Enema flatum inficiendum. B. Tinct. valer. volat. 3ii. Dentur guttae jii. Subinde e cochleari parvulo infusi rad. valer. sylv. sub forma these parati.

"The convulsions continued, but with less violence; and the child expired about one o'clock in the afternoon."

On this case the Doctor makes the following observations.

"The deplorable case which I have related appears to have originated from the irregular action produced in the system by dentition, and from the want of a due secretion of saliva in the mouth, by which the fluid discharges were probably increased in the ventricles of the brain. That these discharges were diminished, and that the extravasated water was absorbed, by the powerful action of the mercury, may be presumed from the mitigation of all the symptoms which succeeded the salivation. And I am inclined to believe, that the convulsions under which the child expired were more owing to the irritation of his gums by the protrusion of four teeth, than to any remaining water in the brain; for the tumour of the head had entirely disappeared, and after death there was a manifest depression of the bregma. During the space of a week, 110 grains of the unguentum mercuriale mitius, which contains about 22 grains of mercury, was consumed, in the usual way of friction. Perhaps half of this quantity might be absorbed, and carried into the course of circulation; to which may be added, part of the two grains of the calomel administered internally. The symptoms of the salivation were not violent; and the effects of the mercury did not appear formidable or alarming, even to the parents of the child, who were apprised of the nature of the disorder, and fully approved of the trial of this new method of treating it."

CASE II. By Dr Dobson.

"On the 13th of February 1775, I was called to the only son of Mr C., a gentleman of this place: the child was between three and four years of age; had been indisposed about eight days; and had frequently complained of pain in his head and weariness, and pains in his limbs; had been sick by fits, and sometimes vomited; was feverish, and could not bear the light.

"I was much alarmed on hearing this account, as the hydrocephalus internus had already proved fatal to three children of this family, who had all been under my care. And that this had been the disease was evident, both from the symptoms and the appearances on dissection. But my alarm was much farther increased on examining the little patient. The pulse I found very frequent and irregular. The head hot, the cheeks flushed, the pupils dilated, and a great degree of strabismus. There remained no doubt with respect to the nature of the disease.

"An emetic, some calomel powders, and a purgative, had been administered, without affording any relief. I directed the pediluvium, and emetic tartar to be given in such doses as to excite nausea.

"February 14th. The symptoms the same, with frequent startings, disturbed sleep, and tossing from side to side on the pillow. A blister was applied between the shoulders, the pediluvium repeated, and the emetic tartar continued.

"15th. Comatose, restless, and shrieking by fits. The pulse slower than in health, and the eyes intangible even to the impressions of strong light.

"As I had no hope of doing anything effectual for the recovery of my patient, I paid my visits, prescribed, and gave directions with a foreboding and heavy heart. Anxiously, however, considering the case in different points of view, and fully convinced that it was vain to pursue the usual line of practice, it occurred to me, that mercurials, so far urged as to enter the course of circulation, and affect the salivary glands, might possibly reach the system of absorbers in the ventricles of the brain, and thus remove the extravasated fluid.

"The short continuance of the disease, and the apparent strength of my patient, were favourable to the trial of this method. No time, however, was to be lost. The parents were consulted, and readily gave their sanction to the proposal; for they were convinced, that, unless some powerful steps were taken, this their only son must be numbered with those of their children who had already fallen a sacrifice to the disease.

"The mercurial course, therefore, was commenced, and urged on with caution and expedition. In 48 hours the breath began to be offensive; the gums were reddish and swollen; and the symptoms of the disease, so far as could be distinguished, were somewhat abated. In 48 hours more the palsy came on, and the disease was Between the 15th and 22d he took 20 grains of calomel, and one drachm of the strongest mercurial ointment was likewise rubbed in well upon the legs and thighs. The dose of calomel was one grain, mixed with a little sugar, and repeated at such intervals as the circumstances of the case pointed out.

"After the 22d no more mercurials were administered; a moderate ptyalism continued for five or six days, then gradually ceased, and the disease was entirely removed. The bark was then given, as the best tonic remedy after the mercurial course, and as the best preservative against a relapse. The strabismus I observed was the last symptom which disappeared.

"From the 15th, no other medicines were used except mercurials. The three filters of the above patient, who all died of this disease, were treated with blisters; and to one of them they were applied in succession to the head, behind the ears, and between the shoulders."

CASE III. By Dr. Percival.

"One of my own children, a girl, aged three years and three months, has lately been a severe sufferer under this alarming malady. As soon as the characteristic symptoms of the disease clearly manifested themselves, I laid aside all other remedies, convinced, by repeated observation, of their insufficiency; and trusted solely, though with much solicitude, to the internal and external use of mercury. In 48 hours, signs of amendment appeared, and her recovery was perfected in six days. During this space of time, thirteen grains of calomel were administered, and seven scruples of unguentum mercuriale fortissim carefuIly rubbed into her legs."

CASE IV. By Mr. John Mackie Surgeon in Huntington.

John Algood, aged 27, of a thin habit of body, accustomed for four or five years past to work in a tan-yard in a very flopping posture, was attacked in the beginning of May with an irregular intermitting fever, accompanied with much pain in his joints. These complaints continued till about the middle of June, when he was seized with a violent and constant pain in the back-part of his head, attended with great giddiness, noise in his head and ears, dimness of sight, &c., and his fever became more continued. He lay in this state upwards of a month, without receiving any benefit from some medicines which he took during this period.

Mr. Mackie was called to him in the middle of July, and found him labouring under the following symptoms: A fixed pain on the right side and back part of his head, which was frequently so acute as to make him quite outrageous, crying out, tearing his hair, beating himself on the head, &c. He had such a giddiness, that, unless strongly held, he could not support himself a moment in an upright posture. He could not bear the light; and, when he did venture to open his eyes, could not see objects distinctly. His pupils were uncommonly dilated; and his right eye seemed drawn outward, and rather contracted in its volume. He complained of a strange palpitating noise in his head and ears; and said, he felt at times as if there was a weight of water falling from one side of his head to the other. He was, in general, sensible; but, on asking him two or three questions together, he became confused, and, like a person with an oppressed brain, answered with hesitation, quite wide of the question, and often opposite to what he meant. Along with these, he had a hot skin, small quick pulse, thirsty, a foul tongue, urine in small quantity and high-coloured; he was emaciated, sick, costive, and sweated much; had often a kind of stupor, but very little sleep. Once in the 24 hours he had generally a remission (of three or four hours continuance) of the febrile symptoms, but of none of the other complaints.

July 16th. Ordered three or four leeches to be applied to each temple immediately; an emetic to be taken in the evening, and a cooling purge to-morrow morning.

17th. In the evening found the leeches had taken away a good deal of blood, and the vomit and purge operated well. No change in the complaints, except that the sickness is a little abated. He seemed greatly on attempting to raise his head from the pillow.

Ordered his head to be shaved, and a sharp blister to be applied all over the occiput, large enough to cover the nape of the neck; also one on the inside of the leg. Internally,—S. Nitri pari, dr. ss. Gum camphor, gr. iv. M. f. pulvis; quarta quaque hora fumendus durante febrili calore. R. Pulv. cort. Peruvian. dr. i. Pulv. rad. valerian. folio. dr. ss. M. f. pulvis, exhibendus quamprimum remissione apparente, & rependetus si ultra horas tres fergat. Thin milk-gruel and barley-water for drink.

July 19th. The blisters have discharged much, and he has taken the medicines punctually; but the fever and other complaints remain as before. Pulse very irregular; pain in the head, and reflexions, extreme.

Left off the camphire; and in its stead added to each nitrous powder, tartar emetic, gr. ½. Dressed the blisters with the unguent ad vesicatoria.

21st. Two doses of the bark and valerian were given during the two last remissions of the fever, which were full four hours each; but today there appears no kind of amendment. All the symptoms continue much the same. Shrieked out much, and talked incoherently. Has had no stool since he took his physic. Ordered a laxative glyster to be thrown up directly, and the medicines to be continued as on the 19th.

23d. The glyster procured two motions. Has sweated profusely through the last 48 hours. Blisters have run freely. The two last diurnal remissions not quite so distinct. No abatement of the other complaints. The pain, giddiness, stupor, contortion of the eyes, &c., remain in as great a degree as ever. Mr. Mackie now left off all other medicines, and ordered ten grains of calomel, made into a bolus with conserve of roses, to be taken at bed-time; at the same time, a dram of the strong mercurial ointment was directed to be rubbed into the ankles; and both to be repeated every night.

25th. Found no alteration. Fever and other symptoms the same. Blister heal, having been dressed these two days with basilicon. The calomel, and mercurial friction, ordered to be continued as on the 23d.

26th. Mr. Mackie found him complaining much of being griped. Had two purging stools in the last His gums were a little tender, and his breath beginning to be tainted. In other respects as usual. Left off the calomel, and ordered a double quantity of the mercurial ointment to be rubbed into his thighs every night.

28th. He had had a calmer night than any these two months past. For the first time, he said the pain of his head was abated; he looked more composed; his skin felt cooler; his pulse more full, and not so quick. He complained of his mouth being sore, and his tongue swelled; and had discharged a good deal of saliva in the night. Only one dram of the ointment to be rubbed in, for the two next nights.

30th. He spit about three quarts during the last 48 hours, and complains of much heat in his mouth; but all his other complaints better. Pain in his head almost gone, excepting now and then a shoot. Giddiness much abated. He said he often felt a trickling kind of motion, as of water running along the inside of his temples; but this sensation was without pain. He could sit up in bed, and feed himself; was sensible, and in spirits. Pulse regular, and not above 70 in a minute. He has had a remission of upwards of six hours to-day; ordered the ointment to be left off.

Aug. 1st. Continues to spit freely. Had yesterday a smart return of the fever; which, however, only held him about 12 hours. To-day there is a perfect remission, and he is in every respect greatly mended. Has had some hours good sleep. Complains very little of pain. Got out of bed for the first time; sat up three hours; and could even bear the light without being disturbed by it. Complained of being hungry. Allowed plenty of milk-porridge and small broth.

3d. The spitting keeps up to about a quart in the 24 hours. Found him out of bed to-day, and almost without complaints. He said his head was well; and that he only wanted strength, and to get rid of his fever and sore mouth. The remissions were now almost as long as the paroxysms, being about 12 hours each. Has taken no medicine internally since he left off the calomel, and was colitive. Ordered a dose of rhubarb; and, after its operation, a dram of the bark every four hours during the remissions.

6th. The spitting begins to decline. He has had no fever for the last 24 hours. He sleeps well; and has an appetite, if the foretaste of his mouth would let him eat. Headach and giddiness gone; but his pupils still continue much dilated. Ordered him another rhubarb-purge, and the bark to be continued every six hours.

9th. Has had no fever, or other complaints. Spitting inconsiderable; mouth better; aspect more natural; is able to walk about, and mends daily. Allowed him a more generous and substantial diet, and continued the bark twice a-day for another week.

From this time, he continued to get strength apace; had good nights, good appetite, a perfect freedom from headach and fever; and, on the 23d, went to work, being in every respect quite well, and has continued so ever since.

This patient did not seem to receive the smallest benefit from the blisters, or any thing else, till he took the mercury, which acted like a specific; and the fever seemed to be altogether symptomatic, as it easily yielded after the other complaints were removed.

XCIX. Apoplexy from Atrabilis. Sp. IV.

Apoplexia atrabiliaria, Sauv. sp. 12. Preysinger, sp. 6.

This takes place in the last stage of the diffusion of bile through the system, i.e., of the black jaundice, and in some cases the brain hath been found quite tinged brown. It cannot be thought to admit of any cure.

C. Apoplexy from External Violence. Sp. V.

Apoplexia traumatica, Sauv. sp. 2. Carus traumaticus, Sauv. sp. 5.

The treatment of this disease, as it arises from some external injury, properly falls under the article Surgery.

CI. Apoplexy from Poisons. Sp. VI.

Apoplexia temulenta, Sauv. sp. 3. Carus narcoticus, Sauv. sp. 14. Lethargus narcoticus, Sauv. sp. 3. Carus plumbaginis, Sauv. sp. 10. Apoplexia mephitica, Sauv. sp. 14. Asphyxia mephitide, Sauv. sp. 9. Asphyxia a multo, Sauv. sp. 3. Catalepsia a fumo, Sauv. sp. 3. Asphyxia a fumis, Sauv. sp. 2. Asphyxia a carbone, Sauv. sp. 16. Asphyxia foricariorum, Sauv. sp. 11. Asphyxia sideratorum, Sauv. sp. 10. Carus ab infestatione, Sauv. sp. 12. Carus a frigore, Sauv. sp. 15. Lethargus a frigore, Sauv. sp. 6. Asphyxia congelatorum, Sauv. sp. 5.

The poisons which bring on an apoplexy when taken internally are those of the stimulant and sedative kind, as spirituous liquors, opium, and the more virulent kinds of vegetable poisons. The vapours of mercury, or of lead, in great quantity, will sometimes produce a similar effect; though commonly they produce rather a paralysis, and operate slowly. The vapours of charcoal, or fixed air, in any form, breathed in great quantity, also produce an apoplexy, or a state very similar to it; and even cold itself produces a fatal sleep, though without the apoplectic snorting.—To enumerate all the different symptoms which affect the unhappy persons who have swallowed opium, or any of the stronger vegetable poisons, is impossible, as they are scarce to be found the same in any two patients. The state induced by them seems to differ somewhat from that of a true apoplexy; as it is commonly attended with convulsions, but hath the particular distinguishing sign of apoplexy, namely, a very difficult breathing or snorting, more or less violent according to the quantity of poisonous matter swallowed.

Of the poisonous effects of fixed air, Dr Percival gives the following account. "All these noxious vapours, whether arising from burning charcoal, the fermenting grape, the Grotti di Cani, or the cavern of Pyrmont, operate nearly in the same manner. When accumulated and confined, their effects are often instantaneous; they immediately destroy the action of the..." the brain and nerves, and in a moment arrest the vital motions. When more diffused, their effects are slower, but still evidently mark out a direct affection of the nervous system.

Those who are exposed to the vapours of the fermenting grape, are as instantly destroyed as they would be by the strongest electrical shock. A state of insensibility is the immediate effect upon those animals which are thrust into the Grotti di Cani, or the cavern of Pyrmont; the animal is deprived of motion, lies as if dead; and if not quickly returned into the fresh air, is irrecoverable. And if we attend to the histories of those who have suffered from the vapours of burning charcoal, we shall in like manner find, that the brain and moving powers are the parts primarily affected.

A cook who had been accustomed to make use of lighted charcoal more than his business required, and to fland with his head over these fires, complained for a year of very acute pain in the head; and after this, was seized with a paralytic affection of the lower limbs, and a slow fever.

A person was left reading in bed with a pan of charcoal in a corner of the room. On being visited early the next morning, he was found with his eyes shut, his book open and laid on one side, his candle extinguished, and to appearance like one in a deep sleep. Stimulants and cupping-glasses gave no relief; but he was soon recovered by the free access of fresh air.

Four prisoners, in order to make their escape, attempted to destroy the iron work of their windows, by the means of burning charcoal. As soon as they commenced their operations, the fumes of the charcoal being confined by the closeness of the prison, one of them was struck dead; another was found pale, speechless, and without motion; afterwards he spoke incoherently, was seized with a fever, and died. The other two were with great difficulty recovered.

Two boys went to warm themselves in a stove heated with charcoal. In the morning they were found destitute of sense and motion, with countenances as composed as in a placid sleep. There were some remains of pulse; but they died in a short time.

A fisherman deposited a large quantity of charcoal in a deep cellar. Some time afterwards, his son, a healthy strong man, went down into the cellar with a pan of burning charcoal and a light in his hand. He had scarcely descended to the bottom, when his candle went out. He returned, lighted his candle, and again descended. Soon after, he called aloud for assistance. His mother, brother, and a servant, hastened to give him relief; but none of them returned. Two others of the village shared the same fate. It was then determined to throw large quantities of water into the cellar; and after two or three days, they had access to the dead bodies.

Celsus Aurelianus says, that those who are injured by the fumes of charcoal become cataleptic. And Hoffman himself, in another part of his works, enumerates a train of symptoms which in no respect correspond with his idea of suffocation. Those who suffer from the fumes of burning charcoal, says he, have severe pains in the head, great debility, faintness, stupor, and lethargy.

It appears from the above histories and observations, that these vapours exert their noxious effects on the brain and nerves. Sometimes they occasion sudden death; at other times, the various symptoms of a debilitated nervous system, according as the poison is more or less concentrated. The olfactory nerves are first and principally affected, and the brain and nervous system by sympathy or consent of parts. It is well known, that there is a strong and ready consent between the olfactory nerves and many other parts of the nervous system. The effluvia of flowers and perfumes, in delicate or irritable habits, produce a train of symptoms, which, though transient, are analogous to those which are produced by the vapours of charcoal; viz. vertigo, sickness, faintness, and sometimes a total insensibility. The female malefactor, whom Dr Mead inoculated by putting into the nostrils dossils of cotton impregnated with variousious matter, was immediately on the introduction, afflicted with a most excruciating headache, and had a constant fever till after the eruption.

The vapours of burning charcoal, and other poisonous effluvia, frequently produce their prejudicial, and even fatal effects, without being either offensive to the smell or oppressive to the lungs. It is a matter of importance therefore, that the common opinion should be more agreeable to truth; for where suffocation is supposed to be the effect, there will be little apprehension of danger, so long as the breath keeps free from pain or oppression.

It may be well to remember, that the poison itself is distinct from that gross matter which is offensive to the smell; and that this is frequently in its most active state when undistinguished by the sense. Were the following cautions generally attended to, they might in some instances be the happy means of preserving life. Never to be confined with burning charcoal in a small room, or where there is not a free draught of air by a chimney or some other way. Never to venture into any place in which air has been long pent up, or which from other circumstances ought to be suspected; unless such suspected place be either previously well ventilated, or put to the test of the lighted candle. For it is a singular and well-known fact, that the life of flame is in some circumstances sooner affected and more expeditiously extinguished by noxious vapours, than animal-life. A proof of which I remember to have received from a very intelligent clergyman, who was present at a musical entertainment in the theatre at Oxford. The theatre was crowded; and during the entertainment, the candles were observed to burn dim, and some of them went out. The audience complained only of faintness and languor; but had the animal effluvia been still further accumulated or longer confined, they would have been extinguished as well as the candles.

The most obvious, effectual, and expeditious means of relief to those who have unhappily suffered from this cause, are such as will dislodge and wash away the poison, restore the energy of the brain and nerves, and renew the vital motions. Let the patient therefore be immediately carried into the open air, and let the air be fanned backwards and forwards to assist its action; let cold water be thrown on the face; let the face, mouth, and nostrils, be repeatedly washed; and as soon With regard to the pernicious effects of cold, there is no other way of counteracting them but by the application of external heat. We are apt to imagine, that the swallowing considerable quantities of ardent spirits may be a means of making us resist the cold, and preventing the bad effects of it from arising to such an height as to destroy life; but these do not appear to be in the least possessed of any such virtue in those countries liable to great excesses of cold.

The Peruvian bark, by strengthening the solids, as well as increasing the motion of the fluids, is found to answer better than any other thing as a preservative; but when the pernicious effects have already begun to discover themselves, nothing but increasing by some means or other the heat of the body can possibly be depended upon; and even this must be attempted with great care; for as, in such cases, there is generally a tendency to mortification in some of the extremities, the sudden application of heat will certainly increase this tendency to such a degree as to destroy the parts. But for the external treatment of such mortifications, see the article Surgery.

CIII. Apoplexy from Passions of the Mind. Sp. VII.

Carus a pathemate, Sauv. sp. 11. Alphixia a pathemate, Sauv. sp. 7. Ecstasis catoque, Sauv. sp. 1. Ecstasis resoluta, Sauv. sp. 2.

Apoplexies from violent passions may be either sanguineous or ferous, though more commonly of the former than the latter species. The treatment is the same in either case. Or they may partake of the nature of catalepsy; in which case the method of treatment is the same with that of the genuine catalepsy. See below.

CIV. The Cataleptic Apoplexy. Sp. VIII.

Cataplexis, Sauv. gen. 176. Lin. 129. Veg. 230. Sag. gen. 281. Berth. 1036. Junck. 44.

Dr Cullen says he has never seen the catalepsy except when counterfeited; and is of opinion that many of those cases related by other authors have also been counterfeited. It is said to come on suddenly, being only preceded by some languor of body and mind; and to return by paroxysm. The patients are for some minutes, sometimes (though rarely) for some hours, deprived of their senses, and all power of voluntary motions; but constantly retaining the position in which they were first seized, whether lying or sitting; and if the limbs are put into any other posture during the fit, they will keep the posture in which they are placed. When they recover from the paroxysm, they remember nothing of what passed during the time of it, but are like persons awakened out of sleep.—Concerning the cure of this disorder we find nothing which can be depended upon among medical writers.

CV. Apoplexy from Suffocation. Sp. IX.

Alphixia suspensorum, Sauv. sp. 4. Alphixia immerorum, Sauv. sp. 1.

This is the kind of apoplexy which takes place in those GENUS XLV. PARALYSIS, the Palsy.

Paralysis, Boerh. 1557. Hemiplegia, Sauv. gen. 170. Lin. 103. Veg. 228. Paraplexia, Sauv. gen. 171. Paraplegia, Lin. 102. Veg. 227. Paralysis, Sauv. gen. 169. Lin. 104. Veg. 226. Func. 115. Atonia, Lin. 120.

CVI. The Partial Palsy. Sp. I.

Paralysis, Sauv. gen. 169. Lin. 104. Veg. 226. Func. 115. Paralytic plethora, Sauv. sp. 1. Paralytic soroa, Sauv. sp. 12. Paralytic nerves, Sauv. sp. 11. Mutitas a gloffolys, Sauv. sp. 1. Aphonia paralytica, Sauv. sp. 8.

CVII. Hemiplegia, or Palsy of one side of the Body. Sp. II.

Hemiplegia, Sauv. gen. 170. Lin. 108. Veg. 228. Sag. gen. 276. Hemiplegia ex apoplexy, Sauv. sp. 7. Hemiplegia spasmodica, Sauv. sp. 2. Hemiplegia soroa, Sauv. sp. 10.

CVIII. Paraplegia, or Palsy of one half of the Body taken together. Sp. III.

Paraplexia, Sauv. gen. 171. Sag. gen. 277. Paraplegia, Lin. 102. Veg. 227. Paraplexia sanguinea, Sauv. sp. 2. Paraplexia a spina bifida, Sauv. sp. 3. Paraplexia rheumatics, Sauv. sp. 1.

Description. The palsy shows itself by a sudden loss of tone and vital power in a certain part of the body. In the slighter degrees of the disease, it only affects a particular muscle, as the sphincter of the anus or bladder, thus occasioning an involuntary discharge of excrements or urine; of the muscles of the tongue, which occasions stammering, or loss of speech; of the muscles of the larynx, by which the patient becomes unable to swallow solids, and sometimes even liquids also.—In the higher degrees of the disease, the paralytic affection is diffused over a whole limb, as the foot, leg, hand, or arm; and sometimes it affects a whole side of the body, in which case it is called hemiplegia; and sometimes, which is the most violent case, it affects all the parts below the waist, or even below the head, though this last is exceedingly rare. In these violent cases, the speech is either very much impeded, or totally lost. Convulsions often take place in the sound side, with the cynic spasm or involuntary laughter, and other distortions of the face. Sometimes the whole paralytic part of the body becomes livid, or even mortifies before the patient's death; and sometimes the paralytic parts gradually decay and shrivel up, so as to become much less than before.

Causes, &c. Palsies must commonly supervene the different species of coma, especially the apoplexy. They are also occasioned by any debilitating power applied to the body, especially by excesses in venery. Sometimes they are a kind of crisis to other distempers, as the colic of Poitou, and the apoplexy. The hemiplegia especially often follows the last mentioned disease. Aged people, and those who are by any other means debilitated, are subject to palsy; which will sometimes also affect even infants, from the repulsion of exanthemata of various kinds. Palsies are also the infallible consequences of injuries of the large nerves.

Prognosis. Except in the slighter cases of palsy, we have little room to hope for a cure; however, death doth not immediately follow even the most severe paralytic affections. In an hemiplegia it is not uncommon to see the patients live several years; and even in the paraplegia, if death does not ensue within two or three weeks, it may not take place for a considerable time. It is a promising sign when the patient feels a slight degree of painful itchiness in the affected parts; and if a fever should arise, it bids fair to cure the palsy. When the sense of feeling remains, there is much more room to hope for a cure than where it is gone, as well as the power of motion. But when we observe the flesh to waste, and the skin to appear withered and dry, we may look upon the disease to be incurable. Convulsions supervening on a palsy are a fatal sign.

Cure. Many remedies have been recommended in palsies: but it must be confessed, that, except in the slighter cases, medicines seldom prove effectual; and before any scheme of cure can be laid down, every circumstance relative to the patient's habit of body and previous state of health should be carefully weighed. If an hemiplegia or paraplegia should come on after an apoplexy, attended with those circumstances which physicians have supposed to denote a viscid state of the blood, a course of the attenuant gums, with fixed alkaline salts, and chalybeate waters, may do service; to which it will be proper to add frictions with the volatile liniment all down the spine: but in habits where the blood is rather inclined to the watery state, it will be necessary to give emetics from time to time; to apply blisters, and cut ulcers.

The natural hot baths are often found useful in paralytic cases; and where the patients cannot avail themselves of these, an artificial bath may be tried by dissolving salt of steel in water, and impregnating the water with fixed air. Frictions of the parts, and scourging them with nettles, have also been recommended, and may do service, as well as volatile and stimulating medicines taken inwardly.

CIX. The Palsy from Poisons. Sp. IV.

Paralysis metallariorum, Sauv. sp. 22. Hemiplegia saturnina, Sauv. sp. 14.

This kind of palsy arises most frequently from lead taken into the body, and is a consequence of the colics pictorum, under which it is particularly treated. See below. CX. TREMOR, or Trembling.

Tremor, Sauv. gen. 129. Lin. 139. Veg. 184. Sag. 236.

This by Dr Cullen is reckoned to be always symptomatic either of palsy, athenia, or convulsions; and therefore cannot be treated of by itself.

ORDER II. ADYNA MIÆ.

ADYNAMIE, Veg. Clas VI. Defectivi, Lin. Clas VI. Order I. Leiopothymia, Sauv. Clas VI. Order IV. Sag. Clas IX. Order IV.

GENUS XLVI. SYNCOPE, or Fainting.

Syncope, Sauv. gen. 174. Sag. 94. Veg. 274. Sag. 280. Funck. 119. Leiopothymia, Sauv. gen. 173. Lin. 93. Veg. 273. Sag. 279. Alphyxia, Sauv. gen. 175. Lin. 95. Veg. 275. Sag. 281. Virium laplus et animi deliquia. Hoffm. III. 267.

CX. The Cardiac Syncope. Sp. I.

Syncope plethorica, Sauv. sp. 5. Senac. Tr. de Coeur, p. 540. Syncope a cardiogmo, Sauv. sp. 7. Senac. de Coeur, 414. Morgagn. de Sed. XXV. 2. 3. 10. Syncope a polyypo, Sauv. sp. 8. Senac. p. 471. Syncope ab hydrocardia, Sauv. sp. 12. Senac. 533. Schreiber Almag. L. III. § 196. Syncope lanzoni, Sauv. sp. 18. Lanzon. Op. II. p. 462. Alphyxia valsalviana, Sauv. sp. 13.

CXI. Occasional Syncope. Sp. II.

Leiopothymia a pathemate, Sauv. sp. 1. Senac. p. 544. Syncope pathetica, Sauv. sp. 21. Alphyxia a pathemate, Sauv. sp. 7. Syncope ab antipathia, Sauv. sp. 9. Senac. p. 554. Syncope a veneno, Sauv. sp. 10. Senac. p. 546. Syncope ab apostematis, Sauv. sp. 11. Senac. p. 554. Syncope a sphacelo, Sauv. sp. 14. Senac. p. 553. Syncope ab insanitione, Sauv. sp. 1. Senac. p. 536. Syncope a phlebotomia, Sauv. sp. 4. Syncope a dolore, Sauv. sp. 2. Senac. p. 583. Alphyxia traumatica, Sauv. sp. 14. Alphyxia neophytorum, Sauv. sp. 17.

Description. A syncope begins with a remarkable anxiety about the heart; after which follows a sudden extinction, as it were, not only of the animal-powers and actions, but also of the vital powers, so that the patients are deprived of pulse, sense, and motion, all at once. In those cases which physicians have distinguished by the name of leiopothymia, the patient does not entirely lose his senses, but turns cold and pale; and the pulse continues to beat, though weakly; the heart also seems to tremble rather than beat; and the respiration is just perceptible. But in the true syncope or full alphyxia, not the smallest sign of life can be perceived; the face hath a death-like paleness, the extremities are cold, the eyes shut, or at least troubled; the mouth sometimes shut, and sometimes gaping wide open; the limbs flaccid, and the strength quite gone; as soon as they begin to recover, they fetch deep and heavy sighs.

Causes, &c. Fainting is occasioned most commonly by profuse evacuations, especially of blood; but it may happen also from violent passions of the mind, from surfeits, excessive pain, &c. People of delicate constitutions are very subject to it from slight causes; and sometimes it will arise from affections of the heart and large vessels not easy to be understood. Fainting is also a symptom of many disorders, especially of that fatal one called a polypus of the heart, of the plague, and many putrid diseases.

Prognosis. When fainting happens in the beginning of any acute distemper, it is by no means a good omen; but when it takes place in the increase or at the height of the disease, the danger is somewhat less; but in general, when fainting comes on without any evident cause, it is to be dreaded. In violent hemorrhages it is favourable; as the bleeding vessels thus have time to contract and recover themselves, and thus the patient may escape.

Cure. When persons of a full habit faint through excess of passion, they ought to be bleded without delay, and should drink vinegar or lemon-juice diluted with water; and, after the bowels are emptied by a clyster, take a paregoric draught, and go to bed.

The passion of anger, in a peculiar manner, affects the biliary secretion, causes an oppression at the stomach, with nausea and retching to vomit, and a bitter taste in the mouth, with giddiness; these symptoms seem to indicate an emetic; which, however, in these cases must be carefully avoided, as it might endanger the patient, by bringing on an inflammation of the stomach.

The general effects of a sudden fright have been mentioned on a former occasion. When these are so violent as to require medical aid, our first endeavours must be to take off the spasmodic constriction, and restore freedom to the circulation; by bleeding, if the habit be at all inclined to fulness; and by giving a mixture, with equal parts of the vinum antimoniale and elixir paregoricum, in some agreeable vehicle, which will bring on sleep and encourage perspiration.

It was formerly mentioned, that convulsions, or even an epilepsy, may be brought on by frights; which should make people cautious of playing foolish tricks in this way.

When a surfeit, or any species of satiety, occasions a leiopothymia, an emetic is the immediate remedy, as soon as the patient, by the help of acid stimulants, shall be so far roused as to be able to swallow one; in these cases, tickling the fauces with a feather dipped in spirit of hartshorn, will be proper, not only to rouse the patient, but also to bring on vomiting.

A syncope is most commonly brought on by profuse discharges or evacuations, either of the blood or of the secreted humours.

In order to revive the patients, they ought to be laid along in a horizontal posture, in an airy place; the legs, thighs, and arms, are to be rubbed with hot flannels; very strong vinegar, or salt of hartshorn, or the spirit of this or of sal ammoniac are to be held to the nostrils, and robbed into them; or, being properly diluted, poured down the throat; cold water is to be sprinkled on the face and neck; and when by these means the patient shall be sufficiently revived, wine boiled up with some grateful aromatic, is to be given in the proper quantity.

In the fainting consequent upon profuse uterine hemorrhages, it will be a safer practice to abstain from all heating and stimulant things; as life, in these cases, is preserved by the coagulation of the blood in the extremities of the open vessels; which might be prevented, by the pouring in hot wine or volatile alkaline spirits.

When a syncope is the consequence of the too violent operation of either an emetic or cathartic, the tinctura thebaica, mixed with spiced wine, is the most efficacious remedy; but the opiate must be given gradually, and in very small doses.

A syncope, or even apoplexy, wherein the patient shall lie for several hours, is frequent in hysterical constitutions; and during the fit requires fetid antispasmodics, together with acid stimulants: to prevent returns, nothing answers better than the bark joined with chalybeates.

CXI. DYSPEPSIA, or Difficulty of Digestion.

Genus XLVI.

Dyspepsia, Veg. 277. Apergia, Veg. 276. Disphora, Veg. 278. Anorexia, Sauv. gen. 162. Lin. 116. Sag. gen. 268. Cardialgia, Sauv. gen. 202. Lin. 48. Veg. 157. Sag. gen. 160. Gastrodynia, Sauv. gen. 203. Sag. gen. 161. Soda, Lin. 47. Veg. 161. Nausea, Sauv. gen. 250. Lin. 182. Veg. 159. Sag. gen. 185. Vomitus, Sauv. gen. 251. Lin. 183. Veg. 214. Sag. gen. 186. Flatulentia, Sauv. gen. 271. Lin. 165. Veg. 127. Sag. gen. 207.

The idiopathic Species are,

Anorexia pituituosa, Sauv. sp. 2. Anorexia a faburra, Sauv. sp. 9. Anorexia exhaustorum, Sauv. sp. 8. Anorexia paralytica, Sauv. sp. 1. Nausea ex cacochylia, Sauv. sp. 11. Vomitus pituitulos, Sauv. sp. 26. Vomitus ruminatio, Sauv. sp. 6. Vomitus a faburra, Sauv. sp. 2. Vomitus a crapula, Sauv. sp. 1. Vomitus lacteus, Sauv. sp. 3. Flatulentia infantilis, Sauv. sp. 5. Flatulentia acida, Sauv. sp. 1. Flatulentia nidrofa, Sauv. sp. 2. Cardialgia bradypepta, Sauv. sp. 9. Cardialgia a faburra, Sauv. sp. 2. Cardialgia lactostium, Sauv. sp. 11. Cardialgia flatulenta, Sauv. sp. 3. Cardialgia paralytica, Sauv. sp. 7. Gastrodynia faburralis, Sauv. sp. 1. Gastrodynia flatulenta, Sauv. sp. 2. Gastrodynia periodynia, Sauv. sp. 7. Gastrodynia astrigens, Sauv. sp. 9. Gastrodynia alterens, Sauv. sp. 10. Gastrodynia a frigore, Sauv. sp. 18.

Besides these there are a great number of symptomatic Species.

