President of the Royal College and Incorporation of Surgeons of Edinburgh.

No. V.

Royal College of Surgeons in Ireland,

Dublin, February 4th, 1807.

Sir,

I am directed to transmit to you the inclosed report of a committee of the College of Surgeons in Ireland, to whom was referred a letter from the Royal College of Physicians in London, relative to the present state of vaccination in this part of the united kingdom; and to state, that the College of Surgeons will be highly gratified by more frequent opportunities of corresponding with the English College of Physicians on any subject which may conduce to the advancement of science, and the welfare of the public.

I have the honour to be,

Sir,

Your most obedient humble servant,

JAMES HENTHORN, Secretary.

At a meeting of the Royal College of Surgeons in Ireland, held at their Theatre, on Tuesday the 13th day of January 1807.

FRANCIS M'EVoy, ESQ. President.

Mr Johnson reported from the committee, to whom was referred a letter from the College of Physicians, London, relative to the present state of vaccination in the united kingdom, &c. &c. that they met, and came to the following resolutions:

That it appears to this committee, That inoculation with vaccine infection is now very generally adopted by the surgical practitioners in this part of the united kingdom, as a preventive of smallpox.

That it appears to this committee, that from the 25th day of March 1806 to the 25th of November 1806, 11,504 persons have been inoculated with vaccine infection at the dispensary for infant poor, and 2831 at the cowpox institution, making a total of 14,335; exclusive of the number inoculated at hospitals and other places, where no registry is made and preserved.

That it is the opinion of this committee, that the cowpox has been found to be a mild disease, and rarely attended with danger, or any alarming symptom, and that the few cases of smallpox which have occurred in this country, after supposed vaccination, have been satisfactorily proved to have arisen from accidental circumstances, and cannot be attributed to the want of efficacy in the genuine vaccine infection as a preventive of smallpox.

That it is the opinion of this committee, that the causes which have hitherto retarded the more general adoption of vaccination in Ireland, have, in a great measure, proceeded from the prejudices of the lower classes of the people, and the interest of some irregular practitioners.

To which report the College agreed.

Extract from the minutes,

JAMES HENTHORN, Secretary.

After this report, we cannot help thinking that the British legislature would be fully warranted for passing an act prohibiting the inoculation of smallpox under very severe penalties, and ordering all those who may be subjected to smallpox by accidental contagion to be confined to lazarettoes, or at least to their own houses, under a proper guard, to prevent the communication of infection, till their complete recovery. By such an act, there is good ground to believe, that the loathsome and dangerous disease of smallpox would in a few years be exterminated in Britain. But although providence has thus furnished mankind with an easy mode of preserving their offspring from the danger of smallpox, by the inoculation of the cowpox at an early period of life, yet not a few deaths from the natural smallpox have occurred in Britain even during the course of the present year.

When the preventive has not been duly employed, after the contagion of variola is introduced into the body, nothing yet known will prevent the disease from running its course, either under the mild or confluent form; and the endeavours of the medical practitioner are altogether to be employed in rendering that course as favourable as possible by mitigating symptoms.

In the mild or distinct smallpox, the strictest antiphlogistic regimen is to be enjoined. Gentle refrigerant cathartics are often useful, and mild diluents should be copiously employed. Under these remedies the disease will generally run its course without much inconvenience. But it will sometimes be necessary to employ remedies for obviating particular urgent symptoms, such as gargarisms or blisters for affections of the throat.

In the malignant smallpox, besides the same refrigerant plan of cure which is best accommodated to the mild, as the secondary fever shews evident marks of a putrid tendency, it is necessary to employ those remedies which are accommodated to typhus, and accordingly recourse is not only had to opiates and cardiacs, but to wine, cinchona, and the mineral acids.

Genus XXIX. VARICELLA.

CHICKENPOX.

Varicella, Vog. 42. Variola lymphatica, Sauv. fp. 1. Anglis, The CHICKENPOX, Edin. Med. Essays, vol. ii. art. 2. near the end. Heberden, Med. Transact. art. 17. The Watery-Pox.

This is in general a very slight disease; and is attended with so little danger, that it would not merit any notice, if it were not apt to be confounded with the smallpox, and thus give occasion to an opinion that a person might have the smallpox twice in his life; or they are apt to deceive into a false security those who have never had the smallpox, and make them believe that they are safe when in reality they are not. This eruption breaks out in many, according to Dr Heberden, without any illness or previous sign; in others it is preceded by a slight degree of chilliness, languor, cough, broken sleep, wandering pains, loss of appetite, and feverish state for three days.

In some patients the chickenpox make their first appearance on the back; but this perhaps is not constant. Most of them are of the common size of the smallpox, but some are less. Dr Heberden never saw them confluent, nor very numerous. The greatest number was about 12 on the face, and 200 over the rest of the body.

On the first day of the eruption they are reddish. On the second day there is at the top of most of them a very small bladder, about the size of a millet seed. This is sometimes full of a watery and colourless, sometime of a yellowish liquor, contained between the cuticle and skin. On the second, or, at the farthest, on the third day from the beginning of the eruption, as many of these pocks as are not broken seem arrived at their full maturity; and those which are fullest of that yellow liquor very much resemble what the genuine smallpox are on the fifth or sixth day, especially where there happens to be a larger space than ordinary occupied by the extravasated serum. It happens to most of them, either on the first day that this little bladder arises, or on the day after, that its tender cuticle is burst by the accidental rubbing of the clothes, or by the patient's hands to allay the itching which attends this eruption. A thin scab is then formed at the top of the pock, and the swelling of the other part abates, without its ever being turned into pus, as it is in the smallpox. Some few escape being burst; and the little drop of liquor contained in the vesicle at the top of them, grows yellow and thick, and dries into a scab. On the fifth day of the eruption they are almost all dried and covered with a slight crust. The inflammation of these pocks is very small, and the contents of them do not seem to be owing to suppuration, as in the smallpox, but rather to what is extravasated under the cuticle by the ferosus vesicles of the skin, as in a common blister. It is not wonderful, therefore, that this liquor appears so soon as on the second day; and that, upon the cuticle being broken, it is presently succeeded by a flight scab: hence too, as the true skin is so little affected, no mark or fear is likely to be left, unless in one or two pocks, where, either by being accidentally much fretted, or by some extraordinary sharpness of the contents, a little ulcer is formed in the skin.

The patients scarce suffer anything throughout the whole progress of this illness, except some languidness of strength, spirits, and appetite; all which is probably owing to the confining of themselves to their chamber.

Remedies are not likely to be much wanted in a disease attended with hardly any inconvenience, and which in so short a time is certainly cured of itself.

The principal marks by which the chickenpox may be distinguished from the smallpox are,

1. The appearance, on the second or third day from the eruption, of that vesicle full of serum upon the top of the pock.

2. The crust, which covers the pocks on the fifth day; at which time those of the smallpox are not at the height of their suppuration.

Foreign medical writers hardly ever mention the name of this distemper: and the writers of our own country scarce mention any thing more of it than its name. Morton speaks of it as if he supposed it to be a very mild genuine smallpox. But these two distempers are certainly totally different from one another, not only on account of their different appearances above mentioned, but because those who have had the smallpox are capable of being infected with the chickenpox; but those who have once had the chickenpox are not capable of having it again, though to such as have never had this distemper, it seems as infectious as the smallpox. Dr Heberden wetted a thread in the most concealed pus-like liquor of the chickenpox which he could find; and after making a slight incision, Exanthemata, it was confined upon the arm of one who had formerly had it; the little wound healed up immediately, and showed no signs of any infection.

From the great similitude between the two distempers, it is probable, that instead of the smallpox, some persons have been inoculated from the chickenpox; and that the distemper which has succeeded, has been mistaken for the smallpox by hasty or unexperienced observers.

There is sometimes seen an eruption, concerning which Dr Heberden is in doubt whether it be one of the many unnoticed cutaneous distempers, or only a more malignant sort of chickenpox.

This disorder is preceded for three or four days by all the symptoms which forerun the chickenpox; but in a much higher degree. On the fourth or fifth day the eruption appears, with a very little abatement of the fever: the pains likewise of the limbs and back still continue, to which are joined pains of the gums. The pox are redder than the chickenpox, and spread wider; and hardly rise so high, at least not in proportion to their size. Instead of one little head or vesicle of a fleshy matter, there have from four to ten or twelve. They go off just like the chickenpox, and are distinguishable from the smallpox by the same marks; besides which, the continuance of the pains and fever after the eruption, and the degree of both these, though there be not above 20 pocks, are circumstances never happening in the smallpox.

Genus XXX. RUBEOLA.

MEASLES.

Rubeola, Sauv. gen. 94. Lin. 4. Sag. 293. Febris morbillosa, Vog. 36. Hoffm. II. 62. Morbilli, Junck. 76.

Sp. I. The Regular MEASLES.

Rubeola vulgaris, Sauv. sp. 1. Morbilli regulares, Sydenh. sect. iv. cap. 5.

Var. 1. The Anomalous MEASLES.

Rubeola anomala, Sauv. sp. 2. Morbilli anomali, Sydenh. sect. v. cap. 3.

Var. 2. The MEASLES attended with Quinsy.

Var. 3. The MEASLES, with Putrid Diathesis of the Blood.

Sp. II. The VARIOLODES.

In Scotland commonly called the NIRLES.

Rubeola variolodes, Sauv. sp. 3.

Description. This disease begins with a cold stage, which is soon followed by a hot, with the ordinary symptoms of thirst, anorexia, anxiety, sickness, and vomiting; and these are more or less considerable in different cases. Sometimes from the beginning the fever is sharp and violent: often, for the first two days, it is obscure and inconsiderable; but always becomes violent before the eruption, which commonly happens on the fourth day. This eruptive fever, from the beginning of it, is always attended with hoarseness, a frequent hoarse dry cough, and often with some difficulty of breathing. At the same time, the eyelids are somewhat swelled; the eyes are a little inflamed, and pour out tears; and with this there is a coryza, and frequent sneezing. For the most part, a constant drowsiness attends the beginning of this disease. The eruption, as we have said, commonly appears upon the fourth day, first on the face, and successively on the lower parts of the body. It appears first in small red points; but, soon after, a number of these appear in clusters, which do not arise in visible pimples, but, by the touch, are found to be a little prominent. This is the case on the face; but, in other parts of the body, the prominency, or roughness, is hardly to be perceived. On the face, the eruption retains its redness, or has it increased for two days; but on the third, the vivid redness is changed to a brownish red; and in a day or two more the eruption entirely disappears, while a mealy desquamation takes place. During the whole time of the eruption, the face is somewhat turbid, but seldom considerably swelled. Sometimes, after the eruption has appeared, the fever ceases entirely: but this is seldom the case; and more commonly the fever continues or is increased after the eruption, and does not cease till after the desquamation. Even then the fever does not always cease, but continues with various duration and effect. Though the fever happen to cease upon the eruption's taking place, it is common for the cough to continue till after the desquamation, and sometimes much longer. In all cases, while the fever continues, the cough also continues, generally with an increase of the difficulty of breathing; and both of these symptoms sometimes arise to a degree which denotes a pneumonic affection. This may happen at any period of the disease; but very often it does not come on till after the desquamation of the eruption.

After the same period, also, a diarrhoea frequently comes on, and continues for some time.

It is common for measles, even when they have not been of a violent kind, to be followed by inflammatory affections, particularly ophthalmia and phthisis. If blood be drawn from a vein in the measles, with circumstances necessary to favour the separation of the fibrine, this always appears separated, and lying on the surface of the crustamentum, 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.

Cause. The measles are occasioned by a peculiar kind of contagion, the nature of which is not understood; and which, like that of the smallpox, affects a person only once in his life.

Prognosis. From the description of this distemper already given, it appears that the measles are attended with a catarrhal affection, and with an inflammatory diathesis to a considerable degree; and therefore the danger of them is to be apprehended chiefly from the coming on of a pneumonic inflammation.

Cure. In measles, as well as in smallpox, the disease from its nature must necessarily run a determined course; and therefore the sole aim of a practitioner is to conduct this course in the easiest manner, by preventing and obviating urgent symptoms.

From the consideration mentioned in the prognosis, 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 referred 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 most to be depended upon; but assistance may also be drawn from cooling purgatives; and from blistering on the sides or between the shoulders. The dry cough may be alleviated by the large use of demulcent pectorals, mucilaginous, oily, or sweet. It may, however, be observed, with respect to these demulcents, that they are not so powerful in involving and correcting the acrimony of the mass of blood as has been imagined; and that their chief operation is by lubricating the fauces, and thereby defending them from the irritation of 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 have indeed by some been supposed to be inadmissible; but experience abundantly demonstrates, that the objection made to their use is merely hypothetical; and even in cases where, from a high degree of pyrexia and of dyspnea, there is reason to fear the presence, or at least the danger, of pneumonic inflammation, opiates are highly useful, after bleeding, to obviate or abate the inflammatory state, has been duly employed: in such cases, while the cough and watchfulness are the urgent symptoms, opiates may be safely exhibited, and with great advantage. In all the exanthemata, there is an acrimony diffused over the system, which gives a considerable irritation; and, for obviating the effects of this, opiates are useful, and always proper, when no particular contraindication prevails.

When the desquamation of the measles is finished, though then there should be no disorder remaining, physicians have thought it necessary to purge the patient several times, with a view to draw off what have been called the dregs of this disease; that is, a portion of the morbid matter which is supposed to remain long in the body. Dr Cullen does not reject this supposition; but at the same time cannot believe that the remains of the morbid matter, diffused over the whole mass of blood, can be wholly drawn off by purging; and therefore thinks, that, to avoid the consequence of the measles, it is not the drawing off the morbid matter which we need to study, so much as to obviate and remove the inflammatory state of the system which had been induced by the disease. With this last view, indeed, purging may still be a proper remedy; but bleeding, in proportion to the symptoms of inflammatory disposition, is still more so.

From our late experience of the use of cold air in the eruptive fever of the smallpox, some physicians have been of opinion that the practice may be transferred to the measles; but this point has not yet been determined by sufficiently extensive experience. We are certain, that external heat may be very hurtful in the measles, as in most other inflammatory diseases; and therefore, that the body ought to be kept in a moderate temperature during the whole course of the disease; but how far, at any period of the disease, cold air may be applied with safety, is still uncertain. Analogy, though so often the resource of physicians, is frequently fallacious; and further, though the analogy with the smallpox might lead to the application of cold air during the eruptive fever of the measles, the analogy with catarrh seems to be against the practice.

When the eruption is upon the skin, there are many instances of cold air making it disappear, and thereby producing much disorder in the system; and there are also frequent instances of these symptoms being removed by restoring the heat of the body, and thereby again bringing out the eruption.

Upwards of 20 years ago, inoculation for the measles was proposed, and practiced in several instances with success, by Dr Home of Edinburgh. His method of communicating the infection was, by applying to an incision in each arm cotton moistened with the blood of a patient labouring under the measles; but with others who have made similar trials, the attempt has not yet succeeded. Attempts have been made to inoculate this disease by means of the fluid discharged under the form of tears, the squamae falling from the surface, and the like; but there is reason to believe, that where it was imagined the infection had thus been communicated, the contagion was only carried about the person inoculating and communicated in the ordinary way.

From inoculation of the measles, it is imagined that several advantages may be obtained; and among others, it is thought the soreness of the eyes may be mitigated, the cough abated, and the fever rendered less severe. But the practice was never much employed, and now is scarce ever heard of.

Genus XXXI. MILIARIA.

The Miliary Fever.

Miliaria, Liv. 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, Junk. 75. Germania der Friezel. God. Welsch. Hist. Med. de novo puerperarum morbo, qui der Friezel dicitur, Lips. 1655. Hamilton, de febr. miliar. 1710. Fontanus, de febr. mil. 1747. Allioni de miliar. 1758. Fordyce, de febr. mil. 1748. Fischer, de febr. mil. 1767. De Haen, de divif. febr. 1769, et in Ration. med. pat. sim. Matt. Collin ad Baldinger de miliar. 1764. Miliaris. Miliaris benigna, Sauv. fp. 1. Miliaris maligna, Sauv. fp. 2. Miliaris recidivans, Sauv. fp. 3. Miliaris Germanica, Sauv. fp. 5. Miliaris Boia, Sauv. fp. a. Miliaris Britannica, Sauv. fp. i. Miliaris nova febris, Sydenh. Sched. monit. Sauv. fp. d. Miliaris sudatoria, Sauv. fp. e. Miliaris nautica, Sauv. fp. g. Miliaris purpurata, Sauv. fp. h. Miliaris lactea, Sauv. fp. c. Miliaris puerperarum, Sauv. fp. k. Miliaris scorbutica, Sauv. fp. l. Miliaris critica, Sauv. fp. 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 military, is said to be of two kinds; the one named the red, the other the white military. The former, which in English is strictly named a rub, is commonly allowed to be a symptomatic affection; and as the latter is the only one that has any pretensions to be considered as an idiopathic disease, it is this only that we shall more particularly describe and treat of under this genus.

What is then called the white military eruption, appears at first like the red, in very small red pimples, for the most part distinct, but sometimes cluttered together. Their little prominence is better distinguished by the finger than by the eye. Soon after the appearance of this eruption, and, at least, on the second day, a small vesicle is visible upon the top of the pimples. At first the vesicle is whey-coloured; but soon becomes white, and stands out like a little globule. In two or three days, these globules break, or are rubbed off; and are succeeded by small crusts, which soon after fall off in small scales. While one set of pimples takes this course, another set arises to run the same; so that the disease often continues upon the skin, for many days together. Sometimes when one crop of this eruption has disappeared, another, after some interval, is produced. And it has been further observed, that in some persons there is such a disposition to this disease, that they have been affected with it several times in the course of their lives.

This disease is said to affect both sexes, and persons of all ages and constitutions; but it has been observed at all times, to affect especially, and most frequently, lying-in women.

It is often accompanied with violent symptoms, and has frequently proved fatal. The symptoms, however, attending it are very various; but no symptom, or concurrence of symptoms, are steadily the same in different persons, so as to give any specific character to the disease. When the disease is violent, the most common symptoms are phrenetic, comatose, and convulsive affections, which are also symptoms of all fevers treated by a very warm regimen.

While there is such a variety of symptoms appearing in this disease, it is not to be expected that any one particular method of cure can be proposed; and, accordingly, we find in different writers different methods and remedies prescribed; frequent disputes about the most proper; and those received and recommended by some opposed and deserted by others.

It appears, however, to Dr. Cullen, very improbable, that this was really a new disease, when it was first considered as such. There are very clear traces of it in authors who wrote long before that period; and though there were not, we know that ancient descriptions were often inaccurate and imperfect, particularly with respect to cutaneous affections; and we know also that those affections which commonly appeared as symptomatic only, were often neglected, or confounded together under a general appellation.

The antecedent symptoms of anxiety, sighing, and pricking of the skin, which have been spoken of as peculiar to this disease, are, however, common to many others; and perhaps to all those in which sweatings are forced out by a warm regimen. Of the symptoms said to be concomitant of this eruption, there are none which can be affirmed to be constant and peculiar but that of sweating. This, indeed, always precedes and accompanies the eruption; and, while the military 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 be avoided. It is therefore probable, that the eruption is the effect of sweating; and that it is the effect of a matter not before prevailing in the vessels of blood, but generated under particular circumstances in the skin itself. That it depends upon particular circumstances of the skin, is also probable from its being observed that the eruption seldom or never appears upon the face, although it affects the whole of the body besides; and that it comes upon those places especially which are more closely covered; and that it can be brought out upon particular places by external applications.

It is to be observed, that this eruptive disease differs from the other exanthemata in many circumstances, especially the following; that it is not contagious, and therefore never epidemic; that the eruption appears at no determined period of the disease; that the eruption has no determined duration; that successive eruptions frequently appear in the course of the same fever, Exanthemata, 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 subtilising contagion communicated to the blood, and thence, in consequence of fever and assimilation, thrown out upon the surface of the body, but a matter occasionally produced in the skin itself by sweating.

This conclusion is further rendered probable from hence, that, while the miliary eruption has no symptoms or concourse of symptoms peculiar to itself, it, upon occasions, accompanies almost every febrile disease, whether inflammatory or putrid, if these happen to be attended with sweating; and from thence it may be presumed, that the miliary eruption is a symptomatic affection only, produced in the manner we have said.

But as this symptomatic affection does not always accompany every instance of sweating, it may be proper to inquire, what are the circumstances which especially determine this eruption to appear? And to this Dr Cullen gives no full and proper answer. He cannot say that there is any one circumstance which in all cases gives occasion to this eruption; nor can he say what different causes, in different cases, may give occasion to it. There is only one observation that can be made to the purpose; and it is, that these persons, sweating under febrile diseases, are especially liable to the miliary eruption, who have been previously weakened by large evacuations, particularly of blood. This will explain why it happens to lying-in women more frequently than to any other persons; and to confirm this explanation, he has observed, that the eruption has happened to other women, though not in childbed, but who had been much subjected to a frequent and copious menstruation, and to an almost constant flux albus. He has also observed it to have happened to men in fevers, after wounds from which they had suffered a great loss of blood.

Further, That this eruption is produced by a certain state of debility, is, he thinks, probable, from its so often attending fevers of the putrid kind, which are always accompanied with great debility. It is true, that it also sometimes attends inflammatory diseases, when it cannot be accounted for in the same manner; but he believes it may be observed, that it especially attends those inflammatory diseases in which the sweats have been long protracted, or frequently repeated, and which have thereby produced a debility, and perhaps a debilitating putrid diathesis.

That, however, the miliary eruption is not necessarily or even generally connected with a certain state of debility, is abundantly evident from its being entirely wanting in by much the greater number of instances of typhoid fever, and in a variety of other diseases where every possible degree of debility occurs: And that it is not connected with any certain state of debility, still farther appears, both from the condition of those affected with it in different instances, which in point of strength is very various; and likewise from the continuance of fresh eruptions with the same individual, although during that time in very different states with respect to debility. It appears, therefore, much more probable, that it depends on some peculiar state of the surface, induced by the concurring influence of certain predisposing and occasional causes.

It appears so clearly that this eruption is always a Miliaria symptomatic and factitious affection, that Dr Cullen is persuaded it may be, in most cases, prevented merely by avoiding sweats. Spontaneous sweatings, in the beginning of diseases, are very rarely critical; and all sweatings not evidently critical should be prevented, or at least moderated; and the promoting them, by increasing external heat, is commonly very pernicious. Even critical sweats should hardly be encouraged by such means. If, therefore, spontaneous sweats arise, they are to be checked by the coolness of the chamber; by the lightness and looseness of the bedclothes; by the persons laying out their arms and hands; and by their taking cold drink: and in this way Dr Cullen thinks he has frequently prevented miliary eruptions, which were otherwise likely to have appeared, particularly in puerperal women.

But it may happen, when these precautions have been neglected, or from other circumstances, that a miliary eruption does actually appear; and the question will then be put, how the case is to be treated? This is a question of consequence; as there is reason to believe that the matter here generated is often of a virulent kind; it is often the offspring of putrefaction; and, when treated by increasing the external heat of the body, it seems to acquire a virulence which produces those symptoms mentioned above, and proves certainly fatal.

It has been an unhappy opinion with most physicians, that eruptive diseases were ready to be hurt by cold; and that it was therefore necessary to cover up the body very closely, and thereby increase the external heat. We now know that this is a mistaken opinion; that increasing the external heat of the body is very generally mischievous; and that several eruptions not only admit, but require the application of cold air. Dr Cullen is persuaded, therefore, that the practice which formerly prevailed in the case of miliary eruptions, of covering up the body closely, and both by external means and internal remedies encouraging the sweatings which accompany this eruption, was highly pernicious, and commonly fatal. He is therefore of opinion, that even when a miliary eruption has appeared, in all cases in which the sweating is not manifestly critical, we should employ all the means of stopping the sweating that are mentioned above; and he has sometimes had occasion to observe, that even the admission of cool air was safe and useful.

This is, in general, the treatment of miliary eruptions: but at the same time, the remedies suited to the primary disease are to be employed; and therefore when the eruption happens to accompany inflammatory affections, and the fulness and hardness of the pulse or other symptoms show an inflammatory state present, the case is to be treated by blood-letting, purging, and other antiphlogistic remedies.

On the other hand, when the miliary eruption attends diseases, in which debility and putrefaction prevail, it will be proper to avoid all evacuations, and to employ tonic and antiseptic remedies, particularly the cinchona, cold drink, and cold air.

The most distressing circumstance attending this affection, is the almost unsupportable sickness at stomach which frequently occurs, and which is often observed to precede fresh eruptions taking place during... Exanthemata. The course of the disease. With the view of counteracting and alleviating this symptom, recourse is had to wine and other cordial medicines. But with many patients nothing is found to have so much influence as the use of camphor, particularly when introduced gradually in small doses, under the form of the *mifura camphorata* of the London Pharmacopoeia, or of the *emulso camphorata* of that of Edinburgh.

**GENUS XXXII. SCARLATINA.**

**SCARLET FEVER.**

Scarlatina, Sauv. gen. 98. Vog. 39. Sag. 294. Junce. 75.

Sp. I. The Mild SCARLET FEVER.

Scarlatina febris, Sayo. sp. i. Sydenham, sect vi. cap. 2.

Sp. II. The SCARLET FEVER with Ulcerated Sore Throat.

Scarlatina anginosa. Withering on the Scarlet Fever.