Description. It is by no means easy to define exactly the distemper called dyspepsia, when considered as an original disease, seeing there are very few maladies which some way or other do not show themselves by an affection of the stomach; and much more difficult still must it be to enumerate all its symptoms. The most remarkable, however, and the most common, are the following: Want of appetite; distention of the stomach when no food hath been taken for some time before; slight dejection of spirits; a gradual decay of the muscular strength; languor, and aversion from motion; the food which is taken without appetite is not well digested; the stomach and intestines are much distended with flatus, whence the patients are tormented with spasms, gripes, and sicknesses; frequently a limpid water, having an acid or putrid taste, is brought up; sometimes the food itself is thrown up by mouthfuls; and sometimes, though rarely, the same is swallowed again, after the manner of ruminating animals. While matters are in this situation, the heart sometimes palpitates, and the breath is quick, and drawn with difficulty; the head aches and is giddy; and sometimes both these symptoms are continual, and very violent, insomuch that the patient is not only tormented with pain, but flaggers as if he was drunk. By reason of the too great acæscency or putrefaction of the aliment, a cardialgia or heartburn comes on, and in this situation a spontaneous diarrhoea sometimes carries off the disease; but in other cases there is an obstinate coliciveness, attended with colic-pains. Frequently the pulse is quick, sometimes slow, but always weak: the circulation is so languid that the blood can scarce reach the extreme vessels, or at least stagnates in them, so that the face becomes livid, swelled, and has an unusual appearance: and at the same time that the circulation and nervous power are in this languid state, the perspiration becomes less copious; the skin becomes dry and corrugated; the natural heat, especially of the extremities, is much diminished; the tongue is white; and an universal laxity takes place, insomuch that the uvula and velum pendulum palati are sometimes enlarged to such a degree as to become extremely troublesome. The patient is either deprived of rest, or wakes suddenly out of his sleep, and is disturbed by frightful dreams; at the same time that the mind seems to be affected as well as the body, and the person becomes peevish, fretful, and incapable of paying attention to anything as usual. At last hectic symptoms come on, and the whole frame becomes so irritable, that the slightest cause excites an universal tremor, and sometimes violent vomiting and diarrhoea. Sometimes the salivary glands are so relaxed, that a salivation comes on as if excited by mercury; the serum is poured out into the cavity of the abdomen and cellular substance of the whole body, and the patient becomes affected with anaërea or ascites.

Causes, &c. The causes of dyspepsia may be anything which debilitates the system in general, but in a

Practice particular manner affects the stomach. Such are opium taken in immoderate quantities, which hurts by its sedative and relaxing powers; spirituous liquors drunk to excess; tobacco, tea, coffee, or any warm relaxing liquor, taken in too great quantity; acid, unripe fruits; vomits or purges too frequently taken; an indolent sedentary life, &c. &c. All these act chiefly upon people of a weak and delicate habit; for the robust and hardy seldom labour under a dyspepsia, or at most a very slight one.

Prognosis. When a dyspepsia first occurs, it is frequently removed without great difficulty; when it is symptomatic, we must endeavour to cure the primary disease; but when it frequently returns with symptoms of great debility, hectic, or dropsy, we have great reason to dread the event.

Cure. A radical cure of dyspepsia is only to be expected from tonic medicines, which can remove from the stomach and system that debility on which the disease depends. But, previous to their use, it will be necessary to evacuate the contents of the alimentary canal by vomits or purgatives. If there is a tendency to putrefaction, antiseptics must then be exhibited; but more frequently there is a prevailing acidity, which creates an intolerable heart-burn. To palliate this symptom, magnesia alba may be given; which is much preferable to the common talcaceous powders, as being purgative when dissolved in an acid, while the others are rather astringent. In the third volume of the Medical Observations, we have an account of two cases of dyspepsia attended with a very uncommon degree of cardialgia, in which magnesia was so successful, that we can scarce doubt of its efficacy in slighter degrees of the disorder. They were communicated by Dr Watson.

"A woman, aged 34, the mother of several children, was taken, in the fourth month of her pregnancy with violent vomitings; which growing daily worse, notwithstanding the endeavours of her apothecary to restrain them, brought on at the end of a month such severe pains in the stomach, and spasms in her abdomen, as to occasion abortion. The vomitings were not lessened by this event, but grew worse, and frequently brought on general convulsions to such a degree, that she was many times supposed to be at the point of death.

"Scarce any medicine flaid with her, she brought up almost instantly whatever was given her as nourishment, either in a solid or liquid form. She was exceedingly pale, and very much emaciated; her flesh was cold to the touch; and, though her urine was little in quantity, it was perfectly limpid. She had a continual thirst, and was, in a considerable degree, colitive. Her pulse was slow and quick, and she was frequently tormented with the hiccup. The pain in her stomach was severe and constant, and whatever she brought up was sharp to such a degree, as to make her mouth and throat very sore. These parts upon examination appeared high-coloured, and in many places excoriated; and the pain felt in her stomach upon swallowing any liquor, that had the least degree of acrimony, or was more than luke-warm, made it probable the stomach itself, in its internal surface, was affected in the same manner.

"In this wretched state I was consulted; and must confess that I was much at a loss how to relieve a patient so debilitated, and whose stomach was in so defeated a state, that it seemed incapable of retaining any appropriated remedies long enough to correct the acrimony of the juices, and restore the secretions to a more mild and natural state. Anti-emetics of various kinds had been tried without effect, particularly saturated solutions of alkaline salt in juice of lemons. Stomachic medicines of the warm and aromatic kind she could not bear, on account of their pungency; and, tho' nothing could so speedily correct the almost caustic acid of the gastric juice as solutions of alkaline salts, neither the faucies or gullet could bear their acrimony.

"My expectations of relieving this patient, small as they were, depended upon my being able to neutralize, and thereby lessen, the stimulus of the acid of the stomach. To accomplish this was not very easy, as no medicine in small doses could in any considerable degree correct so intense an acid; and, in the present situation, it was difficult to get any medicine to stay long enough to exert its effects. To discharge however what acid matter might be already accumulated in the stomach, I directed that the patient should drink plentifully of small, warm, unsalted mutton-broth, and vomit with it so long that it should be discharged with no other taste than that of broth. This was complied with, and a large quantity drank. The pain in her stomach ceased upon this for more than two hours, and was after that time apparently coming on with the same violence as before. Upon which I ordered a drachm of magnesia to be given in two ounces of veal-broth. This kept down, and eased her; I therefore directed the same dose to be repeated as often as the pain returned, without any regard to the quantity that the whole might amount to, supposing that the pain continued severe. This was done; and in three days she took three ounces of magnesia, of which very few doses were vomited up, and she was purged considerably.

"This medicine was continued in a somewhat less quantity for three days longer, in which she took two ounces more of magnesia; by this time the vomitings ceased, the convulsions left her, she had no pains in the stomach, and her mouth and fauces lost their intensely red colour and soreness; nor did even her evacuations longer indicate any acidity.

"Besides veal-broth she was allowed boiled rice, and now then some rice gruel with a small quantity of brandy; and after a few days more she could retain boiled chicken, and other light, solid, animal-food.

"When her stomach was in this state, she took liberally of decoct. cort. Peruvian., with a small portion of French brandy, by which and her nourishment, she recovered her strength surprisingly. To this medicine, as she was during the latter part of her illness considerably anaemicous, were added some preparations of steel; and in about a month she perfectly recovered.

"When this patient's stomach was relieved, the thirst, the general and partial spasms, and other complaints, which were merely symptomatic, soon ceased; and what remained of her cure was by no means difficult.

"Since the above-recited case, I was consulted in another..." CXIII. CHLOROSIS, the Green-sickness.

Genus XLVIII.

Chlorosis, Sauv. gen. 309. Lin. 222. Veg. 305. Sag. gen. 135. Boerh. 1285. Hoffm. iii. 311. Juncck. 86.

Chlorosis virginea, Sauv. sp. 1. a. Chlorosis amatoria.

Description. This disease usually attacks girls a little after the time of puberty, and first shows itself by symptoms of dyspepsia. But a distinguishing symptom is, that the appetite is entirely vitiated, and the patient will eat lime, chalk, ashes, salt, &c. very greedily; while at the same time there is not only a total inappetence to proper food, but it will even excite nausea and vomiting. In the beginning of the disease, the urine is pale, and afterwards turbid; the face becomes pale, and then assumes a greenish colour; sometimes it becomes livid or yellow; the eyes are sunk, and have a livid circle round them; the lips lose their fine red colour; the pulse is quick, weak, and low, though the heat is little short of a fever, but the veins are scarcely filled; the feet are frequently cold, swell at night, and the whole body seems covered with a soft swelling; the breathing is difficult; nor is the mind free from affection as well as the body; it becomes irritated by the slightest causes; and sometimes the patients love solitude, become sad and thoughtful. There is a retention of the menses throughout the whole course of the disorder; and at last, all the bad symptoms increasing, a leucophlegmatia, anaesthesia, atrophy, and death, succeed.

Cause. The cause of chlorosis is thought to be an atony of the muscular fibres of the alimentary canal, especially of the stomach, joined with a similar atony of the perspiratory vessels over the whole surface of the body, and the whole depending on an atony of those small arteries which pour out the menstrual blood. This atony may be occasioned by the same causes which bring on dyspepsia and hypochondriasis, but very frequently arises from love and other passions of the mind.

Prognosis. The chlorosis in all cases is tedious, though it doth not generally prove fatal; but we can never promise a certain cure unless the menses make their appearance.

Cure. The remedies here in general are the same as in the dyspepsia and hypochondriasis; only in the chlorosis stronger purgatives may be made use of; those which stimulate the rectum are useful by stimulating also the vessels of the uterus; and for this reason also venery is to be indulged where it can lawfully be done. The cold bath is also extremely proper.

ORDER III. SPASMI.

Spasmi, Sauv. Class IV. Veg. Class V. Sag. Class VIII.

Motorii, Lin. Class VII.

Morbi spasmodici et convulsivi, Hoffm. III. 9. Spasmi et convulsiones, Juncck. 45, 54. Epilepsia, Boerh. 1071, 1088.

CXIV. CXIV. The TETANUS. Genus XLIX.

Tetanus, Sane. gen. 122. Lin. 127. Veg. 180. Sag. gen. 228. Catochus, Sane. gen. 123. Lin. 128. Veg. 183. Sag. gen. 229. Opilhotonos, Veg. 181. Epilhotonos, Veg. 182.

On this distemper Dr Lionel Chalmers hath published a dissertation in the first volume of the Medical Observations, which being superior to any thing that hath appeared in other medical writers on the subject, we shall here lay before the reader.

"Of all the diseases to which man is subject, none deserves more to be considered than the opilhotonos and tetanus, either with regard to the variety of painful symptoms which almost without intermission distract the sick, or the danger of the diseases themselves, from which few recover, in comparison of the number they attack. In both, the vital actions are very imperfectly performed, most of those which are called natural, being as it were suspended at once, and so far is the patient from being able to execute any voluntary motion, that the whole machine undergoes the most excruciating distortions, from the violent and unnatural contractions of the muscles. Happy it is for the inhabitants of the more temperate climates, that such diseases appear rarely among them; but in those countries which lie in the more southern and warmer latitudes, they are endemic, especially to negro slaves. In South-Carolina, they show themselves at all seasons, but not so often in winter, more frequently in spring and autumn; and are most common in the summer, when people work abroad and are alternately exposed to the scorching heat of the sun and heavy showers, which often happen suddenly, and greatly alter the temperature of the air. Others are seized with the opilhotonos, after sleeping without doors, that they may enjoy the deceitful refreshment of the cool night-air, when the weather is warm: one youth chose to cut off his hair and shave his head on a warm day in March, and went to bed without a cap; but the weather changed, and became cold in the night, and he was found rigid with that disease next morning.

"These diseases so rarely appear as originals in Europe, that a good history of them cannot be expected from the physicians who practice in that part of the world; nor has any thing like a full description been given of them by any ancient or modern author which I have seen. Hippocrates indeed takes notice of them in many places, and seems to regard them only as consequences of other diseases, or of wounds or ulcers of the nervous or tendinous parts, of which symptomatic kind of opilhotonos he gives three remarkable cases in lib. V. § VII. de Morb. vulg., and repeats them in another place; but the few symptoms he recounts do not shew themselves with us. Galen, Caelius Aurelianus, Aretaeus, &c. seem only to have copied Hippocrates, with the addition of some supposititious symptoms, which really do not appear; and the little that Bontius says of it, is very faulty.

"Among the numerous class of spasmodic diseases, there are three which distinguish themselves in a very particular manner, on which the names of emprosthotonos, opilhotonos, and tetanus, have been justly enough bestowed, as being expressive of the posture into which they throw and confine the patient: When therefore those muscles which bend the head, neck, and body forwards, suffer such involuntary, violent, and continued contractions, as fix the chin to the breast, incurvate the spine and body, and retain the sick in this painful and prone posture, the disease is called emprosthotonos. When the posterior muscles are similarly affected, so that the head is drawn towards the spine, and the spine itself is recurvated, it has then the name of opilhotonos; although in fact, in this, all those muscles which act in deglutition, bend the head forwards, or turn it to either side, are equally contracted with those which raise the head and spine. The tetanus differs from, or rather is compounded of, both the others; for in this the patient is found rigid and inflexible, being as it were braced between the opposite contractions of the anterior and posterior muscles; yet even here the head is much retracted.

"I never saw the emprosthotonos; and shall only speak of the opilhotonos and tetanus, the first being by far the most common, and in the last stage of which the tetanus frequently supervenes. And let it be observed, that the following description by no means respects such symptomatic contractions as often happen immediately before death, both in acute and chronic diseases; neither will it agree with that spurious opilhotonos or tetanus, which appear sometimes in the first and second stages of quotidian intermittents in this country, however they may emulate the true diseases in some of their symptoms.

"STAD. I. The opilhotonos, contrary to what Bontius asserts, often comes on gradually and by slighter approaches, the patient complaining rather of an uneasiness in the back-part of the neck and about the shoulders, than of any acute pain, with some degree of a general languor. These increase, and become so troublesome when he attempts to turn his head, or to bend it forward, as to oblige him to walk very erect; for he can by no means look downward, nor to either side, without turning his whole body. He cannot open his jaws without pain; and has some difficulty in swallowing, which discourages him from attempting to eat. At times he feels a sudden and painful traction under the cartilage ensiformis, which strikes thro' the back, and instantly increases the rigidity about the neck and shoulders, draws the head backward a little, and shuts the jaws closer. The pain under the sternum returns more frequently and with greater violence; and the other contractions become so strong, that the head from this time continues much retracted, and he now refuses nourishment, as swallowing is attended with great pain, and occasions a return of the spasm; which extends along the spine quite to the lower extremities, so that they will no longer support him, and he is under the necessity of going to bed.

"In this manner passes over the first stage of the opilhotonos, which sometimes takes up three or four days; the patient, as well as those about him, mistaking the first appearances of it for that rheumatic complaint, which is commonly called a crick in the neck; but it sometimes forms itself much quicker, and

much as possible; and avoid drinking, speaking, or being moved, either of which are apt to occasion a return of the spasm.

"STAD. III. In this last stage, the patient is reduced to the most calamitous and distressful circumstances; for he is on a continual rack, according to the most literal meaning of that word, the spasm returning oftener than once in a minute, is much more violent, and holds him longer, so that he has scarcely any remission. The anterior muscles of the whole body now suffer equal contractions with the posterior; but the last overcome the force of the others, so that the spine is strongly recurvated, and forms a hollow arch with the head, and he rests on the back part of the head and the heels. The belly is flat, and is drawn inward; and the muscles are so rigidly contracted, that they will not give way to pressure, and do not seem in the least to yield to the descent of the diaphragm in inspiration, the several muscles about the neck, sides, and abdomen, being plainly distinguishable from each other. Although the lower extremities are always rigid in this state, yet are they so suddenly and violently distended in the time of the spasms, that were it not for the flanders-by, he would be projected feet foremost off the bed; while others again are as it were pushed upward with such a spring, that the head is struck with great force against whatever happens to be in the way, the thighs and legs being in this case no less rigid than the other parts. The tongue is spasmodically darted out, and is often miserably torn, as the teeth are that moment snapped together, so that it is necessary to prevent this by keeping the handle of a spoon, wrapped round with soft rags, between the teeth, when this can be done. At the time that the tongue is thus thrust out, the muscular flesh, which lies between the arch of the lower jaw and head of the trachea, seems to be drawn upwards within the throat. The countenance is very much contracted, and he is in a foam of sweat, the heat being very great; and the pulse between the spasms is exceeding quick, small, and irregular, although the heart throbs so strongly, that its motions may be plainly seen, and a palpitating subfultory kind of undulation may not only be felt, but perceived all over the epigastric region. The eyes are watery and languid, and a pale or bloody froth bubbles out from between the lips. The jaws are for the most part locked fast, so that it is impossible to give drink or nourishment, nor could he swallow if anything was put into his mouth. In this state they are commonly delirious: and as they cannot subsist many hours, under so great a suspension of the vital and natural functions, a mortal anxiety ensues and releases them; oftener a continued and severe spasm finishes the tragedy, when it was before almost at an end; but most frequently a general convulsion puts a period to their sufferings; and whichever way this happens, they for the most part relax just before death.

"In the tetanus, the general symptoms are nearly the same as in the opithotonos, except that from the first attack, the lateral, abdominal, and other anterior muscles, are equally contracted with the posterior ones; and the arms become rigid as well as the lower extremities. The abdomen is always flat and rigid as in the last stage of the opithotonos, and its contents seem to be thrust up into the thorax, which at the same

Vol. VI. Practice time appears to be much dilated. There are here also some intervals between the spasms, in the time of which the cheeks are drawn towards the ears, so that all the teeth may be seen as in the spasmodus cynicus. Deglutition is more free in this than in the other disease; yet so far is the sick from being equally balanced between the contractions of the opposite muscles, that the head is retracted and the spine is recurvated, although not quite so much as in the opiphotonos. And the spasm, which commences under the sternum, is likewise common to the tetanus, which terminates as the other, and on the same fatal days. But whoever recovers from either, labours long under a general atonia; and they cannot for some months raise themselves from a supine or recumbent posture without pain, nor without help for some time."

Prognosis and Cure. There has never been anything like a crisis observed in these frightful cases, or favourable termination from the mere efforts of nature, and therefore all the physician's dependence must be upon art. Fortunately it has been found, that opium is capable of giving some relief, if administered in proper time, and the disease happens not to be in the most violent degree: the warm bath must also be brought in aid; and the patients should lie horizontally in the bath, and while in it have the whole body extremely well rubbed: when taken out, they are not to be dried, but immediately put to bed wrapped in the softest blankets; and while they remain there, the belly ought either to be stuffed, or two or three bladders filled with warm water kept constantly lying on it. The bowels at the same time must, if possible, be kept open, by solutions of manna and sal polyphretis, or some other purging salt, mixed with oleum ricini; or if that should not be at hand, with oil of sweet almonds and a little tincture of senna. The opiates are to be given in large and frequently repeated doses; such as a grain of the extractum Thebaicum, or 20 drops of the tincture, every second or third hour; and it will be safest not to trust to the Thebaic tincture which is kept ready prepared in the shops, but order the necessary dose of solid opium, and either give it in pills, or dissolve it in some convenient liquid. If swallowing should be difficult, or the jaws closed up, the opium must be given in elysters; for during the whole course of the disease it will be of service to order emollient elysters to be injected from time to time, since these will answer not only as a relaxing fomentation, but also contribute to keep the intestinal canal perfectly free.

When the patients recover, they continue for a long time very relaxed and weak; and no wonder, since it is the nature of all spasmodic affections to leave behind them extreme weaknesses and relaxation of the muscular fibres. In order to perfect the recovery, a course of the cortex and the Peruvian balsam is to be tried; and the spine may be rubbed with spirituous liniments, or with a mixture of rum and Barbadoes tar: but these and all other stimulating things, either internally or externally, during the violence of the spasms, must be omitted, since all of them, as well as blisters, are found to exasperate the disease.

This, in general, is the plan of treatment recommended by Dr Chalmers.

The same dreadful disorders frequently attack young children in the warm climates. Dr Hillary tells us, that they will there arise from the same causes which usually produce convulsions in them in Britain, viz. a retention of the meconium or first excrement after birth; or from a glutinous matter which is too often found in the intestines of young children soon after the other is discharged; or from a cheesy matter from the coagulation of the milk by an acid in the stomach; or from hard excrements; or from something taken in by the mouth which is over acid, or too hard to digest, which irritates their tender bowels, and so produces startings and convulsive spasms, with all the other symptoms which precede and accompany convulsions in young children in England; and shews how much more readily and easily the nerves are affected and irritated in that warm climate, and the tetanus produced from a much less cause there, than it is in England, where it is but seldom seen. But these causes not being timely removed, their acrimony is increased, partly by the heat of the climate, and partly by the fever which they produce, which still renders them more acid, and so increases the irritation of their bowels, that it first brings on startings, then convulsive spasms, and regular convulsion-fits; which, if not soon removed, usually end in a perfect tetanus there, and the disease is but seldom cured in such young children when it arrives at that stage: For when the child lies in this miserable, rigid, immovable condition, upon moving its hands or feet in the most gentle manner, or softly touching any part of its body, or giving it the least motion, even feeling its pulse in the most gentle, tender manner, or the least noise, or even touching its clothes, will bring on the convulsive spasms, and cause it to be strongly convulsed backwards, or drawn into a rigid straight line, strongly extended and immovable like a statue, and will to remain immovable out of either of those postures for a considerable time, a minute or two; and when the disease is arrived at this degree, our author thinks it is never cured. But if the physician is called in time, before the tetanus has come on, (which is too seldom the case there,) though he finds strong convulsive spasms have seized the child, or that it has had a convulsive fit or two, it may most commonly be relieved, the coming of the tetanus be prevented, and the life of the babe saved, as Dr Hillary has more than once seen, by removing and carrying off the irritating cause which stimulates their tender bowels, by such gentle evacuations as are suitable to their age; and then quieting and composing the irritation of their nerves with suitable anodynes, and correcting the remaining acrimony of the nutritious juices in the prime viva.

To answer which intentions, the following method, with variations pro re nata et pro ratione statis, as the cause is different, hath been found to answer the desired effect the best: R. Seri lactis 3ij. Sapon. Venet. 3j. Manum chalab. 3ij. vel iiij. Ol. amigd. dul. 3f. Fanculi dul. gut. iiij. Bals. Peru. gut. v. Mifce, si enema quam primum injicienda.

And if the symptoms of the approaching tetanus will permit, he gives something of the following nature to assist the operation of the elyster, and to carry off the acrimony the sooner: R. Ag. sem. feniculi 3ij. Magnesi alba 3f. Ocul. caner. prep. 3j. Syr. e cicior. Dr Chalmers gives an account of his having cured one child seized with a tetanus, by purging with an infusion of rhubarb; to which a few grains of musk, and a little el. tartar. per deliq. were added, together with the warm bath, and the frequent injection of glysters made with an infusion of camomile-flowers, to each of which was added a small portion of Castile soap. It is much to be regretted, however, that in those cases where the assistance of the medical art is most wanted, it most generally fails. We have been assured by a gentleman who practised for some time in the warm parts of America, that out of 30 cases of the tetanus he had seen, not one of the patients recovered, though he had given opium to the quantity of 20 grains thrice a-day; and others, he was assured, had taken 30 grains thrice a-day. In the beginning of the disease, the medicine produced a violent headache; but towards the end, it had no manner of effect whatever. In two patients, the disease came on from the slightest causes imaginable. The one accidentally fell in attempting to avoid a loaded cart, and put the heel of his shoe upon one of his thumbs in rising; the other, in avoiding the same cart, slightly ruffled the skin of his nose. Both were seized with the tetanus; and both died, notwithstanding all possible assistance was given. The former had his thumb amputated, without effect.

In the Edinburgh Physical and Literary Essays, Vol. III. Dr Donald Monro, describes a new method of cure, communicated to him by a gentleman who was formerly a practitioner in Jamaica. While this gentleman practised in that island, he had under his care a great number of cases of tetanus attended with the locked-jaw. At first, he used to give very freely of opium, musk, and other medicines of this class; to bleed, and make other evacuations; while he used baths, fomentations, embrocations, and other external applications, but all without the least success; and, as he had lost a great many patients without being so lucky as to make one cure, he began to believe that this disorder always proved fatal, and was not to be cured by medicine, notwithstanding what some practitioners had alleged. However, having received an unexpected hint concerning the good effects of the mercurial ointment in such cases, he resolved to try it; and ordered the first patient that offered to be put into a warm room, and to be rubbed two or three times a-day with the ointment, till such time as a salivation was raised; when he with pleasure observed, that, as soon as the mercury began to affect the mouth, the convulsions of the muscles of the jaws, as well as all the other spasms and convulsions, ceased, and the patient was freed of all his complaints. After this, he treated every case of this kind which came under his care in the same manner, and cured twelve, which were all who applied to him for advice so early in the disorder that there was time to bring the mercury to the mouth before the fatal period was expected. A few died, in whom the disease was so far advanced before he saw them that there was not time to raise a salivation. None of the cases which were under this gentleman's care in the West Indies were the consequences of wounds or capital operations; nor has he had any opportunity of trying it since in cases of the locked jaw, which sometimes follows capital operations, owing to his having given over practice: but he thinks, that, from the similarity of the complaint, there is no doubt but that the mercurial frictions would be equally efficacious in such cases, as when the disorder comes from catching cold or other such causes.

In the second volume of the Medical Transactions, we have an account of a cure performed by means very different from any of those above related, by Dr William Carter at Canterbury.—On the 17th of May 1767, the doctor was called to a strong healthy man, in the 21st year of his age, and who had been confined to his bed for three weeks. What gave rise to his present disorder was a wound on the inner ankle of his right leg, which he had received six weeks before from a joiner's chisel. At that time his mouth was so far closed, as to admit only the most liquid nourishment, which he constantly sucked through his teeth; but his legs and jaw, and the whole length of the spina dorsi, were quite immovable, being as stiff and rigid as those of a person long dead; his head was drawn backward, and he was frequently strongly convulsed. The motion indeed of both his arms was but a little impaired. From the beginning to the end, his sight, hearing, and memory, continued perfect; his appetite was good; and his senses, in the day-time, entire, though sometimes wandering in the night. As to his pulse, that was regular; if it deviated at all from the pulse of a person in health, it was rather slow than quick, and somewhat fuller than natural. Such was the situation of his patient; a detail of which had been given before the doctor set out on his journey, which he undertook with a determined resolution to make use of the method recommended by Dr Silverton, in the first vol. of Medical Observations and Inquiries, published in the year 1757, (and which has been related from Dr Chalmers and Dr Hillary.) But, on his arrival at the house, he found great quantities of the extractum thebaticum dissolved had been already given him; and that, for the five last days, he had taken no less than 28 grains of that medicine, with 50 grains of musk, in the space of 24 hours, without any sensible effect, except the bringing on a confused sleep, out of which he frequently awoke in great hurries, attended with a violent pain in the head, which almost deprived him of his senses. The doctor was afraid to extend the dose; and soon determined to take some other method, though at a loss what method to pursue, as, during a course of almost 30 years practice, nothing of the same kind had ever fallen under his cognizance before. Reflecting, however, that this disorder had always been deemed of the spasmodic kind, and that the good effects produced by the extractum thebaticum must probably be owing to the relaxing and resolving faculty of that medicine, he directed a blister to be applied between the shoulders; the whole length of the spine, and jaw, to be anointed with the oleum lacteum; and a purge, consisting of the tinctura sacra jalapii and the syrupus de rhomno cathartico, to be given him. This was repeated three several times afterwards, at the distance of three or four days between each dose. On the intermediate days, he was ordered the oleum succini, the fetid gum, and the oleum amygdalinum. Of Practice

the first he took 30 drops, of the gum 20 grains, and of the last four ounces, in nycthemeri spatio. By these means, and these only, the convulsions soon ceased, and he grew daily better and better, till at the end of a fortnight he was able to walk about his room, and in less than three weeks became in all respects well, some small weaknesses in the parts only excepted. The jaw was relieved first, after that the spine, and last of all the legs. A pain and uneasiness in the places affected, neither of which he had felt before, were the forerunners of his approaching amendment.

From all this it seems reasonable to conclude, either that there is no certain remedy for tetanus in all cases, or that the medicines which prove effectual in one constitution will fail in another. Thus, it is possible, that in cases where opium proves ineffectual, mercury may be a remedy; and on the contrary, where mercury fails, opium may be effectual; and even where both are ineffectual, the antispasmodics recommended by Dr Carter may be of use. It is therefore necessary for physicians to be extremely careful to observe the effects of the first doses of their remedies: for if the symptoms shew not the least appearance of remission after a large dose of opium, it is improbable that it can be cured by a repetition of the medicine; and as no time can be lost with safety, it will then be proper to apply mercurial ointment, or whatever else may be judged proper.—In the Medical Commentaries indeed we have an account of the cold bath being used as a remedy, by Thomas Cochran surgeon at Nevis. The patient was an East Indian boy who had been gored by a cow and afterwards exposed to a rainy damp air for some hours. Mr Cochran attributes his cure to the cold bath, which was applied by dashing the water upon his body. But as the patient at the same time got laudanum at first in the quantity of 200 drops a day, and afterwards in still larger doses; and had besides his throat and shoulders anointed with warm oil of turpentine, was bled, and had lenient glysters and laxatives; it is by no means easy to say what share the cold bath had in his cure, or whether it had any at all. Mr Cochran, however, says he has heard of some cases being treated successfully by cold water and the bark in St Eustatia and St Kitts, and in another letter mentions his having used the cold bath in other cases of tetanus with success. This remedy is now also used by some English physicians.

Genus XLIX. TRISMUS, or the Locked Jaw.

Trismus, Sauv. gen. 117. Lin. 124. Sag. gen. 223. Capistrum, Veg. 208.

CXV. The Locked Jaw in Children under two months old. Sp. I.

Trismus nascentium, Sauv. sp. i. Heisser Comp. Med. Pract. cap. xv. § 10. Clogborn on the Diseases of Minorca, Introd. p. 33. Hofer in Act. Helvet. tom. i. p. 65.

This distemper is so closely connected with the tetanus, that it ought rather to be accounted a symptom of the tetanus than a primary disease. The trismus of young CXVI. The Trismus from Wounds or Cold. Sp. II.

Trismus traumaticus, Sauv. sp. 2. Lond. Med. Obs. Vol. I. art. 1. Vol. II. 34. Vol. III. 31. Vol. IV. 7.

Angina spasmodica, Sauv. sp. 18. Zwingeri Act. Helvet. Tom. III. p. 319.

Convulsio nervi punctura, Sauv. sp. 2.

Trismus catarrhalis, Sauv. sp. 15. Hillary's Barbadoes, 221. Lond. Med. Obs. Vol. IV. 7.

The internal remedies proper in all cases of the locked jaw, from whatever cause it may proceed, have been already mentioned under TETANUS: the external treatment of wounded parts which may give occasion to it belongs to the article SURGERY.

CXVII. CONVULSION. Genus L.

Convulsion, Sauv. gen. 128. Lin. 142. Veg. 191. Sag. gen. 235.

Convulsion universalis, Sauv. sp. 11.

Hieranofo, Lin. 144. Veg. 190.

Convulsion habituialis, Sauv. sp. 12.

Convulsion intermittens, Sauv. sp. 16.

Convulsion hemitonicus, Sauv. sp. 15.

Convulsion abdominis, Sauv. sp. 10.

Convulsion ab inanitione, Sauv. sp. 1.

Convulsion ab onanismo, Sauv. sp. 13.

Scelotyrbe festinans, Sauv. sp. 2.

Description. When convulsions attack only particular parts of the body, they are generally attended with some kind of paralysis at the same time, by which means the affected parts are alternately convulsed and relaxed; a permanent convulsion, or unnatural contraction, of particular muscles, is called a spasms, or cramp. These partial convulsions may attack almost any part of the body; and are not unfrequently symptomatic, in fevers, the cholera morbus, &c. The involuntary startings of the tendons, the picking of the bed-clothes, &c. in acute diseases, &c. are all of them convulsive disorders.

Causes. Convulsions, not only of particular parts, but also over the whole body, often take place from causes not very evident. Sometimes they seem to depend on a certain delicacy or irritability of the nervous system, which is framed with such exquisite sensibility as to be strongly affected by the slightest causes. Delicate women are often subject to hysterical convulsions, as also hypochondriac people. Convulsions, however, often take their rise from wounds, irritations of the stomach and intestines by worms, poisons, violent cathartics and emetics, &c.; and very often they are symptomatic, as in dentition, the small-pox, and many kinds of fevers.

Prognosis. Except in some few cases, convulsive disorders are always to be dreaded; but less in young people than in such as are advanced in life. Those which attack girls under the age of puberty will generally cease on the appearance of the menes; and boys have likewise a chance of being relieved as they advance in life; but in grown up people, unless the cause is very evident, a cure is hardly to be expected.

Cure. See EPILEPSY, below.

CXVIII. CHOREA, or St Vitus's Dance. Genus L.I.

Scelotyrbe, Sauv. gen. 136. Sag. 243.

Chorea, Lin. 139.

Scelotyrbe chorea Viti, Sauv. sp. 1.

Chorea St. Viti, Sydenb. Sched. Monit.

Description. This disease shows itself first by a kind of lameness or instability of one of the legs, which the patients draw after them in a ridiculous manner; nor can they hold the arm of the same side still for a moment; for if they lay it on their breast, or any other part of their body, it is immediately forced away by a convulsive motion. If they are desirous of drinking, they use a number of odd gesticulations before they can bring the cup to their mouths, because their arms are drawn this way and that by the convulsions which affect them.

Causes, &c. The general cause of St Vitus's dance is a debility of the system; and hence we find it attacks only weakly boys, and more especially girls, when under the age of puberty. But the particular causes determining the muscles to be affected in such and such a manner are entirely unknown.

Prognosis. As this disorder scarce ever attacks any persons but such as are under the age of puberty, there is almost a certain prospect of its being then cured, tho' generally the disorder is easily removed before that time.

Cure. See EPILEPSY.

CXIX. RAPHANIA. Genus LII.

Raphania, Lin. 155. Veg. 143. Lin. Amoen. Acad. Vol. VI.

Convulsion raphania, Sauv. sp. 7.

Eclampsia typhodes, Sauv. sp. 1. Sennert de febr. l. iv. cap. 16. Gregor. Hofz. Oper. tom. II. l. viii. obf. 22. Brunner in Ephem. Germ. D. iii. A. ii. obf. 224. Willisch. ibid. cent. vii. obf. 13. Weffer de Affect. Capitis, obf. 120. Breslauer Sammlung 1717, Julio, Septembri, & Decembr. Ibid. 1723, Januar. A. N. C. Vol. VII. obf. 41. Bruckmann. Com. Norimb. 1743, p. 50.

Description. According to Sauvages, this distemper begins with a laxitude of the limbs, transient colds and shiverings, pain of the head, and anxieties of the praecordia. Then come spasmodic startings of the fingers and feet; also of the tendons and muscles, conspicuous below the skin. The disease is attended with heat, fever, delirium, stupor, constriction of the breast, suffocating dyspnea, loss of voice, horrid convulsions of the limbs, preceded by a formication, or sensation as of ants or other small insects creeping on the parts. In this state of the disease, the convulsive paroxysms are attended with most violent pains in the limbs, vomiting, or diarrhoea, with the passing of worms, thirst, and in young people an unnatural hunger. It continues from ten days to three months. About the eleventh or twentieth day, some are relieved by copious sweats, or purple exanthemata; while others fall into a tabes, with stupor, or stiffness of the joints.