The mild scarlet fever is described by Sydenham, who tells us that he can scarce account it a disease; and indeed nothing more seems to be necessary in the treatment of it than an antiphlogistic regimen, avoiding the application of cold air and cold drink. The disease, however, often rages epidemically, and is attended with very alarming symptoms, in which case it is called *scarlatina anginosa*.—The best description of this distemper has been published by Dr Withering in the year 1778. This disease made its appearance, we are told, at Birmingham and the neighbouring villages, about the middle of May 1778. It continued in all its force and frequency to the end of October; varying, however, in some of its symptoms, as the air grew colder. In the beginning of November it was rarely met with; but towards the middle of that month, when the air became warmer, it increased again, and in some measure resumed those appearances it presented in the summer months, but which it had lost during the cold winds in October.

It affected children more than adults; but seldom occurred in the former under two years of age, or in the latter if they had passed their fifth year.

**Description.** With various general symptoms of fever, the patient at first complains of a dejection of spirits, a slight forenoon or rather stiffness in the neck, with a sense of tightness in the muscles of the neck and shoulders, as if they were bound with cords. The second day of the fever this soreness in the throat increases, and the patients find a difficulty in swallowing; but the difficulty seems less occasioned by the pain excited in the attempt, or by the tightness 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 floughs in the putrid sore throat, sometimes occur, yet those are easily washed off; and real ulcerations of those parts were never observed.

These are the most usual appearances of this disorder; but it too frequently assumes a much more fatal form. In some children the delirium commences in a few hours after the first attack; the skin is intensely hot; the scarlet colour appears on the first or second day, and they die very early on the third. Others again, who survive this rapid termination, instead of recovering, as is usual, about the time the skin begins to get its natural colour, fall into a kind of lingering, and die at last in the course of six or eight weeks.

In adults, circular livid spots were frequently observed about the breast, knees, and elbows; also large blotches of red, and others of white intermixed, and often changing places.

In the month of October, when the air became colder, the scarlet colour of the skin was both less frequent and less permanent. Many patients had no appearance of it at all; while others, especially adults, had a few minute red pimples, crowned with white pellucid heads. The inside of the throat was considerably tumefied, its colour a dull red, sometimes tending to a livid. The pulse beat in general 130 or 140 strokes in a minute; was small, but hard, and sometimes sufficiently so to justify the opening of a vein; and the blood thus taken away, in every instance, when cool, appeared fizzy, and the whole countenance firm.

Happy would it be, Dr Withering observes, if the baneful influence of this disorder terminated with the febrile symptoms. But in ten or fifteen days from the cessation of the fever, and when a complete recovery might be expected, another train of symptoms occurs, which at last frequently terminate fatally. The patients, after a few days amendment, feel something that prevents their farther approach to health; health; an unaccountable languor and debility prevails, a flabbiness in the limbs, an accelerated pulse, disturbed sleep, disrelish to food, and a scarcity of urine. These symptoms, we are told, are soon succeeded by swellings of a real dropsical nature, forming sometimes an anaëma, and on other occasions an ascites; and not unfrequently scarlatina has proved fatal, from supervening hydrothorax in consequence of the effusion of water into the chest. It is unnecessary to remark, that when this happens, a fatal termination is more sudden than from any other modification of dropsy.

Dr Withering, after examining the accounts given of this disease by different authors, proceeds to the diagnosis. It may be distinguished, he observes, from the petechial fever, by the eruption in the latter appearing seldom before the fourth day, by the regularity and distinctness of the spots, and by its principally occupying the neck, the back, and the loins. On the other hand, in the scarlet fever, the eruption generally appears about the third day; and consists either of broad blotches, or else one continued redness, which spreads over the face and the whole body.

In the fever called purpura, the pustules are prominent, keep their colour under pressure, and never appear early in the disease; whereas in the scarlet fever, the eruption appears more early, is not prominent, but perfectly smooth to the touch, and becomes quite white under pressure.

Although the purple fever and scarlatina may be connected by some general cause, yet our author takes occasion to observe, that they cannot be mere modifications of the same eruption; for examples occur, he says, of the same person being first seized with one of these disorders, and afterwards with the other; but he never met with an instance of the same person having the scarlet fever twice; and he believes it to be as great an improbability as a repetition of the smallpox.

This disorder is particularly distinguished from the measles, we are told, by the want of that cough, watery eye, and running at the nose, which are known to be the predominant symptoms in the early state of the measles, but are never known to exist in the scarlatina.

From the erysipelas this disease is distinguishable, by the limited seat of the former, together with its not being contagious.

The cynanche maligna, however, is according to Dr Withering more difficult to distinguish from this disease than any other; and yet the distinction is, he thinks, a matter of the greatest importance, as the method of treatment, according to him, ought to be extremely different.—Although, in a number of circumstances, these two diseases bear a very great resemblance, yet, with a little attention, the one may in general, he thinks, be distinguished from the other. From Dr Fothergill's account of the sore throat attended with ulcers, our author has made out the following characteristic circumstances of the two diseases, contrasted to one another.

| Scarlatina Anginosa. | Angina Gangrenosa. | |---------------------|--------------------| | Season. Summer . . Autumn. | Season. Spring . . Winter. |

It is not pretended, Dr Withering remarks, that all the above-contrasted symptoms will be met with in every case. It is enough, he observes, that some of them appear; and that if, conjoined with the consideration of the prevailing constitution, they enable us to direct that mode of treatment which will most contribute to the relief of the sick.

But notwithstanding the attention which Dr Withering has bestowed upon this subject, we are still decidedly of opinion, that the disease which he has so accurately described under the title of scarlatina anginosa, is in reality the same affection with the malignant ulcerous sore throat of Huxham and Fothergill. During different epidemics, this disease, like smallpox and measles in different seasons, is considerably varied in its appearance. But still there occurs such a similarity as clearly marks the sameness of the affection. And indeed this, as in the case of the smallpox, is abundantly demonstrated by infection from one contagion giving protection against succeeding ones, although the appearances be much varied. This has particularly appeared at Edinburgh, where the disease has of late prevailed as an epidemic on five different years, viz. 1774-75, 1782-83, 1789-90, 1797-98, and 1804-5. During the first of these occasions, in the greater part of patients, the sore throats were of a very gangrenous and malignant nature; during the second, the disease more commonly appeared under the form of what might be called simple scarlatina; and during the other epidemics, the contagion was, if we may be allowed the expression, of an intermediate nature. But it is farther to be remarked, that during every one of those epidemics, when several children of a family were at the same time subjected MEDICINE.

Exanthemata subjected to the infection, in one the disease would have been attended with almost all the symptoms mentioned in the column of scarlatina anginosa, with respect to skin, eyes, throat, breath, bowels, termination of the affections, &c. In another, would have occurred all the symptoms with respect to those particulars which he has mentioned under the column of angina gangrenosa. While at the same time, in numberless instances, even in the same patient, the disease at its commencement has shown evident marks of an inflammatory, and at its termination of a putrid tendency. And there cannot be a doubt, that both the scarlatina anginosa of Withering, and the cynanche maligna, as described by Fothergill and Huxham, have occurred in every season and situation, and have affected persons of every age and constitution not before subjected to either disease.

Causes. Dr Withering affirms, that the immediate cause of this disease is a poison of a peculiar kind communicable by contagion.

2. That this poison first takes possession of the mucous membrane lining the fauces and the nose; and either by its action upon the secretory glands, or upon the mucus itself, assimilates that mucus to its own nature.

3. That it is from this beginning, and from this only, that it spreads to the stomach, &c. and at length acts upon the system at large.

4. That its first action upon the nerves is of a sedative or debilitating nature.

5. That in consequence of certain laws of the nervous system, when the debilitating effects operate upon the sensorium commune, a reaction takes place; and that this reaction is, ceteris paribus, proportioned to the debilitating power.

6. That, in consequence of this reaction of the nervous system, the vibratory motion of the capillary blood-vessels dependant thereon is greatly increased; an unusually large quantity of blood is accumulated in those vessels; the heart and large blood-vessels are deprived of their customary proportion; and hence, though stimulated to more frequent contraction, the pulse must necessarily be feeble.

7. That as violent exertions are followed by debility, upon the cessation of the fever, the capillary vessels, which had acted with such unusual violence, are left in a state of extreme debility, and are long in recovering their tone; hence it is that so many patients afterwards become dropical.

Dr Withering next proceeds to the consideration of the different remedies, which either are at present in common use, or have been recommended as proper in this disease.

Cure. Blood-letting has been recommended by authors; but such was the state of the pulse in this disorder, at least during the summer months, that it was not in any instance thought advisable to take away blood. In some cases, indeed, where the fiery redness of the eyes seemed to demand the use of leeches, they were had recourse to, but never with any advantage. In the harvest months, when the pulse was more firm, and when suffocation seemed to be threatened from the swelling in the fauces, blood-letting was sometimes advised; but still with less advantage than one would have expected in almost any other situation.

Vomiting.] This, Dr Withering observes, seems to be the remedy of nature; and he is surprised how it should have been omitted by several authors who have gone before him. Vomiting, he says, most amply fulfils the indications arising both from a consideration of the cause and of the effects; and a liberal use of the remedy he holds forth as the true foundation for successful practice in scarlet fever and sore throat. His common form of emetic is a combination of tartar emetic and ipecacuanha, given in pretty smart doses; and these are to be repeated at least once in 48 hours, and in the worst cases so often as twice in 24 hours.

Purging.] The action of purgatives is considered by Dr Withering as altogether repugnant to the curative indications in this disease: for the poisons, as formerly remarked, being received into the system by the fauces, the operation of a purge, instead of discharging it, can only promote its diffusion along the alimentary canal; and in fact, we are told, that when even a spontaneous purging supervenes in this disease, the patients think to amazingly fast, that it is not within the reach of art to support them. When, however, a considerable quantity of acrid matter passing from the fauces into the stomach, makes its way to the rectum, a considerable degree of looseness often takes place. And although evacuations from the system in general by means of cathartics may be hurtful, yet patients often obtain great relief from a free discharge of this matter; and by discharging it, purgatives have the effect even of preventing an evacuation from the system, which would otherwise take place.

Sudorifics. Cordials. Alexipharmics.] None of these remedies were found beneficial. With respect to cordials, Dr Withering observes, that although they seem to be indicated by the great loss of strength and feeble pulse, yet the certain consequence of their use always was, an increase of restlessness, of the delirium, and of the heat.

Diuretics.] These were found very beneficial. The vegetable fixed alkali is recommended as the most proper article of this kind: a dram or two may be easily swallowed every 24 hours, by giving a small quantity in every thing the patient drinks. Diuretics, however, have been found principally serviceable, by practitioners in general, in those cases where the urine is observed to be scanty, and where dropical symptoms have taken place.

Cinchona.] No medicine, we are told, ever had a fairer trial in any disease than the Peruvian bark had in this epidemic; for the feeble pulse, great prostration of strength, with here and there a livid spot, were thought to be such undeniable evidences of a putrid tendency, that cinchona was poured down not with a sparing hand. But this was only at first; for these livid spots and the floughs in the throat being found to be the effects of inflammation instead of putrefaction, and the bark instead of diminishing, rather increasing these symptoms, it was at last entirely laid aside by Dr Withering in his practice. But although cinchona may not have been successful with a particular epidemic at a particular place; yet from the concurring testimony of many practitioners, it is very commonly monly found to be productive of good effects: And there is perhaps no remedy on which greater dependence is in general put, particularly in the advanced periods of the disease, where the factor is considerable.

Upon the same principles that cinchona was prescribed, fixable air was at first likewise advised, but with no evident effects either one way or another. Dulcified acids were also had recourse to, but with no advantage.

Opiates.] These, although recommended by some authors for the removal of inquietude and watchfulness, yet in this epidemic, instead of effecting their purpose, always increased the distress of the patient.

Blistering.] In the former appearance of the disease, blisters were universally detrimental; they never failed to hasten the delirium; and if the case was of the worst kind, they too often confirmed its fatal tendency. But although this may have been the case during the epidemic which Dr Withering describes, it has by no means been generally observed. On the contrary, by the early application of blisters to the external sores, both the glandular swellings and likewise the discharge from the mouth and sores have been much diminished; and practitioners have believed, not without probable reason, that the after-attacks of the throat were less considerable than would otherwise have been the case.

Injected gargles of contrayerva decoction, sweetened with oxymel of squills, &c. were found very beneficial in bringing always large quantities of viscid ropy stuff from the sores.

The immersion of the feet and legs in warm water, although it did no harm, yet did not either procure sleep or abate the delirium, as it frequently does in other kinds of fever.

As in summer it was found difficult to keep the patients sufficiently cool, they were ordered to lie upon a mattress instead of a feather-bed; a free circulation of air was kept up; and where the patients strength would admit of it, they were ordered frequently out of doors. Animal food and fermented liquors were denied them, and nothing allowed but tea, coffee, chocolate, milk and water, gruel, barley-water, and such articles.