Causes, &c. This disease is frequently epidemic in Swabia and other parts of Germany; where it is said to be produced by seeds of radishes, which are often mixed with rye in that country; and from this supposed cause GENUS LIII. EPILEPSY, or FALLING-SICKNESS.

Epilepsia, Sauv. gen. 134. Lin. 143. Vog. 188. Sag. gen. 24. Boerh. 1071. Hoffm. III. 9. Junck. 54. Eclampsia, Sauv. gen. 133. 180. Sag. gen. 240.

CXX. The Cerebralis, or Epilepsy depending on an affection of Brain. Sp. I. Epilepsia plethorica, Sauv. sp. 1. Eclampsia plethorica, Sauv. sp. 7. Epilepsia cachectica, Sauv. sp. 2.

CXXI. The Sympathica, or Sympathetic Epilepsy, with a sensation of something rising from a certain part of the body towards the Head. Sp. II. Epilepsia sympathica, Sauv. sp. 8. Epilepsia pedilymptomatica, Sauv. sp. 6.

CXXII. The Occasionalis, or Epilepsy arising from various irritating Causes. Sp. II. Epilepsia traumatica, Sauv. sp. 13. Eclampsia traumatica, Sauv. sp. 9. Epilepsia a dolore, Sauv. sp. 10. Epilepsia rachialgica, Sauv. sp. 14. Eclampsia a dolibus, Sauv. sp. 4. a. Rachialgica. b. Ab otalgia. c. A dentitione. Eclampsia parturientum, Sauv. sp. 3. Eclampsia verminosa, Sauv. sp. 2. Eclampsia ab atrope, Sauv. sp. 11. Eclampsia ab omanthe, Sauv. sp. 12. Eclampsia a cicuta, Sauv. sp. 13. Eclampsia a coriaria, Sauv. sp. 14. Epilepsia exanthematica, Sauv. sp. 11. Epilepsia cachectica, Sauv. sp. 2. Epilepsia stomachica, Sauv. sp. 3. Eclampsia a saburra, Sauv. sp. 5. Epilepsia a pathemate, Sauv. sp. 7. Eclampsia ab inanitione, Sauv. sp. 8. Epilepsia neophytorum, Sauv. sp. 15.

Description. The epilepsy often attacks suddenly, and without giving any warning; but more frequently is preceded by a pain in the head, lassitude, some disturbance of the senses, unquiet sleep, unusual dread, dimness of sight, a noise in the ears, palpitation of the heart, coldness of the joints, and in some there is a sensation of formication, or a cold air, &c. ascending from the lower extremities towards the head. In the fit, the persons fall suddenly to the ground (whence the name of the falling sickness), frequently with a violent cry. The thumbs are shut up close in the palms of the hands, and are with difficulty taken out; the eyes are distorted, so that nothing but the whites are to be seen; all sensation is suspended, insomuch, that by no smell, noise, or otherwise, nor even by pinching the body, can they be brought to themselves; they froth at the mouth, with a hissing kind of noise; the tongue is frequently lacerated by the teeth, and there is a violent convulsive motion of the arms and legs. Sometimes, however, the limbs, instead of being agitated by convulsive motions, are all stiff, and the patients are as immovable as a statue. In children the penis is erected; and in young men there is an emission of the semen, and the urine is often thrown out to a considerable distance. At length there is a remission of the symptoms, and the patients recover after a longer or shorter interval; when they complain of a pain, torpor, and heaviness of the head, with a laxitude of all the joints.

Causes, &c. The dissection of epileptic subjects has shown a variety of morbid appearances, which may be supposed to have contributed to the disease; such as, indurations in the brain or meninges; caries of the internal surface of the cranium; projections of the honey substance of the same, pressing upon the brain; collections of serum or purulent matter, and earthy concretions within the skull; besides many others which are recorded by Bonetus, Morgagni, and Lieutaud. But often the causes are impossible to be discovered; for even in those who have died of the disease, the brain and all other parts of the nervous system have been apparently sound. The disease will attack strong as well as weak people; and in those who are subject to it, any considerable excess in drinking, a surfeit, violent passion, or venery, &c. will certainly bring on a fit. Some have epileptic paroxysms returning periodically after considerable intervals; and the disease hath been thought to have some dependence on the phases of the moon.

Prognosis. If the epilepsy comes on before the time of puberty, there are some hopes of its going off at that time. But it is a bad sign when it attacks about the 21st year, and still worse if the fits grow more frequent; for then the animal-functions are often destroyed, as well as those of the mind, and the patient becomes stupid and foolish. Sometimes it will terminate in melancholy or madness, and sometimes in a mortal apoplexy or palsy. It hath sometimes, however, been observed, that epilepsies have been removed by the appearance of cutaneous diseases, as the itch, small-pox, measles, &c. While the disease is recent, therefore, we are not to despair of a cure; but if it is of long standing, or hereditary, there is very little reason to expect that it can be removed.

Care. In all convulsive disorders, excepting those which are cured by nature about the time of puberty, the cure by artificial means is very difficult. Numberless specifics have been recommended, but all of them have failed of answering the expectation. When the cause can be discovered, that must be removed. In other cases, the cold bath, valerian root, earl, musk, opium, the fetid gums, Peruvian bark, with the whole tribe of nervous and antispasmodic medicines, have been recommended; but none of these, or indeed any combination of them, have been found generally useful; though the lighter, or symptomatic cases, may often be removed by them.

Of late the salts, improperly called the flowers, of zinc, have obtained such reputation in convulsive disorders as to be received into the Edinburgh dispensatory. They were proposed by Dr. Gausius as an antispasmodic, in his Adversaria; and their efficacy hath since been confirmed by various observations. In an inaugural dissertation published by Dr. Hart at Leyden, the medical virtues of the flowers of zinc are considered. He observes, that they have long been used externally, chiefly for inflammations. mations of the eyes from acid lymph. Glauber first proposed the internal use of them; and Gaubius discovered them to be the remedy of the celebrated empiric Ludde manus, under the title of luna fixata. After this he exhibited them with success in convulsive and spasmodic diseases. Our author supposes, that they act either as abortives, or as possessing a specific virtue; but is a strong advocate for their efficacy, on whatever principles they may operate; and, in favour of his opinion, relates seven cases in which they proved successful. A girl of 17 was seized with a flight caused from a fright; and when the disease had continued five days, began to take the flowers of zinc, by which her disorder was removed in less than three weeks. Her cure required only 16 grains of the calx. In a few months the complaints returned, from the same cause; and were removed by four grains of the medicine divided into ten doses.—A boy of about four years old, labouring under a real epilepsy, suspected to be hereditary, was cured by a grain of the flowers of zinc taken every day for some time.—A man 50 years old, thrown into convulsions from a violent passion, was cured by a grain of the calx taken every two hours. The disease had gone off upon venefication and the use of some other remedies; but returned again in two weeks, when it was finally removed by the zinc.—The two last cases are related from Dr Gaubius, who affirms that he has used the flowers of zinc in cases of the chiccough, hysteric hiccup, and spasms cynicus; that they frequently did more than other medicines, but were by no means successful in every case. The other cures mentioned by Dr Hart are similar to those above-mentioned, and it does not appear that he ever saw a confirmed epilepsy cured by this medicine.

In the first volume of Eden's Medical Commentaries, p. 204, we have an account by Mr Benjamin Bell, of a man afflicted with a confirmed epilepsy, who was considerably relieved by the flowers of zinc. He was about 35 years of age, and had been subject to the disease for 10 years. At first the paroxysms did not return oftener than once a month; but becoming gradually more frequent, they came at last to be in a manner continual, in such a manner that he would have ten, eleven, or twelve attacks in a day, and very seldom had an interval of 24 hours. His memory and judgment were so much impaired, that he could scarce answer a question distinctly, though he had used a great variety of medicines. About three years before applying to Mr Bell, he had violent rheumatic pains in his limbs, which left such an extreme debility that he was never afterwards able to get out of bed without the assistance of two or three people.

On the 22d of October 1772, Mr Bell found him in the above-mentioned condition, and prescribed as follows:

R. Flor. Zinc. gr. xxiv. Ext. Gent. 3i. M. f. mass. et divid. in pil. xxiv. cap. i. m. & v.

He continued to take two pills a-day till the first of November, without any sensible benefit. The dose was then doubled, and continued till the 12th; when the fits, though equally violent, became less frequent. The medicine was gradually augmented to ten pills thrice a-day; and the consequence was, that his memory and understanding returned, the fits became much lighter and less frequently repeated, though the disease could not be radically subdued.

In a young man labouring under the epilepsy, in whom the fits were preceded by an aura epileptica, or sensation like air arising from the inside of the knee-joint, the disease was also relieved, but not cured.

Dr Percival relates some cases of epilepsy which seem to have been cured by the flowers of zinc; and in other cases, where the disease was not entirely removed by it, the spasms were nevertheless much mitigated. He did not observe that it promoted any evacuation; except that in some, upon being first taken, it occasioned a little sickness, which went off with a stool. He adds, that those apothecaries who do not prepare this medicine themselves, are in great danger of being imposed upon, as it is sometimes a mere corrosion of the zinc by an acid, and even imperfectly washed.

The good effects of flowers of zinc as an antispasmodic are also attested by Dr Haygarth of Chester and Dr White of York. The former gives a talk of their goodness which may be of use to those who do not prepare them, namely, that the true flowers of zinc when strongly heated become yellow, but reassume their white colour on being allowed to cool. The latter gives a case of hiccanosus, or strange convulsions of almost all the muscles of the body, cured by zinc, after a number of other remedies had failed. The patient, however, had been formerly much relieved by Ward's antimonial pill.

In Dr Home's clinical experiments and histories; also, the flowers of zinc are mentioned as having been found serviceable upon trial in the Royal Infirmary of Edinburgh. Of the other principal remedies which have been recommended for the epilepsy and other convulsive disorders allied to it, we have the following account by the same author.

1. The cold-bath was tried in one who had a convulsive disorder of one side, but the symptoms were rendered much worse by it.

2. Venefication. Not to be depended on in convulsions.

3. Electricity. In two convulsive cases this was of no service. See the section on Electricity, below.

4. Epilepsia. Do not seem to be powerful antispasmodics.

5. Valerian. In nine convulsive cases, for which this remedy hath been reckoned almost a specific, it not only made no cure, but could scarcely be reckoned to do any good. Dr Home supposes that it acts as a bitter tonic, something like the serpentaria Virginia. "Tho' much used at present, (says he), it has always appeared to me a weak, often a hurtful, medicine."

6. Musks. Six convulsive patients treated with large doses of this remedy, were neither cured nor in the least relieved.

7. Caster seems to be unworthy of the confidence formerly put in it. It is indeed possessed of a sedative power, and therefore may be useful in spasmodic feverish cases.

8. Asafoetida hath considerable antispasmodic powers, but is not always successful. It heats and quickens the pulse; and is therefore improper in cases attended with inflammation. It disagrees with some from a peculiarity of constitution; exciting pain in the stomach, and vomiting; but this can be known only after

Practice after the exhibition of the medicine.

9. Cortex Peruvianus. Of seven spasmodic cases, six were either cured or mitigated. An epilepsy of eight years standing was very much relieved by taking the bark for a month, and one of two years standing by taking it for ten days. But the medicine is of a heating nature, and therefore is not to be employed in cases attended with inflammatory symptoms.

10. Peony-root was given to two epileptic patients without the least success.

11. Viscum quercinum, or mistletoe, was given in the quantity of two scruples five times a-day to an epileptic patient, without success.

12. Extractum hyoscyami, was given to an epileptic patient, to one afflicted with the hemitonus, and to one who laboured under the hysterical affection, without the least good effect.

13. Folia aurantiacum, were exhibited with the like bad success. Five drachms of the powdered leaves were taken at once without any sensible effect.

14. Cardamine pratensis, in three epileptic cases was not attended with any success.

15. Opium, did no good.

16. Cuprum ammoniacale, made no cure in four cases of epilepsy in which it was tried.

Genus LIV. PALPITATIO, PALPITATION of the Heart.

Palpitatio, Sauv. gen. 130. Lin. 132. Veg. 213. Sag. 237. Hoffm. III. 83. Junck. 33.

The palpitation of the heart is sometimes so violent, that it may be heard at a considerable distance. It may proceed from a bad conformation of the heart itself, or some of the large vessels. It may also be occasioned by wounds or abscesses in the heart; or it may proceed from polyposy concretions or ossifications of that viscus, or from plethora, fear, or spasmodic affections of the nervous system. When it proceeds from diseases of the heart or large vessels, it is absolutely incurable. In spasmodic cases, the remedies above-related may be used. If the patient is plethoric, bleeding will probably remove the disorder, at least for the present.

Genus LV. ASTHMA.

Asthma, Sauv. gen. 145. Lin. 161. Veg. 268. Sag. gen. 282.

Asthma convulsivum et spasmodica flatulentum, Hoffm. III. 94.

Asthma spasmodicum, Junck. tab. 51.

CXXII. The Spontaneous Asthma. Sp. I.

Asthma humidum, Sauv. fp. 1. Flatulentum, Floyer on the Asthma, chap. i.

Asthma convulsivum, Sauv. fp. 2. Willis Pharm. rat. P. II. sect. i. cap. 12.

Asthma hystericum, Sauv. fp. 3. Floyer on the Asthma, chap. i.

Asthma stomachicum, Sauv. fp. 8. Floyer, Scheme of the Species of Asthma. Periodic Asthma 6.

Orthopnea spasmodica, Sauv. fp. 3.

Orthopnea hysterica, Sauv. fp. 4.

CXXXIII. The Exanthematic Asthma. Sp. II.

Asthma exanthematicum, Sauv. fp. 11.

Asthma cacheticum, Sauv. fp. 13.

CXXXIV. The Plethoric Asthma. Sp. III.

Asthma plethoricum, Sauv. fp. 15.

The asthma is a chronic disease, which may continue to give very great distress, at intervals, for a considerable number of years. Sir John Floyer, when he wrote his celebrated treatise, had laboured under repeated paroxysms for 30 years.

The common distinction is into humid and dry; the former is accompanied with an expectoration of mucus or purulent matter, but the latter is not so attended. In the genuine humoral asthma, the patients are obliged to lean forward; the inspiration is short and spasmodic; and the expiration very slow.

Asthmatic persons have generally some warning of the attack, from a languor, loss of appetite, oppression, and swelling of the stomach from flatulence, which precede the fit, but it is usually in the middle of the night, that the violent difficulty of breathing comes on.

The duration of the paroxysm is uncertain, as it will sometimes terminate in three or four hours, while at other times it shall continue for as many days; nay, it has been known to last three weeks without intermission. While it subsists, the patient is in very great distress, not being able to lie in bed, nor scarcely to speak or expectorate, so great is the difficulty of breathing; and yet notwithstanding all this apparent interruption to the free passage of the blood through the lungs, an inflammation here seldom or never supervenes a fit of the asthma. As the paroxysm wears off, and the breathing becomes free, there is more or less of an expectoration of mucus; and the urine, from being pale and limpid, becomes high-coloured, and lets fall a copious sediment.

In order to obtain relief in the fit, we must sometimes bleed, unless extreme weakness or old age should forbid, and repeat it according to the degrees of strength and fulness: a purging clyster, with a solution of asafoetida, must be immediately injected; and if the violence of the symptoms should not speedily abate, it will be proper to blister the nape of the neck.

In the height of the paroxysm, an emetic might be followed by dangerous symptoms, as it would increase the accumulation of blood in the vessels of the head; but vomiting will often prevent a fit of the asthma, especially if the stomach should chance to be loaded with any sort of satura. A very strong infusion of roasted coffee has been found to give ease in an asthmatic paroxysm.

Dr Pringle says it is the best abater of the paroxysms of the periodic asthma that he has seen. The coffee ought to be of the best Mocco, newly burnt, and made very strong immediately after grinding it. He commonly ordered an ounce for one dish; which is to be repeated fresh after the interval of a quarter, or half an hour; and which is to be taken without milk or sugar. The medicine in general is mentioned by Musgrave in his treatise de Arthritide anomala; but he first heard of it from a physician in Litchfield, who had been informed formed by the old people of that place, that Sir John Floyer, during the latter part of his life, kept free from, or at least lived easy under his asthma, from the use of very strong coffee. This discovery, it seems, he made after the publication of his book upon that disease. Dr Percival says he has frequently directed coffee in the asthma with great success.

In the intervals of the fits, persons subject to the asthma, especially the humid species, should take emetics from time to time. An infusion of tobacco is an emetic that has been found very serviceable in some asthmatic cases; and smoking or chewing the same has been known to prevent the frequency and severity of the paroxysms. They should also use the lac ammoniaci, with a due proportion of oxymel scillitium and visum antimoniale, with a view to promote expectoration; or the gum ammoniaci, and others of similar virtues, may be formed into pills, and combined with soap, as beforementioned for the dyspnea pituitosa; or a mafs may be composed of astaetidae and balsam of Tolu, with fer. ex allio; and these pills may be washed down by a medicated wine, impregnated with squills, horseradish root, and mustard-seed; or a strong bitter infusion, with a little antimonial wine.

In some cases crude mercury will be found serviceable; in others flowers of sulphur, made into an electuary with honey or syrup of garlic; and if, notwithstanding the use of these things, a coltive habit should prevail, it will be necessary, from time to time, to give a few grains of the pil. Ruf., soap and aloes, or a mafs of equal parts of rhubarb, scammony, and soap.

The dry or spasmodic asthma, during the extreme violence of the fit, is best relieved by opiates; and sometimes very large doses are required. But, in order to obtain permanent relief, nothing is found to answer better than the radix ippecacanhae, in small doses. Three, five, eight or ten grains, according to the strength and constitution of the patient, given every other day, have been productive of the happiest effects; acting sometimes as an evacuant, pumping up the viscid phlegm; at others, as an antispasmodic or sedative. Issues are generally recommended in both species, and will often be found useful.

Changes of weather are usually felt very sensibly by asthmatic people, who in general cannot live with tolerable ease in the atmosphere of large cities; though we shall sometimes meet with patients who agree better with this air, which is so replete with gross effluvia of various kinds, than with the purest that can be found in country situations. And some are found who breathe with the most ease in a crowded room, with a fire and candles.

A light diet of meats that are easy of digestion, and not flatulent, is requisite for asthmatic people; and the exercise of riding is indispensably necessary.

When the asthma is found to depend on some other disease, whether it be the gout or an intermittent fever, or when it proceeds from the striking in of some cutaneous eruption, regard must always be had to the primary disease: thus, in the asthama arthriticum, siapismos to the feet, or blistering, will be absolutely necessary, in order, if possible, to bring on a fit of the gout. And when the dregs of an ague give rise to an asthma, which is termed febriculofusum, and invades at regular intervals, we must have recourse to the cortex. The asthama exanthematicum will require blisters or ulcers, to give vent to the acrid matters which were repelled from the surface of the body; and courses of sulphurous waters, goat's whey, and sweetening diet-drinks, or perhaps mercurial alteratives, in order to correct the sharpness of the juices.

GENUS LVI. DYSPNOEA, or Habitual Difficulty of Breathing.

Dyspnea, Sauv. gen. 144. Lin. 160. Veg. 267. Seg. 251. Junck. 32.

CXXV. The Catarrhal Dyspnoea. Sp. I.

Asthma catarrhale, Sauv. sp. 16. Asthma pneumonicum, Willis Pharm. Pat. P. II. sect. i. cap. 12. Asthma pituitolum, Hoffm. III. sect. ii. esp. 2. § 3. Asthma pneumodes, Sauv. sp. 17.

This is readily known by the symptoms of pneumonia and catarrh attending it, and towards the removal of these symptoms the care of the physician must be principally directed.

CXXVI. The Dry Dyspnoea. Sp. II.

Dyspnea a tuberculis, a hydatibus, &c. Sauv. sp. 2. 4. 5. 20. Orthopnea a lipomate, Sauv. sp. 18.

This is generally accompanied with a phthisis pulmonalis; but Sauvages mentions one species of phthisis to which the dry dyspnea seems more particularly to belong. The patients fall away by degrees, and have a great difficulty of breathing, continual thirst, and little or no spitting. When opened after death, their lungs are found not to be ulcerated, but shrivelled and contracted as if they had been smoke-dried. Goldsmiths and chemists are said to be subject to this disease by reason of the vapours they draw in with their breath. Our author doth not mention any particular remedy. Shortness of breath arising from tuberculosis, as they are termed, or a scirrhus enlargement of the lymphatic glands which are dispersed through the lungs, is commonly found in scrofulous habits, and may be distinguished by the concomitancy of those external swellings and appearances which particularly mark the scrofula. This species of dyspnea generally ends in a phthisis. Courses of goat's whey, and of sea-water, have been known to do service; but it must be confessed, that a perfect cure is seldom obtained. Issues are of use in these cases, as they appear to prevent the ill effects of an over-fulness, if it should happen at any time to supervene.

CXXVII. Dyspnoea from Changes in the Weather. Sp. III. (Sauv. sp. 12.)

This seems to be a disease entirely spasmodic, and the antispasmodics already related are accordingly indicated.

CXXVIII. The Dyspnoea from Earthy Substances formed in the Lungs. Sp. IV.

Sauvages mentions this disease as much more common in brutes than in the human race: but Dr Cullen mentions his having seen some instances of it; and we have several accounts by different authors of calculous matters being coughed up by people labouring under dyspnoea, and threatened with consumption. In three cases of this kind which fell under Dr Cullen's inspection, there was no appearance of earthy or stony concretions in any other part of the body. The calcareous matter was coughed up frequently with a little blood, sometimes with mucus only, and sometimes with pus. In one of these cases, an exquisitely formed phthisis came on, and proved mortal; in the other two the symptoms of phthisis were never fully formed; and after some time, merely by a milk-diet, and avoiding irritation, the patients entirely recovered.

Sauvages also greatly recommends milk in these cases, and soap for dissolving the concretions. The reason why brutes are more subject to these pulmonary calculi than mankind, is, that they very seldom cough, and thus the stagnating mucus or lymph concretes into a kind of gypseous matter.

CXXIX. The Watery Dyspnoea. Sp. V. Dyspnoea pituitosa, Sauv. sp. 1. Orthopnoea ab hydropleumonia, Sauv. sp. 12.

This may arise from too great a delusion of mucus on the lungs, or from an effusion of serum, as is mentioned under the pneumonia. The treatment of the disease may be gathered from what has been already said under the heads of pneumonia, catarrh, empyema, &c.

CXXX. The Dyspnoea from Corpulency. Sp. VI. Orthopnoea pinguedine, Sauv. sp. 6.

There have been many instances of suffocation and death occasioned by too great corpulency. These fatal effects, however, may be almost always avoided if the persons have resolution to persist in an active and very temperate course of life; avoiding animal-food, much sleep, and using a great deal of exercise. In the third volume of the Medical observations, however, there is an extraordinary instance of internal obesity which neither shewed itself externally, nor could be removed by any medicines.

Other species of dyspnoea have been treated under Pathesis. It is frequently symptomatic of diseases of the heart and large vessels, or swellings of the abdomen, &c.

CXXXI. PERTUSSIS, the CHINCOUGH. Genus LVII.

Pertussis Sydenham, Ed. Leid. p. 200. 311. 312. Huxham de acre, ad ann. 1732. Tussis convulsa, tussis ferina, Hoffm. III. 111. Tussis ferina, Sauv. sp. 10. Sag. sp. 10. Tussis convulsa, Sauv. sp. 11. Sag. sp. 11. Amphimerina tussiculosa, Sauv. sp. 13.

Description. This disease comes on at first like a common cold; but is from the beginning attended with a greater degree of dyspnoea than is common in that disease; and there is a remarkable affection of the eyes, as if they were swelled, and a little pushed out of their sockets. By degrees the fits of coughing become longer and more violent, till at last they are plainly convulsive, so that for a considerable time the patient cannot respire; and when at last he recovers his breath, inspiration is performed with a shrill kind of noise like the crowing of a cock. This kind of inspiration serves only as an introduction to another convulsive fit of coughing, which is in like manner followed by another inspiration of the same kind; and thus it continues for some time, very often till the patient vomits, which puts an end to the paroxysm at that time. These paroxysms are attended with a violent determination of the blood towards the head, so that the vessels become extremely turgid, and blood not unfrequently flows from the mouth and nose. The disease is tedious, and often continues for many months. It is not commonly attended with fever.

Causes, &c. The chincough is an infectious disorder, and very often epidemic; but the nature of the contagion is not understood. It generally attacks children, or adults of a lax habit, making its attack generally in the spring or autumn; and those children who live upon unwholesome watery food, or breathe unwholesome air, are most liable to its attacks, and suffer most from them. In general it may be concluded, that whatever weakens the solids, or tends to bring on a dissolution of the fluids, predisposes to this disease.

Prognosis. The chincough is not very often fatal. In children under two years of age it is most dangerous; and kills them by producing convulsions, suffocation, inflammation, and suppuration of the brain, ruptures, and incursion of the spine. In pregnant women it will produce abortion; and, in adults, inflammations of the lungs, and all the consequences of pneumonia, more frequently than in children. From a long continuance of the disease patients will become asthmatic, ricketty, and scrophulous. It is generally reckoned a good sign when a fit terminates by vomiting; for in this disease there seems to be a prodigious increase of the secretion of mucus, and the vomiting affords great relief.

Cure. The most approved remedies in this disease are vomits, purges, bleeding, and the attenuating pectorals, for the other kinds generally do hurt. But large evacuations of any kind are pernicious. In the Medical Observations, Vol. III. Dr Morris recommends castor and the bark; but in cases attended with any degree of inflammation, the latter must certainly do hurt, and the former will generally be insignificant. Dr Butter, in a dissertation expressly on the subject, instances 20 cases of it cured by the extract of hemlock. He directs half a grain a-day for a child under six months old; one grain for a child from six months to two years; afterwards allowing half a grain for every year of the patient's age till he be 20: beyond that period, he directs ten grains to be given for the first day's consumption, gradually increasing the dose according to the effect. If the patient has not two stools a-day, he advises magnesia or polychrest salt to be added to the hemlock mixture. By this method he says the peculiar symptoms of the disease are removed in the space of a week; nothing but a slight cough remaining. The use of hemlock, however, hath by no means become universal in consequence of this publication, nor indeed is the remedy at present much used in cases of chincough or any other disease. The remedy most to be depended upon in this disease is change of air. The patient, as soon CXXXII. PYROSIS, the Heart-Burn.

Genus LVIII.

Pyrosis, Sauv. gen. 200. Sag. 158. Soda, Lin. 47. Veg. 154. Scotia, the Water-Brash. Pyrosis Suecica, Sauv. sp. 4. Cardialgia Ipotatoria, Sauv. sp. 5.

This disease, whether considered as primary or symptomatic, hath already been fully treated under Dyspepsia.

Genus LIX. COLICA. The Colic.

Colica, Sauv. gen. 204. Lin. 50. Veg. 160. Sag. 162. Junck. 106. Colica spasmodica et flatulenta, Hoffm. II. 284. Rachialgia, Sauv. gen. 211. Sag. 168. Ileus, Sauv. gen. 252. Veg. 162. Sag. gen. 187. Ilia, Lin. 185. Dolor et spasmus iliacus, Hoffm. II. 263. Pessio iliacus, Junck. 107.

CXXXIII. The Spasmodic Colic. Sp. I.

Colica flatulenta, pituitosa, &c. Sauv. sp. 1. 2. 5. 6. 7. Ileus phytodes, volvulus, inflammatorius, &c. Eysjd. sp. 1. 3. 5. 7. 8. 9.

Description. The colic is chiefly known by a violent pain in the abdomen, commonly about the umbilical region. The pain resembles various kinds of sensations, as of burning, twifling, boring, a ligature drawn very tight, &c. The belly is generally costive, though sometimes there is a violent evacuation of bilious matters upwards and downwards. In these cases the disease is sometimes accompanied from the beginning with a weak and intermittent pulse, cold sweats, and fainting. In some the disease comes on gradually, beginning with an habitual colliciveness; and if purgatives are taken, they do not operate. The pain comes on generally after a meal, and soon occasions nausea and vomiting. Sometimes the disease is attended with pyrexia, violent thirst, and a full pulse; the vomiting becomes more violent, and excrementitious matters are thrown up with the most exquisite pain and tension of the abdomen; an hiccup comes on, which continues obstinately; till at last a cessation of pain and fetid breath indicates a mortification of the intestines, and approaching death. Sometimes the peristaltic motion of the intestines is so totally inverted, that all the contents of the intestines are evacuated by the mouth, and even clots will be vomited; which constitutes that disease commonly called the iliac passion.

Causes, &c. Colics may arise from any sudden check given to perspiration, as by violent cold applied to any part of the body, especially to the lower extremities and abdomen. Very frequently they are occasioned by ulcers, acid, or indigestible aliments taken into the stomach. By any of these, a violent colic, or indeed an iliac passion, may be occasioned; for Dr Cullen justly observes, that this last, though commonly accounted a different species of disease, differs from a colic in no other way than in being in every respect in a much higher degree. In those who have died of this disease and been dissected, the gut hath sometimes been found twisted; but more commonly there hath been an intussusception of the intestine, that is, one part of the gut seems to have entered within the other. In the Edinburgh Medical Essays, Vol. III. we have a dissertation on the use of the warm bath in the bilious colic, in which the author derives the disorder from a spasmodic contraction of the intestine occasioned by the acrimony of the bile. By this, he says, the intestine is not only contracted into an unusual narrowness, but coats of it have been found, upon dissection, so closely joined, that no passage could be made downwards more than if they had been strongly tied by a ligature. The formation of the intussusception he explains by quoting a passage from Peyerus, who made the following experiment on a frog. Having irritated the intestine of the animal in several different places, he observed it to contract at those places most violently, and to protrude its contents upwards and downwards wherever the relaxed state of the part would permit; by which means the contents were heaped together in different parts. Hence some parts of the intestine being dilated much more than enough, by reason of the great quantity of matter thrown into them, formed a kind of sack which readily received the constricted part into it. If this happens in the human body, there is the greatest danger of a mortification, because the part which is constricted, and at any rate disposed to inflammation, hath that disposition very much increased by its confinement within the other, and by the pressure of the contents of the alimentary canal from the stomach downwards upon it. An iliac passion may also arise from the strangulation of part of the intestine in a hernia; and even a very small portion of it thus strangulated may occasion a fatal disease. In the Medical Observations, Vol. IV. however, we have an account of an iliac passion arising from a very different cause, which could neither have been suspected nor cured by any other way than the operation of gastrotomy, or opening the abdomen of the patient, in order to remove the cause of the disorder. The patient, a woman of about 28 years of age, died after suffering extreme torture for six days. The body being opened, some quantity of a dirty-coloured fluid was found in the cavity of the abdomen. The jejunum and ileum were greatly distended with air. A portion of the omentum adhered to the mesentery, near that part where the ileum terminates in the cecum. From this adhesion, which was close to the spine, there ran a ligamentous cord or process about two inches and a half long, unequally thick, in some places not thicker than a packthread; which by its other extremity adhered to the coats of the ileum, about two inches above the caecum. This cord formed a circle with the mesentery, large enough to admit a hen's egg to pass through it. The chord had formed a noose (in a manner difficult to be explained), which included a doubling of about two inches of the lower end of the ileum; and was drawn so tight, that it not only put a stop to the passage of everything through the bowels, and brought on a gangrene of the strangulated part, but it had even cut through all the coats of the intestine on the opposite side to the mesentery, and made an aperture about an inch long. In the Memoirs of the Academy of Surgery are mentioned several similar cases.

Prognosis. The colic is never to be reckoned void of danger, as it may unexpectedly terminate in an inflammation and gangrene of the intestines. Those species of it which are attended with purging must be considered as much less dangerous than those in which the vomiting is very violent. The iliac passion, or that attended with the vomiting of feces, is always to be accounted highly dangerous; but if the passage through the intestines is free, even though their peristaltic motion should be inverted, and clysters evacuated by the mouth, there is much more hope of a cure, than when the belly is obstinately costive, and there is some fixed obstruction which seems to bid defiance to all remedies.

Cure. As the chief danger in colics arises from an inflammation and consequent mortification of the intestines, it is essentially necessary, in the first place, to diminish the tendency to a pyrexia, if there should happen to be any. This is accomplished by bleeding, emollient injections, warm bathing, and cooling medicines taken inwardly. Dr. Porter, in the essay above-mentioned, strongly recommends the warm bath in those colics attended with violent evacuations of bile. He supposes it to do service by relaxing the contraction of the intestines, and thus preventing or removing the introfusception. In the mean time opiates may be given to ease the pain, while every method is tried, by cathartics and clysters of various kinds, to procure a stool. In obstinate cases, where stimulating cathartics have proved ineffectual, the milder kinds, such as saffron, senna, oleum ricini, &c., will succeed; but where everything of this kind fails, recourse must be had to some of the more extraordinary methods. Some have recommended the swallowing of leaden bullets, on a supposition that by their weight they would force through the obstruction into the gut; but these seem much more likely to create than to remove an obstruction. It is impossible they can act by their gravity, because the intestines do not lie in a straight line from the pylorus to the anus; and though this were actually the case, we cannot suppose that the weight of a leaden bullet could prove very efficacious in removing either a spasmodic contraction, or an obstruction from any other cause. But when we consider, not only that the intestines consist of a great multitude of folds, but that their peristaltic motion (by which only the contents are forced through them) is inverted, the futility of his remedy must be evident. It might rather be supposed to aggravate the disease; as the lead, by its pressure, would tend to fix the introfusception more firmly, or perhaps push it still further on. The same thing may be said of quicksilver: not mention the pernicious consequences to be apprehended from swallowing large quantities of this mineral, even if it should prove efficacious in relieving the patient for the present. Another method hath been proposed, in the Medical Essays, for relieving the miserable patients in this disorder, which at least can be attended with no bad consequences, and in many cases hath been known to do service. The patient is to be taken out of bed, and made to walk about on the cold floor of a damp apartment. At the same time, porringers of cold water are to be dashed on his feet, legs, and thighs; and this must be continued for an hour or longer, if a stool is not procured before that time, though this will generally be the case much sooner. The exercise doth not at all impair the patient's strength, but rather adds to it; and some very remarkable instances are adduced in the 6th volume of the Medical Essays, where this proved effectual after all other medicines had failed. In one person the disease had come on with an habitual costiveness, and he had been for a week tormented with the most violent pain and vomiting, which could be stopped neither by anodynes nor any other medicines, the sharpest clysters being returned unaltered; and all kinds of purgatives thrown up soon after they were swallowed; but by the above-mentioned method, a stool was procured in 35 minutes, and the patient recovered. In some others the costiveness had continued for a much longer time.—Other remedies are, the blowing air into the intestines by means of a bellows, and the injecting clysters of the smoke of tobacco. But neither of these seem very capable of removing the disease. They can affect only the parts below the obstruction; while, to cure the disease, it is necessary that the obstructed parts themselves should be reached by the medicine, and therefore we have not many well-attested instances of their success. The cold water gives a general and very considerable shock to the system, checks the perspiration, and thus drives the humours inward upon the intestines, by which they receive a much more effectual stimulus than can be supposed to arise from any kind of clyster. But when all methods have failed, the only chance the patient can have for life is by a manual operation. See Surgery.

In those colics which are attended with faintings, &c., from the beginning, and which generally attack hysterical women and other debilitated persons, all kinds of evacuations are pernicious; and the cure is to be attempted by anodynes and cordials, which will seldom fail of success.

CXXXIV. Colica Pictonum; the Colic of Poitou. Sp. II.

Rachialgia Pictonum, Sauv. sp. 1. Rachialgia metallica, Sauv. sp. 3. Colica Pictonum Citatis et succedentium auctorum.

Another cause to which violent colics are frequently to be ascribed, and which often gives occasion to them where it is very little suspected, is lead, or To this cause is evidently owing the colics to which plumbers, lead-miners, and smelters of lead, are subject. To the same cause, though not so apparent at first sight, are we to ascribe the Devonshire colic, where lead was received into the body dissolved in cider, the common drink of the inhabitants of that county. This hath been proved by experiment; for lead hath been extracted from cider in quantity sufficient to produce pernicious effects on the human body. The colic of Poitou, and what is called the dry belly-ache in the West Indies, are of the same nature; for which reason we give the following general description of the symptoms of all these diseases.

The patient is generally first seized with an acute pain at the pit of the stomach, which extends itself down with gripping pains to the bowels. Soon after there is a distention, as with wind; and frequent reachings to vomit, without bringing up any thing but small quantities of bile and phlegm. An obstinate coliciveness follows, yet sometimes attended with a tenesmus, and the bowels seem to the patient as if they were drawn up towards the back; at other times they are drawn into hard lumps, or hard rolls, which are plainly perceptible to the hand on the belly, by strong convulsive spasms. Sometimes the coats of the intestines seem to be drawn up from the anus and down from the pylorus towards the navel. When a stool is procured by artificial means, as clysters, &c., the feces appear in little hard knots like sheep's dung, called scybals, and are in small quantity. There is, however, usually an obstinate coliciveness; the urine is discharged in small quantity, frequently with pain and much difficulty. The pulse is generally low, though sometimes a little quickened by the violence of the pain; but inflammatory symptoms very seldom occur. The extremities are often cold, and sometimes the violence of the pain causes cold clammy sweats and fainting. The mind is generally much affected, and the spirits are sunk. The disease is often tedious, especially if improperly treated, insomuch that the patients will continue in this miserable state for twenty or thirty days successively; nay, instances have been known of its continuing for six months. In this case the pains at last become almost intolerable: the patient's breath acquires a strong fetid smell like excrements, from a retention of the feces, and an absorption of the putrid effluvia from them by the lacteals. At last, when the pain in the bowels begins to abate, a pain comes on in the shoulder-joints and adjoining muscles, with an unusual sensation and tingling along the spinal marrow. This soon extends itself from thence to the nerves of the arms and legs, which become weak; and that weakness increases till the extreme parts become paralytic, with a total loss of motion, though a benumbed sensation often remains. Sometimes, by a sudden metastasis, the brain becomes affected, a stupor and delirium come on, and the nervous system is irritated to such a degree as to produce general convulsions, which are frequently followed by death. At other times, the perilactic motion of the intestines is inverted, and a true iliac passion is produced, which also proves fatal in a short time. Sometimes the paralytic affection of the extremities goes off, and the pain of the bowels returns with its former violence; and on the cessation of the pain in the intestines, the extremities again become paralytic, and thus the pain and palsy will alternate for a very long time.

Care. Various methods have been attempted for removing this terrible disease. The obstinate coliciveness which attends it, made physicians at first exhibit very strong purgatives and stimulating clysters. But these medicines, by increasing the convulsive spasms of the intestines, were found to be pernicious. Balsam of Peru, by its warm aromatic power, was found to succeed much better; and Dr Sydenham accordingly prescribed it in the quantity of 40 drops twice or thrice a-day taken on sugar. This, with gentle purgatives, opiates, and some drops of the hotter essential oils, continued to be the medicine commonly employed in this disease, till a specific was published by Dr Lionel Chalmers of South Carolina. This receipt was purchased by Dr Chalmers from a family where it had long been kept a secret. The only unusual medicine in this receipt, and on which the efficacy of it chiefly if not wholly depends, is Roman vitriol. This must be dissolved in water, in the quantity of one grain to an ounce, and the dose of the solution is a wine-glassful given fasting for nine successive mornings. For the first four or five days this medicine discharges much serous bile both ways; but the excretions of this humour lessen by degrees; and before the course is ended, it hath little other effect than to cause some degree of squeamishness, or promote a few bilious stools, or perhaps may not move the patient at all. At the time of using this medicine the patients should live upon broth made of lean meat, gruel, or panado; but about the seventh or eighth day, they may be allowed bread and boiled chicken. Here the copper seems to do service by its tonic power; and for the same reason, alum, recommended by Dr Percival, most probably cures the disease. He says he hath found this very efficacious in obstinate affections of the bowels, and that it generally proves a cure in the lighter cases of the colica pictorum. It was given to the quantity of fifteen grains every fourth, fifth, or sixth hour; and the third dose seldom failed to mitigate the pain, and sometimes entirely removed it. Among purgative medicines, the oleum Ricini is found to be the most efficacious.

CXXXV. The Colic from Coliciveness. Sp. III.

Colica stercorea, Saut. sp. 3. Ileus a fecibus induratis, Saut. sp. 2.

For the treatment of this species, see above.

CXXXVI. The Accidental Colic. Sp. IV.

Colica Japonica,—accidentalis,—lactentium,—a veneno, Saut. sp. 10, 14, 18, 20. Cholera ticca auriginosa a fungis venenatis, ejusd. sp. 2.

When colics arise from acid poisonous matter taken into the stomach, the only cure is either to evacuate the poison itself by vomit, or to swallow some other substance which may decompose it, and thus render it inactive. The most common and dangerous substances The former is easily decomposed by alkaline salt; and therefore a solution of salt of tartar, if swallowed before the poison hath time to induce a mortification of the bowels, will prove a certain cure. Much more uncertain, however, is the case when arsenic is swallowed, because there is no certain and speedy solvent of that substance yet known. Milk hath been recommended as efficacious; and lately solution of hepatic sulphuris. The latter may possibly do service; as arsenic unites readily with sulphur, and hath its pernicious qualities more obfuscated by that than by any other known substance: but indeed, even the solvent powers of this medicine are so weak, that its effects as well as those of others must be very uncertain. See Chemistry, no. 466.

Some kinds of fungi, when swallowed, are apt to produce colics attended with stupor, delirium, and convulsions; and the same sometimes happens from eating a large quantity of mucus*. Some of the fungi, doubtless, may have an inherent poisonous quality; but generally they as well as the mucus act on a different principle. Their pernicious effects happen most commonly when they are taken on an empty stomach; and are then occasioned by their adhering so close to its coats, that it cannot exert its powers, and the whole system is thrown into the utmost disorder. The malady may therefore be very easily prevented; but when once it hath taken place, it cannot be removed till either a vomiting is excited, or the stomach hath recovered itself in such a manner as to throw off the adhering matter.

CXXXVII. Colic of New-born Infants from a Retention of the Meconium. Sp. V. (Sauv. sp. 19.)

This disorder would be prevented were children allowed immediately to suck their mothers, whose milk at first is purgative. But as this is not commonly done, the child is frequently troubled with colics. These, however, may be removed by a few grains of ipecacuanha, a grain of emetic tartar, or a drop or two of antimonial wine. By these means the stomach is cleansed by vomiting, and the belly is generally loosened; but if this last effect doth not happen, some gentle purge will be necessary.

CXXXVIII. The Colic from a Callosity of the Colon. Sp. VI.

It is in a manner impossible to discover this distemper before the patient's death; and though it should, it doth not admit of a cure.

CXXXIX. The Colic from Intestinal Calculi. Sp. VII. (Sauv. sp. 10. 15.)

When certain indigestible bodies, such as cherry-stones, plum-stones, small pieces of bones, &c. are swallowed, they frequently prove the basis of calculi, formed by an accretion of some kind of earthy matter, and being detained in some of the flexures of the intestines, often occasion very violent colics. These calculi do not discover themselves by any peculiar symptoms, nor do they admit of any method of cure. In the Medical Essays we have an instance of colics for six years, occasioned by calculi of this kind. The concretions were at last passed by stool; and their passage was procured by causing the patient drink a large quantity of warm water, with a view to promote the evacuation of bile, a redundancy of which was supposed to be the cause of her disorder.

Genus LX. CHOLERA, the Cholera Morbus.

Cholera, Sauv. 253. Lin. 186. Veg. 110. Sag. 188. Hoffm. II. 165.

Diarrhoea cholérica, Junck. 112.

CXL. The Spontaneous Cholera, coming on without any manifest cause. Sp. I.

Cholera spontanea, Sauv. sp. I. Sydenb. sect. iv. cap. 2.

Cholera Indica, Sauv. sp. 7.

CXLI. The Accidental Cholera, from acid matters taken inwardly. Sp. II.

Cholera crapulosa, Sauv. sp. II.

Cholera a venenis, Sauv. sp. 4. 5.

The cholera shews itself by enormous vomiting and purging of corrupted matters, with violent pain, inflammation and diffusion of the belly. Sometimes the patients fall into universal convulsions; and sometimes they are affected with violent spasms in particular parts of the body. There is a great thirst, small and unequal pulse, cold sweats, fainting, coldness of the extremities, and hiccup; and death frequently ensues in 24 hours. The cure of this distemper is effected by giving the patient a large quantity of warm water, or very weak broth, in order to cleanse the stomach of the irritating matter which occasions the disease, and injecting the same by way of clyster, till the pains begin to abate a little. After this, a large dose of laudanum is to be given in some convenient vehicle, and repeated as there is occasion. But if the vomiting and purging have continued for a long time before the physician is called, immediate recourse must be had to the laudanum, because the patient will be too much exhausted to bear any further evacuations. Sometimes the propensity to vomit is so strong, that nothing will be retained, and the laudanum itself thrown up as soon as swallowed. To settle the stomach in these cases, Dr Douglas, in the Medical Essays, recommends a decoction of oat-bread toasted as brown as coffee; and the decoction itself ought to be of the colour of weak coffee. He says he does not remember that this decoction was ever vomited by any of his patients. An infusion of mint-leaves in good simple mint-water is also said to be very efficacious in the same case.

Genus LXI. DIARRHOEA, or Looseness.

Diarrhoea, Sauv. gen. 253. Lin. 187. Veg. 105. Sag. gen. 189. Junck. 112.

Hepatirrhoea, Sauv. gen. 246.

Cholerica, Lin. 190.

Colica, Sauv. gen. 255. Lin. 189. Veg. 109. Sag. gen. 199.

Lienteria, Sauv. gen. 256. Lin. 188. Sag. gen. 191. Veg. 108.

Pituitaria, & leucorrhoeis, Veg. 111. 112.

CXLI. The Diarrhoea from Surfeit. Sp. I.

Diarrhoea stercoreosa & vulgaris, Sauv. sp. 1. 2.

This is occasioned by the too great quantity of matter CXLIII. The Bilious Diarrhoea. Sp. II.

(Sauv. sp. 8.)

This distemper shows itself by copious stools of a very yellow colour, attended with gripes and heat of the bowels, thirst, bitterness, and dryness of the mouth, yellowness of the tongue, and frequently follows an intermittent or bilious fever. When the fever is gone, the diarrhoea is to be removed by acidulated and cooling drinks, with small doses of nitre.

CXLIV. The Mucous Diarrhoea. Sp. III.

Diarrhoea lactentium, Sauv. sp. 19. Dysenteria Parviflora, Sauv. sp. 3. Diarrhoea ab hypercatarhisi, Sauv. sp. 16. Dysenteria a catharticis, Sauv. sp. 12. Pituitaria, Vog. 111. Lecorhois, Vog. 112. Diarrhoea pituitosa, Sauv. sp. 4. Coelica mucosa, Sauv. sp. 3. Diarrhoea ferula, Sauv. sp. 10. a. Diarrhoea urinosa.

This kind of diarrhoea, besides the matters usually excreted, is attended with a copious dejection of the mucus of the intestines with great pain; while the patient daily pines away, but without any fever.—Persons of all ages are liable to it, and it comes on usually in the winter-time; but is so obstinate, that it will sometimes continue for years. In obstinate loosenesses of this kind, vomits frequently repeated are of the greatest service. It is also very beneficial to keep the body warm, and rub the belly with stimulating ointments; at the same time that astringent clysters, rhubarb, and stomachic medicines, are to be exhibited. Starch clysters are very often efficacious.—Some kinds of loosenesses are contagious; and Sir John Pringle mentions a solder who laboured under an obstinate diarrhoea, who infected all those that used the same privy with himself. In the loosenesses which frequently followed a dysentery, the same author tells us that he began the cure with giving a vomit of ipecacuanha, after which he put the patients on a course of astringents. He used a mixture of three drachms of extract of logwood, dissolved in an ounce and a half of spirituous cinnamon-water, to which was added seven ounces of common water, and two drachms of japonic tincture. Of this the patient took two spoonfuls once in four or five hours, and sometimes also an opiate at bed-time. He recommends the same medicine in obstinate diarrhoeas of all kinds. A decoction of simarauba bark was also found effectual, when the dysenteric symptoms had gone off.

Dr Huck, who used this remedy in North-America, also recommends it in diarrhoeas. Two or three ounces of it are to be boiled in a pound and a half of water to a pound, and the whole quantity taken throughout the day. He began with the weakest decoction; and, when the stomach of the patient could easily bear it, he then ordered the strongest; but at the same time he acknowledges, that, unless the sick found themselves sensibly better within three days from the time they began the medicine, they seldom afterwards received any benefit from it. But when all astringents have failed, Sir John Pringle informs us, he hath known a cure effected by a milk and farinaceous diet; and he thinks in all cases the disorder would be much more easily removed, if the patients could be prevailed on to abstain entirely from spirituous liquors and animal-food. If the milk by itself should turn sour on the stomach, a third part of lime-water may be added. In one case he found a patient receive more benefit from good butter-milk than from sweet-milk. The chief drinks are decoctions of barley, rice, calcined hartshorn, toast and water, or milk and water.

CXLV. The Coeliac Passion. Sp. IV.

Coelica chylota, Sauv. sp. 1. Coelica lactea, Sauv. sp. 4.

There are very great differences among physicians concerning the nature of this disease. Sauvages says, from Aretaeus, it is a chronic flux, in which the aliment is discharged half digested. It is attended with great pains of the stomach, resembling the pricking of pins; rumbling and status in the intestines; white stools, because deprived of bile, while the patient becomes weak and lean. The disease is tedious, periodical, and difficult to be cured. Sauvages adds, that none of the moderns seem to have observed the disease properly; that the excrements indeed are white, on account of a deficiency of the bile, but the belly is bound as in the jaundice. Dr Cullen says there is a dejection of a milky liquid of the nature of chyle; but this is treated by Vogel as a vulgar error. He accuses the moderns of copying from Aretaeus, who mentions white faeces as a symptom of the distemper; from whence authors have readily fallen into the notion that they never appeared of any other colour in persons labouring under the coeliac passion. This error quickly produced another, which hath been very generally received; namely, that the chyle was thrown out of the lacteals by reason of some obstruction there, and thus passed along with the excrements; of which he says there is not the least proof, and agrees with Aretaeus that the whiteness is only occasioned by the want of bile. He endeavours to prove at length, that the coeliac passion can neither be occasioned by an obstruction of the lacteals, nor of the mesenteric glands; though he owns that such as have died of this disease and were dissected, had obstructions in the mesenteric glands; but denies that all those in whom such obstructions occur, are subject to the coeliac passion. He considers the distemper as arising from a cachexy of the stomachic and intestinal juices; and directs the cure to be attempted by emetics, purgatives, antiseptics, and tonics, as in other species of diarrhoea.

CXLVI. The CXLVI. The Lientery. Sp. V. Lienteria spontanea, Sauv. sp. 2.

The lientery, according to Sauvages, differs from the celiac passion only in being a slighter species of the disease. The aliment passes very quickly through the intestines, with scarce any alteration. The patients do not complain of pain, but are sometimes affected with an intolerable hunger. The cure is to be attempted by stomachics and tonics, especially the Peruvian bark.

CXLVII. The Hepatic Flux. Sp. VI. Hepatirrhoea intestinalis, Sauv. sp. 2.

The hepatic diarrhoea is by Sauvages described as a flux of bloody serous matter like the washings of flesh, which percolates through the coats of the intestines by means of the anastomosing vessels. It is the colic passion of Trallian; and which, according to Sauvages, rarely, if ever, occurs as a primary disease. It hath, however, been observed to follow an inflammation of the liver, and then almost always proves fatal.

Genus LXII. DIABETES, or too great a Quantity of Urine.

Diabetes, Sauv. gen. 263. Lin. 197. Veg. 115. Sag. gen. 199. Junck. 99. Dobson, Med. Observ. Vol. V. p. 298. Home's Clinical Experiments, sect. xvi. Diuresis, Veg. 114.

CXLVIII. The Diabetes with sweet Urine. Sp. I. Diabetes Anglicus, Sauv. sp. 2. Mead on Poisons, Effay I. Ejusdem Monita Med. cap. ix. sect. 2. Dobson in Lond. Med. Observ. Vol. V. art. 27. Myers Diff. inang. de Diabete. Edinb. 1779. Diabetes febricolus, Sauv. sp. 7. Sydenh. Ep. refp. ad. R. Brady.

CXLI. Diabetes with insipid Urine. Sp. II. M. Lister Exerc. Medicin. II. de Diabete. Diabetes legitimus, Sauv. sp. 1. Aretaeus de morb. diurno. lib. ii. cap. 2. Diabetes ex vino, Sauv. sp. 5. Ephem. Germ. D. I. A. II. Observ. 122.

Description. The diabetes first shows itself by a dryness of the mouth and thirst, white frothy spittle, and the urine in somewhat larger quantity than usual. A heat begins to be perceived in the bowels, which at first is a little pungent, and gradually increases. The thirst continues to augment by degrees, and the patient gradually loses the power of retaining his urine for any length of time. It is remarkable, that, tho' the patients drink much, the quantity of urine always exceeds what is drank. In Home's Clinical Experiments we have an account of two patients labouring under this disease: one of them drank between 10 and 12 English pints a-day, without being satisfied. The quantity was greater in the forenoon than in the afternoon. In the other the case was reversed. He drank about four pints a-day, and more in the afternoon than the forenoon. The former passed from 12 to 15 pints of urine a-day: the latter, 11 or 12; so that his urine always exceeded his drink by eight, or at least seven pints. When the urine is retained a little while, there is a swelling of the loins, ilia, and testes; the strength gradually decays; the skin is dry and shrivelled; oedematous swellings arise in various parts of the body, but afterwards subside without relieving the disease in the least; and the patient is frequently carried off by convulsions.

The most singular phenomenon in this disease is, that the urine seems to be entirely or very much divided of an animal-nature, and to be largely impregnated with a saccharine salt scarcely distinguishable from that sold in the shops. This discovery was first made by Dr Dobson of Liverpool, who made some experiments on the urine of a person labouring under a diabetes, and who made 28 pints of urine every day, taking during the same time from 12 to 14 pounds of solid and liquid food. Some of this urine being set by, fell into a spontaneous effervescence, changed first into a vinous liquor, and afterwards into an acetic one, before it became putrid and offensive. Eight ounces of blood taken from the same patient, separated into crassamentum and serum; the latter being sweet to the taste, but less so than the urine. Two quarts of the urine, evaporated to dryness, left a white cake weighing four ounces two drachms and two scruples. This cake was granulated, and broke easily between the fingers: it smelled sweet like brown sugar; neither could it by the taste be distinguished from sugar, except that it left a slight sense of coolness on the tongue. The experiment was repeated after the patient was recovered to such a degree as to pass only 14 pints of urine a-day. There was now a strong urinous smell during the evaporation; and the residuum could not be procured in a solid form, but was blackish, and much resembled very thick treacle. In Dr Home's patients, the serum of the blood had no supernatural sweetness; in one of them the crassamentum 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 hath not been examined by physicians.

Cause. There are exceedingly obscure and uncertain; pains of the nervous system, debility, and everything inducing it, but especially strong diuretics and immoderate venery, have been accused as bringing on the diabetes. It hath, however, occurred in persons where none of all these causes could be suspected; nor have the best physicians been able to determine it.—Difficulties have only shewn that the kidneys were in an enlarged and lax state. In one of Dr Home's patients who died, they smelled sour; which shewed 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 the throat, where it produces a sense of suffocation, and difficulty of breathing or swallowing. All this time there are the most violent pains both in the external and internal parts of the abdomen; the muscles are convulsed; the navel 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 driving into it, and all visible objects seem to turn round; grievous pains attack the loins, back, and bladder, and the patients make 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.

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 may be brought on by whatever debilitates and renders the body irritable. Hence the disease most frequently attacks females of a weak and lax habit of body, though there are some instances of men also attacked by it. The disease 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 usually seizes barren women and young widows, than such as are bearing children.

Prognosis. Though the appearance of this disease is so very terrible, it seldom proves mortal unless by wrong treatment: but notwithstanding this it is extremely difficult of cure, and rarely admits of anything 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 most powerful remedy hitherto discovered in hysterical cases is opium, or the solution of it called laudanum. By this commonly the most violent paroxysms are stopped, though it is insufficient to accomplish a radical cure. In Home's Clinical Experiments we find an instance of a cure performed by venesection, though this remedy hath 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. Either 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 is 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. A plaster of galbanum and asafoetida 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, the Peruvian bark, chalybeates, mineral waters, and other tonics.

Genus LXIV. HYDROPHOBIA, the Dread of Water.

Hydrophobia, Sauv. gen. 231. Lin. 86. Veg. 30. Sag. gen. 343. Boerh. 1138. Junck. 124. Mead on poisons. Defaut sur la rage. Sauv. diff. sur la rage. James on canine madness. Dalby, Virtues of cinnamon and musk against the bite of a mad dog. Nugent on hydrophobia. Choiseul, Nouvelle méthode pour le traitement de la rage. Journal de Medicine, passim. Medical Obs. and Inquiries, vol. iii. art. 34. vol. v. art. 20. 26. and App. Med. Transact. vol. ii. art. 5. 12. and 15. Heychan, Diff. inaug. de rab. canin. Edinb. 1777. Parry, Diff. inaug. de rab. contagiose. five canin. Edinb. 1778. Andry, Recherches sur la rage, 1778. Vaughan, Causes of hydrophobia, second edit. 1778.

CLII. Hydrophobia Rabies, or Hydrophobia consequent on the Bite of a Mad Animal. Sp. I.

Hydrophobia vulgaris, Sauv. sp. I.

Description. This disease commonly does not make its attack till a considerable time after the bite. In some few instances it hath 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 hath been 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; 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 hath a 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 have a real dread of water or any liquid before they try whether they can swallow it or not. 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 anything clear or pellucid, will give the utmost uneasiness, or even throw them 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 hath 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 anything 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 sternum cardis, 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 shew 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 is ready to suffocate them. In some male patients there is an involuntary erection of the penis, and emission of the 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 hath 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 tell us, that among dogs the disease is infectious by staying in the same place; and that after a kennel hath 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.

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, the dogs are said not to be subject to this distemper. 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 small-pox 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 by means of the intercourse which they have with one another.

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 doth not appear that this can operate through the cuticle; but, when that is rubbed off, the smallest quantity is sufficient to communicate the disease, and a slight scratch with the teeth of a mad animal hath been found as pernicious as a large wound. It is certain also, that the infection hath 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 hath hitherto appeared on that subject. A nurse also frequently kissed this child during the 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 faucæ, where we might have expected that the disease would have shewn itself most evidently, there was not the least appearance even of inflammation. The stomach, intestines, diaphragm, oesophagus, &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 hydrophobous 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 the dread of water, he treats it as misrepresentation, as well as that the oesophagus with the muscles subservient to deglutition are specially concerned in this disease. The principal foundation of the evil, he thinks, rests on a morbid sensibility both of the external and internal faucæ. For the sight of a liquid, or the application of any substance to the internal faucæ, but more especially of a fluid, instantly excites the most painful feelings. Nay, the same symptoms are produced by touching the external faucæ with a fluid, or by the contact of cold air with these parts; and nearly in as great a degree. But a solid or a fluid substance being conveyed into the oesophagus, 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 faucæ and throat: it is, he says, at the scrobiculus cordis; to which the sufferers applies his hand. From this last circumstance, therefore, from the presence of the risus 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 faucæ, 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; nay, Dr Vaughan relates, that out of 30 bit by a mad dog, only one was seized with the hydrophobia. During the interval betwixt the bit 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 hath made its appearance, the prognosis is exceedingly fatal.

Prevention and Cure. It hath been generally allowed by practitioners, that though the hydrophobia may be prevented, yet it can seldom or ever be cured after it has made its appearance. A great number of different methods of prevention have been attempted. 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 preventative. When this was known to fail, a long course of anti-phlogistic 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 shew, that in all ages the greatest success hath been reaped from diuretics, for which reason he proposes the following powder:

"Take ash-coloured ground-liverwort, half an ounce; black-pepper, two drachms: reduce them separately to powder, then mix them together." But this medicine, which was inserted in former editions of the London Dispensatory under the name of Pulvis Antisyphiliticus, has long lost its credit.

There is a famous East-India medicine, composed of 24 grains of native and as much saffroned cinnabar, made into a powder with 16 grains of musk. This is called the Tongan medicine, and must be taken in a tea-cup full of arrack 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 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, poly-pody, 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 drachm, or a drachm and an half, taken every day.

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

In the beginning of December 1728, a young gentleman, aged 17, was bit by a dog in the middle-finger of the right-hand about the middle of the nail. In the beginning of January 1729, he complained of pain in that finger reaching along the back of the hand to the elbow. In the night between the sixth and seventh days of that month, he became hot and restless; emollient and anodyne fomentations were applied; but the pain became very sharp, and the hydrophobia came on in the night-time. He was blooded; but became worse every hour, and at last quite furious and outrageous. The bandage was thrown off from his arm, and he lost about 20 ounces of blood besides what had formerly been taken from him. This, however, made no abatement of the symptoms, and he died the same night.

In 1753, a woman, seized with the hydrophobia in consequence of the bite of a dog supposed to be mad, was treated in the following manner by Dr Nugent. First she was blooded to about 15 ounces; she took 15 grains of musk in powder, and along with it a pill of two grains of pure opium, every three hours. A plaster of galbanum, with half an ounce of pure opium, was laid She began to take these medicines on a Saturday morning, an hour or two after the dread of water had commenced. In the evening she was a little easier at intervals. The musk and opium pill were continued as before, and the hand that was bit was ordered to be washed with warm salad oil several times a day. Only two papers of powder and two pills were taken in the night; for the last made her sick and vomit. She had little or no sleep, but lay pretty quiet.—On Sunday, 20 ounces of blood were taken away, and a clyster with antimonial wine injected: the pills and powders were continued as before. On Sunday evening she could swallow liquids a little better, and she lay quiet most of the night. On Monday her swallowing was greatly better: The musk and opium were continued, and twelve ounces more of blood were taken from her; the plaster was renewed with only two drachms of opium, and the oil was used as before. At night she was better; her hand easy; and by a continuance of these remedies she recovered.—This was the case which chiefly brought opium into reputation.

The following cases published by De Sault, a Frenchman, first brought mercury into reputation.—Four men were bitten by the same wolf, on the same day, at the same hour. They were dipped in salt-water, and came back persuaded that they had nothing to fear. Some days after, one of them felt a numbed pain about his scars, while the scars themselves grew hard and rote like an embroidery: he was soon after seized with the usual symptoms, as did also another. The son of the former likewise began to feel a pain about the cicatrices, and a swelling with hardness; as did also the fourth. They were ordered to rub a drachm and a half of the mercurial or blue ointment upon the cicatrices and about the whole arm. This was repeated three days successively, and then every other day: after the fifth friction, he allowed an interval of two days. Besides this, they took every day a drachm and an half of Palmarius's powder. After the third friction the cicatrices grew flat and soft, the pain went off, their courage returned, and their mind resumed its former tranquillity.

But how far mercury, or indeed anything else, is from being a specific in the hydrophobia, will appear from the following account of Dr Wolf's patients.—In the middle of April 1767, seventeen people and a great number of cattle were bitten in the neighbourhood of Warsaw by a mad wolf. One of these, an officer, was brought into the city that same day, and had the best advice of the surgeons and physicians in that place; besides which, he took the bark very copiously with camphire. He continued well till the seventh week, when he became hydrophobic, and died.

Eleven of the others applied to Dr Wolf on the ninth day. Their wounds were all deeply scarified; diligently washed and fomented with vinegar, salt, and theriac; and kept open till the 80th day, in those who lived so long. Every two weeks they were bleded largely, and were purged every week with salts and jalap. Their diet was mostly vegetable, and their drink whey and water. They all eat as much as could be got of the herbs matriflora and anagallis flore puniceo; and they all took often of the pulvis Palmarii. The muscus cinereus terrestris could not be got, or it would also have been prescribed. Besides the general treatment, two were rubbed daily with a drachm of mercurial ointment, and had their purges with calomel. Two took every day four ounces of vinegar, three drachms tincture of poppies, and half an ounce of rob sambuci every night. One took every day 16 grains of camphire, with four scruples of saltpetre, and at night half an ounce of rob sambuci. Two took 24 grains of musk, with 50 grains of cinnabar. Other two took from 40 to 60 drops of spirit of sal ammoniac with quicklime, and the last took a scruple of crystallized salt of tartar made by the mixture of a little spirit of sal ammoniac with a solution of that salt.

One of the first who used the mercurial ointment was seized with the hydrophobia on the 22d day, immediately after being well purged with calomel. He was blooded copiously, plunged abundantly in cold water, and had several clysters administered, without effect. Two pounds of oil, and as much of drink, were poured down by force: also a drachm of soap of tartar and half a drachm of musk were given in three doses. He then began to drink freely, but died the third day. His companion then left off the use of mercury, and took 80 drops a-day of Dippel's animal-oil, till he had taken six drachms of it; after which he went on with 100 drops daily of vinous spirit of sal ammoniac made with alkali.

One of those who took the vinegar fell sick the 33d day. He was immediately blooded, and vomited with ipecacuanha. This man was too strong to make experiments on by force: he refused everything, and died the third day. His companion, an old man, began to be seized in the same manner: he was purged with salts, took the nosules halstani Peruviana, and drank lemonade. He recovered, and used afterwards 100 drops of spirit of sal ammoniac daily. This was the patient formerly mentioned, whose blood had the fetid smell.

The man who used the camphire fell sick the 33d day. He was thrice copiously blooded, was plunged forcibly into the coldest water for the space of two hours, and was nearly drowned. He was clystered with effect. He himself forced down, with incredible aversion and labour, a great quantity of drink; by which he vomited more than 50 times abundance of frothy slime. He took several ounces of oil, and several boluses of castor and opium, of each four grains, without effect; and died the fourth day.

A girl who used the musk with cinnabar, fell ill the 62d day, and died the third day after. No farther attempt was made to save her life, she being then at a distance. Her companion, a pregnant woman, then left off the musk, and took in its stead vinous spirit of sal ammoniac.

A woman who had taken nothing, fell ill on the 40th day. She suffered terribly in the night, but less in the day-time. Besides the usual symptoms, she had great pain and swelling in her belly. In the space of two days she drank about two bottles of brandy, but would taste no other liquor. The Doctor ordered her to mix an equal quantity of oil with her brandy, and to take every day two boluses of castor and opium. She recovered; and at last took two doses. After the 80th day, all the surviving people took thrice the turbit-mineral, except the pregnant woman; and they afterwards continued their alkaline medicines to the 100th day.

On these cases Dr Wolf makes the following observations.—"Thus we see, that the bark, the mercury, the acids, the musk, the feeding on the most famous herbs, the sweating, the cura antiphlogistica, are no specifica. I don't know what to say to the alkalies: the danger is not yet over; and there are still four people who used nothing, in as good health as my patients."

The following case by Dr Raymond of Marseilles, shows the inefficacy of mercury even as a preventative.

—On the 19th of July 1765, Mr Boyer, aged 25, of a bloated cachetic 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 Dr 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 cicatriced. The second day a bolus of four grains of turbit and eight grains of camphire was exhibited. This produced 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 drachms of mercurial ointment being used in each friction. During the same time the bolus was five times repeated; and this treatment kept up a flight salivation to the 40th day. The evening of the third day he took the Tonguin 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 drachm of the anagallis flore puniceo, fresh gathered and powdered. The 41st day, the turbit bolus was prescribed for the seventh time; he was bathed in the tea, and continued the bathing for two days more. On the 74th he was seized with the distemper; and died on the 76th, seemingly suffocated or strangled, his mouth covered with flaver, and 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. The Doctor says he has reason to suspect the wound was not well cauterized.

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 shamo 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.

The same author tells us, "there are many examples of the inefficacy of mercurial frictions. A surgeon of Marseilles treated a girl about 12 years of age bit by a mad dog, with mercurial frictions; applying them as in the lues veneris: 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. 1778, 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 drachms 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 ammoniacale, 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 ammoniacale, the same quantity of opium, three grains of flowers of zinc, and ten grains of afaetida; whilst a solution of that fetid gum, with a drachm 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 reflexions soon returned, his pulse sunk, and he died about two o'clock in the morning.

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

"Take half an ounce of chalk, three drachms of Armenian bole, ten grains of alum, one drachm of elecampane 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 preventative against the hydrophobia; however, there is a possibility that there may be some unknown ingredient in the genuine powder; for it is difficult to analyze 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 is. The following cases, however, too well determine that it is not infallible, as was at first pretended.

On the 14th of February 1774, Mr Bellamy of Holborn, aged 40, was bit by a cat, 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, spicaeuanhae, and pil. japon. 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 cinchona 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 drachms 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 bled 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 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 preventative; 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 Ormskirk 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 burning 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 turpith mineral, and five grains of opium, was directed to be taken once in three hours; 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 drachms of powdered camphire, half an ounce of opium, and fix drachms conficitio Democriti. By these medicines the disease seemed to be somewhat suspended, but they returned with violence in the evening. His medicine was repeated at seven; and at eight, five grains of opium were exhibited without musk or turpith. 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 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 capsulae muscae cyninae, 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 Practice ounce of sp. sal. ammoniae, ten drachms of oil olive, six drachms of oil of amber, and ten drachms of laudanum. Two ounces of strong mercurial ointment were rubbed upon the shoulders and back; and as a further means of kindling a ptyalism speedily, he received the smoke of cinnabar into the mouth by throwing a drachm 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 turpith mineral, and four grains of opium. He was earlier 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: the danger of acquiescing in 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. Of the great variety of remedies which have had their day of reputation, there is not one which has not forfeited 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 the hydrophobia 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 odor; 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 hath not the same ability to throw off any offending matter that the vascular system hath.