With respect to the tropical disorder which so frequently succeeds to this complaint, it was never observed, Dr Withering remarks, when the preceding symptoms had been properly treated.

When called upon to patients in the tropical state, he began his practice by a dose of calomel at night, and a purgative in the morning. When a febrile pulse attended the other symptoms, emetics were useful, as well as the saline draughts and other neutral salts. When great debility, comatose or peripneumonic symptoms occurred, blisters were found very serviceable; but when tropical symptoms were the principal cause of complaint, small doses of rhubarb and calomel were advised; recourse was also had to diluted solutions of fixed alkalies, squills, Seltzer waters, and other diuretics.

When the urine flows freely, steel and other tonics are recommended; together with gentle exercise, high-feathered food, wine, and the wearing of flannel in contact with the skin.

Dr Withering 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; at least for the epidemic under the form in which it then appeared.

Since Dr Withering's publication, two other practices have obtained considerable celebrity in this disease. The one is dashing cold water on the surface of the body in the manner recommended by Dr Currie in proper fevers. It is, however, very certain that although this may obviate symptoms, and particularly diminish the heat when very urgent, yet it never produces an artificial termination of the disease as some have alleged. When the contagion of scarlatina is introduced into a human body, never before subjected to the disease, it must, like smallpox and measles, run a certain course, and the attention of the practitioner must merely be employed in endeavouring to render that course as mild as he can, principally by obviating urgent symptoms.

The other remedy, lately introduced, and highly commended in scarlatina anginosa, is the oxygenated muriatic lead. This has been particularly extolled by Mr John Ayre Braithwaite, surgeon at Lancaster. One dram of the oxygenated muriatic acid is mixed with eight ounces of distilled water. This quantity he directs to be taken by a patient at the age of puberty every day. But the quantity must be regulated by the age and situation of the patient. This remedy also is only useful as obviating symptoms, particularly the affection of the throat. But with this intention we have often employed it with great advantage.

GENUS XXXIII. URTICARIA.

NETTLE-RASH.

Febris urticata, Vog. 40. Uredo, Lin. 8. Purpura urticata, Funk. 75. Scarlatina urticata, Sauv. fp. 2. Erytipeletis species altera, Sydenham, sect. vi. cap. 6. Febris scarlatina, et febris urticata, Meyerey, Mal. des armées, 291 et seq.

Description. This disease has its English name of nettle-rash from the resemblance of its eruption to that made by the stinging of nettles. These little elevations upon the skin in the nettle-rash often appear instantaneous, 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 except from them; and where many of them rise together, and continue an hour or two, the parts are often considerably swelled; which particularly happens in the face, arms, and hands. These eruptions will continue to infect the skin, sometimes in one place and sometimes in another, for one or two hours at a time, two or three times every day, or perhaps for the greatest part of the 24 hours.—In some persons they last only a few days, in others many months; nay, sometimes the disease has lasted for years with very short intervals.

But though the eruption of the urticaria resembles, as already observed, that produced by the stinging of nettles, Exanthemata, it is sometimes accompanied with long weals, as if the part had been struck with a whip. Whatever be the shape of these eminences, they always appear solid, without having any cavity or head containing either water or any other liquor; and this affords an easy mark whereby this disease may be distinguished from the itch. For it often happens, that the insufferable itching with which this eruption is attended, provokes the patient to scratch the parts so violently, that a small part of the cuticle on the top of these little tumors is rubbed off; a little scab succeeds; and, when the swelling is gone down, there is left an appearance hardly to be distinguished from the itch, but by the circumstances just now mentioned. The nettle-rash also further differs from the itch, in not being infectious.

Cayley, &c. Dr Heberden is inclined to ascribe this difference to some mechanical cause outwardly applied to the skin. He observes, that most people suffer in a similar manner from the real stinging of nettles. Cowhage, or, as it is corruptly called, cow-itch, a sort of phaeolus, or French bean, the pod of which is covered over with a kind of down or hair, and the effect of which upon the skin is much the same as that of nettles; and almost any hairs cut equally short, and sprinkled upon the skin, whenever they happen to stick in it, will make the part itch or smart in such a manner as to give great uneasiness; it is also a considerable time before the skin can be cleared of the finer ones, when once they are screwed upon it.

Reaumur, in the fourth memoir of his History of Insects, describes a species of caterpillars to which belong a fort of hairs almost invisible to the naked eye, which are easily detached, and frequently float in the air round their nests, though it have not been at all disturbed. The touch of these hairs has a similar effect with the cow-itch; that is, they occasion intolerable itchings, with little bumps and redness, arising sometimes to a slight inflammation. These he found would continue four or five days, if the animal or the nest had been much handled; and though they had not been touched at all, yet, by only walking near their nests, the same effects would be brought on, but for a shorter time. These hairs affect the skin in this manner by sticking in it, as he could perceive with a glass of a great magnifying power; for with one of a small power they were not visible. The uneasy sensations caused by these small wounds, not only, as he says, last several days, but move from one part of the body to another; so that they will cease upon one wrist, and immediately begin on the other; from the wrist they will go to the fingers or the face, or even to the parts of the body which are covered. He supposes, that the motions of the body, when much of this fine down lies near or upon the skin, may drive it from one part to another, or change what was lying there inoffensively to a situation fit to make it penetrate into the skin. Neither cold water, nor oil, nor spirit of wine, with which the parts affected were bathed, had any effect in removing the itching. He thinks the most efficacious remedy which he tried for this complaint was, to rub the parts strongly with parsley, which instantly lessened the sensations, and after two or three hours, entirely freed the patient from them. It is also well known, that many species of caterpillars, by only walking over the hands, will produce something like this effect on the parts which they touch, and undoubtedly from the same cause.

Dr Heberden asks, Is it impossible that the nettle-rash should arise from the same causes, or from others similar, which we miss by looking too deeply for them in the blood and humours? Such, says he, may have been its origin in some instances, where it has lasted only a few days; but where this affection has continued for some years, in persons who change their linen every day, and who bathe frequently all the time, it can hardly be ascribed to such an external cause. He has observed it frequently to arise from cantharides; but though it has continued many weeks after the removal of the blister, yet it might be suspected that this arose from the fine spicules of the cantharides sticking all this time about the skin; it being customary to throw 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 dried; muscles, shrimps, and even honey, and the kernels of fruits, will also sometimes produce symptoms of a similar kind. But whatever be its cause, Dr Heberden never saw any reason to suppose that the nettle-rash had in any way vitiated the humours to such a degree as to require the use of internal remedies; and if the itching could be certainly and expeditiously allayed, there would be no occasion for any farther cure. He concludes this history of the disorder with a case communicated to him by Dr Monney, 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 10 years. He tried several hospitals, and had advices from many physicians, without the least abatement of his complaints. At last it was agreed by a consultation of physicians, that he should try dipping in salt water; which he did at Yarmouth for 13 weeks, without any visible amendment. One hot day, having pulled off his clothes and gone into the sea in the middle of the day, the heat diffused itself so violently all over his body, that, by the time he had put on his clothes, his eyesight began to fail, and he was compelled to lie down upon the ground to save himself from falling. The moment he lay down, the faintness went off; upon this he got up again; but had no sooner arisen, than he found himself in the former condition; he therefore lay... down 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.

GENUS XXXIV. PEMPHIGUS.

Pemphigus, Sauv. gen. 93. Sag. 291. Morta, Lin. i. Febris bullola, Vog. 41. Pemphigus major, Sauv. sp. i. Exanthemata serosa, C. Pflon. Obs. 150. Febris pemphygodes, Ephem. Germ. D. I. A. viii. Obs. 56. Pemphigus castrensis, Sauv. sp. 2. Febris syneches, cum vesiculis per pectus et colum sparvis, 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, inasmuch that Dr Culien 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, and was treated by the late Dr David Stuart, then physician to that hospital, who soon after published an account of it in the Edinburgh Medical Commentaries. A private folder 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, headache, latitude, 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 smallpox. 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 headache, sickness at stomach, oppression about the precordia, thirst, sore throat, with difficulty of swallowing; his tongue was foul, his skin felt hot and feverish; pulse from 110 to 120, rather depressed; belly colicive; eyes dull and languid, but without delirium. The whole surface of his skin was interspersed with vesicles, or phlyctaneae, 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 hand-breadth 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 chiefly on the neck and face; others showed a tolerably laudable pus. However, by far the greatest number were perfectly entire, turgid, and of a bluish colour. Upon opening them, it was evident that the cuticle elevated above the cutis, and 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 snipped, and dressed with unguent, &c. 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:

Rp Decoët, Cort. Peruvian. 3 vj. Vini rubri. Lusitan. 3ij. M. Hujus mixturæ capiat 3 B. tercia quaque hora.

"His "His acidulated drink was continued; and on account of the very offensive smell on approaching near him, some vinegar was placed in a basin before the bed, and sprinkled on the floor; and the room was kept properly aired.

"April 17. His sores looked tolerably clean, unless on his arms and thighs; where they were livid, a little ulcerated, and discharged a bloody ichor.

"His headache, sickness, &c., were almost gone; his tongue was rather cleaner; pulse 68, and soft. As the decoction of the bark sat easily on his stomach, the following prescription was ordered:

\[ \text{Rp Pulv. subtilis Cort. Peruv. } \frac{3}{5} \text{S. Vini rubri Lusitan. Aque fontan. } \frac{2}{5} \text{S. M. ft. Hault. tertia quaque hora repetend.} \]

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 much cleaner and better; the fever was gone, his pulse natural, and he had no complaint but weakness and a troublesome itching of the skin: The Peruvian bark, &c., were continued.

"April 20. Some of the ulcers still poured forth a bloody ichor; most of them, however, looked well, and had begun to heal—fever gone—medicines continued.

"From the 21st of April, he went on gaining strength, and his sores appeared to heal fast; he was desired to take only four doses every day; and by the 27th his sores, &c., were totally dried up—he had no complaint, and was dismissed cured."

Since the publication of this case of pemphigus by Dr Stuart, observations on this disease have been published by Dr Stephen Dickson of Dublin, in the Transactions of the Royal Irish Academy. In these observations, an account is given of six different cases which Dr Dickson has had an opportunity of seeing. Judging from these, Dr Dickson thinks that Dr Cullen's definition of this disease requires correction; and that it ought to be defined, "a fever accompanied with the successive eruption, from different parts of the body, internal as well as external, of vesicles about the size of an almond, which become turgid with a faintly yellowish serum, and in three or four days subside."

From the cases which have fallen under Dr Dickson's observation, he concludes, that the disease varies considerably as to its mildness or malignity. In three of the cases which he has seen, the symptoms were extremely mild, but in the other three strong symptoms of putrefaction were manifested, and the life of the patient was in great danger. With respect to the method of cure, he is of opinion, that the general symptoms of weakness, and tendency to putrefaction, obviously point out the proper treatment. Nourishment must be supplied, and the Peruvian bark and wine carefully administered; and when vesicles appear on internal parts, irritation must be guarded against by opiates, demulcents, and gentle laxatives.

Some additional observations on the subject of pemphigus have lately been published in the London Medical Journal by Mr Thomas Christie. From a case which Mr Christie describes, he is disposed to agree with Dr Dickson in thinking that sometimes at least pemphigus is not contagious. He remarks, however, that the pemphigus described by some foreign writers was extremely infectious; which he thinks may lead to a division of the disease into two species, the pemphigus simplex and complicatus; both of which, but especially the latter, seem to vary much with respect to mildness and malignity.

**GENUS XXXV. APHTHA.**

*The Thrush.*

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 lactucimem, Sauv. lp. 1.)

The aphtae are whitish or ash-coloured pustules, invading the uvula, fauces, palate, tonsils, inside of the cheeks, gums, tongue, and lips. They for the most part begin at the uvula, sending forth a glutinous mucus, and the pustules covering all or the greatest number of the parts above mentioned, with a thick whitish crust adhering most tenaciously. This crust does not induce an ulcer on the parts on which it lies by eating into them, but comes off in whole pieces after the pustules have arrived at maturity. This will often happen in a short time, so that the throat and internal parts of the mouth are frequently observed to be clean, which a few years before were wholly covered with white crusts. Neither is this disease confined to the throat and fauces, but is said to affect the oesophagus, stomach, and all parts of the alimentary canal. Of this indeed there is no other proof, than that, after a great difficulty of swallowing, there is sometimes an immense quantity of aphtae evacuated by stool and vomiting, such as the mouth could not be thought capable of containing.

Cautery, &c. The aphtous 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 aphtae often appear without any fever at all.