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 coagulum. 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 stomach seems totally, or in a great measure, to lose the power which at other times it possesses. Two grains of cuprum ammoniacale 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. The bark hath 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 turpith 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 florics abundantly show, that though the warm bath... CLII. The Spontaneous Hydrophobia. Sp. II.

Hydrophobia spontanea, Sauv. Sp. 2.

This disease very much resembles the former, so that it has undoubtedly been often mistaken for it. It has been known to come on in an inflammation of the stomach, where it was cured by repeated and large blood-letting; 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 anything which makes a strong impression on the senses, exceedingly. It is probable, therefore, that this was only a spontaneous hydrophobia, especially as it readily yielded to vaccination, 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 scarce any effect. This patient also dreaded the sight of a dog.

ORDER VI. VESANIAE.

Paranoia, Veg. Clas IX. Deliria, Sauv. Clas. VIII. Ord. III. Sag. Clas XI. Ord. III. Ideales, Lin. Clas V. Ord. I.

CLIV. AMENTIA; FOLLY, or Idiotsim. Genus LXV.

Amentia, Sauv. gen. 233. Veg. 337. Sag. 346. Morosis, Lin. 106. Stupiditas, morosis, fatuitas, Veg. 336. Amnesia, Sauv. gen. 237. Sag. 347. Oblivio, Lin. 107. Veg. 338. Memorix debilitas, Junck. 120.

CLV. MELANCHOLIA, Melancholy Madness. Genus LXVI.

Melancholia, Sauv. gen. 234. Lin. 71. Veg. 332. Sag. 347. Boerb. 1089. Junck. 121. Demonomania, Sauv. gen. 236. Sag. 348. Demonia, Lin. 69. Vesania, Lin. 70. Paraphobia, Lin. 75. Athymia, Veg. 329. Delirium melancholicum, Hoffm. III. 251. Erotomania, Lin. 82. CLVI. MANIA, RAVING or FURIOUS MADNESS.

GENUS LXVII.

Mania, Sauv. gen. 235. Lin. 68. Vog. 331. Sag. 349. Boerh. 1178. Junck. 122. Battle on Madness.

Paraphrofyne, Lin. 66.

Amentia, Lin. 67.

Delirium maniacum, Hoffm. III. 251.

Although these distempers 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 of them all at once.

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 idiotism 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 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 of his predecessor in the care of Bethlem 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 distresses, 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.

Cure, &c. 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, let them arise from what source soever. Very often, mere waste, or 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 ipecacuanæ; 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 menes, or hemorrhoidal discharge, then aloetic purges will be more proper. 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 distemper abound, he says, is not to be got the better of by repeated vomits; and he observes, that the purges have not their right effect, or do not operate to so good purpose, until the phlegm is 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 and nitrous medicines having been premised. Camphor has also been highly commended; but, if we 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 drachm 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 half of it every day; the patients having been previously prepared by bleeding and purging, 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 shew the necessity of confining such as are deprived of their senses; and no small share of the management consists in hindering them to hurt themselves, or do mischief to other persons. 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 fluff; are open at the back, and laced on like a pair of stays; 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, 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 bedhead, 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.

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 anything that is required. The physician, however, should never deceive them in any thing, but more especially with regard to their distemper: 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.

Though blistering the head has generally been directed, Dr. Mead says he has oftener found it to do harm than service: but he recommends ills in the back; and advises to keep the head always close shaved, and to wash it from time to time with warm vinegar. Opium is usually forbidden in maniacal cases, as supposing 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 diffused 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; and 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.

CLVIII. ONEIRODYNYA, Uneasiness in Sleep. Genus LXVIII.

Somnium, Vog. 339. Somnambulismus, Saxo. gen. 221. Lin. 77. Sag. 333. Hypnabatais, Vog. 340. Noctambulatio, Junk. 124. Ephialtes, Saxo. gen. 138. Lin. 163. Sag. 245. Incubus, Vog. 211. Junk. 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 precordia. 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 hath 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 slight 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. CLASS III. CACHEXIÆ.

Cachexia, Sauv. Clas X. Sag. Clas VIII. Sag. Clas III. Deformes, Lin. Clas X.

ORDER I. MARCORES.

Magies, Sauv. Clas X. Order I. Sag. Clas III. Order I. Emaciantes, Lin. Clas X. Order I.

CLIX. TABES, or WASTING of the Body. Genus LXIX.

Tabes, Sauv. gen. 275. Lin. 209. Veg. 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 for the proper treatment of the tabes proceeding from this cause, see below, Ulcer, Syphilis, Scrofula, Scurvy, &c. also the article Surgery.

CLX. ATROPHY, or Nervous Consumption. Genus LXX.

Description. This is 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.—Dr. Cullen, however, affirms, 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 hath got the name of tabes dorsalis. It will 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 dropy.

Cure. Stomachic and nervous medicines are only to be depended upon in this case. The Peruvian bark, elixir of vitriol, and chalybeates, are excellent; and the diet should be as light and nutritive as possible. 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 useless. But this is so seldom complied with, that the tabes dorsalis almost always proves mortal.

ORDER II. INTUMESCENTIÆ.

Intumescentiae, Sauv. Clas X. Ord. II. Sag. Clas III. Ord. II. Tumidofi, Lin. Clas X. Ord. II.

CLXI. POLYSARCIA, or Corpulency. Genus LXXI.

Polysarcia, Sauv. gen. 279. Lin. 213. Veg. 540. Sag. 160. Steatites, Veg. 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 vessels. But in many constitutions the oily part of the blood appears to exceed the requisite proportion, and easily separates from the other constituent parts; and then it is apt to accumulate in such quantities, that we may suppose it to burst those vessels which were originally defined to hinder it from spreading too far.

The increase of the omentum particularly, and the 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 therewith, are in like manner so encumbered, that neither the systolic nor subtilary motion can be performed with sufficient freedom, whence weakness and flowness 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 inextirpate by the time that people begin to think of pursuing the proper means of relief.

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-lees would be more powerful, and might be more easily taken, sheathed, as hereafter directed when recommended as a dissolvent of the stone.

Lieutaud advises to take acetum salicinum in small doses, with frequent purging and brisk exercise. But it will seldom happen that the patients will be found sufficiently steady to persit in any of these courses, it being the nature of the disorder to render them irrefractive 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 CLXII. PNEUMATOSIS, Emphysema, or Windy Swelling. Genus LXXII.

Pneumatosis, Sauv. gen. 280. Vog. 391 Sag. 167. Emphysema, Sauv. gen. 13. Lin. 288. Vog. 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 infuses 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 the scarifications and compresses, and in some cases only by the paracentesis of the thorax. See Surgery.

CLXII. TYMPANITES, the Tympany. Genus LXXIII.

Tympanites, Sauv. gen. 291. Lin. 219. Vog. 316. Sag. 118. Bech. 226. Funck. 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 frequently unequal. 2. When the flatus is contained in the cavity of the abdomen; in which case the swelling is more equal, and the belly bounds when struck, without any considerable emission of flatus. In both cases the rest of the body falls away.

Causes, &c. The tympamy 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 into an alcrites. Sometimes, if the patient be healthy and strong, the disease may terminate favourably, and that the more readily if it has followed some other disorder. A hectic consumption, dry cough, and emaciated countenance in a tympamy, with a swelling of the feet, denote approaching death in a very short time.

Cure. The cure of the tympamy is to be 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 tympamy by Dr Monro senior. The patient was a young woman of 22 years of age, who fell into the distemper after having 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, some doses of calomel; used the warm bath; and had an antiphlogistic plaster applied over the whole belly, but with very little effect. She was monstrously distended, insomuch that the skin seemed to be in danger of bursting; her breathing was much straitened; and the swelling gradually decreased without any evacuation. The returns and degree of this swelling were very uncertain; and when the belly was most detumesced, 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 coticive, had her menses at irregular periods, but no edematous swellings appeared in the feet or anywhere else. In this situation she continued from the time of her admission till the 21st of June, during which interval she had only her menses twice. Throughout this space of time it was 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. Blooding and emetics, which were made use of for some accidental urgent symptoms, had no very sensible effect in making the tympamy either better or worse. 4. She never had passage of wind either way, except a little belching some days before the first monthly evacuation.

Some time before the last eruption of the menses the purgatives were given more sparingly, and the doses of the antiphlogistics of the strongest kind, such as asafoetida, oleum C. C. &c. mixed with soap, were given in large doses, accompanied with the hotter antiflatuses as they are called, as horse-radish 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 exercise. Immediately before the menstrua 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. Borborygmus were for the first time observed on the same day, June 25th; and having taken some tinctura facia at night, she passed a small quantity of blood next day by stool. This was the first appearance of the return of the hemorrhoids, to which she had been formerly subject.

The two following days her saponaceous, antiphlogistic, and antiflatus 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.

CLIV. CLIV. PHYSOMETRA, or Windy Swelling of the Uterus. Genus LXXIV.

Physometra, Sauv. gen. 290. Sag. 119. Hydrophysis, Vog. 317.

The treatment of this is not different from that of the tympany.

CLV. ANASARCA, or Watery Swelling over the Whole Body. Genus LXXV.

Anasarca, Sauv. gen. 281. Lin. 215. Vog. 313. Sag. 108. Boerb. 1225. Hoffm. III. 322. Junck. 87. Monro on the Dropsy. Milman Animadversiones de hydropoe 1779. Phlegmatia, Sauv. gen. 282. Angina aquosa, Boerb. 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; which 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 hereafter mentioned under Ascites, is attended with a remarkable difficulty of breathing.—For the cure, see Ascites.

Only it may be here noticed, that in anasarca it is usual to scarify the feet and legs. By this means the water is often discharged; but the operator must be cautious not to make the incision too deep; they ought barely to penetrate through the skin; and especial care must be taken, by spirituous fomentations and proper digestives, 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.

CLXIV. HYDROCEPHALUS, or Water in the Head. Genus LXXVI.

Hydrocephalus, Sauv. gen. 285. Lin. 216. Boerb. 1217. Hydrocephalum, Vog. 384.

This differs from the hydrocephalus formerly mentioned, as the water is 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 tumour 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 dipped in brandy. The tumour 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 one place about the size of a shilling, which continued thin, and at times appeared as if it would burst. He continued in this situation for about 17 months, when the circumference of the head was 20 inches, the base 16½, the middle 18½, and from the base to the apex near 2½. 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 bone.

CLXX. HYDRORACHITIS, or Spina Bifida. Genus LXXVII.

Hydrorachitis, Sauv. gen. 287. Morgagni, defed. XII. 9. et seq. Spinola, Lin. 289. Spina bifida, Vog. 386.

CLXVI. HYDROTHERAX, or Dropsy of the Breast. Genus LXXXVIII.

Hydrothorax, Sauv. gen. 150. Vog. 311. Boerb. 1219.

For these two diseases. See the article Surgery.

CEXVII. ASCITES, or Dropsy of the Abdomen. Genus LXXIX.

Ascites, Sauv. gen. 288. Lin. 217. Vog. 314. Sag. gen. 115. Boerb. 1226. Hoffm. III. 322. Junck. 87. D. Monro on the Dropsy, 1765. Milman, Animadversiones de hydropoe, 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. It may be contained in sacs and hollow glands, 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 abovementioned physicians have been led into the mistake from observing the water collected in the cellular substance of the peritoneum.

In the beginning of an ascites the patient becomes languid, breathless, and hath an aversion at 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 red. The pulse is small and frequent; and as the belly swells, the other parts waste away. A fever at last arises, which, constantly increasing, at last 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 left wasted; nor is there so great thirst or difficulty of breathing.

Cause, &c. The immediate cause of dropsy is a greater effusion of serum by the exhalent arteries than the absorbers can 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 chlorotic girls especially are very apt to become dropsical.

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, 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 are less damaged, 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 sanguineous tumours in the omentum, and many more from a scirrhus liver or spleen, and from an infection and obstruction of the mesenteric glands, by which means the lymph coming from the extremities is prevented from arriving at the heart.

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 exhalent arteries, at the same time that it prevents their return by the absorptive veins. This hath been established by experiment. For Lower having perforated the right side of the thorax in a dog, tied the veins close, 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 creature died. On dissection, all the muscles and glands were vastly distended, and quite pellucid, with limpid serum. From these experiments, and some cases of 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 tenacity 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 of Halefins 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 thro' the extremities of the sanguineous 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 Schultze, 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 drank 12 pounds of that liquor every day for a month, and thus fell into an almost incurable distemper. But if this quantity had been taken only during the prevalence of the fever, he would in all probability have suffered no inconvenience, as is probable from what we have formerly related concerning the dieta aquae 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 absorbed, unless some laxity of the solids hath already taken place. Dr Mufgrave 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 fix 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 creature 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, dispose to the dropsy. A lazy indolent life, rainy wet weather, 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 viscid aliments, such as poor people in some countries who use coarse brown bread, and children who Practice 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 fatal, as 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 tumours 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; but if we can by any means remove the disease of the glands, the dropsy easily ceases. But in those who fall into dropsy without any disease preceding, it is not quite so dangerous; and even though a disease hath preceded, if the patient's strength is not greatly weakened, if the respiration is free, and the person is 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; but they are very frequently cured who fall into this disease without any preceding hemorrhage.

Cure. In the cure of this disease authors chiefly mention two indications. 1. To expel the superfluous quantity of 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 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 persons 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 not, however, 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 are 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 almost our only 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 hath long ago observed, that this part of medicine is of all others the most lame and imperfect; but a certain French physician named Bacher, lately found 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 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 "spiritu vini armato alkæst." 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 Rhenish 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 are then mixed together with two parts of boiling water to one of the decoction. The whole is then evaporated in a silver vessel to the consistence of a syrup. One part of the extract is again added with two parts of boiling water, and the whole inspissated as before.—By this means, says he, the volatile nauseous acid 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. Our author 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 invigorating and indurating nature; yet so prepared that it will be readily soluble in the stomach, even of a person already debilitated. For answering these purposes, he chose myrrh and carduus benedictus, and then 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 drachms and a scruple. Mix them together, and form into a mass, dividing it into pills of a grain and an half each."

The effects of these pills were very surprising. Dr Daiguen relates, that he gave them to 18 hydropic 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 anaëra following intermittent fevers. The second class contained those who had an anaëra, 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 anaëra 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 arteries 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 inflamed. In the other, the liver and pancreas were scirrhouss, and the spleen very hard.

The same medicines were given by Dehorne to eight persons, six of whom had both an anaemia 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 thrice, with an interval of an hour between each dose. At first they proved purgative, and then diuretic; by which last evacuation they finally cured the disease. But though Becher 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 certain that different medicines will prove equally efficacious in dropsical cases, provided this regimen is made use of.

For a great number of ages it hath been recommended to dropsical 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 shews 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 affirms, that unless plenty of diluting drink is given, the best diuretics can have no effect. He condemns also in the strongest terms the practice of giving dropsical 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 scarce, 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 putrid humours produced by these kinds of food float about the praecordis, 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 1000 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 implore the abovementioned 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 method, related by Dr Milman, of his practice in the Middlesex hospital.

If the patient is 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 aceticum fellitium every fifth 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 distemper without allowing the drinks; 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 diuretum; 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 cream of tartar dissolved in two pounds of barley-water, made agreeably sweet with syrup, adding one or two ounces of French brandy.

To this composition Dr Milman was induced by the great praises given to cream of Tartar by some physicians in hydropic cases. In the Acta Bononiensia, 15 cases of hydropic patients are narrated, 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 abovementioned, of which they drink at pleasure along with their medicines.

Among purgative medicines Dr Milman recommends the radix feneki; but says, the decoction of it according to the Edinburgh Dispensatory 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 drachms 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 feneki, or any other purgative, if the patients are 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 dropsy is removed, moved, the patients will sometimes die without any evident cause; and of this it is proper that the physician should be aware. It is remarkable with what ease a flux of urine is induced in those who have a febrile liver; while on the other hand, in one who had the mesenteric glands obstructed, along with a scirrhus of the liver and vitiated state of the lungs, the most powerful diuretics proved ineffectual. In some cases our author thinks the kidneys may be so pressed with the weight of the water, as to be unable to perform their office.

The water having been drawn off, we are to put the patient on a course of strengtheners; such as the cortex and filings of iron, with some of the warm aromatics, and a due proportion of rhubarb infused in wine. Enjoin brisk exercise and frictions on the belly, with such a course of diet as shall be light and nourishing.

When the patient can by no other means be relieved, the operation of paracentesis must be had recourse to. See the article Surgery.

CLXVII. HYDROMETRA, or Dropsy of the Uterus. Genus LXXX.

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

CLXVIII. HYDROCELE, or Dropsy of the Scrotum. Gen. LXXXI.

Ofchecoele, Sauv. gen. 41. Veg. 388. Olcheophyma, Sag. 44. Hydrops feroci, Veg. 389. Hydrops tellium, Boerh. 1227.

For the treatment of these two diseases, see Articles above, and Surgery.

CLXIX. PHYSCONIA, or Swelling of the Belly. Genus LXXXII.

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

This 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 febrile 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.

CLXX. RACHITIS, the Rickets. Genus LXXXIII.

Rachitis, Sauv. gen. 294. Lin. 212. Veg. 312. Sag. gen. 120. Boerh. 1480. Hoffm. III. 487. Zottiani della Rachitide. Glisson 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 tumour 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 is a protuberance 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 is 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 knobby. In such patients as have died of this disease, all the folds appeared soft and flaccid, and the fluids dissolved and mucous.

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

Prognosis. The rickets do not usually prove mortal; 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 unction 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 unction, which again brings on the fever, is repeated as the former. When no fever can be longer excited by this unction, 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 unctions; and is continued till the cure is completed, which it commonly is in a short time.

A German physician, named Dr Strack, hath 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 affirms 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 our author, 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 complection are by degrees removed, while the natural colour of the countenance and firmness of the body in general are gradually restored. This practice, he affirms us, has never failed of success in any one instance; not even in those children born of parents greatly afflicted with the rickets.

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.

ORDER III. IMPETIGINES.

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

CLXXI. SCROPHULA, or King's-evil.

Genus LXXXIV.

Scrophula, Sauv. gen. 285. Vog. 367. Sag. 121. Struma, Lin. 284.

Description. This disease shows itself by hard, scirrhouss, and often indolent tumours, which arise by degrees in the glands of the neck, under the chin, arm-pits, and different parts of the body; but most commonly in the neck, and behind the ears. In processes 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 scirrhouss 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 on 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 meantime 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 sponges, different kinds of soap, and other alkaline substances, as the best remedies for acidity. But although a fourness of the stomach and prime viz does no doubt frequently occur in these complaints, yet it 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 asecrecy of the fluids to take place; as the case very frequently, it is well known, even in other complaints, occurs without the least suspicion of any acid acrimony existing. This is also rendered very probable from the indolent nature of scrophulous tumours, 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.

Gentle mercurials are sometimes of use as resolvents in scrophulous swellings; but nothing has such considerable influence as a frequent and copious use of Peruvian bark. 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 scrophulous inflammation of the eyes, or ophthalmia strumosa, the bark has also been given with extraordinary advantage: and we meet with an instance of its having cured the gutta serosa in the face; a complaint which it is often difficult to remove, and 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, the bark is a most efficacious medicine, and that it acts as a resolvent and deficient. 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 are affected, nor where the scrophulous tumour...

Practice is 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 the bark is of no effect: instead of lessening, it rather increases the fever that accompanies those circumstances; and, if it does not really aggravate the complaint, it seems at least to accelerate the progress of the disease.

Various are the modes in which the bark is administered; but 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.

The powder soon becomes disagreeable to very young patients; and the extract seems not to 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 Wintera 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 is 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 also has been strongly recommended by Dr Ruffel.

Dr Fothergill also acquaints us, that the cicuta is not without a considerable share of efficacy in removing scrophulous disorders. He mentions the case of a gentlewoman, about 28 years of age, afflicted from her infancy with scrophulous complaints, severe ophthalmies, glandular swellings, &c., cured by the extractum cicuta 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.

Our author gives several other instances of the success of cicuta in scrophulous 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 strumous 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, our author 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, seems 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 virous than those that grow in the shade. The lets 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, is added, the lets boiling will be necessary, and the medicine will be the more efficacious. But let the extract be prepared in what manner ever it may, provided it is made from the genuine plant, at a proper season, and is 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 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 are felt; and in three or four days, advance a few grains more. For the general experience of all who have used this medicine to any good purpose agree, 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 abovementioned.

Patients commonly bear a greater quantity of the extract at night than at noon, and at noon than in the morning. Two ounces may be divided into thirty pills, not gilt. 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.

CLXXII. SYPHILIS, the Lues Venerea, or French Pox. Genus LXXV.

Syphilis, Sauv. gen. 3086. Lin. 6. Veg. 319. Seg. 126. Lues venerea, Boerh. 1440. Hoffm. III. 413. Junck. 96. Afric de lue venerea.

Astruc, who writes the 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.

The venereal infection, however, cannot, like the contagious mischief of the small-pox 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 by actually touching some Practice some person who is affected. 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 been instances known of lying in women being infected very violently, from having employed a person to draw their breaths 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 infective case he ever saw, was caught by a midwife, who happened to have a whitlow on one of her fingers, when she delivered a woman ill of the last venereal.

But by far the most ready way of contracting this disease is by coition, the genital parts being much more liable 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 usually 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 pathognomonic 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 lymph; 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 scab being picked off, the skin appears of a reddish brown, or rather copper-colour, underneath; whereas leprous eruptions are itchy, throw off a greater quantity of scales, and rise in greater blotches, 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 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 tawny 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 scorbute, in the following manner: 1. Venereal ulcers first affect the tonsils, faucets, and uvula; but these very rarely; on the contrary, scorbute ulcers affect the gums first of all; then the fauces, tonsils, and uvula. 2. Venereal ulcers frequently spread to the nose; scorbute ones never. 3. Venereal ulcers are callous in the edges; scorbute ones are not so. 4. Venereal ulcers are circumscribed, and, for the most part, are circular, at least they are confined to certain places; scorbute 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 scorbute ones are more apt to grow up into loose fungi. 6. Venereal ulcers are red in their circumference, but scorbute ones are always livid. 7. Venereal ulcers frequently rot the subjacent bones, the scorbute ones seldom or ever. 8. And lastly, Venereal ulcers are most combined with other symptoms which are known to be venereal; scorbute ones with the distinguishing signs of the scurvy, such as strait breathing, litheness, swelling of the legs, rotten gums, &c.

Another sure sign of the confirmed lues, are certain deep-seated nocturnal pains, particularly of the shins, 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, under the periosteum, ganglia upon the tendons, tophi upon the ligaments, exostoses upon the bones, and fistulae 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 independent of any venereal infection, and perhaps may proceed from a scrophulous taint, unless they are 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 syphilitic 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 various 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 fetuses, happening without any manifest cause to disturb the fetus before its time, or to destroy it in the womb, may be reckoned as a sure 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 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 eye-lids. 2. A ringing and hissing noise in the ears, with ulcers or caries in the bones of the meatus auditorius. 3. Obstinate head-aches. 4. Obstructive cutaneous eruptions, of the itchy or leprous 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.

Upon the whole, we are first to distinguish and consider the several symptoms apart; and then, by comparing them with each other, a clear judgment 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; which seems owing to the menstrual and other uterine discharges, by which perhaps a good share 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 acid 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 scrofulous or scrophulous 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 affluence, 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; 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. 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 indispensible; 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 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 is one of the most active of all the mercurial preparations, insomuch as to become a poison even in very small doses. It therefore cannot be given in substance; but must be dissolved, in order to render it capable 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 of use there time out of mind.

It appears to have been totally forgotten in other places, until of late years, when the Baron Van Swieten brought it into vogue; so that now, if we credit Dr Locker, they use 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 way to prepare 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 pithan or barley-water, and this to be taken morning and evening: the patients should keep mostly 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, pithan, 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 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 prac- tice 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, intitled, 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.

If therefore it is determined to have recourse to the mercurial frictions, the patient must be prepa- red by going into the warm bath some days succes- sively; having been previously blooded if of a ple- thoric habit, and taking a dose or two of some proper cathartic.

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

If the person be of a robust habit, and in the prime of life, we may begin with two drachms of the an- guentum caruleum fortius, (Ph. Lond.) which is to be rubbed in about the ankles by an assistant whose hands are covered with bladders: then having inter- mitted a day, we may expend two drachms more of the ointment, and rest for two days; after which, if no forenoon of the mouth comes on, use only one drachm; and at every subsequent friction ascend till the oint- ment 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 keep- ing the patient in a constant perspiration from the warmth of the room, and by drinking plentifully of barley-water, whey, or pitan; but if, nevertheless, the mercury should tend to raise a spitting, then, from time to time, we are either to give some gentle cathar- tic, or order the patient into a vapour-bath: and thus we are to go on, rubbing in a drachm 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 is necessary to be rubbed in, as this will vary ac- cording to circumstances; but we are always to con- tinue the frictions for a fortnight at least, after all symptoms of the disease shall have totally disappear- ed; and when we have done with the mercury, warm bathing, and sudorific decoctions of the woods, are to be continued for some time longer.

Some venereal cases are so very obstinate as not to yield to mercury; and some of the particular symp- toms will remain even after repeated courses, particu- larly the nodes and swellings of the periosteum. These are sometimes cured by a decoction of the roots of me- zereon, an ounce being boiled in a gallon of water down to two quarts; a pint of this decoction is to be consumed in the course of a day. Such other symp- toms as are found to result mercury, may perhaps be conquered by a long continuance of the decoction prac- tice of laraparilla, aided by the warmth of a southern climate.

This is a general sketch of the methods of treat- ment for the confirmed lues; but for a complete his- tory of the disease, and for ample directions in every situation, we refer to Atreus, and his abridger Dr Chapman.—We have to add, however, that a method of curing this disease by fumigation has been lately re- commended in France; but it seems not to meet with great encouragement. The most recent proposal for the cure of the venereal disease is that of Mr Clare, and consists in rubbing a small quantity of mercury on the inside of the cheek; by which means we not only avoid the inconveniences of unction, but also the purgative effects that are often produced by this medi- cine when taken into the stomach.

SCORBUTUS, the Scurvy. Genus LXXXVI.

Scorbatus, Sauv. gen. 391. Lin. 223. Vog. 318. Sag. 127. Boerb. 1148. Hoffm. III. 369. Junck. 91. Lind on the Scurvy. Hulme de scor- buto. Roupp de morbis navigationum.

Description. The first indication of the scorbute di- atheis, is generally a change of colour in the face, from the natural and healthy look to a pale and bloated com- plexion, with a little flesh, and aversion from every fort of exercise; the gums soon after become itchy, foul, 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 fung- ous and putrid, as being continually in contact with the external air; which in every case favours the pu- refaction of substances disposed to run into that state, and is indeed absolutely requisite for the production of actual rottenness.

The symptoms of the scurvy, like those of every other disease, are somewhat different in different sub- jects, according to the various circumstances of consti- tution; and they do not always proceed in the same regular course in every patient. But what is very re- markable in this disease, notwithstanding the various and immense load of distress under which the patients labour, there is no sickness at the stomach, the appe- tite keeps up, and the senses remain entire almost to the very last; when lying at rest, they make no com- plaints, and feel little distress or pain; but the mo- ment 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 catch- ing of the breath upon motion, with the loss of strength, dejection of spirit, and rotten gums, are held as the ef- fential 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 anerine appearance; but much oftener it is smooth and shining; and, when examined, is found 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 mostly 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 dropsical or truly oedematous swellings. The slightest wounds and bruises, in scorbutic habits, degenerate into foul and untoward 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 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 elixiories, 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 puffed 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 good while, 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 the most pernicious things that can be administered 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 the higher degrees of tension, and consequently of pain.

The state of the bowels are various: in some there is an obdurate constiveness; 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 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.

Causa. The term scurvy hath 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, and to people pent up in garrisons without sufficient supplies of sound animal-food and fresh vegetables; or which 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 this distemper; for the appearances, on dissecting scorbutic subjects, sufficiently shew that the scurvy may, with great propriety, be termed a distemper 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 these cells naturally occupied by pure blood), 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 flagrant blood, when its crisis comes to be destroyed, and it loses that glutinous quality which, during health, hinders it from escaping thro' the pores in the coats of the blood-vessels.

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 dissector; and in some instances, where the skin happened to be broken, it irritated and festered the wound.

The flabby fibres were found to 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, im- And yet, 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 putrid 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 the putrefactive 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 inefficient."

He also, in the preface to this third edition, talks of the mischief done by an attachment to delusive theories; 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 cloister 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 strange, 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 vessels 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 due supplies of wholesome food; while the insoluble, superfluous, effete, and acid 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 greatly, if not entirely, on the presence of their aerial principle; since 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 air 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; and 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 the 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 efulent 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, (in which, notwithstanding any cavilling that may be raised about terms, fermentation must be allowed to have a principal share), 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), wherein 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 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 disordered, or debilitated, that the nutritious parts of the food cannot be properly developed, the blood must be deprived 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, acid, 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 de- barred 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. 6. Above all, the being obliged to live continually on salted meats, perhaps not well cured, without a due proportion of the milder farinaceous or mucilaginous vegetables, sufficient to correct the pernicious tendency of the salt, by supplying the bland oil and saccharine matter requisite for the purposes of nutrition.

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 enjoy 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 found fermented liquors; and if spirits be allowed, to have them properly diluted with water, and sweetened with melasses or coarse 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 hath 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 (which confirms the hypothesis that it is seated in the gross fluids, and particularly the blood), that if a sufficiency of new matter, of the truly mild nutritious sort, 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, drachms or ounces. For here, as the subtile fluids are not sensibly affected, and 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 disorder; 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 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 these nutritious parts to be easily developed; for though the victims in scorbutic patients may be all perfectly found, 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 farinaceous, and the hard salted flesh of animals, into nourishment. We must therefore search for the antiscorbutic virtue in the tender sweet flesh of graminivorous animals; in new milk; and in the mucilaginous juices of recent vegetables, whether they be fruits, leaves, or roots. And provided they be fresh, and succulent, and of such mildness as will permit them to be abundantly taken, it is of little importance whether they be sweet or sour, acid or alkaline; for such is the power of the alimentary fermentation, that by the time the chyle is ready to enter the lacteals, their native qualities are obliterated, and the oily and saccharine matter which lay hid in the mucilage entirely extricated.

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 shews, and our experiments confirm it, that the virtue of these juices (and, we presume, of every other that has been known to cure the scurvy) depends on their aerial principle, and consequently resides in the mucilage, whether it be sweet or sour; 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 vomiting; he therefore found it necessary to add 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 tipped a little of this frequently, according as their strength would permit; others who were stronger took about two ounces of it every four 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, that 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 gains 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 afflicted by stewed prunes, or a decoction of tamarinds with cream of tartar, in order to abate the coliciveness; 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 scurvy patients than moderate sweating.

With regard to particular symptoms, antiseptic mouth-waters composed of a decoction of the cortex and tincture of roses, with 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, dipped in a strong decoction of Peruvian bark.

This disease at no time requires, or indeed bears, large evacuations, either by bleeding or purging; and, as hath 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 scurvy 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 this, however, that has 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 provisions; therefore, in order that a remedy for the scurvy might never be wanting, Dr Macbride, in the year 1762, first conceived the notion, that 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 experiment's 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 much importance to the seafaring part of mankind, these were immediately communicated to the public in a pamphlet with the title of An historical account of a new method of treating the scurvy at sea.

This was in 1767; but since that time a considerable number of letters and medical journals, sufficient to make up a small volume, were transmitted to the author, particularly by the surgeons of his Majesty's ships that have 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 last 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.

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 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 affirms, 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 found, 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 mashed, 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 panado 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 coliciveness nevertheless prevails, gentle laxatives must be interposed from time to time, together with diaphoretics, and the topical afflatus, fomentations and gargles, as in the common way of management.

Captain Cook was also provided with a large stock of sour kraut; (cabbage-leaves cut small, fermented and stoppered in the second stage of fermentation.) A pound of this was served to each man, twice a-week, while they were at sea. He 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.

Newly brewed spruce-beer (made from a decoction of the tops of the spruce-fir, and molasses) is an excellent antiscorbutic; acts in the same way that the wort does, and will be found of equal efficacy, therefore may be substituted. 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 sourish; which generally happens, in moderately warm weather, in the space of two days. The liquor is then strained off from the grounds, 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 off, than a land-scurvy, as a distinct species of disease from this 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 foulnesses and eruption, which indeed are vulgarly termed scorbutic, but which are akin to the itch or leprosy, and for the most part require mercurials.

CLXXIV. ELEPHANTIASIS. Genus LXXXVIII.

Elephantiasis, Sans. gen. 302. Veg. 321. Sag. gen. 128. Elephantia Arabum, Veg. 322.

The best account of this disease is that by Dr. Herberden, 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 feverish, of a livid or copper colour, and sometimes of the natural colour of the skin, or at least very little altered; and sometimes they after some months 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 eye-brows seems inflated; the hair of the eye-brows falls off, as does the hair of the beard; but our author has never seen any whose hair has not remained on his head. The alae 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 hath 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 distemper advancing, corrodes the parts gradually with a dry scalding, or gangrenous ulcer; so that the fingers and toes rot and separate, joint after joint. In some patients the legs seem rather pots 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, and not so white as those observed in the lepra Gracorum. The whole limb is overspread with tubercles, interspersed with deep fissures; sometimes the limb is covered with a thick moist scabby crust, and not seldom the tubercles ulcerate. In others the legs are emaciated, and sometimes 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 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 the 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 CLXXVI. FRAMBOESIA, the Yaws.

Genus LXXXIX.

Framboesia. Sauv. gen. 125. Sag. 125.

Description The description which is given of this distemper by the anonymous author of a paper in the fifth volume of the Edinburgh Medical Essays, (art. 76.) differs, in some circumstances, from one that Sauvages received from M. Virgile, an eminent surgeon of Montpelier, who practised 12 years in the island of St Domingo; and therefore he distinguishes the framboesia into two species, Guineensis, and Americana.

The framboesia 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 tumour, 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 they 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 arm-pits, 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 fores occasion.

Mr. Virgile describes the species of yaws that is common among the Negroes of St Domingo, and which Sauvages has termed framboesia 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 circumstances save 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 mucous. Besides these, the soles of the feet and palms of the hands became raw, the skin fretting off, so as to leave the mutes bare; these excoriations are sometimes moist with ichor and sometimes dry, but always painful, and consequently very distressing. They are also mentioned by the author of Practice the article in the Medical Essays; and both he and M. Virgile observe, that there is always one excrecence, or yaw, of an uncommon size, which is longer in falling off than the others, and which is considered as the matter-yaw, and so termed. These two, are the only accounts that have hitherto been published of this disease.