Prognosis. There is no symptom by which the coming out of aphtae can be foretold, though they are common in many fevers; but they themselves are in general a bad symptom, and always signify a very tedious disorder: the danger denoted by them is in proportion to the difficulty of deglutition; and a diarrhoea accompanying them is likewise bad. This indeed generally carries off old people when they become affected with aphtae. The dark-coloured aphtae also are much more dangerous than such as are of a brown or ash colour; but it is a good sign when the appetite returns, and the dark-coloured ones are succeeded by others of a whiter colour. Neither are those which are unaccompanied with fever so dangerous as the other kind.

Cure. As the aphtae are seldom a primary disease, we must generally endeavour to remove the disorder upon which they depend, after which they will fall off; ORDER IV. HÆMORRHAGIÆ.

Hæmorrhagiae, Vog. Clasf II. Ord. I. Hoffm. II. 194. Junck. 5. Sanguifluxus, Sauv. Clasf IX. Ord. I. Sag. Clasf V. Order I.

GENUS XXXVI. EPISTAXIS.

BLEEDING at the Nose.

Hæmorrhagia, Sauv. gen. 239. Lin. 173. Sag. gen. 174. Hæmorrhagia narium, Hoffm. II. 196. Junck. 6. Hæmorrhagia plethorica, Sauv. fp. 22. Hoffm. II. 198.

The other species enumerated by authors are all symptomatic.

Description. The milder species of this hæmorrhage comes on more frequently in summer than in winter, and for the most part without giving any warning, or being attended with any inconvenience; but the less benign kind is preceded by several remarkable symptoms. These are, congestions of the blood sometimes in one part, and sometimes in another, and which are often very troublesome in the sides of the head: there is a redness of the cheeks; an inflation of the face, and of the vellus 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 tension of the hypochondria, especially the right one.

Cause, &c. This hæmorrhage may occur at any time of life; but most commonly happens to young persons, owing to the peculiar state of the system at that time. Sometimes, however, it happens after the axum 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 vellus of the nose; or to the particular weakness of these vessels.

In all these cases the disease may be considered as an arterial hæmorrhage, and depending upon an arterial plethora; but it sometimes occurs in the decline of life, and may then be considered as the sign of a venous plethora in the vellus of the head. It often happens at any period of life in certain febrile diseases, which are altogether or partly of an inflammatory nature, and which show a particular determination of the blood to the vessels of the head. As by this evacuation, other diseases are often removed, it may on these occasions be deemed truly critical. It happens to persons of every constitution and temperament; but most frequently to the plethoric and languid, and more commonly to men than women.

Prognosis. In young people, the bleeding at the nose may be considered as a slight disease, and scarce worth notice. But, even in young persons, when it recurs very frequently and in great quantity, it is alarming; and is to be considered as a mark of an arterial plethora, which in the decline of life may give the blood a determination to parts from which the 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 axum, returning frequently and violently. Even in the decline of life, however, it may be considered as in itself very salutary; but at the same time it is a mark of a dangerous state of the system, i.e., of a strong tendency to a venous plethora in the head, and it has accordingly been often followed by apoplexy, palsy, &c. When it happens in febrile diseases, and is in pretty large quantity, it may be generally considered as critical and salutary; but it is very apt to be too profuse, and thus becomes dangerous. It sometimes occurs during the eruptive fever of some exanthemata, and is in such cases sometimes salutary; but if these exanthemata be accompanied with any putrid disposition, this hæmorrhage, as well as artificial bleedings, may have a very bad tendency.

Care. The treatment in cases of epistaxis may be referred to two heads. 1st, The treatment during the time of the discharge; and, 2dly, The treatment after the discharge is stopt, with the view of preventing the return of it. During the former of these periods, it is necessary in the first place to consider whether the discharge should be left to its natural course or stopped by artificial means. In determining this question, regard must be paid to the quantity of the discharge; the appearance of the blood; the constitution with which epistaxis occurs; the former habit of the patient; and the consequences which result from the discharge. When, from due consideration of these circumstances, there is reason to fear that further evacuation would be attended with bad consequences, though this disease has been generally thought very slight, it should seldom be left to the conduct of nature; and in all cases it should be moderated by keeping the patient in cool air, by giving cold drink, by keeping the body and head erect, by avoiding any blowing of the nose, speaking, or other irritation; and if the blood has flowed for some time without showing any tendency to stop, we are to attempt the suppression of the hæmorrhage, by pressing the nostril from which the blood flows, washing the face with cold water, or applying this to some other parts of the body. These measures Dr Cullen judges to be proper even on the first attacks, and even in young persons where the disease is in the least hazardous; but they will still be more requisite if the disease frequently recurs without any external violence; if the returns happen to persons not disposed. disposed to a plethoric habit; and more particularly if no signs of plethora appear in the symptoms preceding the discharge.

When the bleeding is so profuse that the pulse becomes weak and the face pale, every means must be used to put a stop to it, and that whether the patient be young or old. Besides those methods above mentioned, we must use astringents both internal and external; but the latter are the most powerful, and the choice of these may be left to the surgeon. The internal astringents are either vegetable or fossil; but the vegetable astringents are seldom powerful in the cure of any hemorrhages except those of the alimentary canal. The fossil astringents are more active, but differ considerably in strength from one another.—The chalkbeats 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 naturna*, 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 by-standers, 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 fulnels 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 XXXVII. HÆMOPTYSIS.**

**Spitting of Blood.**

*Hæmoptysis*, Sauv. gen. 240. Lin. 179. Vog. 84. *Sag. gen. 175*. Junck. 8. *Hæmoptoe*, Boerh. 1198. *Sanguinis fluxus ex pulmonibus*, Hoffm. II. 202.

**Sp. I. Hæmoptysis from Plethora.**

**Sp. II. Hæmoptysis from External Violence.**

*Hæmoptysis accidentalis*, Sauv. sp. 1. *Hæmoptysis habitialis*, Sauv. sp. 2. *Hæmoptysis traumatica*, Sauv. sp. 12.

**Sp. III. Hæmoptysis with Phthisis.**

*Hæmoptysis phthisica*, Sauv. sp. 9. *Hæmoptysis ex tuberculo pulmonum*, Sauv. sp. 10.

**Sp. IV. The Calculous Hæmoptysis.**

*Hæmoptysis calculosa*, Sauv. sp. 14.

---

**Sp. V. The Vicarious Hæmoptysis.**

*Hæmoptysis catamenialis*, Sauv. sp. 4. *Hæmoptysis periodica*, Sauv. sp. 5.

**Description.** This hemorrhage commonly begins with a sense of weight and anxiety in the chest, some uneasiness in breathing, pain of the breast or other parts of the thorax, and some sense of heat under the sternum; and very often it is preceded by a saltish taste in the mouth. Immediately before the appearance of blood, a degree of irritation is felt at the top of the larynx. The person attempts to relieve this by hawking, which brings up a little florid and somewhat frothy blood. The irritation returns; and in the same manner blood of a similar kind is brought up, with some noise in the windpipe, as of air passing through a fluid. Sometimes, however, at the very first, the blood comes up with coughing, or at least somewhat of coughing, and accompanies the hawking above mentioned.

The blood is often at first in very small quantity, and soon disappears; but in other cases, especially when it frequently recurs, it is in greater quantity, and often continues to appear at times for several days together. It is sometimes profuse, but rarely in such quantity as either by its excess or by a sudden suffocation to prove immediately mortal.

It is not always easy to discover whether the blood evacuated by the mouth proceeds from the internal surface of the mouth itself, from the fauces or adjoining cavities of the nose, from the stomach, or from the lungs. It is, however, very necessary to distinguish these different cases; and for this Dr Cullen offers the following considerations.

1. When the blood proceeds from some part of the internal surface of the mouth, it comes out without any hawking or coughing; and generally, upon inspection, the cause is evident.

2. When blood proceeds from the fauces, or adjoining cavities of the nose, it may be brought out by hawking, and sometimes by coughing. In this case, there may be a doubt concerning its real source, and the patient may be allowed to please himself with the thought that the blood does not come from the lungs. But the physician must remember that the lungs are much more frequently the source of a hemorrhage than the fauces. The latter seldom happens but to persons who have before been liable to a hemorrhage from the nose, or to some evident cause of erosion; and in most cases, by looking into the fauces, the distillation of the blood from thence will be perceived.

3. When blood proceeds from the lungs, the manner in which it is brought up will commonly show from whence it comes; but, independent of that, it may also be known from the causes of 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. 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 has also its peculiar antecedent signs and causes.

Causes, &c. A haemoptysis may be produced at any time of life by external violence; and, in adult persons, while the arterial plethora prevails in the system, i.e., from the age of 16 to 35, a haemoptysis may at any time be produced merely by a plethoric state of the lungs. More frequently, however, it arises from a faulty proportion between the capacity of the lungs and that of the rest of the body. Thus it is often an hereditary disease, which implies a peculiar and faulty conformation.

This disease especially happens to persons who discover the smaller capacity of their lungs by the narrowness of their chest, and by the prominence of their shoulders; which last is a mark of their having been long liable to a difficulty of respiration. In such cases, too, the disease very frequently happens to persons of a sanguine temperament, in whom particularly the arterial plethora prevails. It happens also to persons of a slender delicate make, of which a long neck is a mark; to persons of much sensibility and irritability, and therefore of quick parts; to persons who have formerly been liable to 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 a limb.

All this constitutes the predisposing cause of haemoptysis; 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 folds, which had before been contracted by the cold of winter. Another exciting cause is a sudden diminution of the weight of the atmosphere, especially when concurring with any effort in bodily exercise. The effort alone, may often be the exciting cause in those who are already predisposed; and more particularly any violent exercise of respiration. In the predisposed, also, the disease may be occasioned by any degree of external violence.

Prognosis. Haemoptysis 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 menses; when, without any marks of predisposition, it arises from external violence; or, from whatever cause it may proceed, when it leaves no cough, dyspnea, or other affection of the lungs, behind it. But, even in these cases, a danger may arise from too large a wound being made in the vessels of the lungs, from any quantity of red blood being led to stagnate in the cavity of the bronchi, and particularly from any determination of the blood being made into the vessels of the lungs, which by renewing the hemorrhage may have these consequences.

Cure. In the treatment of this disease, with a view of stopping the discharge, it is first necessary to have recourse to those measures which tend to diminish the impetus by which the blood is expelled. This is to be effected by a removal of plethora when it exists; by diminishing the general impetus of circulation; by diminishing local increased action when it takes place in the vessels of the lungs; and by producing a determination of blood to other parts of the system remote from the lungs. But besides practices diminishing impetus, it is often also necessary to employ such as augment the resistance to the passage of blood through the ruptured vessels of the lungs. With these views a variety of practices may be employed, particularly blood-letting, refrigerants, sedatives, astringents, and the like.

On this subject Dr Cullen differs from those who prefer chalybeates and cinchona in the cure of haemoptysis. Both of these, he observes, contribute to increase the phlogistic diathesis then prevailing in the system, and the haemoptysis from predisposition is always accompanied with such a diathesis. Instead of these, therefore, he recommends blood-letting in greater or smaller quantity, and more or less frequently repeated as the symptoms shall direct. At the same time cooling purgatives are to be employed, and every part of the antiphlogistic regimen is to be strictly enjoined. In the London Medical Observations, the use of nitre is greatly recommended by Dr Dickson, to whom its efficacy was made known by Dr Letherland, physician to St Thomas's Hospital. The most commodious method of exhibiting it he found was in an electuary. Four ounces of conserve of roses were made into an electuary with half an ounce of nitre; of which the bulk of a large nutmeg was directed to be given, four, six, or eight times a day, according to the urgency of the case. The good effects of this, he tells us, have often astonished him; and when given early in the disease, he says he can depend as much upon it for the cure of an haemoptysis, as on cinchona for the cure of an intermittent. He agrees with Dr Cullen, however, that in those cases where there is any hardness in the pulse, and which almost always happens, there is a necessity for venefication. A cool regimen, and quiet of body and mind, are certainly useful; but Dr Cullen observes that some kinds of gestation, such as sailing, and travelling in an easy carriage on smooth roads, have often proved a remedy. When the cough is very troublesome, it is absolutely necessary to exhibit frequently a small dose of an opiate. Dr Dickson also informs us, that the nitre joined with spermaceti, or pulv. tragacanth. comp., has produced equally good effects with the electuary above mentioned; in the composition of which he at first considered the conserve only as a vehicle for the nitre, though he means not to insinuate that the former is totally destitute of efficacy.

When this hemorrhage has resisted other modes of cure, and there is reason to apprehend, even from the mere quantity of blood evacuated, that the patient may sink under the discharge, blisters, particularly when applied to the breast, are often had recourse to with great advantage; and the sulphuric acid, properly diluted, PHTHISIS.

PULMONARY CONSUMPTION.

Phthisis, Sauv. gen. 276. Lin. 208. Vog. 319. Sag. 101. Junct. 33. Phthisis pulmonis, Baerh. 1196. Affectio phthisica, five tabes pulmonalis, Hoffm. II. 284.