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, provided the morbid disposition of body be present.

It is believed, that the disease never appears twice in the same person; since all the Negroes who have had the yaws in Africa, and have been cured there, remain exempt from the disorder ever after; and the writer of the paper in the Medical Essays affirms, that, in nine years practice in the West Indies, he never knew any patient to relapse after having been once thoroughly cured.

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 his skin been suddenly cleared thereby, the cure will be very difficult, if not impracticable.

Cure. This is 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, Lev. xiii. and in that time you may be commonly certain.

As soon as you are convinced that it is the yaws, give a bolus of flowers of sulphur, with camphire 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 a dry scaly crust or scab; 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 of itself. [A dram of corrosive sublimate dissolved in an ounce of rum or brandy, and the solution daubed on the yaws, will 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 alterative electuary of athiops and gum guaiacum. He may likewise use the decoction of guaiacum and saffron fermented with melsaffa, for his constant drink while the electuary is taking, and a week or a fortnight after the electuary is spent.

The matter-yaw must be consumed an eighth or a tenth part of an inch below the skin, with Mercur. corros. rub. & alum. usf. an. part. aquat. and digested with Ung. bals. flav. 3j. and mercur. corros. rub. 3j. and cicatrized with lint pressed out of spirits of wine, and with the vitriol stone.

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 matter-yaw. The gentle echarotics are to be preferred, especially here; 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 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 taraparilla. 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.

CLXXVII. TRICHOHA, the Plica Polonica, or Plaited Hair. Genus XC.

Trichoma, Sauv. gen. 311. Sag. 137. Plica, Lin. 313. Plica five rhopalosis, Vog. 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 five or six yards long; one patient hath 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 infect 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 known; for if the discharge be checked, or the vessels cut off, the consequence is an increase of more miserable symptoms, and in the illuse death. Sennertus says, when all the morbid matter is thrown out of the body the plica 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 CLXVIII. ICTERUS, the Jaundice.

Genus XCI.

Icterus, Lin. 224. Vog. 306. Boerh. 918. Junck. 90. Aurigo, Sauv. gen. 306. Sag. 132. Cachexia icterica, Hoffm. III. 301.

Description. The jaundice first shows itself by a listlessness and want of appetite; the patient becomes dull, oppressed, and generally colicive. 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 tingling linen; the stools are whitish or grey. In some there is a most violent pain in the epigastric region, which is considerably increased after meals. Sometimes the patient hath a continual propensity to sleep; but in others there is too great watchfulness; and sometimes the pain is so great, that tho' the patient be sleepy he cannot compose himself to rest. The pains come by fits; and all the 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 directions, where the bones have been found tinged sometimes for years after the jaundice hath 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 yellow 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 process 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 this diffusion is also to be reckoned among the causes of jaundice. Many disputes have arisen concerning the manner in which the bile is restored 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 anything obstructing the passage of the bile into the duodenum, or from anything 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 scirrhus of the liver or other viscera pressing upon the biliary ducts, and obstructing the passage of the bile; from status 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 forbes: but by far the most frequent cause of jaundice is the formation of calculi. These are found of almost all sizes, from that of a small pea to that of a walnut, or bigger; are of different colours; and sometimes appear as if formed in the inward part by crystallization, but of lamellae on the outer part; tho' 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 stone 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 hath 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 hath been by some deemed a sufficient proof of the spasmodic contraction of the ducts; but their opponents suppose, 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.

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 yellow taint 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 consistence 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.

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, are 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 stones are seldom of such a size but that the ducts will let them pass through, though frequently not without extreme pain. Indeed this pain, though so violent, and almost intolerable to Practice 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 stone through the biliary ducts is accompanied only with a sensation of slight uneasiness.

Cure. When the jaundice arises from indurated swellings or scirrhus of the visceræ, it is absolutely incurable; nevertheless, as these cannot always be discovered, the physician must 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 hath not yet afforded a solvent for biliary concretions. They cannot even be dissolved when taken out of the body either by acids or alkalies, or any thing besides 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 worse 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 hath to it. The juice of common grapes hath indeed been recommended as a specific in the jaundice, but on no very 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 grapes in the spring; and Van Swieten tells a strange story of a man who cured himself of the jaundice by living almost entirely on grapes, 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 calculus 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 visceræ; 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 is 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 stone 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 dose, 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 shake it gives to the visceræ; 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 prime vœ, and soliciting a discharge of the bile into the intestines; but they must not be of too drastic a nature, or they may produce incurable obstructions, by bringing forward stones that are too large to pass. Anodynes, the warm bath, and fomentaceous medicines, are serviceable by their relaxing quality. Soap hath been supposed to do service as a solvent; but this is now found to be a mistake, and it acts in no other way than as a relaxant.

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 hath 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 Peruvian bark and antiseptics: but we can by no means be certain that the jaundice will not return, and that at any imaginable interval; for there may be a number of stones in the gall-bladder, and though one hath 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 hath 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 mercurius dulcis 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.

Vitia, Sauv. Clas I. Lin. Cl. XI. Veg. Cl. X. Sag. Cl. I.

Plaga, Sag. Cl. II. Morbi organici Auctorum.

ORDER I. DYSÆSTHESIÆ.

Dysæsthesia, Sauv. Cl. VI. Ord. I. Sag. Cl. IX. Ord. I.

CLXXIX. CALIGO, the CATARACT. Genus XCII.

Caligo, Sauv. gen. 153. Veg. 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 touched, or rather extracted; for which operation, see Surgery.—Dr Buchan 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.

CLXXX. AMAUROSIS, the GUTTA SERENA. Genus XCIII.

Amaurosis, Sauv. gen. 155. Lin. 110. Veg. 238. Sag. gen. 261. Amblyopia, Lin. 168. Veg. 236.

A gutta serena is an abolition of the sight without any apparent cause or fault in the eyes. 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 languid 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 influes 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 of 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 sarsaparilla after it.—Of late electricity hath been much celebrated as efficacious, when no other thing could do service. See below on Electricity.

In the amaurosis; Dr Porterfield observes, that it is of the utmost consequence to know of how long stand-

ing the disease has been; which is not always easily done if one eye only is affected. This is a very essential point; because an amaurosis of long standing is altogether incurable. Mr Boyle mentions the case of a man who had a cataract for several years without knowing it himself, though others did. He discovered it at last by happening to rub his sound eye, and was surprised 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 was but lately lost, though perhaps it hath been so for years before. On the other hand, he may imagine that a recent 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, stuffing a candle, 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. Our author 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 abovementioned for about a month, he drew a favourable prognostic, and the disease was cured.

CLXXXI. DYSOPIA, or Depraved Vision. Genus XCIV.

Amblyopia, Sauv. gen. 154. Sag. 258.

There are several species referable to this genus, viz:

1. Dysopia Tenebrarum; 2. Dysopia Luminis.—The former of these is properly the myelops, or night-blindness, of ancient authors. But among both the Greek and Latin writers, there is a direct opposition in the use of this word myelops; some saying it signifies those who cannot see by night, and others express 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 intermittent kind; the difference then will consist in the different times of its approach; so may be called periodical blindness. Intermittents appearing in a variety of modes, and the success of the bark in some instances of this sort of blindness, both favour the opinion of its being an intermittent disease of the eyes. See Lond. Med. Transf. Vol. I. and Lond. Med. Offr. and Inquir. Vol. I. p. 111, &c.

3. Dysopia Dissimorum, (Presbyopia;) or the defect of those who see only at too great a distance. 4. Dysopia Proximorum, (Myopia,) or the defect of those who are short-sighted.—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 concave, and the latter of a convex 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 eye to the right, and vice versa.—This disorder may proceed from various causes both natural and accidental, some of which admit of no remedy, CLXXXII. PSEUDOBLERIS, or Imaginary Vision of Objects which do not exist. Genus XCV.

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

This very often takes place when the body is diseased, 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 hath 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 apoplexy 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.

CLXXXIII. DYSECOEA, Deafness, or Difficulty of Hearing. Genus XCVI.

CLXXXIV. PARACUSIS, or Deprivation of Hearing. Genus XCVII.

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

The functions of the ear may be injured by wounds, ulcers, or any thing that hurts its fabric. The hearing may likewise be hurt by excessive noise; violent colds in the head; fevers; hard wax, or other substances 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 owing 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 of the head, the patient must be careful to keep his head warm, especially in the night; he should likewise take some gentle purges, and keep his feet warm, and bathe them frequently in lukewarm water at bed-time. When deafness is the effect of a fever, it generally goes off after the patient recovers. If it proceeds from dry wax sticking in the ears, it may be softened by dropping oil into them; afterwards they must be syringed with warm milk and water.

If deafness proceeds from dryness of the ears, which may be known by looking into them, half an ounce of the oil of sweet almonds, and the same quantity of liquid apodoloch, or tincture of afaetida, may be mixed together, and a few drops of it put into the ear every night at bed-time, 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 istrice or feton, 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. Emuller 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. 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 the 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.

CLXXXV. ANOSMIA, or Defect of Smelling. Genus XCVIII.

Anosmia, Sauv. gen. 156. Lin. 113. Veg. 248; Sag. 262.

Causes. The sense of smelling may be diminished or destroyed by diseases; 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 benjamin, 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, marjoram, and aniseed; or a sternutatory of calcined white vitriol, 12 grains of which may be mixed with two ounces of marjoram-water and filtrated. The steam or vapour of vinegar upon hot iron received up the nostrils is likewise of use for softening the mucous, 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 serena. The ulcer ought likewise to be washed CLXXXVI. AGHEUSTIA, or Defect of Tasting. Genus XCIX.

Agheustia, Sauv. gen. 157. Sag. 263. Agheustia, Lin. 114. Apogeuflis, Vog. 449.

Cause. The taste may be diminished by crusts, filth, mucus, sputhas, pellicles, warts, &c., covering the tongue; it may be deprived 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.

Care. 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 things 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 ridiculous taste, arising from putrid humours, 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, or other stimulating substances, will help to recover it.

CLXXXVII. ANÆSTHÆSIA, or Defect of the Sense of Feeling. Genus C.

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

Cause, &c. This sense may be hurt by anything 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, sal volatile oleosum, horse-radish, &c., may be taken inwardly; the disordered parts, at the same time, may be frequently rubbed with fresh nettles or spirit of sal ammoniac. Blistering and sinapisins applied to the parts will likewise be of use; as also warm bathing, especially in the natural hot baths.

ORDER II. DYSOREXIA.

Sect. I. APPETITUS ERRONEI.

Morositates, Sauv. Clas VIII. Order II. Sag. Clas XIII. Order II. Pathetici, Lin. Clas V. Order II. Hyperaesthesis, Vog. Clas VII.

CLXXXVIII. BULIMIA, Insatiable Hunger, or Canine Appetite. Genus CI.

Bulimia, Sauv. gen. 223. Lin. 79. Sag. gen. 335. Bulimus, Vog. 296. Adedephagia, Vog. 297. Cynorexia, Vog. 298.

This disease is commonly owing to some fault in the stomach or viscera, by which the aliments are thrown out too soon; and unless the person is 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. 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 hath been useful; and frequent smoking tobacco hath relieved some. 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.

CLXXXIX. POLYDIPSIA, Excessive Thirst. Genus CII.

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

This is almost always symptomatic; and occurs in fever, dropsy, fluxes, &c.

CXCV. PICA, Longing, or False Appetite. Genus CIII.

Pica, Sauv. gen. 222. Sag. 334. Citta, Lin. 78. Allotriophagia, Vog. 299. Malacia, Vog. 300.

The pica is also symptomatic of chlorosis, pregnancy, &c. See the article Longing in the order of the Alphabet.

CXCI. SATYRIASIS. Genus CIV.

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, CXCII. NYMPHOMANIA, or FUROR UTERINUS. Genus CV.

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

The furor uterinus is a species of madness, or an high degree of hysterics. 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 continues, it degenerates into a mania.—In order to the cure, bleed in proportion to the patient's strength. Camphor in doses of 15 or 20 grains, with nitre, and small doses of the tinct. Thesh. should be repeated at proper intervals. Some venture to give the sac. saturn. in doses of 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 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 Riveius, may be frequently thrown up into the uterus: this is called specific; but matrimony, if possible, should be preferred.

CXCIII. NOSTALGIA, a Vehement Desire of revisiting one's Country. Genus CVI.

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

This is to be reckoned a species of melancholy.

Sect. II. APPETITUS DEFICIENTES.

Anepithymia, Sauv. Clas. VI. Ord. II. Sag. IX. Ord. II. Privativi, Lin. Clas. VI. Order III. Adynamia, Vog. Clas. VI.

CXCIV. ANOREXIA, Want of Appetite. Genus CVII.

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

The anorexia is symptomatic of almost all diseases, but seldom appears as a primary. See Anorexia in the order of the alphabet.

CXCV. ADIPSIA, or Want of Thirst. Genus CVIII.

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 sensibilia communes.

CXCVI. ANAPHRODISIA, Impotence to Venery. Genus CIX.

Anaphrodisia, Sauv. gen. 164. Sag. 270. Alechmia, Lin. 119. Ageneia, Vog. 283.

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

ORDER III. DYSCINESIÆ.

CXCVII. APHONIA, or Loss of Voice. Genus CX.

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, is cut, the person is capable of only as it were a half-pronunciation; but if both are cut, the speech and voice are both lost. The loss of speech happening in hysterical patients is also called aphonia; but more properly that loss of speech is thus named which depends on some fault of the tongue.

Seeing that the motion of any part is destroyed, or lessened at least, by the interception of the nervous fluid in its passage thither, and that 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 said fifth pair of nerves, and that the immediate cause is a diminution or total destruction of the nervous fluid through them. Hence a palsy of the tongue, which is either antecedent or subsequent to hemiplegic or apoplectic disorders, demand our utmost attention.

If an aphonia appears alone, it generally bespeaks an approaching hemiplegy or apoplexy; but if it succeed these disorders, and is complicated with a weak memory and a sluggishness of the mental powers, it threatens their return. That aphonia 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 afflicting to the patient, and is very obstinate of cure.

Other causes of this disorder are, the striking in of eruptions on the skin, a congestion of blood in the sores and tongue, obstructed periodical evacuations in plethoric habits, spasmodic affections, worms, a crumb of bread falling into the larynx, fears, too free a 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 or causes. That species which is owing immediately to spasms, soon gives way on the removal of them. If a palsy of the tongue is the cause, it is very apt to return, if relieved, but often continues incurable.

In order to the cure, endeavour first to remove whatever obstructs the influx of the nervous fluid into the tongue, and secondly to strengthen the weak parts. If worms are the cause, antispasmodics give present relief, but the cure depends on the destruction of these vermin.—In case of a congestion of blood about the head, bleeding and nitrous antispasmodics are to be used.—That species of apoplexy which remains after the shock of an hemiplegy or apoplexy, requires blisters to be applied to the nape of the neck; other means are rarely effectual.—If spasmodic contractions about the fancies and tongue are the cause, external paretories are of the greatest service; anodyne antispasmodics may be laid under the tongue, and the feet bathed in warm water; carminative elixirs 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 fp. C. C. facin. or the vin. antim. may be mixed with halfa trauent. or with the halfa Peruv. and given, at proper distances of time, in the patient's drink, or on a lump of sugar.—Sometimes the serum flows so rapidly to the sauces 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.

CXCIII. MUTITAS, DUMBNESS. Genus CXI.

Muititas, Sauv. gen. 165. Vag. 257. Sag. 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*. When it proceeds from a defect of any of the organs necessary for speech, the tongue for instance, it is also incurable; but if it arises from a palsy, the medicines applicable in that case will sometimes restore the speech.

CXCIX. PARAPHONIA, or Change in the Sound of the Voice. Genus CXII.

Paraphonia, Sauv. gen. 168. Cacophonia, Sag. 274. Raucedo, Lin. 146. Raucitas, Vag. 252. Asaphia, &c. Vag. 250, 251, 254, 255, 256.

The voice may be changed from various causes. In males it becomes much more harsh 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.

CC. PSELLISMUS, or Defect in Pronunciation. Genus CXIII.

Pellismus, Sauv. gen. 167. Lin. 138. Sag. 273. Traulotis, &c. Vag. 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 flammering, 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.

CCII. STRABISMUS, or Squinting. Genus CXIV.

Strabismus, Sauv. gen. 116. Lin. 304. Vag. 514. Sag. 222.

Description. This disease shews 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. I. This disease may proceed from custom and habit; while in the eye itself, or in its muscles, nothing is premature 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 dilated 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 Practice 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 the object.

That all this may be the better perceived; for an object, cause them to look at the image of the upper-part of your nose in a plain mirror, while you stand directly behind them, to observe the direction of their eyes.

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 them 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 on 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 eyes, 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 clearer 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 that 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. And, 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 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 dilate 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 a favourable prognostic; excepting only when, by a fault in the first conformation, any of the muscles are longer or shorter than their antagonist; in which case, if ever it should happen, no medicine can be of any value.

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 eye-lids: of this we have an instance in Langris. And that the same thing may also be occasioned by a tumour 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 and as for what concerns the optical phenomena, they must be the same as in the case immediately preceding.

Cure. This, 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 contractility of them after having covered his eyes from the light. These observations were carefully made by writing single letters on shreds 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 a half. By the use of this machine he soon found it less inconvenient to view all oblique objects with the eye next to them instead of 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.

CCII. CONTRACTURA, Contractions of the Lines. Genus CXV:

Contractura, Sauv. gen. 119. Lin. 299. Sag. 225. Oblitipitas, Sauv. gen. 11. 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 hath been found to perform surprising cures in this way.

ORDER IV. APOCENOSES.

Apocenooses, Vog. Clas. II. Ord. II. Fluxus, Sauv. Clas. IX. Sag. Clas. V. Morbi evacuatorii, Lin. Clas. IX.

CCIII. PROFUSIO, or Flux of Blood. Genus CXVI.

Profusio, Lin. 239. Hemorrhagia, Vog. 81. Beerb. 218.

For the treatment of this genus, see Menorrhagia, Hemoptysis, &c. above.

CCIV. EPHIDROSIS, or Excessive Sweating. Genus CXVII.

Ephidrosis, Sauv. gen. 258. Sag. gen. 194. Sudor, Lin. 208. Hydropelisis, 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 Peruvian bark, the cold bath, and other tonics. CCV. EPIPHORA, or Flux of the Lachrymal Humour. Genus CXVIII.

Epiphora, Sauv. gen. 259. Lin. 172. Veg. 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 immoderate study, or anything that weakens the eyes: hence it comes on about the age of 50 years, when the eyesight naturally becomes weak. It becomes worse in the winter-time, and is very hard to cure. Some authors recommend 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; 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 white vitriol dissolved in it, &c. have also been recommended.

CCVI. PTYALISMUS, Salivation. Genus CXIX.

Ptyalismus, Sauv. gen. 261. Lin. 176. Veg. 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 salivary 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 the Peruvian bark, 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 meantime an exact regimen had been prescribed: she had been ordered to ride constantly; and to confine herself to a mucilaginous diet, such as veal, calf's feet, &c. Likewise a gently opening medicine had now and then been interposed. The disease still continuing unaltered, she had afterwards tried the tinctura faturnina; and had, at the same time, been encouraged to chew the Peruvian bark, and to swallow the saliva. But all these attempts had been vain; and after that she had taken some or other of the medicines abovementioned, until the end of September 1753, namely, above two years, it appeared to her physician (Dr 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 might be continued by the force of habit, tho' 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 spit. 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 disagreeable 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.

CCVII. ENURESIS, an Involutory Flux of Urine. Genus CXX.

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 greatly 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 bark and elixir 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 palsies 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 strain, was cured of both CCVIII. GONORRHOEA. Genus CXXI.

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

The gonorrhoea is a flux of viscid matter of various colours, from the urethra in men, and the vagina in women. It commonly proceeds from coition with a person infected with the venereal disease, and is the first symptom by which that disease usually shows itself.

Description. The first symptoms of the disease in men, are commonly a scalding 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 is 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 subject from the stimulus, particularly when warm in bed, occasion a distention 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 prepuce 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 phimosis; at others, as in the paraphimosis, it remains in an inflamed state below the glans, so that it cannot be drawn forwards; and, if the irritation and inflammation are violent, may terminate in gangrene. Now and then, especially when there is a phimosis, 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.

In mild cases, the seat of the disease is in the urethra, not far from its orifice; but it frequently happens that the virus infatuates 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 parts of generation being fewer and more simple, the disease is less complicated 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 labiae, clitoris, earuncula myrtiformes, the orifice and sometimes the whole of the mentum urinarium. Very often the deep-seated glands of the vagina are affected, and it is sometimes difficult to distinguish the discharge of a gonorrhoea from that of the flor albus.

Causes, &c. Many ingenious arguments have of late been advanced to prove, that the gonorrhoea and the lues veneris are different affections, originating from two distinct species of virus. It would be happy for mankind if this opinion were well founded; but, unfortunately, every day's experience shows it to be erroneous. It has been proved, that the matter of a chancre introduced into the urethra will generate a gonorrhoea; and that the discharge of a gonorrhoea will produce a chancre, bubo, and lues.

The matter of a gonorrhoea itself, when absorbed into the patient's own body, will also produce a lues; but in order for it to do this, it is perhaps necessary (though this is by no means certain) that it should be taken up from an ulcerated surface; and there are many practitioners, of no inconsiderable eminence, who deny that any such ulceration is ever produced in the urethra by a gonorrhoea. 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 the latter the whole membrane of the nose is equally irritated; whereas in the gonorrhoea, 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 discharge is produced from that part of the urethra where 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 glands. 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 gonorrhoea 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 gonorrhoea 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 con- Besides, from a neglected or badly-treated gonorrhea, we often see fistulas in perineum, and other ulcers of the urethra penetrating through its submucosa, 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 papillae 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.

Perhaps, all things considered, the most rational idea we can form of the causes and phenomena of this disease, will be, that particles of the venereal virus being blended with the semen, and with the mucus that oozes from the urethra, during coition, may be drawn up a certain way into that canal, where the irritation they occasion will be in proportion to the virulence of the infecting matter, and the irritability, habit of body, &c. of the patient. The consequences of this irritation will be inflammation and an increased secretion of mucus, and so far the complaint will be local. But now and then it will happen, as in other inflammations, that ulceration will take place, and expose the patient to the danger of a constitutional infection. Nay, we are not certain but this may happen without ulceration. Drastic purges are known to be great promoters of absorption, and some instances of lues venerea have been met with which seemed to be owing to the imprudent use of such remedies in a previous gonorrhea.

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

Cure. From the foregoing description of the progress of the disease, it will easily be perceived that the chief curative indications are to subdue the inflammation, and remove the virus that occasions it.

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 assailing 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. Advice 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 choroid 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, spiceries, 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. Everything 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 anything that is liable to increase the heat and 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 substances are found to have the best effect, particularly the gum tragacanth. It is a common practice to give equal doses 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. Cream of tartar, 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 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. of such an injection must be extremely hazardous. Ex-

coriation of the urethra has but too often been produced by remedies of this sort in the hands of adventurous and unskilful 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 is checked before the virus that excited the discharge is properly subdued, the patient will be exposed to all the dangers of a confirmed lues; and, perhaps, to a variety of local complaints, such as obstructions in the urethra, and abscesses in perineum, 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 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 cerufla or any other preparation would have. A diluted solution of sulphate injected into the urethra will, like a solution of verdigris, or blue vitriol, or any other astringent, constringe the mouths of the lacunae; 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 mercury extinguished by means of mucilage, or of mercurial unction, 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,

For the truth is, that mercury has no power over the venereal virus, until it has been introduced into the body, and undergone certain changes, with which we are, and probably shall forever remain, unacquainted. The local application of mercury can therefore have no other effects than what it derives from its stimulating and astringent properties: for the mercury not being absorbed in the urethra, of course cannot be carried into the system; and even if it could, the quantity that would be introduced in this way would be too minute to be of any efficacy. The stimulus of calomel, however, has often been found of considerable efficacy; and in women, when the vagina only was affected, after washing the parts well, the cure hath been accomplished by rubbing them repeatedly with mercurial ointment.

As the gonorrhea is often a local affection, it may be imagined, perhaps, 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 gonorrhea, was rendered much worse by it. In some it degenerated into a gleet, that was cured with extreme difficulty; in others it brought on a variety of distressing symptoms. In cases of gonorrhea, therefore, whenever mercury is administered, it ought not to be with a view to expedite the cure, but merely to obviate the dangers of absorption. 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 is of a weak, relaxed, and irritable habit, likely to be injured by mercurial medicines. On the other hand, whenever the discharge is violent, the inflammation considerate, or the seat of the disease high up in the urethra, it is advisable to give mercurials in small doses, and in such forms as seem the best adapted to the constitution of the patient.

The mercurial pill of the London Dispensatory, on account of the turpentine that enters into its composition, will sometimes pass through the body undissolved, and of course can then be of no use; but when the mercury is extinguished by means of honey, and made into pills, in the manner directed in the last edition of the Edinburgh pharmacopoeia, it becomes as mild and perhaps as efficacious a preparation as any. Its efficacy will depend on its not irritating the bowels, and so 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. ii. 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 or bubo, no appearance, in short, that the infection is likely to be carried into the system, it would be improper to administer corrosive sublimate, the mercurius calcinatus, or any other of the more acid preparations of mercury.

After a gonorrhea proceeding from venereal causes hath been removed, another kind of running without pain, called the gonorrhoea mucosa, or gleet, sometimes remains. Sometimes it arises from a contraction 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 gonorrheas. 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 florid albus, after a gonorrhea, will often be mistaken for a gleet.

When there is no reason to suspect a venereal taint, 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 giving the bark, chalybeate waters, cold bathing, and such other remedies as will tend to strengthen the system. When there is no tendency to inflammation, the balsam of copaiba may be prescribed with advantage in large doses. Dr Simons 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 abovementioned 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 gonorrhea, in which the semen itself is ejected, especially during sleep, may be cured by tonics, and a mild cooling regimen.

ORDER V. EPISCHESSES.

CCIX. OBSTIPATIO; COSTIVENESS.

Genus CXXII.

Obstipatio. Lin. 166. Veg. 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 excessive heat 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 infipid 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, a cold dry state of the intestines, &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 grievous 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,

Practice currants, butter, honey, sugar, and such like. Broths with spinach, 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 coliciveness should eat white bread alone, especially that which is made of fine flour. The best bread for keeping the belly soluble is what in some parts of England they call melin. It is made of a mixture of wheat and rye, and is very agreeable to those who are accustomed to it.

Coliciveness is increased by keeping the body too warm, and by every thing that promotes the perspiration; as wearing flannel, lying too long a-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, astringent and astringent wines, as port, claret, &c. ought to be avoided. Malt-liquor that is fine and of a moderate strength, is very proper. Buttermilk, whey, and other watery liquors, are likewise proper, and may be drank in turns, as the patient's inclination directs.

Those who are troubled with coliciveness 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 coliciveness to use animal-oils, as fresh-butter, cream, marrow, fat broths, especially those made of the internal parts of animals, as the liver, heart, midriff, &c. He likewise recommends the expressed oils of mild vegetables, as olives, almonds, pistachios, and the fruits themselves; all oily and mild fruits, as figs; decoctions of mealy vegetables; these lubricate the intestines; some faponaceous substances which stimulate gently, as honey, hydromel, or boiled honey and water, unrefined sugar, &c.

The doctor observes, that such lenitive substances are proper for persons of dry atrabiliarian constitutions, who are subject to affections 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, sour milk, and buttermilk, have that effect.—That new milk, especially after milk, stimulates still more when it flows on the stomach; and that whey, turned sour, will purge strongly.—That most garden-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 senna and manna may likewise be taken, or half an ounce of soluble tartar 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.

CCX. ISCHURIA, or Suppression of Urine.

Genus CXXXIII.

Ischuria, Sauv. gen. 293. Lin. 167. Vog. 129. Sag. 212. Home's Clinical experiments, sect. xv.

This distemper 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 Experiment describes such a case. In the end of December 1774, a man of a full habit, aged 35, was seized with shivering, coldness, and feverish 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 mostly in the ankles and abdomen, which last 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 head-ache, and a very slow pulse, beating only 48 strokes in a minute. He had taken a great many diuretic medicines before he came in. The day after his reception, he was seized with a spontaneous diarrhoea, which continued during the remainder of his life. Cream of Tartar was exhibited in doses of half an ounce each morning; in bed-time he took 20 drops of laudanum 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 Infus. bacc. junip. and Pilul. ex alio; 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, and which was fizzy. 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. Fomentations 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 town 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... 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 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 five 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 icterus 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 this kind for a long time before.

2. The icterus urinarius 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 icterus, 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 and vomiting, and spasmodic contraction of the precordialia, a difficulty of making water, constipation of the belly, difficulty of breathing, stupor of the thigh, retraction of the testicle to the os pubis, inquietude, loss of strength, syncope, and convulsions. 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 dropy 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 is 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 marshmallow roots have been boiled, injecting at the same time an emollient clyster. After the posset-drink has been vomited up, and the clyster returned, give a pretty large dose of an opiate. But if the patient is old or weak, or subject to the vapours, bleeding may be omitted, especially if his urine at the beginning of the fit is coffee-coloured, and mixed with gravel; but as to other things, the cure is the same.—Huxham greatly recommends an emollient bath prepared of a decoction of marsh-mallow root, linseed, 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 nitre as proper to relax the spasmodic stricture. It is to be taken with suitable distilled waters, and syrup of poppies; or in broth, with a few spoonsfuls of oil of sweet almonds. Turpentine glysters are also accounted very serviceable; and may be prepared of ten ounces decoction of chamomile, with half an ounce of turpentine dissolved in the yolk of an egg, with as much honey. The sal diureticum, or terra foliata tartari, is much esteemed by some, when taken along with an opiate. But when the stone is too big to pass, Arbutnott recommends a cool and diluent diet to hinder the further growth of it. Whey, linseed, decoction of marshmallows, and gently resolving diuretics, are also proper. To put a stop to the vomiting, balsamum traumaticum may be used with success when almost every other means have failed.

3. The icterus 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, is passed, the patient dies from the retention of a still greater quantity in the bladder. Of this Dr Home gives the following instance. 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 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 tumour was discovered between the navel and spine of the os ilium on the left side, which gave him much pain, especially when pressed. This tumour 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 the tumour 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 hiccup, which increased and lasted till his death. On the 20th day of his disease, after some doses of squills, the general swelling of his abdomen fell, became much softer and more The next day a vomiting came on; he became more delirious, and died the day following. The body being opened, it appeared that the tumour which was so distinctly felt in the left side of the abdomen, was owing to a dilatation of the bladder with urine. Its fundus reached to about the division of the aorta into 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 scirrhusosity, 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 rose over the spine, and they were united together by their membranes and sublances, 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 everywhere 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 doth 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 hiccup, but without success. His disease was mistaken for an abscess; 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 60 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 hiccup. He had lost all appetite; was thirsty, and coughive. 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 fifth 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 hiccup, though not very severe, had come on. In this way he continued without fever, though frequently troubled with the hiccup, especially during those nights in which the urine had not been drawn off. A month after admittance, the bladder, with the assistance of the catheter, was almost entirely, though insensibly evacuated, and the hiccup had left him; he had no other complaint but that of voiding his urine insensibly, the natural effect of a scirrhus bladder, and which was probably incurable. With this patient the hot bath and mercurials were tried, in order to soften the scirrhusosity of the bladder, but without effect.

4. The *ifiburia vesicularis* arises from some tumour stopping up the passage of the urethra, and thus hindering the flow of urine. It is an uncommon disorder, and generally 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 ten days before his admission into the clinical ward, it was attended with pains in the glands, and ardor urinis; he had passed only about eight ounces the day before his admission, and that with very great difficulty; and the hypogastric region was swollen and painful. 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 tumour 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 turpith-mineral, 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 vomit and some external applications; and the cure was completed by bleeding, and a decoction of mezereon-root.

CCXII. DYSURIA, or Difficulty of making water. Genus CXXIV.

*Dysuria*, Sauv. gen. 265. Lin. 57. Vog. 164. Sag. 213.

*Stranguria auctorum*.

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 depends upon the 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

**Stone in the Bladder.**

*Dysuria calculosa*, Sauv. sp. 12.

The signs of a stone in the bladder are, Pain, especially...

Part II.

Practice cially about the sphincter; and bloody urine, in consequence of riding or being jolted in a carriage; a sense of weight in the perineum; an itchiness of the glans penis; flinty 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 the catheter.

Causes, &c. It is not easy to say what the particular causes are that occasion the 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 straining off 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 chiefly owing to their long confinement, and to the 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.

Whatever may be the particular cause of the disposition to lithiasis, the kidneys appear to be the most likely places for the earthy particles to concret 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 kidney.

It is in this vesicular part of the kidney that we presume the earthy particles 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 vesiculae the earthy 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 earthy matter shall be dislodged and washed off by the force of the circulating fluids, or loosened by some spasmodic action of the motory 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 earthy 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 accretion of earthy 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 hath remained till lately uncontroverted, that the stone and gravel are generated by the use of hard water. And from this quality, which the waters of certain springs possess, of depositing a large earthy sediment, either in the aqueducts thro' which they are conveyed, or in the vessels in which they are boiled or preserved, it was obvious to infer, that in passing through the kidneys, and especially whilst retained in the bladder, they would let fall their groser 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 à 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 distempered 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 in 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 is 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 concret 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 terreous 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 thro' 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 The practice of beer or ale, is the great diluter, vehicle, and menstruum, both of our food, and of the saline, earthy, and recremitious 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, hath 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 Ofterrod, 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 softer water of a neighbouring spring; and that this change alone, without the use of any medicine, hath 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 weights, 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 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 dif-

ease 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 is 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 happens 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 flinty fluid, with tenesmus, and difficulty in making water.

There have been various attempts and pretences made to dissolve the stone. The things which have been found most effectual are those that powerfully absorb the fixed air from bodies, and at the same time readily combining with oils, render them miscible with water. There is scarce any earthy substance that abounds more in oil, and also contains such a quantity of fixed air as the human calculus; and hence it is that the caustic fixed alkaline salt is such a powerful dissolvent of the stone: 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 vehicle for the soap-lice.

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

An infusion of the seeds of ducus syriacus sweetened with honey, is another simple and approved remedy; and 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 uva urfi were strongly recommended by the late very celebrated De Haen. But where the stomach will bear it, and there is no ulceration

In the Medical Commentaries, vol. 3., 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) assures us he has seen frequently performed with never-failing success. By means of a catheter they inject into the bladder a weak solution 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 greatly 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, 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. Dr Percival and others have shewn by experiments, that fixed air will dissolve some kinds of calculi; but whether these would not more readily be dissolved by alkalies or acids, hath not yet been discovered. This solvent, however, is much more safe than either of the other two, and ought always to be first employed; as it may perhaps facilitate the action of the others, though its own solvent powers should not be sufficient. 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 scheme 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 heartburning, 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 merely chimerical. But cutting into the bladder for the same purpose, is an ancient and well-known operation, and often crowned with success. But a description 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 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.