Sp. I. The Incipient Phthisis, without expectoration of Pus.

Phthisis incipiens, Morton Physiolog. L. II. cap. 3. Phthisis sicca, Sauv. sp. 1.

Sp. II. The Confirmed Phthisis, with an expectoration of Pus.

Phthisis confirmata acutiorum. Phthisis humida, Sauv. sp. 2.

Sometimes, notwithstanding all the care that can be taken, the haemoptysis will degenerate into a phthisis pulmonalis, or consumption of the lungs; and sometimes haemoptysis will be the consequence of this dangerous disorder. It has indeed been supposed, that an ulceration of the lungs, or phthisis, was the natural and almost necessary consequence of haemoptysis; but according to Dr Cullen, this is in general a mistake; for there are many instances of ja haemoptysis from external violence without being followed by any ulceration. The same thing has often been observed where the haemoptysis arose from an internal cause; and this not only in young persons, when the disease returned for several times, but when it has often recurred during the course of a long life; and it may easily be conceived, that a rupture of the vessels of the lungs, as well as of the vessels of the nose, may be sometimes healed. The causes of phthisis, therefore, Dr Cullen reduces to five heads. 1. A haemoptysis. 2. A suppuration of the lungs in consequence of a pneumonia. 3. A catarrh. 4. An asthma; and 5. Tubercles.

1. When a phthisis arises from a haemoptysis, 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 bronchiæ, 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 haemoptysis.

2. The second cause of an ulceration of the lungs mentioned above is a suppuration formed in consequence of pneumonia. When a pneumonia, with symptoms neither very violent nor very slight, has continued for many days, it is to be feared it will end in a suppuration; but this is not to be determined by the number of days; for, not only after the fourth, but even after the tenth day, there have been examples of a pneumonia ending by a resolution; and if the 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 now mentioned. But if a moderate disease, in spite of proper remedies employed, be protracted to the 14th day without any considerable remission, a suppuration is pretty certainly to be expected; and it will be more certain still, if no signs of resolution have appeared, or if an expectoration which had appeared shall have again ceased, and the difficulty of breathing has continued or increased, while the other symptoms have been rather abated.

That in a pneumonia, the effusion is made which may lay the foundation of a suppuration, may be concluded from the difficulty of breathing becoming greater when the patient is in a horizontal posture, or when the patient can lie more easily on the affected side. That, in such cases, a suppuration is actually begun, may be inferred from the patient's being frequently affected with slight cold shiverings, and with a sense of cold felt sometimes in one sometimes in another part of the body. We form the same conclusion also from the state of the pulse, which is commonly less frequent and softer, but sometimes quicker than before. That a suppuration is already formed, may be inferred from there being a considerable remission of the pain which had before subsided; while with this the cough, and especially the dyspnoea, continue, and are rather increased. At the same time the frequency of the pulse is rather increased, the feverish state suffers considerable exacerbations every evening, and by degrees a hectic fever in all its circumstances comes to be formed.

In this state of symptoms, we conclude very confidently, that an abscess, or, as it is called, a vomica, 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 enclosed in a cyst; but commonly not long before it comes to be either absorbed and transferred to some other part of the body, or breaks through into the cavity of the lungs, or into that of the thorax. In the latter case it produces the disease called empyema; but it is when the matter is poured into the cavity of the bronchiæ that it properly constitutes the phthisis-pulmonalis. In the case of empyema, the chief circumstances of a phthisis are indeed also present; but we shall here consider only that case in which the abscess of the lungs gives occasion to purulent expectoration.

An abscess of the lungs, in consequence of pneumonia, is not always followed by a phthisis: for sometimes a hectic fever is not formed; the matter poured into the bronchiæ is a proper and benign pus, which frequently is coughed up very readily, and spit out; and though this purulent expectoration should continue for some time, if it be without hectic fever, the ulcer soon heals, and every morbid symptom disappears. This has so frequently happened, that we may conclude, that neither the access of the air, nor the constant motion of the lungs, will prevent an ulcer of these parts from healing, if the matter of it be well-conditioned. An abscess of the lungs, therefore, does not necessarily produce phthisis pulmonalis; and if it be followed by such a disease, it must be in consequence of particular circumstances which corrupt the purulent... 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 fever 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 vomica, or by its connexion with an empymema, 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 cause 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, in the opinion at least of some physicians, liable to several difficulties. The catarrh is properly an affection of the mucous glands of the trachea and bronchiae, 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.

Farther, 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.

But notwithstanding these objections, experience affords numerous examples of cases in which a disease long subsisting under the form of catarrh has at last degenerated into phthisis, and proved fatal from supervening hectic fever. It must, however, at the same time be allowed, that catarrh, degenerating into a phthisis, chronic state after subsiding for many years, has of itself often proved fatal without inducing phthisis.

4. If phthisis does not frequently follow catarrh, it is still more rarely a consequence of asthma. Innumerable examples are unquestionably afforded of that disease subsiding for many years without any symptom whatever of phthisis as a consequence of it. But at the same time, there are unquestionable examples of phthisis deriving its origin from asthma; which, however, probably happens only in cases where a peculiar state of the lungs at the same time takes place: But without the concurrence of asthma, this state would not of itself have been sufficient for inducing the affection.

5. Of all the causes formerly mentioned, phthisis most frequently arises from tubercles. Dr Simmons informs us, that he has had opportunities of inspecting the bodies of many people who died in this way, and never found them totally absent. He has 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 be 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 tumors 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 also 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: Dr Kirkland observes, that the teeth-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, however, in by much the greater number of instances, have their source from a scrophulous disposition; and some eminent physicians have supposed that the generality of pulmonary consumptions are of this kind. This notion, however, they have perhaps carried too far: they have probably been misled by those 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, vances, usually become of a milky white colour, and more or less transparent. Of those who are carried off by this disease, Dr Simmons affirms, the greater number will be found never to have had a carious tooth. This circumstance, however, does not seem to us to hold so generally as Dr Simmons is disposed to imagine; and instances not unfrequently occur of patients dying of phthisis, although they have had many teeth subjected to caries; and some of these beginning even at an early period of life.

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 time, 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. But this, by proper care, is often relieved; and the patient remains in this state for a considerable time, and even for many years, if he be 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 catarrh. This is usually ascribed to cold; and but too generally neglected, till the disease become 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 begins in the form of a catarrh, is attended with more or less expectoration of mucus.

When the cough begins in the form of a catarrh, and appears to be occasioned by an increased secretion of a thin fetid 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 by means of the machine contrived for that purpose, 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 be of a moderate temperature, and he carefully avoid exposure to a cold, damp, or raw air, till the complaint be 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 bedclothes, 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 flannel 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 dimity, worn over the breast next the skin, will prevent the return of colds and coughs in persons of a delicate habit, who had before been liable to them on the slightest occasions. Shirts made of cotton cloth are much more effectual than linen in preserving an equable temperature of the surface, and guarding against the action of external cold; while at the same time they are much more pleasant to most people than even the finest flannel. 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 bedtime, either by themselves or combined with gummy and mucilaginous medicines, will then generally be useful as a sedative and antiphlogistic.

In this, as well as in the catarrhal cough just now mentioned, many practitioners are too eager to administer cinchona, with the view, as they term it, of bringing up the patient; but this never fails to increase the cough, and of course to do great and very 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 suffus stomachica. This complaint is so far from being relieved by bleeding, that it constantly grows worse after it, especially if the evacuation be in any considerable quantity. The oily remedies seldom fail to exasperate this cough, which at first is dry, frequent, and often extremely violent, but which seldom fails to give way to one or two gentle pakes, and the occasional use of mild cathartics. 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 forenses, and of slight lancinating pains shooting through the breast, sometimes in the direction of the mediastinum, and sometimes confined chiefly to one side. The forenses 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 hands 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 some pain of the breast, 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 fever 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 circumcubed redness of the cheeks, while the rest of the face is pale, and appears as if it were not clean washed. The colifluviums that commonly accompanies the beginning of the disease is usually succeeded by a diarrhoea; the spitting lessens, 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 meantime, 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 smallpox 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 often appears to be of the putrid kind, and has been denominated febris hectica putrida by the judicious Morton, who considers it as being combined with a peri-pneumonic 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 bronchiae, or absorbed and carried into the system from one part of the lungs, other parts are in a 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 the pustules abscesses, we find the form of the hectic fever 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 the hectic state, 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 affords that a disease is incurable.

The most formidable effects of ulcerated lungs are the abortion 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 abortion, diminish the premature 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 physicians art has hitherto proved very unsuccessful in these cases; but may not this be owing to the remedies that are employed being very often such as are inimical to the cure?

The cinchona is, perhaps, the most commonly employed of any, and often considered in as an ultimate resource in these cases. But besides this, the sulphuric acid, 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 cinchona, Deffault long ago observed, that it had been productive productive of great mischief in consumptive cases; and Dr Fothergill, in a paper lately published by him on this subject, very judiciously remarks, that it is so far from curing the hectic fever 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 has been the opinion of several attentive observers, that whenever pus or any kind of matter excites an hectic fever, by being absorbed and carried into the circulation, the cinchona will never fail to exacerbate the complaint, especially if it be 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 it 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, especially if this ulceration be attended with an inflammatory disposition; or if the separation of vitiated pus be the consequence of a peculiar increased morbid action of the vessels at the part, it ought to be laid aside; and in the genuine tuberculous consumption, perhaps, it is rarely advisable.

Dr Fothergill, however, observes, that there are two causes of consumption, which often produce symptoms so similar to those of the genuine phthisis, as sometimes to have led him to make use of cinchona, in apparent tendencies to a genuine pulmonary consumption, with advantage.

One of the causes is, the suckling 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 cinchona 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 enfeebling evacuations. That cinchona is, for the most part, of use in these cases, when the lungs are not inflamed, is indubitable; and if they be 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 cinchona 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 perseverence in the use of cinchona will increase the disease. If such also should be the appearances in the progress of the disease, or, from whatever cause, if cinchona be 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 appear 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 produce 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 peri-pneumonic fevers; but that it stops this discharge, changes flight wandering pains into such as are fixed, and increases them with all their consequences, in a variety of cases.

The elixir of vitriol, or the sulphuric acid properly diluted, though in many instances a highly useful remedy, is often exhibited in consumptive cases with no less impropriety than cinchona. This medicine, from its astringency, 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 be not injured past reparations, 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 stages 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 astringency, 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, particularly from bad to good, is of great consequence to all chronic diseases of the lungs. In consumptive cases, 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 regarded. 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.

Exercise on horseback 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 husky 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 gain 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 haemoptysis; 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 remained 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 and purity 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 persons 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.

Another species of motion has of late been extolled as highly useful in consumptive cases. Dr James Gar-michael Smyth of London, has lately published an account of the effects of swinging, employed as a remedy in the pulmonary consumption and hectic fever. In this treatise Dr Smyth contends, that sea air, in place of being of advantage, is constantly prejudicial to hectic and consumptive patients, and even to those who have a tendency to such complaints. He thinks, therefore, that the benefit derived from sea voyages must certainly be referred to some other cause. In stating his sentiments on this subject, he attempts to establish a distinction between exercise and motion. By exercise, he understands muscular action, or the exertion of the locomotive powers of the body either alone or combined. This he represents as increasing the force and frequency of the heart's contraction, the velocity and momentum of the blood, the quickness of breathing, the heat, the irritability, and the transpiration of the whole body. By motion, in contradistinction to exercise, he means such motion as is not necessarily accompanied with any agitation or succussion of the body, and which is totally independent of any muscular exertion. The effects of this, both on the heart, the lungs, and indeed on the system in general, he considers as of the sedative kind; thus it suspends the action of coughing, and lessens the frequency of the pulse. He is, therefore, led to refer the good effects of sea voyages entirely to this cause. And on these grounds he was led to conclude, that the motion given by swinging might be of equal if not greater service. This conclusion, we are told, in the treatise above alluded to, experience in many cases cases has fully confirmed; and he recommends it as a mode of cure which may be employed with advantage in every stage of phthisis. While, however, the reasoning of Dr Smyth on this subject seems to be liable to many objections, we are sorry to add, that his observations in practice have by no means been confirmed by those of others, who have had recourse to this mode of cure.

The best adapted diet in consumptive cases is milk; the milk of asses, both as an article of diet and as a medicine, has in particular been highly extolled. It may however be remarked, that there are constitutions in which this salutary nutriment seems to disagree. A propensity to generate bile, or too strong a disposition to aceesity 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 milk 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 by some 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 fizzy; 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, even where the pulse is quick, with some degree of fulness, and the blood last drawn considerably fizzy, it may not prove 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, about the age of 15 or 16, and upwards, are often subject to consumptions. When the disease has advanced considerably, the menstrual flow has 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, which, without obtaining this end, have tended to aggravate the distemper. This deficiency is often of no real disadvantage in these 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 Dr Simmons 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 be capable of dispersing a tubercle, he believes it to be emetics. 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, he does not mean that vomits will be useless 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 emetics 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 second day, or even every day, for several days together, as Dr Simmons 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 has often employed the sulphate of copper, concerning the effects of which we meet with some groundless assertions in several medical books. Its operation is confined to the stomach; it acts almost instantaneously; and its altrigency 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 sulphate of copper 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 be 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 sulphate of copper and tartarite of antimony. It has the benefit also of producing instantaneous operation; but it is more apt to excite nausea than the sulphate of copper alone, and is liable to some of the objections stated to antimonial emetics.

Another remedy which Dr Simmons strongly recommends in consumptive cases, both from his own observation, and on the authority also of many other eminent practitioners, is gum-myrh. This given by itself to the extent of a scruple or half a drachm for a dose, two or three times a-day, or, if there be much inflammatory tendency, combined with a proportion of nitre or of cream of tartar, has often been serviceable in cases which were apparently instances of incipient phthisis even of the tuberculous kind. But when the disease is far advanced, or even decidedly marked, as far as our experience goes it has rarely been productive of any benefit.

Besides the use of internal remedies in pulmonary affections, physicians have often prescribed the smoke of resinous and balsamic substances to be conveyed into the lungs. The vapour of sulphuric ether, dropped into warm water, has likewise been used in these cases. The inhaling of fixed air has also been spoken of as an useful practice. Dr Simmons has seen all 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 has often found the two first to be too stimulating. He therefore preferred the simple vapour of warm water, and has 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 has seen it bring on profuse sweats, especially when used in bed, and therefore he 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, phthisic, and, on account of the valve and mouth-piece, a more useful instrument of this kind, the inhaler, invented by the ingenious Dr Mudge.

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 phthisic pulmonary, 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 phthisic, 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 scrofula. Dr Priestley observes, that the Indians, he has been told, have Practice.

Haemorrhoidalis fluxus, Hoffm. 219. Haemorrhoides, Junck. 11. et 12. Leucorrhoea, Vog. 112.

Sp. I. External Piles.

Var. A. Bloody Piles. Haemorrhoides moderata, Sauv. sp. 1. Haemorrhoides ordinata, Junck. 11. Haemorrhoides nitidae, Junck. 11. Haemorrhoides immodica, Sauv. sp. 2. Haemorrhoides excedentes, Alberti de haemorrhoid. p. 179. Haemorrhoides polypoda, Sauv. sp. 3.

Var. B. Mucous Piles. Haemorrhoides decoloratae, albae, et mucidae, Junck. 13. Alberti, p. 248.

Sp. II. The Piles from a Procidentia Ani.

Haemorrhoides ab exanxia, Sauv. sp. 4.

Sp. III. The Running Piles.

Sp. IV. The Blind Piles.

Haemorrhoides coecae, Junck. 12. Alberti, p. 274.

Description. The discharge of blood from small tumors on the verge of the anus constitutes what is called the hemorrhoids or piles. They are distinguished into the external and internal, according to the situation of the tumors, either without or within the anus. Sometimes, however, these tumors appear without discharging any blood; and in this case they are called the hemorrhoides coecae, or blind piles. Sometimes the disease appears without the verge of the anus in distinct separate tumors; but frequently only one tumid ring appears, seeming as it were the anus pushed without the body. Sometimes these tumors appear without any previous disorder of the body; but more frequently, before the blood begins to flow, and sometimes even before the tumors are formed, various affections are perceived in different parts of the body; as headache, 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 fulness, heat, itching, and pain, in and about the anus. Sometimes the disease is preceded by a serious discharge from the anus; and sometimes this serious 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 serious discharge has therefore been named the hemorrhoides 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 feces. In other cases it flows without any discharge of feces; 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 the hazard of life. Indeed, though rarely, it has been so great as to prove suddenly fatal. These considerable discharges occur especially to persons who have been frequently liable to the disease. They often induce great debility, and frequently a leucophaemia or dropy which proves fatal. Sometimes the tumors 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 tumors are affected with inflammation, which ends in suppuration, and gives occasion to the formation of fistulous ulcers in those parts.

The hemorrhoidal tumors have often been considered as varices or dilatations of the veins; and in some cases various dilatations have appeared upon diffusion. These, however, do not appear in the greater part of cases; 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, in consequence of the blood being coagulated.

Causes, &c. It would seem probable, that the hemorrhoidal tumors 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 show a connection of the topical affection with the state of the whole system, it is probable that the interruption of the blood in the veins produces a considerable resistance to the motion of the blood through the arteries, and consequently that the discharge of blood is commonly from the latter. Some have thought, that a difference of the hemorrhoids, and of its effects upon the system, might arise from the difference of the hemorrhoidal vessels from whence the blood flows. But Dr Cullen is of opinion, that we can scarcely 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 hemorrhoids, however, he 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 hemorrhoidal vessels cannot be supposed to occur; 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 that part, and interrupt the course of the blood in them. For this reason the disease so frequently happens to those who are habitually colitive. 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 constrictive is made, which prevents the protruded gut from being replaced, and at the same time prevents 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 difficulty replaced; and in this confuses 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 tumors 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 tumors may be formed within the anus; and probably it also happens, that some of the tumors 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 from the pressure of the uterus upon the rectum, and partly from the colitive habit to which pregnant women are liable. Dr Cullen has 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 acid kind, and particularly aloetias, are apt to produce the piles when frequently used; and as they stimulate particularly the larger intestines, 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 state of the whole system; and this will more readily happen in persons who have been once affected with the disease, if they be frequently exposed to a renewal of the causes which occasioned it. It happens also to persons much exposed to a congestion in the hemorrhoidal vessels, in consequence of their being often in an erect position of the body, and in an exercise which pushes the blood into the depending vessels, while at the same time the effects of these circumstances are much favoured by the abundance and and laxity of the cellular texture about the anus. It is to be particularly observed, that when an haemorrhoidal affection has either been originally or has become a disease of the system, it then acquires a particular connexion with the stomach; so that certain affections of the stomach excite the haemorrhoidal disease, and certain states of this disease excite the disorders of the stomach.

It has been an almost universally received opinion, that the haemorrhoidal flux is a salutary evacuation, which prevents many diseases which would otherwise have happened; and that it even contributes to give long life: and as this opinion has been strenuously adopted by Dr Stahl, it has had a very considerable influence on the practice of physic in Germany. But Dr Cullen maintains that we can never expect to reap much benefit from this flux, which at first is purely topical; and, granting that it should become habitual, it is never, he thinks, proper to be encouraged. It is a disagreeable disease; ready to go to excess, and thereby to prove hurtful, and sometimes even fatal: at best it is liable to accidents, and thus to unhappy consequences. He is therefore of opinion, that even the first approaches of the disease are to be guarded against; and that, though it should have proceeded for some time, it ought always to be moderated, and the necessity of it superseded.

Cure. The general intentions of cure in cases of haemorrhoids are much varied, according to the circumstances of the affection at the time. When haemorrhoids exist in the state of tumor, the principal objects are to counteract inflammation, and to promote a discharge of blood from the part. When it is in the state of evacuation, the chief intentions of cure are, to diminish the impetus of blood at the part affected, and to increase the resistance to the passage of blood through the ruptured vessels. And finally, when the disease exists in the state of suppression, the aims of the practitioner must chiefly be, to obviate the particular affections which are induced in consequence of the suppression; to restore the discharge, as a means of mitigating these and preventing others; or, when the discharge cannot with propriety or advantage be restored, to compensate the want of it by vicarious evacuations.

With these various intentions in different cases, a variety of different remedies may be employed with advantage.

When any evident cause for this disease is perceived, we ought immediately to attempt a removal of that cause. One of the most frequent remote causes is an habitual coliciveness; which must be obviated by a proper diet, such as the person's own experience will best direct; or if the management of diet be not effectual, the belly must be kept open by medicines, which may prove gently laxative, without irritating the rectum. In most cases it will be of advantage to acquire a habit with regard to the time of dilatation, and to observe it exactly. Another cause of the haemorrhoids to be especially attended to is the prolapsus ani, which is apt to happen on a person's having a stool. If this shall occur to any considerable degree, and be not at the same time easily and immediately replaced, it most certainly produces piles, or increases them when otherwise produced. Persons therefore who are liable to this prolapsus, should, after having been at stool, take great pains to have the intestine immediately replaced, by lying down in a horizontal posture, and pressing gently upon the anus, till the reduction shall be completely obtained. When this prolapsus is occasioned only by the voiding of hard and bulky feces, it is to be removed by obviating the coliciveness which occasions it. But in some persons it is owing to a laxity of the rectum; and in those it is often most considerable on occasion of a loose stool. In these cases, it is to be treated by astringents, and proper artifices are to be employed to keep the gut in its place.

When the disease has frequently recurred from neglect, and is thus in some measure established, the methods above mentioned are no less proper; but in 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 haemorrhoidal flux, when this is immediately to come on, both walking and riding, as increasing the determination of the blood into the haemorrhoidal 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 haemorrhoidal 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.

Besides general antiphlogistic regimen, in some cases where the inflammation runs high, recourse may be had with great advantage both to general blood-letting and to leeches applied at the anus. Relief is also often obtained from the external application of emollients, either alone or combined with different articles of the sedative kind, as acetate of lead or opium, by which it is well known that pain in general, particularly when depending on increased sensibility, or augmented action of the vessels, is powerfully allayed.

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 haemorrhoidal 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 be external or internal. The pain of the external piles happens especially when a considerable protrusion of the rectum has taken place; and while it remains unreduced, it is strangled by the constriction of the sphincter; and at the same time no bleeding happens to take off the swelling of the pro-

Vol. XIII. Part I. truded 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 cases 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 dilate shall be entirely and radically cured, the preventing any return of the haemorrhoids seems perfectly 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 has 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 haemorrhoidal vessels, be increased, and the return of the disease be too much favoured. Dr Stahl is of opinion, that the haemorrhoidal flux is never to be accounted excessive, excepting when it occasions great debility or leucophlegmata; but Dr Culjen thinks, that the smallest approach towards producing either of these effects should be considered as an excess which ought to be prevented from going farther; and even in the cases of congestion and plethora, if the plethoric habit and tendency can be obviated and removed, the haemorrhoidal flux may then with safety be entirely supprest. In all cases therefore of excessive bleeding, or any approach to it, astringents both internal and external may be safely and properly applied; not indeed to induce an immediate and total suppression; but to moderate the haemorrhage, and by degrees to suppress it altogether; while at the same time measures are to be taken for the removing the necessity of its recurrence.

**GENUS XXXIX. MENORRHAGIA.**

*Immoderate Flow of the Menses.*

Menorrhagia, Sauv. 244. Lin. 202. Vog. 96. Menorrhagia, Sag. gen. 179. Uteri haemorrhagia, Hoffm. II. 224. Haemorrhagia uterina, Junck. 14. Leucorrhea, Sauv. gen. 267. Lin. 201. Vog. 119. Sag. gen. 202. Cachexia uterina, five fluor albus, Hoffm. III. 348. Fluor albus, Junck. 133. Abortus, Sauv. gen. 245. Lin. 204. Sag. gen. 180. Junck. 92. Abortio, Vog. 97. Fluor uterini fanginis, Boerh. 1303. Convulso uteri, five abortus, Hoffm. III. 176.

Sp. I. The Immoderate Flow of the Menses, properly so called.

Menorrhagia rubra, Cul. Menorrhagia inmodica, Sauv. sp. 3. Menorrhagia illatitia, 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 large flow of the menses has been preceded by headache, giddiness, or dyspnoea; 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 morbid. 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 has 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 slight causes, especially those presented by surprise. A large flow of the menses attended with barrenness in married women, may generally be considered as preternatural and morbid. Generally, also, that flow of the menses may be considered as immoderate, which is preceded and followed by a leucorrhoea.

**Cause, &c.** The proximate cause of the menorrhagia is either the effort of the uterine vessels preternaturally 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 intoxications. 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 coltive 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 childbearing without nursing, and difficult or 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. The practices employed, however, are chiefly used with one of two intentions; either with the view of restraining the discharge when present, or of preventing the return of an excessive discharge at the succeeding period. The first is chiefly to be accomplished by employing such practices as diminish the force occasioning the discharge of blood, or as augment the resistance to its passage through the vessels by which it is to be discharged. The last is in some degree to be obtained by avoiding causes which either increase the general impetus of the blood, or the impetus at the uterus in particular; but principally... pally by giving additional vigour to the uterine vessels.

In all cases, the first attention ought to be given to avoiding the remote causes, wherever 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 of course 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 coffeefees, 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 female 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 hemorrhage, but also by avoiding all irritation, every irritation having a 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 occurs, 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, affinements 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.

Sp. II. Abortion.