CCXIII. DYSPERMATISMUS, or Difficult Emission of Semen. Genus CXXV.

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

This impediment proceeds generally from obstructions in the urethra, either by tumours in itself, or in the cavernous bodies of the penis; in which case the treatment is the same as in the itchura 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 by them, or flows into the bladder, and is expelled along with the urine. The last case is very difficult, or indeed impossible to cure; as proceeding from scirrhi, or other indissoluble tumours of the verumontanum, or the neighbouring parts. 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.

CCIV. AMENORRHOEA, Suppression of the Menses. Genus CXXVI.

Amenorrhoea, Vog. 130. Dysmenorrhoea, Lin. 168. Sag. 218.

This, with some other symptoms, as dyspepsia, yellowish, yellowish or greenish colour of the skin, unusual appe- tites, &c., constitutes the chlorosis already treated off, and which seldom or never appears without a suppres- sion of the menses. In Dr Home's Clinical Experi- ments 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 heliotrope 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, recom- mended 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 pro- duces the same effects as the approach of the menses, and has every appearance in its favour; yet does not suc- ceed. Dr Home supposes that the uterus is more fre- quently in too plethoric and inflammatory a state, when this remedy will do hurt, than in a state of inaction; however, he owns, that in the case in which it did suc- ceed, the patient was plethoric and inflammatory. Ve- nection 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 ple- thoric state of the uterus, relaxing the fibres, and gi- ving the vessels full play; so that their action over- comes all resistance, and the evacuation takes place. It is of no great moment from whence the blood is taken: the saphena vein will perhaps empty the uterus more; but it is difficult to get the proper quantity from it, and it cannot be so well measured. The pow- der of savine is a powerful remedy; and proved suc- cessful in three cases out of four in which it was tried. It was given in the quantity of half a drachm twice a- day. It is a strong topical stimulus, and seems impro- per in plethoric habits. Madder root is a very power- ful medicine in this disease; and proved successful in 14 out of 19 cases in which it was tried, being some- times exhibited in the quantity of two scruples, or a drachm, four times a-day. It has scarce any sensible effects; never quickens the pulse, or excites inflamma- tory symptoms: on the contrary, the heat, thirst, and other complaints abate; and sometimes these symptoms are removed, though the disease is not cured; but when it succeeds, the menses appear from the third to the 12th day.—For other methods of curing the amenor- hea, see Chlorosis.

We have now considered all those diseases enumerat- ed in Dr Cullen's Nosology, whose cure is to be at- tempted chiefly by internal medicines. The other ge- nera either require particular manual operations, or a very considerable use of external applications; and therefore properly fall under the article Surgery. It now remains to treat of some diseases which are not yet yet arranged in his system.

CCXV. ANGINA PECTORIS.

Dr Heberden was the first who described this dis- ease, though it is extremely dangerous; and, by his ac- count, not very rare. 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 re- spects 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 conti- nued 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 their beds every night for many months together. In one or two very in- teresting cases, it has been brought on by the motion of a horse or carriage; and even by swallowing, cough- ing, 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. Some- thing like it, however, was observed in one woman, who was paralytic; and one or two young men com- plained of it in a slight degree, and other practitioners have observed it in very young persons.

When a fit of this sort comes on by walking, its du- ration is very short, as it goes off almost immediately upon stopping. If it come 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 which time the patient seemed to be in imminent danger of death. Most of those attacked with the distemper died sud- denly: though this rule was not without exceptions; and Dr Heberden observed one who sunk under a lin- gering illness of a different nature.

The os sterni is usually pointed to as the seat of this malady; but 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 sometimes there is joined with it a pain about the middle of the left arm.

The appearance of Dr Heberden's paper in the Me- dical Transactions very soon raised the attention of the faculty, and produced other observations from physi- cians of eminence; namely, Dr Fothergill, Dr Wall of Worcester, Dr Haygarth of Chester, and Dr Per- cival of Manchester. It also induced an unknown sufferer under the disease to write the Doctor a very sensible letter, describing his feelings in the most nat- ural 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 chaly- beate bitter: this was continued for some months, af- ter 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 a very brisk trot; for moderate ex- Practice 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, that (according to Dr Fothergill's observation) particularly marks this singular disease; and which is apt to supervene a certain degree of muscular motion, or whatever agitates the nervous system.

In such cases as fall under the inspection of Dr Fothergill, he very seldom met with one that was not attended with an irregular and intermittent 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 authorize us in giving the name to the disease: thus, when we find the constrictory 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 spirits or cordials; the influence which passionate affections of the mind have over it; the case which comes from varying the posture of the head and shoulders, or from remaining quite motionless; the number of years 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, from 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 incubus, convulsive asthma, and other ills, justly attributed to the disordered functions of the nerves, are peculiarly apt to return or to be aggravated.

But though it should be admitted, that the whole distress in these cases arises from spasms, 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, and, if it had been constantly observed, it would be insurmountable, is, that the pulse is not always interrupted during the paroxysm. The appearances in two of the practice directions, favour the opinion that the spasm affects the heart; as in one subject the left ventricle (and, tho' it be not mentioned, we may presume the right one also), 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 directions 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 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. So that 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 consistence, without any separation into serum and coagulum.

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 obliged for first making the disorder known), confesses, that bleeding, vomiting, 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 antimonial medicines joined with the fetid gums: he was filli Dr Fothergill's directions are chiefly calculated with the view to prevent the disorder from gaining ground, and to alleviate present distresses. Accordingly he enjoins such a kind of diet as may be most likely to prevent irritability; in particular, not to eat voraciously; to be particularly 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 which occurred to the English physicians of opposing this formidable disease; but Dr Smyth of Ireland has since 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 watch-maker), 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 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 distressing 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 distention in the head, a bloated and flushed countenance, turgid and watery eyes, and a very irregular and unequal pulse. The paroxysm invaded, 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 o'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 ag. calc. mag. c. with a little of the ag. junip. c. and an alternative proportion of Hoxham'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 perspired 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 in 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; insomuch that 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."

Doctor Doctor Macbride, in a letter to Dr Duncan, 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 seemed 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 shewed 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 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 afa foetida. This he persisted in for about six weeks; in the meanwhile, he had large acrimonious gleatings from the sternum, 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."

CCXVII. The PUERPERAL or CHILD-BED FEVER.

This species of fever, as its name imports, is peculiar to women in child-bed; 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 times, 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 characteristic, 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 purpuraceous 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 of 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 froth, the consequence of putrid exhalations, adheres to the edges of 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 inordinate 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; nay, 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 fifth 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 cure, it will be proper to mention here the circumstances whereby it may be known with greater certainty.

The pains of the abdomen, attending the child-bed 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; insomuch 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 in the other. The pulse is fuller and stronger; the skin is more hot; and the tongue, whether moist or dry, tho' 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, and cordials generally increase it.

When the original attack of the puerperal fever happens to coincide with the febrile commotion which is excited in child-bed 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 dispel 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 best 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.

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 derive its origin either from a redundancy or too great acrimony 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 are 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 judgment 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 the cure of the child-bed 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 hemorrhages 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 child-bed 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, can we ever 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 abovementioned. 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 child-bed fever, the disease ought to have been prevented by a large evacuation of blood, when that happened previous to its seizure. 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 venefiction improperly used the person's strength may be so far reduced as not to support the tedious loofenels 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 loofenels, 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 authorizes the assertion, that more women appear to have recovered of the child-bed 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 foments 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 child-bed 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 stage 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 freer use of the more cordial and spirituous kinds of liquors might perhaps sooner 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. In 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 is best answered by the remedy prescribed by Dr Denman, of which the following is the receipt. Of a powder thus prepared, Dr Denman gives from two to six grains, and repeats it as circumstances require. If the first dose does 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 is over. But if any alarming symptoms remain, he does not hesitate one moment to repeat the powder, in the same quantity as first given; tho' this is 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 produces 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 judgment 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 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 abovementioned; but when they are used even in the decline of the disease, gentle laxatives of rhubarb and magnesia, as advised by Dr Denman, ought to be frequently interposed, since, as he justly observes, without stools we can do little service.

Notwithstanding 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 the following draught taken every six hours, has produced better effects than could be expected.

R. Tartar. emetic. gr. ii. Ocul. cancror. prep. 3i. Intime misceantur.

While these medicines are using, 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 abovementioned. 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 least 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 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 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 it afflicts, it would be equally general and unavoidable.

But how peculiarsoever this author's sentiments are in respect of the proximate cause of the 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 colicive 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 Practice 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 of the stomach or vomiting attend, he advises shifting the efforts of nature, by drinking plentifully of camomile 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, abovementioned, imputes the puerperal fever to a putrefactive disposition of the humours, contracted during pregnancy, and fomented by the hot regimen commonly used by women in child-bed. In conformity to this opinion, the chief means which he recommends for preventing the disease is a cool regimen and free circulation 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 prime vies, 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.

The next writer that treats of the child-bed fever is Dr Leake, who made observations on this disease in the interval from April 1768 to the autumn of the year 1770; but chiefly from December 1769 to May 1770, during which period the child-bed 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; tho' 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 ever happened in this fever, which he imputes to the great oppresion 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 venefection is the only remedy which can give the patient a chance for life. But, tho' it is 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 anoodyne 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 fermentation take place, antifeptics and the Peruvian bark may be administered.

The great uniformity of the symptoms in all Dr Leake's patients might authorize 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 Part II.

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, the author 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, head-ach, &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.

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 sentiments 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 a 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.

CCXVIII. CEPHALALGIA, the Head-Ach.

This headache is symptomatic of very many disorders, but is rarely an original disease itself. Dr Home acquaints us that his report-books only furnish four instances of it; and of these four, three were women. The disease proved fatal to the man; and after death, a considerable effusion of blood was found on the brain, together with some hydatids, and water in the ventricles.

Headaches appear frequently to be occasioned by effusions of blood and serum; as well as by ulcers, and abscesses of the brain, dura and pia mater. Accretions and ossifications of different parts of the dura mater, falx, and brain, are also frequently discovered. An ossification of the falx, however, does not always produce headache; for Dr Home mentions a patient who had the falx ossified without headache; but he had been observed to be very furious when drunk. Congestions of blood in the vessels of the brain are also discovered from dissections to be a frequent cause of the headache; and nervous irritation alone will frequently produce it, as we see in the clavus hystericus.

In the cure of this disease we have little or no power over ossifications, effusions, or ulcerations; and hence... the headach is frequently incurable. In congestions, and nervous affections, medicines may indeed be of some service. Congestion may be relieved by an evacuation of blood, either general or topical; as venefication, cupping, or leeches; by erthines; which, however, Dr Home thinks are little to be depended upon; by topical evacuations near the head by blisters, ills, or fetons; by purgatives; or by determining the fluids to other parts, by rubefacients applied to the temples, pediluvia, &c.

Nervous irritation may be diminished, 1. By a great quantity of cold water drunk every morning. This is recommended by Hoffman; and will wash off all acrid particles from the stomack, while the cold strengthens and diminishes the sensibility of the part. This remedy was tried for a considerable time in one of Dr Home's patients, without any effect. 2. Nervous and tonic medicines; as the bark, valerian, &c. These were tried in two of Dr Home's patients, but also without success. In a third the valerian succeeded. 3. By cold water applied to the head, immersion, or the shower-bath. 4. Cacuphas of cephalics; as lavender, rosemary, &c. In slight cases, the smell of eau de luce, or any strong volatile alkali, will generally prove a cure.

CCXIX. A Dangerous Affection of the OESOPHAGUS.

This distemper has only been treated of by Dr Munckley, who reckons it one of the most deplorable distempers of the human body. Its beginning is in general so slight as to be scarce worth notice, the patients perceiving only a small impediment to the swallowing of solid food: they usually continue in this state for many months; during which, all liquid foods, and even solids themselves, when cut small and swallowed leisurely, are got down without much difficulty: by degrees the evil increases, and the passage through the esophagus becomes so narrow, that not the smallest solid whatever can pass through it; but, after having been detained for some time at the part where the obstacle is formed, is returned again with a hollow noise of a very peculiar kind, and with the appearance of convulsion.

The seat of this malady is sometimes near the top of the esophagus, and at other times farther down, nearer the superior orifice of the stomack. In this last case, the part of the alimentary tube which is above the obstruction, is frequently so dilated by the food which is detained in it as to be capable of containing a large quantity; and the kind of vomiting, by which it is again returned through the mouth, comes on sooner or later after the attempt to swallow, in proportion to the nearness or remoteness of the part affected. In the last stage of this disease, not even liquids themselves can be swallowed so as to pass into the stomack, and the patient dies literally starved to death.

On the direction of such as have died in this manner, the esophagus is found to be considerably thickened; and in some so contracted within at the diseased part, as scarcely to admit the passing of a common probe; in others, to adhere together in such a manner as entirely to close up the passage, and not to be separated without great difficulty.

He comes next to shew what he has found to be the most efficacious method of treating this disease, which, though not uncommon, yet in general has been considered as incurable.

He claims not the merit of having discovered the method of cure, but hopes that some service may arise from publishing what his experience has confirmed to him; having first received the hint from another eminent physician.

The only medicine, then, from the use of which he has ever found any service, is mercury; and in cases which are recent, and where the symptoms have not risen to any great height, small doses of mercury given every night, and prevented, by purgative medicines, from affecting the mouth, have accomplished the cure.

But where the complaint has been of long standing, and the symptom has come on of the food's being returned through the mouth, a more powerful method of treatment becomes necessary. In this case he has never found anything of the least avail in removing any of the symptoms, but mercury, used in such a manner as to raise a gentle, but constant spitting; and this method he has pursued with the happiest success. If this method be commenced before the complaint has gained too much ground upon the constitution, the case is not to be despised of; and of those who have come under his care in this state, by much the greater part have received considerable benefit from it, and many been entirely cured.

The complaint itself, he observes, is not very uncommon; but there is no instance, to his knowledge, recorded, of success from any other manner of treating it, than that he has recommended.

CCXX. WORMS.

Those infecting the human body are chiefly of three kinds: the ascarides, or round and short white worm; the terer, or round and long worm; and the taenia, or tape-worm.

The ascarides have usually their seat in the rectum.—The round worms 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 stomack, 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.

In the Medical Transactions, Vol. I. 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 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 os pubis. If this pain was very severe, a bloody mucus followed, in which there were often found ascarides alive. They were also sometimes suspected 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 ascariasis 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 abovementioned patient used purging and irritating clysters with very little success. One drachm 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 coughiveness, but had no good effect. Six grams of salt of lyeel were dissolved in five ounces of water, and injected. This clyster in a few minutes occasioned an ache in the rectum, gripped a little without purging, and excited a tenesmus. Some few ascariasis 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 ascariasis 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 ascariasis, 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 ascariasis were alive and moving in the mucus itself, which probably hindered the oil from coming in contact with them and killing them.

The Doctor also observes, that mucus or slime is the proper nest of the ascariasis, 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 infants born dead. 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 ascariasis 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 little consequence in the cure of all other worms as well as ascariasis; the insects 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 the case above-mentioned, and from Dr Heberden's observations, we may easily see why it is so difficult to destroy these insects; and why anthelmintics, greatly celebrated for some cures, 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 distempers 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, constipation of his bowels, and an almost total loss of sleep and appetite. He soon became greatly emaciated, and could neither stand nor walk upright; his belly grew small and hard, and closely retracted, insomuch 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 lumpish, 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 his stomach, grew extremely sick, and vomited violently; on the fourth training he brought up about half a pint of small worms, part aecarii, and the rest resembling those worms which are called the botii, 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 in all kinds of worms, either taken in the form of calomel, corrosive sublimate, or even the crude metal boiled in water and the water drunk. There can be no possible objection to it, but only that it is not endowed with any attenuating quality whereby the mucus in which these infects resides 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 rabs 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. Cabbage-tree 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 infected 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 vermiformis, and three of them were entwisted in such a manner as to block up the valvula Taupii, so that nothing could pass from the small to the great guts.—The bark of the cabbage-tree, 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 attributes to the negroes who make the decoction, (in which form the bark is used), and not to the remedy itself.

Mr Anderson, surgeon in Edinburgh, hath also given an account of this bark and its operation, in a letter to Dr Duncan, Med. Com. volume iv. p. 84. From this account it appears, that there are two different kinds of bark; the one much paler than the other; the pale kind operates much more violent 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 cassis 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. 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 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 produced more than one or two loose stools, a few drops of liquid laudanum may be given; and, in general, Mr Anderson gave fifteen or twenty drops of the spirit of lavender with each dose.

In a letter from Dr Rush, 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 plaint among physicians, that we have no vermifuge medicine which can be depended up. 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 bark of the summits of the cabbage-tree, 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.

Notwithstanding these encomiums, however, the cabbage-tree bark hath not come into general use; so that we can only look upon it as a drastic purgative, the effects of which must necessarily be as precarious as those of others.

4. Cowage, or cow-itch. This is the Delicibus urens or pruriosus of Linnæus; 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. The only objection to its use is, 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.

5. Indian pink. This is also an American plant, and was first recommended in the Edinburgh Physical and Literary Essays by Dr Garden of Charlestown in South Carolina. He is of opinion that a vomit ought always to precede the use of it; and informs us, that half a drachm 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. This 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 drachms of the infusion, twice a-day.

This medicine hath also had its day, and is now very far from being considered as a specific. From what hath been already observed, it must pretty clearly appear, that powder of tin, cow-itch, or fixed alkaline salts, bid fairest for destroying worms in all the variety of cases in which they can occur. Alkalies indeed have been but little tried. We have known one case in which all the complaints have been removed by a single dose: we have also an instance of their efficacy, in an extraordinary case of a worm bred in the liver, mentioned in the 2d volume of the Medical Observations. The patient had a violent pain in the side, and sometimes in the shoulder, as the worm shifted its place; but, on the application of a laxial poultice, the pain went out of the side entirely, and kept in the shoulder for some weeks; and had a similar poultice been applied there, it is probable the animal would have died.

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, loofenels, fainting, slender intermittent pulse, itching of the nose, and epileptic fits. By the consumption of the chyle they produce hunger, paleness, weakness, coliciveness, tumour of the abdomen, eructations, 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 eye-lids, 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 tumour then broke, discharged upwards of a pound of thin watery fauces, 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 the bark 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 the inflammation; so that in all probability it arose entirely from the worm itself.

The tenia, or tape-worm, as it is called, is one of those most difficult to be cured. It is of two kinds, tenia folium and tenia lata; for a description of which, see the article TENIA. 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 tenia lata hath been lately so much celebrated in France, that the king thought proper to purchase it from the proprietor (Madam Nouffer), and the account of it hath 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..." 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 oil olive." Next morning, about eight or nine hours after the supper abovementioned, the specific is to be taken. This is no other than two or three drachms of the root of male fern 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 is 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 is 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 drachms 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 is 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 feces becoming more limpid towards the end of the purging, pass 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 of their own accord, 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 does not come away during the night, she gives them early the next morning another dose of the specific, and, two hours afterwards, six drachms 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 care 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, it was exhibited to five different persons; but only one of them was certainly known to have the tenia lata by having discharged parts of it before. That person was cured; the second voided a portion of the tenia folium; the third some aascarides, with a part of the tenia folium; the fourth and fifth voided no worms; 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 tenia, 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 effected in much the same manner. Some others who were not relieved, were supposed not to have a tenia.

This specific, however, is not to be considered as a new discovery; the efficacy of fern in cases of tenia having been known long ago. Theophratus 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 beforehand. Pliny, Galen, Oribasius, and Aëtius, ascribe this same virtue to fern; and are followed in this by Avicenna, and the other Arabian physicians. Dorstenius, the purgative is 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 is 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 are previously evacuated, and if the specific is 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 *tenia folium*; but as the rings of this worm separate from each other more easily than those of the *tenia 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 ceases to void any portions of worms. It must likewise be repeated, if, after the expulsion of one *tenia folium*, 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 many of them exist together. Two living *teniae* have frequently been expelled from the same patient. M. de Haen (*Rat. Med.* tom. vii. p. 157.) relates an instance of a woman who voided 18 *teniae* 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 severe and ill-judged a regimen 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, seem 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 Practice 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 tenia. Dr De Haen saw a worm of this sort five ells long expelled by the resin of jalap alone. Dr Gaudius knew a woman who had taken a variety of anthelmintic remedies without any effect, though she had voided a portion of tenia 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 tenia measuring 300 ells expelled from a Russian by means of the vitriolum maritimum. All these methods, however, have been too often ineffectual.

On the subject of worms, see further below, under the Diseases of Children.

Of Poisons.

These have all been treated of already, except 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 foaming 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 is 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 hieranofus, which was formerly thought to be the effect of evil spirits.

It hath 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 anything 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 obviate the poison. 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 hath 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 rattle-snake. But Mr Cateby, who must have had many opportunities This is a distemper not very common, but which has been observed by the ancient physicians, and is described by Hippocrates under the name of *morbus niger*. It shews itself by a vomiting and purging of black tar-like matter; which Hippocrates, Boerhaave, and Van Swieten, supposed to be occasioned by atra bilis. But Dr Home, in his Clinical Experiments, shews that it is owing to an effusion of blood from the mecerae 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 is not attended with any great degree of fever. In one of Dr Home's patient's 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 vitriolic 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 the bark.

Of the DISEASES of CHILDREN.

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 where it can be done, he affirms that it ought never 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 Buchan 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 is 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 shews 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 as soon as it comes into the breast. 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 is left thus long without food, it will not easily relish it 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. Neither can it be shewn, 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 shew, that by this preposterous 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 is excessively agreeable to children, and they ought to be indulged with it in moderation; and this will prove a much better remedy for those acidities with which children are often troubled, than magnesia alba, crab's eyes, or other aborments, 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 prevailed upon 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 simper 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 go 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, four, curdled, or green stools, the watery-gripes, and convulsions. The thrush indeed very often terminates in these last symptoms. Therefore, as these complaints naturally run into one another, or succeed each other, 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, four, 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, spurt out 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 fictions 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 suction, mixing with the milk, &c. in the stomach, perhaps contributes towards increasing the spasms above-mentioned. He 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, which ought never to be done. 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. In case they are 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 dole, 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 a decoction of the Peruvian bark, 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 is tied. Thus the oppression of the brain will be relieved, and the disagreeable consequences... sequences 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 fennelcup, too, would seem to be useful in this case, by deriving 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 fails, 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 blow-pipe, 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 is threatened, it must be prevented, and the body kept always gently open; and 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 of 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, 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 glysters. But, on the contrary, if the child is low, sunk, and much weakened, repeated doses of the spirit of hartshorn, tinctura fuliginis, and the like reviving medicines, ought to be prescribed. Blister 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 forbidden by coliciveness or otherwise, is sometimes of great service in difficult teething, as, by mitigating pain, they have a tendency to prevent its bad effects, as a fever, convulsions, or other violent symptoms; and often they are absolutely necessary, along with the tefaceous powders, for checking an immoderate diarrhoea.

When cathartics are necessary, but 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 virtues to the milk as will be sufficient to purge the infant.

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 watchings and frights; symptoms which seldom or never occur but either in consequence of some present disorder not yet taken notice of, or as the certain forerunners of an approaching indisposition. We should immediately, therefore, endeavour to find out their cause, 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 an hectic fever, diarrhoea, and all the other consequences of weakness and debility. These symptoms, being always the effects of irritation and pain, may proceed, in very young infants, from crudities or other affections of the prime 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 which have been already enumerated; but it must be observed, that all the symptoms commonly attributed to worms alone, may be produced by a foulness of the bowels. Hence practitioners ought never to rest satisfied with administering 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 prime vie; 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 viscid humours in the intestines affording lodgment 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, it is observed, is of the same opinion on this point; and 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 disorders having been of very different natures.

The spasmodic 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; though a poor cold diet may, he thinks, occasionally give birth to it. 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 the event is fatal, he 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 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 stupor, coma, 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 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 pellets, and now and then a single worm.

Strong purgatives, or purges frequently repeated, in this disorder, are greatly condemned by our author, 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, is 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 coltive, to throw up, every second or third day, a clyster, composed of half a dram of aloes, dissolved in five 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.

The following is the form recommended.

"Take of leaves of wormwood and rue, each equal parts: make a saturated decoction in a sufficient quantity of water, with which foment the region of the stomach and abdomen for a quarter of an hour, repeating the fomentation every three or four hours. A poultice of the boiled herbs is to be applied after the fomentation, and constantly renewed as it cools." For internal use, the following is all that has been found necessary. "Take of spirituous and simple cinnamon-water, each half an ounce; oil of almonds, an ounce and an half; balsamic syrup, three drachms. Mix, and shake the vial when used." From two to six drachms are given every third hour.

When any nervous symptoms come on, or remain after the disorder is abated, they are easily removed by giving a pill of four grains 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. Barefoot is still more exceptionable, being in truth to be ranked rather among poisons than medicines. Worm-feed and bitters are too offensive to the palate and stomach to be long persisted in. The powder of coraline 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 strong decoction of rue and wormwood, is much recommended. It is a perfectly safe remedy, and, by invigorating the bowels, has thereby a considerable 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. Of internal medicines, the best is asafoetida, with an aloetic pill or two at proper intervals.

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. Their 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 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, and some have happened to our authors, 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.

Of MEDICAL ELECTRICITY.

The application of this subtle fluid to medicinal purposes was thought of soon after the discovery of the electric shock; and after various turns of reputation, its medical virtues seem now to be pretty well established. After giving so particular a description of the electrical apparatus under the proper article, it would here be superfluous to say anything farther on that head. We shall only observe, that Mr Cavallo, who hath published the latest and the best treatise on Medical Electricity, entirely disapproves of giving violent shocks, and finds it most efficacious to expose the patient to the electrical aura discharged from an iron or a wooden point; or if shocks are given, they should be very slight, and not exceed 12 or 14 at a time. In this way he recommends it as effectual in a great number of disorders. The patient may be electrified from three to ten minutes; but if sparks are drawn, they should not exceed the number of shocks abovementioned.

Rheumatic disorders, even of long standing, are relieved, and generally quite cured, by only drawing the electric fluid with a wooden point from the part, or by drawing sparks thro' flannel. The operation should be continued for about four or five minutes, repeating it once or twice every day.

Deafness, except when it is occasioned by obliteration, or other improper configuration of the parts, is either entirely or partly cured by drawing the sparks from the ear with the glass-tube director, or by drawing the fluid with a wooden point. Sometimes it is not improper to send exceedingly small shocks (for instance, of one-thirtieth of an inch) from one ear to the other.—It has been constantly observed, that whenever the ear is electrified, the discharge of the wax is considerably promoted.

The toothache, occasioned by cold, rheumatism, or inflammation, is generally relieved by drawing the electric fluid with a point, immediately from the part, and also externally from the face. But when the body of the tooth is affected, electrization is of no use; for it seldom or never relieves the disorder, and sometimes increases the pain to a prodigious degree.

Swellings in general, which do not contain any matter, are generally cured by drawing the electric fluid with a wooden point. The operation should be continued for three or four minutes every day.—It is very remarkable, that in some cases of white swellings, quite cured by means of electricity, the bones and cartilages were in some measure disfigured.

Inflammations of every sort are generally relieved by a very gentle electrization.

In inflammations of the eye, the throwing of the electric fluid by means of a wooden point is constantly attended with great benefit; the pain being quickly abated, and the inflammation being generally dissipated in a few days. In these cases, the eye of the patient must be kept open; and care should be taken not to bring the wooden point very near it, for fear of causing any spark. Sometimes it is sufficient to throw the fluid with a metal point; for in these cases, too great an irritation should be always avoided. It is not necessary to continue this operation for three or four minutes without intermission; but, after throwing the fluid for about half a minute, a short time may be allowed to the patient to rest and to wipe his tears, which generally flow very copiously; then the operation may be continued again for another half minute, and so on for four or five times every day.

The gutta serena has been often cured by electrization; but at the same time it must be confessed, it has proved ineffectual in many such cases, in which it was administered for a long time and with all possible attention. However, it hath never been known that any body was made worse by it. The best method of administering electricity in such cases, is first to draw the electric fluid with a wooden point for a short time, and then to send about half a dozen of shocks of one-twentieth of an inch from the back and lower part of the head to the forehead, very little above the eye.

A remarkable disease of the eye was some time ago perfectly perfectly cured by electrization; it was an opacity of the vitreous humour of the eyes. This seems to be the only case of the kind to which electricity was applied.

All the cases of fistula lacrymalis which Mr Cavallo hath known to have been electrified by persons of ability for a sufficient time, have been entirely cured. The method generally practised, has been that of drawing the fluid with a wooden point, and to take very small sparks from the part. The operation may be continued for about three or four minutes every day. It is remarkable, that in those cases, after curing the fistula lacrymalis, no other disease was occasioned by it, as blindness, inflammations, &c. by suppressing that discharge.

Pustules are seldom perfectly cured by means of electricity, especially when they are of long standing; but they are generally relieved to a certain degree. The method of electrifying in those cases, is to draw the fluid with the wooden point, and to draw sparks through flannel, or though the usual coverings of the part if they are not too thick. The operation may be continued for about five minutes per day.

Ulcers, or open sores of every kind, even of a long standing, are generally disposed to heal by electrization. The general effects are a diminution of the inflammation, and at first a promotion of the discharge of properly formed matter; which discharge gradually lessens, according as the limits of the sore contract, till it is quite cured. In these cases the gentlest electrization must be used, in order to avoid too great an irritation, which is generally hurtful. To draw or throw the fluid with a wooden or even with a metal point, for three or four minutes per day, is absolutely sufficient.

Cutaneous eruptions have been successfully treated with electrization: but in these cases it must be observed, that if the wooden point is kept too near the skin, so as to cause any considerable irritation, the eruption will be caused to spread more; but if the point be kept at about six inches distance, or farther, if the electrical machine is very powerful, the eruptions will be gradually diminished, till they are quite cured. In this kind of disease, the immediate and general effect of the wooden point is to occasion a warmth about the electrified part, which is always a sign that the electrization is rightly administered.

The application of electricity has perfectly cured various cases of St Vitus's dance, or of that disease which is commonly called so; for it is the opinion of some very learned physicians, that the real disease called St Vitus's dance, which formerly was more frequent than it is at present, is different from that which now goes under that name. In this disease, shocks of about one-tenth of an inch may be sent through the body in various directions, and also sparks may be taken. But if this treatment proves very disagreeable to the patient, then the shocks must be lessened, and even omitted; instead of which, some other more gentle applications must be substituted.

Scrophulous tumours, when they are just beginning, are generally cured by drawing the electric fluid with a wooden or metal point from the part. This is one of those kinds of diseases in which the action of electricity requires particularly the aid of other medicines in order to effect a cure more easily; for scrophulous affections generally accompany a great laxity of the habit, and a general cachexy, which must be obviated by proper remedies.

In cancers, the pains only are mostly alleviated by drawing the electric fluid with a wooden or metal point. Mr Cavallo, however, mentions one case in which a most confirmed cancer of very long standing, on the breast of a woman, has been much reduced in size. It is remarkable, that this patient was so far relieved by drawing the fluid with a metal point from the part, that the excruciating pains she had suffered for many years did almost entirely disappear; and also, that when the electric fluid was drawn by means of a wooden point, the pains did rather increase. This person is still under the application of electricity; and the cancer seems not unlikely to be perfectly cured, although contrary to the expectations even of the judicious physician who electrifies her, and who knows too well the nature of that dangerous disease.

Abscesses, when they are in their beginning, and in general whenever there is any tendency to form matter, electrization disperses them. Lately, in a case in which matter was formed upon the hip, called the lumbar abscess, the disease was perfectly cured by means of electricity. The sciatica has also been often cured by it. In all such cases, the electric fluid must be sent through the part by means of two directors applied to opposite parts, and in immediate contact either with the skin or with the coverings, when these are very thin. It is very remarkable, that the mere passage of the electric fluid in this manner, is generally felt by the patients afflicted with those disorders, nearly as much as a small shock is felt by a person in good health. Sometimes a few shocks have been also given, but it seems more proper to omit them; because sometimes, instead of dispersing, they rather accelerate the formation of matter.

In cases of pulmonary inflammations, when they are in the beginning, electrization has been sometimes beneficial; but in confirmed diseases of the lungs, it does not seem to have ever afforded any unquestionable benefit; however, it seems that in such cases the power of electricity has been but seldom tried.

Nervous head-aches, even of a long standing, are generally cured by electrization. For this disease, the electric fluid must be thrown with a wooden, and sometimes even with a metal point, all round the head successively. Sometimes exceedingly small shocks have been administered; but these can seldom be used, because the nerves of persons subject to this disease are so very irritable, that the shocks, the shocks, and sometimes even the throwing the electric fluid with a wooden point kept very near the head, throw them into convulsions.

The application of electricity has often been found beneficial in the dropsy when just beginning, or rather in the tendency to a dropy; but it has never been of any use in advanced dropsies. In such cases, the electric fluid is sent through the part, in various directions, by means of two directors, and sparks are also drawn across the flannel or the cloaths; keeping the metal rod in contact with them, and shifting it continually from place to place. This operation should be continued at least ten minutes, and should be repeated peated once or twice a day. — Perhaps in those cases, a simple electrization, (viz. to infuse the patient, and to connect it with the prime conductor whilst the machine is in action) continued for a considerable time, as an hour or two, would be more beneficial.

The gout, extraordinary as it may appear, has certainly been cured by means of electricity, in various instances. The pain has been generally mitigated, and sometimes the disease has been removed so well as not to return again. In those cases, the electric fluid has been thrown by means of a wooden point, although sometimes, when the pain was too great, a metal point only has been used.

Agues very seldom fail of being cured by electricity, so that sometimes one electrization or two have been sufficient. The most effectual and sure method has been that of drawing sparks through flannel, or the cloths, for about ten minutes or a quarter of an hour. The patients may be electrified either at the time of the fit, or a short while before the time in which it is expected.

The suppression of the menses, which is a disease of the female sex that often occasions the most disagreeable and alarming symptoms, is successfully and speedily cured by means of electricity, even when the disease is of long standing, and after that the most powerful medicines used for it have proved ineffectual. The cases of this sort in which electrization has proved useless are so few, and the successful ones so numerous, that the application of electricity for this disease may be justly considered as an efficacious and certain remedy. Great attention and knowledge is required, in order to distinguish the arrest of the menses from a state of pregnancy. In the former, the application of electricity, as we observed above, is very beneficial; whereas, in the latter, it may be attended with very disagreeable effects: it is therefore a matter of great importance to ascertain the real cause of the disease, before the electricity be applied in those cases. Pregnant women may be electrified for other diseases, but always using very gentle means, and directing the electric fluid through other parts of the body distant from those subservient to generation. In the real suppression of the menses, small shocks, i.e. of about one-twentieth of an inch, may be sent thro' the pelvis; sparks may be taken through the cloths from the parts adjacent to the seat of the disease; and also the electric fluid may be transmitted by applying the metallic or wooden extremities of two directors to the hips, in contact with the clothes; part of which may be removed in case they are too thick. Those various applications of electricity should be regulated according to the constitution of the patient. The number of shocks may be about 12 or 14. The other applications may be continued for two or three minutes; repeating the operation every day. But either strong shocks, or a stronger application of electricity than the patient can conveniently bear, should be carefully avoided; for by those means, sometimes more than a sufficient discharge is occasioned, which is not easily cured. In cases of uterine hemorrhages, it is not known that the application of electricity was ever beneficial, neither that it has been often tried. Perhaps a very gentle electrization, as to keep the patient insulated and connected with the prime conductor, whilst the electrical machine is in action, may be some benefit.

In respect to unnatural discharges and fluxes in general, it may be observed, that some discharges are quite unnatural or adventitious, as the fistula lacrymalis, and some species of the venereal disease; but others are only increased natural discharges, such as the menes, perspiration, &c. Now the power of electricity in general, has been found more beneficial for the first, than for the second sort of discharges, which are mostly increased by it.

In the venereal disease, electrization has been generally forbidden; having mostly increased the pains, and other symptoms, rather than diminished them. Indeed, considering that any sort of stimulus has been found hurtful to persons afflicted with that disorder, it is no wonder that electricity has produced some bad effects, especially in the manner it was administered some time ago, viz. by giving strong shocks. However, it has been lately observed, that a very gentle application of electricity, as drawing the fluid by means of a wooden or metal point, is peculiarly beneficial in various cases of this kind, even when the disease has been of long standing. Having remarked above, that tumours, when just beginning, are dispersed, and that unnatural discharges are gradually suppressed by a judicious electrization, it is superfluous to describe particularly those states of the venereal disease in which electricity may be applied; it is only necessary to remind the operator to avoid any considerable stimulus in cases of this sort.

The application of electricity has been found also beneficial in other diseases besides those mentioned above; but as the facts are not sufficiently numerous, so as to afford the deduction of any general rules, we have not thought proper to take any particular notice of them.

We may lastly observe, that, in many cases, the help of other remedies to be prescribed by the gentlemen of the faculty is required to assist the action of electricity, which by itself would perhaps be useless; and, on the other hand, electrization may often be applied to assist the action of other remedies, as of sudorifics, strengthening medicines, &c.

Of FIXED AIR as a Medicine.

The antiseptic qualities of fixed air have of late introduced it as a medicine in cases of putrid disorders. Dr Percival observes, that, though fatal if inspired in a very large quantity, it may in smaller quantities be breathed without danger or uneasiness. And it is a confirmation of this conclusion, that at Bath, where the waters copiously exhale this mineral spirit, the bathers inspire it with impunity. At Buxton also, where the bath is in a close vault, the effects of such effluvia, if noxious, must certainly be perceived.

Encouraged by these and some other considerations, he has administered fixed air in more than 30 cases of the phthisis pulmonalis, by directing his patients to inspire the steam of an effervescing mixture of chalk and vinegar through the spout of a coffee-pot. The hectic fever has in several instances been considerably abated, and the matter expectorated has become less offensive and better digested. He hath not yet, however, been so fortunate in any once case as to effect a cure; although the use of mephitic air has been accompanied with proper internal medicines. But Dr Withering has been more successful. One phthisical patient under his care, by a similar course entirely recovered; another other was rendered much better; and a third, whose case was truly deplorable, seemed to be kept alive by it more than two months. It may be proper to observe, that fixed air can only be employed with any prospect of success in the latter stages of the phthisis pulmonalis, when a purulent expectoration takes place.

After the rupture and discharge of a vomica, also, such a remedy promises to be a powerful palliative. Antiseptic fumigations and vapours have been long employed, and much extolled, in cases of this kind. The following experiment was made to determine whether their efficacy in any degree depends on the separation of fixed air from their substance.

One end of a bent tube was fixed in a phial full of lime-water; the other end in a bottle of the tincture of myrrh. The junctures were carefully luted; and the phial containing the tincture of myrrh was placed in water, heated almost to the boiling point, by the lamp of a tea-kettle. A number of air-bubbles were separated, but probably not of the mephitic kind; for no precipitation ensued in the lime-water. This experiment was repeated with the tinct. Tolatanum Ph. Ed. and with sp. cinof. camph., and the result was entirely the same. The medicinal action therefore of the vapours raised from such tinctures, cannot be ascribed to the extrication of fixed air; of which it is probable bodies are deprived by chemical solution as well as by mixture.

If mephitic air be thus capable of correcting purulent matter in the lungs, we may reasonably infer it will be equally useful when applied externally to foul ulcers; and experience confirms the conclusion. Even the pains of a cancer, when the carrot-poultice failed, has been sweetened by it, the pain mitigated, and a better digestion produced. But though the progress of the cancer seems to be checked by the fixed air, it is to be feared that a cure will not be effected. A palliative remedy, however, in a disease so desperate and loathsome, may be considered as a very valuable acquisition. Perhaps nitrous air might be still more efficacious. This species of salutinous air is obtained from all the metals, except zinc, by means of the nitrous acid; as a sweetener and antiseptic, it far surpasses fixed air.

In the ulcerous sore throat, much advantage has been experienced from the vapours of effervescing mixtures drawn into the faucies. But this remedy should not supersede the use of other antiseptic applications.

In malignant fevers, wines abounding with fixed air may be administered to check the septic ferment, and sweeten the putrid cellules in the prime via. If the laxative quality of such liquors be thought an objection to the use of them, wines of a greater age may be given, impregnated with mephitic air. —The patient's common drink might also be medicated in the same way. A putrid diarrhoea frequently occurs in the latter stage of such disorders; and it is a most alarming and dangerous symptom. If the discharge be stopped by astringents, a putrid fomes is retained in the body, which aggravates the delirium, and increases the fever. On the contrary, if it be suffered to take its course, the strength of the patient must soon be exhausted, and death unavoidably ensue. The injection of mephitic air into the intestines, under these circumstances, bids fair to be highly serviceable. And in some cases of this kind,

the vapour of chalk and oil of vitriol conveyed into the body by the machine employed for tobacco-clysters, quickly restrained the diarrhoea, corrected the heat and fetor of the stools, and in a short time removed every symptom of danger.

As a solvent of the calculus, its virtues have been already mentioned; but the experiments made on that subject have been too few to determine the matter with sufficient accuracy.

CONCLUSION;

Being a Discourse on the Hygeine, or Method of Preserving Health.

I. RULES for the Management of VALETUDINARIANS.

That part of the medical system which lays down rules for the preservation of health, and prevention of diseases, termed Hygeine, 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 should rather be considered as relating to valetudinarians, or to such as, though not actually sick, may yet have sufficient reasons to fear that they will soon become so; hence it is that the rules must be applied to correct morbid dispositions, and to obviate the various things that were thrown to be the remote or possible causes of disease.

From the way in which the several temperaments are usually mentioned by systematic writers, it should seem as if they meant that every particular constitution must be referred to one or other of the four; but this is far from being reducible to practice, since by much the greater number of people have constitutions 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. Too much strength and rigidity of fibre, and too much sensibility; 2. Too little strength, and yet too much sensibility; 3. Too much strength, and but little sensibility; or, 4. But little sensibility, joined to weakness;

we should look on such persons as more or less in the valetudinary state, who require that these morbid dispositions be particularly watched, lest they fall into those diseases which are allied to 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, wherein 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 The scheme here should be, to strengthen the solids by moderate exercise, cold bathing, the cortex, 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 salubrity 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, nor stronger 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, because of that freedom from care and serious business of every kind, which generally obtains in all the places laid out 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 remissness of the circulation in general: whence corpulency, dropsy, jaundice, and different degrees of scrofulous 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, horse-radish, and the like sort of stimulating dietetics, is serviceable in these torpid habits.

When the general mass of fluids is accumulated 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 endeavour 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 affected 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 gout, rheumatism, stone, 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 horse-radish 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 frictions on the stomach, belly, and lower extremities.

Where the fluids tend to the putrefactive state, which shows itself by rottenness of the teeth, 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, brisk exercise, and strengthening bitters.

Where acrimony shows itself by itching eruptions, uncommon thirst, and slumbering heats, nothing will answer better than such sulphureous waters as the Harrowgate and Moffat in Britain, or the Lucan and Swadlincote in Ireland; at the same time using a course of diet that shall be neither acid 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, in some degree, if not altogether, to prevent the ill consequences. Thus, there are instances where returns of the gout 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.

The stone may be retarded in its progress, and prevented from creating much dilution, by the internal use of soap and lime-water, or by soap-lees taken in milk or in veal-broth.

The putrid scurvy may be prevented by warm clothing and perseverance in brisk exercise, by drinking wine or cider, 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 scrophula, if early precautions be taken to strengthen the solids by cold bathing, a nourishing course of diet, and moderate use of wine, the acrimony 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 does 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, see the Hydrophobia, Poisons, &c.

The ill effects that may arise from the different species of saburra 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 pangs.

Crude vegetables, milk, butter, and other oily substances, are to be avoided by persons troubled with a sourness 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 ardent spirit, such as rum or brandy. Selters and Vahl's water are to be drunk medicinally; and aromatic bitters, infusions, or tinctures, with the acid elixir of vitriol, from ten to twenty drops, 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, the magnesia alba, or Creta preparata, will seldom fail; and the magnesia, as well as the other, 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 saburra.

In constitutions where there is an exuberance or flagration 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, cream of tartar, some of the common purging salts, or the natural purging waters.

When there is a tendency to the empyreumatic and rancid saburra, people should carefully avoid all the various kinds of those oily and high-seasoned things generally termed monde-dishes, and eat sparingly of plain meat, without rich sauces or much gravy; and in these cases the properest drink is pure water.

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 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 spirit of vitriol, 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 exercise until they are sensible that the stomach is unloaded, and that they no longer feel any oppressive weight about the precordia.

If a man is obliged to fast, he ought, if possible, during the 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 join an absolute fast: neither is it safe to rest totally 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, they cannot fail of producing some kind or 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, or dancing, as each shall be found most agreeable or convenient, are to be used in their turns, 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 extremely 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 regard to body and mind, as it blunts the senses, and encourages the fluids to flagitate in the cellular systems; whence corpulency, and its necessary consequences languor and weakness.

The proper time for sleep is the night season, when darkness and silence naturally brings it on: therefore day-sleep in general is not so 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, it ought to be indulged.

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. INDEX

ABORTION, no 361 Absorbent vessels, the same with lymphatics. Their action exemplified under Jaundice no 453. Absorbent medicines. See their use under the Diseases of Children and Dyspepsia.

Abstinence, 43 Acrimony of the fluids, 215-217 Actions, corporeal, are considered by medical authors as voluntary, or such as are the effect of reason and will; spontaneous, or such as are the effect of instinct; and mixed, or those where it is difficult to say whether reason or instinct have the greatest share. All the actions of the human body are much influenced by changes in the state of the system itself, as has been seen in the preceding treatise; also by custom, &c. See the article Custom and Habit.

Adiposity, 470 Aetiology, that part of pathology which treats of the causes of diseases. See the Theory, p. 4871.

Aetius, his doctrines, 87 Ague. See Intermittents, infra; and p. 4871. Albugo. See Surgery. Alexander, his tenets, 88 Alterants. Those medicines which produce an alteration in the body without any remarkable evacuation.

Amaurosis, 455 Amenorrhea, 488 Amentia, 477 Amphimerina cardiaca, 261. Paludosa, or remitting fever, 262 Anaphasis, 462 Anaphrodisia, 471 Anarca, 437 Angina Pectoris, 70, 480 Anorexia, 469 Anosmia, 460 Anxiety, 110, 172 Aphonia, 472 Aphthor, 342 Appoplexy, 368, 373-376 Appetite, want of, 469 Arabian physicians, 90 Arthrodynia, 313 Arthropoisis, 321 Ascariasis, 493 Afebrile, 441 Afebrile, 75-77 Asthma, 396-398 Atrophy, 432 B. Bathing, 45 Bleeding, 56 Bleeding at the nose, 344 Blindness. See Dysopia. Blistering, p. 4669 Blood. See Fever, pustules; and no 197-213 Blood-vessels, 131, 195, 196 Boerhaave's theory, 101-122 Opposed by Hoffman, 123 Boil. See Phlogosis, infra. Bubs. See Surgery. Bulimia, 463 C. Calculi, 235 Caligo, 454 Cancer, 226, and p. 4870, 4872; and see Surgery. Canine madness, 425 Carditis, 293 Catalepsy, 375 Cataract, 454 Catarrh, 365, 366 Cancer, predisponent, exciting, and proximate, 161, 162 Causus, or burning fever, 250 Cellular texture, 167 Cellulitis, 81, 82 Cephalalgia, 491 Charcoal fumes, 373 Chemistry, when introduced into medicine, 95 Chicken-pox, 329 Child-bed fever, 490 Children's diseases, 497 Chin-cough, 405 Chlorosis, 386 Cholera, 229, 414, 415 Chorea, 391, and p. 4870 Chrysopteryx, 64 Circulation of the blood, 98 Celiac passion, 224, 419 Cobson, 128, 165 Cold, 141 Cold fit of fevers, 109 Colic, 407-413 Coma, 116 Consumption of the lungs, 351-353, and p. 4870, 4871 Contagious, 140 Continued fever, 134, 273 Contractions of the limbs, 477 Convulsions, 118, 390 Corpus. See Surgery. Corpuscles, 404, 433 Coryza, 222, 484 Cough, 219 Crises, 23 Critical days, 24, 146 Croup, 286, and p. 4701 Cullen's theory, sect. ii. p. 4599 Cynanche tonsillaris, 285. Magna, 286. Trachealis, 286, and p. 4701. Pharyngeal, 287. Parotidea, 288 Cystitis, 305, 306 D. Damp linen: Heberden's opinion of the dangers arising from sleeping in it, p. 4656, col. 2. Deafness, 458, 459, and p. 4870 Death, 126, 131, 142 Delirium, 135, 144 Delirium, 115, 135, 184 Dentition, p. 4867 Diabetes, 422, 423 Diarrhoea, 120, 223, 416-418 Diabetes phlegmatica, 152, 188 Dict, 19, 42, 44, and p. 4874 Digestion, 221 Dormitifere, 63, 74 Dropsy of the breast, 430. Of various other parts of the body, 370, 431-444. See also p. 4870, col. 2. Dumbness, 473 Dysaccea, 408 Dysentery, 225, 367 Dyspnea, 456 Dyspnea, 384 Dyspnea, 487 Dyspnea, 399-404 Dysuria, 233, 486 E. Effluvia of charcoal. See Charcoal, supra. Eggs. The shells of eggs are prepared by boiling them in water, to separate the membrane which lines their inner surface, and then powdering them by levigation. They bind the belly the least of all the tallowy absorbents. Eggs are nutritious, but if hard boiled are difficultly digested. The yolk is used as a medium for uniting balsams with water; but the white is preferable, as it is less distasteful to many stomachs.

Weak stomachs digest the white more easily than the yolk. Betwixt the serum of the blood and the white of egg there is great analogy.

Elafficity, 165 Electricity, 497 Elephantiasis, 449 Empirics, 63, 72, 73 Emphysema, 55, 292 Enteritis, 209, 300 Enuresis, 482 Epilepsy, 479 Epilepsy, 393-395 Epithora, 480 Epistaxis, 344 Erysipelas, 65-69 Erysipelas, 322-324 Erythema, 282 Exanthemata, 281 F. Fatness. See Corpulency, supra. Feeling, 170. Loss of it, 462 Fever: Boerhaave's theory of it, 126-122. Cullen's account of the phenomena, 133, 134. Explication of their causes, 135, 138. Different kinds of fevers, 134. Erroneous opinions refuted, 136 Fissural lacrimalis, p. 4870; and see Surgery. Fixed air, 498 Flexibility, 165 Fluor albus, 364 Flux of blood, 478 Fog, p. 4657, col. 2. Fractura, 451 Friction. See Rheumatism, infra. Frost-bitten. See Gangrene, infra. Functions of the body, 158 Furor uterinus, 467 Furunculus. See Phlogosis, infra. G. Galens, 83, 84 Gall sickness, p. 4655, col. 1. Gangrene, 155, 281 Gastritis, 297, 298 Genus nervosum, 169 Glaucoma, 454 Gonorrhoea, 483 Gout, 315-319, and p. 4874 Gregory's theory, sect. iii. p. 4611. Growth of the body, 125 Gutta rosea. See Phlogosis. INDEX.

Gutta serena, 455, and p. 4869

Hemoptysis, 345—350 Hemorrhagia, 343 Hemorrhoids, or Hemorrhoids, 354—358 Headache, 491, and p. 4870 Health; on preserving it, 499, 500 Hearing, 176 Heart-burn, 406 Heat, 115 Hellebore, 280 Hemiplegia. See Palsy, infra. Hepatic flux, 421 Hepatitis, 301 Herophilus, 70 Heraculum, 11 Herpes. See Surgery Hickey, 113, 393—395 Hieroglyphs, p. 4787, col. 2. Hippocrates; the bookshewrote, 13. His account of the humours of the human body; health, sickness, and different diseases, 14—18. Directions with regard to diet, 19. Method of clasping distempers, 21. Definition of a crisis, 23. His prognostics, 26—34. Method of preserving health, 27. General maxims of his practice, 40. Directions concerning bathing, 45. Concerning purgatives, 47—50. Doctrine with regard to vomits, clysters, &c. 52—54. Remedy for an empyema, 55. Rules concerning bleeding, 56. Diuretic and sudorific medicines, 57. Hypnotics and specifics, 58, 59. External applications, 60. His compound medicines, 61

Hooping-cough, 405 Hunger, immoderate, 463 Hydrocephalus, 370, 438 Hydropathia, 425, 426 Hydrophobia, 439 Hydrothorax, 430 Hypochondriasis, 385 Hygiene, 499 Hysteria, 424 Hysteritis, 397

I. Jaundice, or Icterus, 453 Idiots, 427 Ilia, 228 Inflammation, 105, 148 Incubus, 430 Infants, 497 Inhaler, p. 4763. Plate CLXXIV. fig. 5. Shows the Inhaler as constructed by Mr Mudge. a, The grating turned back, to show the opening into the valve. b, The adjoining fig. is a section of the cover. c, The construction of the cork valve; d, the conical part into which the flexible tube d is fixed. The flexible part of the tube is about six inches long, and may be made by winding a long slip of silk oil-skin over a spiral brass wire.

Some little inconvenience is supposed to attend the use of this machine, as the empty part of the inhaler must contain part of the air which the person has already breathed. Mr Aitken surgeon in Edinburgh has contrived the inhaler fig. 6, where this inconvenience is avoided. The machine is supplied with heated water at the screwed juncture of the flexible pipe marked A, which precludes the entrance of the air by a fold of soft leather interposed. The expired air is emitted by the corner of the mouth, as in smoking tobacco; so that there is no occasion for any other hole or valve in the machine.

Inoculation, p. 4769. Internal senses, their disorders, 183 Intermittent, 122—136, 148, 156. Interpneumonia, a Sardinian disease, p. 4656, col. 1. Intoxication, 432 Involuntary laughter, the same with risus cynicus or sardonicus; a symptom of many nervous diseases, and likewise of some inflammatory ones. See Hydrophobia, Pleuritis, &c.

Joy. All the depressing passions of the mind are hurtful to a sick person; but excess of joy is no less prejudicial on account of the vehement commotion it occasions. See the practical part of this treatise, passions, and the article Passions.

Icterus, 232 Icthy. See Surgery. Itching, 173

L. Lachrymal humour, flux of, 480 Leecher, 281 Leucorrhea, 364 Lentery, 420 Loathing, 112 Lochia, immoderate flux of, 362 Longing, 465 Long-fingeredness, 465 Lumbago, 310 Lumbreus; a name for the long round worms, which sometimes infect the human body. See Worms, infra. Lunacy. See Mania, infra. Lycanthropy, a new distemper, 86

M. Mathematical or Mechanical theory, 99 Mania, and Melancholy, 185, 428, 429 Measles, 330—335 Melena, 495 Menstruation, 359 Menstrual suppression of, 488, and p. 4871. Immoderate flow of, n° 359—264 Methodists, 78—80 Miasma, 139 Military fever, 336 Mobility, 187, 189 Moles, 209 Morbus niger, the same with Melena. Morbus vesicularis, the same with Pemphigus. Muscles, a part of the nervous system, 127 Muscular power, disorders in it, 186. Multitas, 473.

N. Nausea and vomiting, 227 Nephritis, 304 Nerves and nervous power, 129, 130, 132 Nervous fever, 275 Nervous system, 169 Nervous consumption, 432 Nettle-rash, 340 Night-mare, 430 Nosophy, sect. iv. p. 4631. Nostalgia, 468 Nutrition by the nerves, 130 Nymphomania, 467

O. Odontalgia, 314 Oesophagus, a dangerous affection of it, 492 Oneirodynia, 430 Ophthalmia, 283 Oribasius, 85

P. Pain, 171 Palpitation of the heart, 206, 395 Palps, 190, 377—380, and p. 4870 Paroxysms of fever accounted for, 137 Paulus Aegineta, 89 Pemphigus, 431 Peritonitis, 294—296 Periphraxis, 230, 231 Peritus, 405 Pestilence, the plague, 325 Phlogosis, 281 Phrenitis, 284 Phthisis, 351—353, &p. 4870, 4871 Physicians; their origin, theories, methods of cure, &c. among different nations, till the time of Pythagoras, 1—9. Divided into dogmatists and empirics, 63 Physiometry, 436 Pica, 465 Plague, 210 Pleurisy, bastard, 312 Pleuritis, 290 Plica polonica, 452 Pneumonia, 289 Pneumatisis, 434 Podagra, 315 Poisons, 373, 494 Polypidipsia, 464 Polypi, 209 Polysarcia, 433 Praxis, 62 Prognostics of Hippocrates, 26—34 Psilis, 475 Pseudobellefis, 457 Ptyalism, 481 Puerperal fever, 490 Pulse, 198—203. Pustules, 121 Putrid malignant fever, 277, and p. 4872 —fore throat, 286, and p. 4872 Putrefaction, 145, 216 Pyrosis, 406

Q. Quartan fever, 134, 263. Duplicated, 264. Triplicated, 265. Double, 266. Triple, 267. Accompanied with symptoms of other diseases, 268. Complicated with other diseases, 269. Remitting, 270. Quotidian, genuine, 271. Partial, 272. Remitting, 273 Quotidiana deceptiva, 260

R. Rachitis, 445 Raphania, 392 INDEX.

Spitting of blood, 345—350 Splenitis, 303 Squinting, 181, 476 Stahl's theory, 100 Stammering, 475 Stone, 486 Strangury, 234 Strabismus, 476 Sweating, 119. Excess of, 479 Sweating sickness, 94 Syncope, 207, 382, 383 Synocha, 274 Synochia, 279 Syphilis, 447

T. Takes, 431. Dorfalis, 432 Tenia, or Tape-worm, 493 Taste, 174. Want of, 401 Teething, p. 4867 Tensinus, n° 226 Tertian fever, 134, & p. 4643. Irregular, n° 237. Double, 238. Duplicated, 239. Triple, 240. Semiterian, 241. Sleepy tertian, 242. Convulsive, 243. Eruptive, 244. Inflammatory, 245.

Complicated with other disorders, 246. Arising from various causes, 247. With only a remission between the fits, 248 Tertiana subcontinua, 259 Tetanus, 387, 389 Thirst excessive, 464. Want of it, 470 Thrush, 342 Tooth-ach, 314, and p. 4869 Torpor, 189 Tremor, 381 Trichoma, 452 Trismus, 388 Trisophya syncopalis, 249. Caulus, 250. Vratislavien-fis, 251. Typhodes, 252. Elodes, 253. Carotica, 255. Leipyria, 256. Deceptiva, 257. Americana, 258. Tympaniter, 435. Typhus, 275

V. Valetudinarians, rules for them, 499 Varicella, 329 Variola, 326—328

Venereal disease, 96, 447, and p. 4871. Venery, impotence of, 471 Vertigo, 182 Vesania, 426 Vitae medicatrix naturae, 136 Vision, 177—180 Vitus's Dance, 391, & p. 4870 Vonica, 231 Vomiting, 113 Voice, loss of, 472. Sound of it changed, 474 Ulcers, p. 4870, 4872; and see Surgery. Urine, involuntary flux of, 482. Suppression of, 232. Difficulty of making, 233, 486 Urticaria, 340

W. Watchfulness, 117 Weakness, 114 Whites, 364 Worms, 493 Worms-fever, p. 4868

Y. Yaws, 451 Yellow-fever, 278.

END OF THE SIXTH VOLUME. Directions for placing the Plates in this Volume.

| Number of Plates | Plate | To face | Page | |------------------|-------|---------|------| | 175 | CLVIII.| | 4061 | | 176 | CLIX. | | 4064 | | 177 | CLX. | | 4165 | | 178 | CLXI. | | 4255 | | 179 | CLXII. | | 4262 | | 180 | CLXIII.| | 4375 | | 181 | CLXIV. | | 4380 | | 182 | CLXV. | | 4384 | | 183 | CLXVI. | | 4469 |

| Number of Plates | Plate | To face | Page | |------------------|-------|---------|------| | 184 | CLXVII.| | 4528 | | 185 | CLXVIII.| | | | 186 | CLXIX. | | | | 187 | CLXX. | | | | 188 | CLXXI. | | | | 189 | CLXXII.| | | | 190 | CLXXIII.| | | | 191 | CLXXIV.| | |

N. B. Errata, Omissions, &c. noticed and supplied in the Appendix at the end of the Work. days he has every evening a return of more considerable pain and pyrexia, and which continue with more or less violence till morning. After continuing in this manner for several days, the disease sometimes goes entirely off, not to return till after a long interval.

When the disease, after having thus remained for some time in a joint, ceases entirely, it generally leaves the person in very perfect health, enjoying greater ease and alacrity in the functions of both body and mind than he had for a long time before experienced.

At the beginning of the disease, the returns of it are sometimes only once in three or four years; but as it advances, the intervals become shorter, and at length the attacks are annual; afterwards they come twice each year; and at length recur several times during the whole course of autumn, winter, and spring; and as, when the fits are frequent, the paroxysms become also longer, so, in the advanced state of the disease, the patient is hardly ever tolerably free from it, except perhaps for two or three months in summer.

The progress of the disease is also marked by the parts which it affects. At first, it commonly affects one foot only; afterwards every paroxysm affects both feet, the one after the other; and as the disease proceeds, it not only affects both feet at once, but, after having ceased in the foot which was secondly attacked, returns again into the first, and perhaps a second time also into the other. Its changes of place are not only from one foot to another, but from the feet into other joints, especially those of the upper and lower extremities; so that there is hardly a joint of the body that, on one occasion or other, is not affected. It sometimes affects two different joints at the very same time; but more commonly is at any one time fever in a single joint only, and passes successively from one joint to another; so that the patient's affliction is often protracted for a long time.

When the disease has often returned, and the paroxysms have become very frequent, the pains are commonly less violent than they were at first; but the patient is more affected with sickness, and the other symptoms of the atomic gout, which shall be hereafter mentioned.

After the first paroxysm of the disease, the joints which have been affected are entirely restored to their former suppleness and strength; but, after the disease has recurred very often, the joints affected do neither so suddenly nor entirely recover their former state, but continue weak and stiff; and these effects at length proceed to such a degree, that the joints lose their motion entirely.

In many persons, but not in all, after the disease has frequently recurred, concretions of a chalky nature are formed upon the outside of the joints, and for the most part immediately under the skin. The matter seems to be deposited at first in a fluid form, afterwards becoming dry and firm. In their firm state, these concretions are a friable earthy substance, very entirely soluble in acids. After they have been formed, they contribute, with other circumstances, to destroy the motion of the joint.

In most persons who have laboured under the gout for many years, a nephritic affection comes on, and discovers itself by all the symptoms which usually attend calculous concretions in the kidneys, and which we shall have occasion to describe in another place.

All that is necessary to be observed here is, that the nephritic affection alternates with paroxysms of the gout; and that the two affections, the nephritic and the gouty, are hardly ever present at the same time. This also may be observed, that children of gouty or nephritic parents commonly inherit one or other of these diseases; but whichever may have been the principal disease of the parent, some of the children have the one, and some the other. In some of them, the nephritic affection occurs alone, without any gout supervening; and this happens to be frequently the case of the female children of gouty parents.

In the whole of the history already given, we have described the most common form of the disease, and which therefore, however diversified in the progress of it, may be still called the regular state of the gout. Upon occasion, however, the disease assumes different appearances; but as we suppose the disease to depend always upon a certain diathesis, or disposition of the system; so every appearance which we can perceive to depend upon that same disposition, we still consider as a symptom and case of the gout. The principal circumstance, in what we term the regular gout, is the inflammatory affection of the joints; and whatever symptoms we can perceive to be connected with, or to depend upon, the disposition which produces that inflammatory affection, but without its taking place or being present at the same time, we name the irregular gout.

Of such irregular gout there are three different states, which we name the atomic, the retrocedent, and the misplaced gout.

The first is, when the gouty diathesis prevails in the system; but, from certain causes, does not produce the inflammatory affection of the joints. In this case, the morbid symptoms which appear, are chiefly affections of the stomach, such as loss of appetite, indigestion, and its various circumstances of sickness, nausea, vomiting, flatulency, acid eructations, and pains in the region of the stomach. These symptoms are frequently accompanied with pains and cramps in several parts of the trunk, and the upper extremities of the body, which are relieved by the discharge of wind from the stomach. Together with these affections of the stomach, there commonly occurs a coliciveness; but sometimes a looseness, with colic pains. These affections of the alimentary canal are often attended with all the symptoms of hypochondriasis, as dejection of mind, a constant and anxious attention to the slightest feelings, an imaginary aggravation of these, and an apprehension of danger from them.

In the same atomic gout, the viscera of the thorax also are sometimes affected; and palpitations, faintings, and asthma, occur.

In the head also, occur headaches, giddiness, apoplectic and paralytic affections.

When the several symptoms now mentioned occur in habits having the marks of a gouty disposition, this may be suspected to have laid the foundation of them; and especially when either, in such habits, a manifest tendency to the inflammatory affection has formerly appeared, or when the symptoms mentioned are intermixed with and are relieved by some degree gree of the inflammatory gout. In such cases there can be no doubt of considering the whole as a state of the gout.

Another state of the disease we name the retrocedent gout. This occurs when an inflammatory state of the joints has, in the usual manner, come on, but without arising to the ordinary degree of pain and inflammation; or at least without these continuing for the usual time, or without their receding gradually in the usual manner; these affections of the joints suddenly and entirely cease, while some internal part becomes affected. The internal part most commonly affected is the stomach; which then is affected with anxiety, sickness, vomiting, or violent pain; but sometimes the internal part is the heart, which gives occasion to a syncope; sometimes it is the lungs, which are affected with asthma; and sometimes it is the head, giving occasion to apoplexy or palsy. In all these cases there can be no doubt of the symptoms being all a part of the same disease, however different the affection may seem to be in the parts which it attacks.

The third state of irregular gout, which we name the misplaced, is when the gouty diathesis, instead of producing the inflammatory affection of the joints, produces an inflammatory affection of some internal part, and which appears from the same symptoms that attend the inflammations of those parts arising from other causes.

Whether the gouty diathesis does ever produce such inflammation of the internal parts without having first produced it in the joints, or if the inflammation of the internal part be always a translation from the joints previously affected, we dare not determine; but, even supposing the latter to be always the case, we think the difference of the affection of the internal part must still distinguish the misplaced from what we have named the retrocedent gout.

With regard to the misplaced gout, Dr Cullen, whom we here follow, tells us, that he never met with any cases of it in his practice, nor does he find any distinctly marked by practical writers, except that of a pneumonic inflammation.

There are two cases of a translated gout; the one of which is an affection of the neck of the bladder, producing pain, strangury, and a catarrhus vesicae; the other is an affection of the rectum, sometimes by pain alone in that part, and sometimes by hemorrhoidal symptoms. In gouty persons such affections have been known to alternate with inflammatory affections of the joints; but whether these belong to the retrocedent or to the misplaced gout, our author pretends not to determine.

It is commonly supposed, that there are some cases of rheumatism which are scarcely to be distinguished from the gout; but these, our author thinks, are but few; and that the two diseases may be for the most part distinguished with great certainty, by observing the predisposition, the antecedents, the parts affected, the recurrences of the disease, and its connection with the system; which circumstances, for the most part, appear very differently in the two diseases.

Causes, &c. The gout is generally an hereditary disease: but some persons, without any hereditary disposition, seem to acquire it; and in some an hereditary disposition may be counteracted from various causes. It attacks the male sex especially; but it sometimes, though more rarely, attacks also the female. The females liable to it are those of the more robust and full habits; and it very often happens to those before the menstrual evacuation hath ceased. Dr Cullen hath also found it occurring in several females whose menstrual evacuations were more abundant than usual.

The gout seldom attacks eunuchs; and when it does, seems to fall upon those who happen to be of a robust habit, to lead an indolent life, and to live very full. It attacks especially men of robust and large bodies, who have large heads, are of full and corpulent habits, and whose skins are covered with a thicker reticulate surface, which gives a coarser surface. To speak in the style of the ancient physicians, the gout will seldom be found to attack these of a sanguine, or such as are of a purely melancholic temperament; but very readily those of a choleric-sanguine temperament. It is, however, very difficult to treat this matter with precision. The gout seldom attacks persons employed in constant bodily labour, or those who live much upon vegetable aliment. It does not commonly attack men till after the age of 35; and generally not till a still later period. There are indeed instances of the gout appearing more early; but these are few in comparison of the others. When the disease does appear early in life, it seems to be in those who have the hereditary disposition very strong, and to whom the remote causes hereafter mentioned have been applied in a very considerable degree.

As the gout is an hereditary disease, and affects men particularly of a certain habit, its remote causes may be considered as predisposing and occasional. The predisposing cause, as far as expressed by external appearances, hath been already marked; and physicians have been very confident in assigning the occasional causes; but in a disease depending so much upon a predisposition, the assigning occasional causes must be uncertain; as in the predisposed the occasional causes may not always appear, and in persons not predisposed they may appear without effect; and this uncertainty must particularly affect the case of the gout.

The occasional causes of the disease seem to be of two kinds. First, those which induce a plethoric state of the body. Secondly, those which, in plethoric habits, induce a state of debility. Of the first kind are a sedentary, indolent manner of life, and a full diet of animal-food. Of the second kind of occasional causes which induce debility are excess in venery; intemperance in the use of intoxicating liquors; indigestion, produced either by the quantity or quality of the aliment; much application to study or business, night-watching, excessive evacuations; the ceasing of usual labour; a sudden change from a very full to a very spare diet; the large use of acids and acescents; and lastly, cold applied to the lower extremities. The former seem to act by increasing the predisposition; the latter are commonly the exciting causes, both of the first attacks, and of the repetitions of the disease.

With respect to the proximate cause of the gout, it hath generally been thought that it depends on a certain morbid matter always present in the body; and that this matter, by certain causes, thrown upon the joints