Menorrhagia abortus, Cul. Menorrhagia gravidarum, Sauv. sp. 6. Abortus effluxio, Sauv. sp. 1. a, Abortus subtrimetris. b, Abortus subsemefembris. c, Abortus octimetriss. Abortus ab uteri laxitate, Sauv. sp. 2.

Sp. III. Immoderate Flux of the Lochia.

Menorrhagia lochialis, Sauv. sp. 8. Cul.

For the description, treatment, and cure, of these two last diseases, see MIDWIFERY.

Sp. IV. Immoderate Flow of the Menses from some local disorder.

Menorrhagia vitiorum, Cul. Menorrhagia ex hydropoecil, Sauv. sp. 5. Menorrhagia ulcerosa, Sauv. sp. 9.

Sp. V. The Leucorrhoea, Fluor Albus, or Whites.

Menorrhagia alba, Cul. Leucorrhoea, Sauv. gen. 267. 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 it is 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 a wan sickly aspect.

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 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 often proceeds from the vessels subservient to menstruation; because, in delicate habits, where those vessels are weak, and consequently remain too long... long uncontracted, the *flor albus* sometimes immediately follows the menes, 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, as 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 *peffers*, from the pain and irritation they occasion, is also apt to bring on this discharge. Hence we may conclude, that this disease may happen although the blood be in a pure state. Here the fault seems to be placed in the vessels at the part, by which the fluids are vitiated and changed from their natural qualities.

The *flor albus* has been supposed to supply the want of the menes; 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 *flor albus*, which is a preternatural evacuation, occasions the absence of that which is natural; as is evident from the return of the menes after the *flor albus* has been cured. Indeed, when this discharge appears about the age of 13 or 14, and returns once a month, with symptoms like those of the menes, then it may be deemed strictly natural, and therefore ought not to be flopped.

**Prognosis.** The *flor 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 menes, 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 gross 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 to cure; and dilposes the patient to barrenness, a bearing down, droopy, or consumption.

**Cure, &c.** The causes of those two kinds of this disease being different, so they will require a very different method of cure. For this purpose, 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 *flor albus* follows the menes, 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-fryinge as an injection twice a day. Should the disease prove uncommonly obstinate, the patient may go into the cold bath every second day; and also drink lime-water with milk, which will expedite the cure, and prevent a relapse. Volatile liniment, and afterwards a strengthening plaster, may be applied to the small of the back.

By way of caution, the female should abstain from the immoderate use of tea; and be removed into a dry clear air; or if she be 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 species 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 system be restored to a more sound and vigorous condition.

A purging potion may be taken twice a week, and in the intervals an alternative pill night and morning. After this course has been continued a fortnight or three weeks, the may begin with the strengthening bitter infusion, or some other tonic, in the quantity of a tea-cupful twice a day, or to a greater extent if the stomach will allow.

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 be weak, and of a cold bloated habit of body, a little French brandy may be added occasionally.

When the begins to take the bitter infusion, it will be proper to use the Tunbridge or Pyrmont water for common drink; but if those cannot conveniently be had, the alkaline aerated water, impregnated with iron, will make an excellent substitute. If it should render her collyve, and occasion headache, she may detest, and drink a solution of crystals of tartar, or a little senna tea sweetened with manna, till those complaints be 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 droopy, 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 *flor albus* in the autumn than at any other season. 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 cinchona with aromatics. He observed, that several about this time who escaped the disorder, were visited with bad colds, a defluxion on the throat, or a diarrhoea, which were removed by a similar treatment.

Among other remedies which have been recommended in leucorrhoea, recourse has lately been had to the internal use of cantharides. This remedy for leucorrhoea has, in particular, been highly extolled in a late publication on the powers of cantharides, when used internally, written by Mr John Robertson, surgeon in Edinburgh. The analogy between gleet and leucorrhoea, Mr Robertson tells us, suggested to him, that the cantharides which he had employed with such good effects in gleet, might also be useful in leucorrhoea. The event, he affirms, fully answered his expectations, and he has employed the remedy with very great success. The cantharides were used under the form of tincture: the *Tinctura meliae vehicatorii* of the Edinburgh Pharmacopoeia. This medicine he employed in much larger doses than is commonly preferred. Thus a mixture containing an ounce of the tincture of cantharides, diffused in six ounces of water, was taken to the extent of half an ounce, four times a day; nay, in some cases, the tincture was exhibited to the extent of half an ounce in a day, without any inconvenience, and with the best effects. As examples of the power of this remedy, Mr Robertson has given a detail of six cases, selected from a number which have been under his care. In three cases, as being the most inveterate, the effects of the cantharides were most evident. And we shall only observe, that if this remedy be found by other practitioners to be equally successful in the cure of leucorrhoea, it will be a very valuable acquisition in the practice of medicine, especially if it shall be found by others, as well as by Mr Robertson, that not only the general symptoms of leucorrhoea are removed, but that the tone and functions of the uterine system are completely restored by the use of cantharides.

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 whites: for if the first be mistaken for the last, and be either neglected or improperly treated, the worst consequences may arise.

The following signs will best inform the patient whether there be 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 weakness; 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 forerunners of the discharge; the orifice of the urinary passage is prominent and painful, *Catarrhus*, 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, strains, 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*, although sometimes of the same colour, especially in bad habits of body, and after long continuance, it is usually more offensive and redundant in quantity.

All the other kinds of haemorrhage enumerated by medical writers, are by Dr Cullen reckoned to be symptomatic.

**Stomacace**, Sauv. gen. 241. Lin. 175. Vog. 85. Sag. gen. 177.

Species: Scorbutica, Purulenta, &c.

**Hematemesis**, Sauv. gen. 242. Lin. 184. Vog. 89. Sag. gen. 177.

Species: Plethora, Catamenialis, Scorbutica, &c.

**Hematuria**, Sauv. gen. 233. Lin. 198. Vog. 92. Sag. gen. 178.

Species: Purulenta, Calculosa, Hæmorrhoidalis, &c.

**Order V. PROFLUVIA.**

**Genus XL. CATARRHUS.**

The *Catarrh*.

Catarrhus, Sauv. gen. 186. Vog. 98. Sag. gen. 145.

Coryza, Lin. 174. Vog. 100. Sag. gen. 196.

Rheuma, Sauv. gen. 142.

Tuffis, Sauv. gen. 142. Lin. 155. Vog. 205. Sag. gen. 245, 255. Junck. 32.

Tuffis catarrhalis et rheumatica, Hoffm. III. 109.

Sp. I. Catarrh from Cold.

Catarrhus a frigore, Cul.

Catarrhus ben guas, Sauv. sp. 1.

Catarrhus pectorosus, Sauv. sp. 6.

Coryza catarrhalis, Sauv. sp. 1.

Coryza phlegmatorrhaea, Sauv. sp. 2. Salmuth. Obs. cent. 1, 37. Junck. 28. Morgagni de fed. xiv. 21.

Coryza febricola, Sauv. sp. 6.

Tuffis catarrhalis, Sauv. sp. 1. N. Reichen Dill. apud Haller, Dilput. Pract. tom. ii.

Rheuma catarrhalis, Sauv. sp. 1.

Amphimerina catarrhalis, Sauv. sp. 2.

Amphimerina tufficulosa, Sauv. sp. 13.

Cephalalgia catarrhalis, Sauv. sp. 10.

Sp. II. Sp. II. Catarrh from Contagion.

Catarrhus à contagio, Cul. Catarrhus epidemicus, Sauv. fp. 3. Rheuma epidemicum, Sauv. fp. 2. Synocha catarrhalis, Sauv. fp. 5.

There are several symptomatic species: as, Catarrhus Rubecolofus; Tufis Variofosa, Vermifosa, Calculofa, Phthisica, Hyferica, à dentitione, Gravidarum, Metallicolarum, &c.

Description. The catarrh is an increased excretion of mucus from the mucous membrane, of the nose, fauces and bronchiae, attended with pyrexia.

Practical writers and nosologists have distinguished the disease by different appellations, according as it happens to affect different parts of the mucous membrane, 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 tuffis or cough; and a cough, indeed, always attends the chief form of catarrh, that is, the increased excretion from the bronchiae; but as it is so often also a symptom of many other affections, which are very different from one another, 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 graveo 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 soreness 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 comes to be attended with a more copious excretion of catarrhus mucus; which is at first thin, but gradually becoming thicker, is brought up with less frequent and less laborious coughing. The hoarseness and soreness of the trachea are also relieved or removed; and the febrile symptoms abating, the expectoration becomes again less considerable, 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 subjected to catarrh seems to be more than usually liable to be affected by cold air; and upon exposure of the body to fresh 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 these 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 haemoptysis, or perhaps form tubercles in the lungs; and still more readily 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 influx of fluids to the lungs, with some degree of inflammation, it may produce the peripneumonia notha, or more properly chronic catarrh, a disease continuing often for many years, or at least returning regularly every winter; which in such cases is very often fatal.

Causes, &c. The proximate cause of catarrh seems to be an increased influx 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 phlegmatis. The remote cause of catarrh is most commonly cold applied to the body. This application of cold producing catarrh is generally evident; 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 discharge usually made Practice.

MEDICINE.

Profuse 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 inensible evacuation, is owing to an exhalation from the lungs, there is probably a connexion between this exhalation and the cutaneous perspiration; 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 remarks 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, leave the matter, in general, without doubt; and there are several other observations which show a connexion 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 in addition to this the matter of perspiration be at the same time determined to the mucous glands, and there excites a particular irritation, may be uncertain; but Dr Cullen 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; yet we are 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 epidemic catarrhs.

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 almost 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. And indeed catarrh from cold and contagion are in every respect so similar, that when this epidemic rages, it is impossible to determine with a person having symptoms of catarrh after exposure to cold, whether the disease proceeds from the one cause or the other. In most instances, however, catarrh from contagion comes on with more cold shivering than the catarrh arising from cold alone; and the former does also not only sooner throw 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 military 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 catarrh-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 commonly 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, viz., by degenerating into its chronic state. But though chronic catarrh be often the termination of that species which arises from cold, we have not, in any case, observed it to arise as a consequence of a catarrh from contagion. This species of catarrh, however, is not unfrequently followed by phthisis; or rather, where a phthisical tendency before existed, the affection has been begun and its progress accelerated from this cause.

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. In some cases, where the febrile symptoms are considerable, it is proper for that length of time to lie in 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 distaste 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-ammonia, 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. Very considerable advantage is often derived from employing opiates in such a manner as to act more immediately on the head of the wind-pipe. For this purpose, opium may often be advantageously conjoined with demulcents, melting slowly in the mouth. And perhaps no form is more convenient, or answers the purpose better, than the trochisci glycyrrhiza cum opio of the Edinburgh Pharmacopoeia. MEDICINE.

Practice.

"In a catarrhal 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 be 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 necessary to the cure of the catarrhous cough, as that the success of the inhaler against that complaint at all depends upon it.

"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 bronchial vesicles during the night; the thinner parts of which being evaporated, what remains is soon got rid of by 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 forenoon of the respiratory organs, or the petulance of the cough, show 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. be 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 be 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 expectorate 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 be accomplished, a proper dose of elixir paregoricum for a few successive nights will be found very useful in suppressing the fatiguing irritation and inefficual cough, occasioned by a matter which, dripping in the early state of the disease into the bronchial 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, MEDICINE.

Profluvia, 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 pelting and fatiguing to the breast, continue dry, husky, and without expectoration; provided there be 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 dram of gum-ammoniacum, with 18 or 20 drops of liquid 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 3i or 3ij of bals. sulph. anfus. 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 revolution made from the lungs by the simple application of a large plaster, about five or six inches diameter, of Burgundy pitch, between the shoulders; for the perspirable matter, which is locked up under it, becomes so sharp and acid, that in a few days it seldom fails to produce a very considerable itching, some little tendency to inflammation, and very frequently a great number of boils. This application should be continued (the plaster being occasionally changed), for three weeks or a month, or longer, if the complaint be not so soon removed.

"And here I cannot help observing, that, though seemingly a trifling, it is however by no means an useless caution to the tender patient, not to expose his shoulders in bed, and during the night, to the cold; but when he lies down, to take care they be kept warm, by drawing the bedclothes up close to his back and neck.

"If, however, notwithstanding these and other means, the cough, continuing dry or unattended with a proper expectoration, should persevere in harassing the patient; if, at last, it should produce, together with a forenoon, shooting pains through the breast and between the shoulders, attended also with shortness of the breath; and if, added to this, flushes of the cheeks after meals, scalding in the hands and feet, and other symptoms of a hectic, should accompany the disorder; there is certainly no time to be lost, as there is the greatest reason to apprehend that some acrimony in the habit is determined to the tender substance of the lungs, and that consequently tubercular suppurations will follow. In this critical and dangerous situation, I think I can venture to say from long experience, that, accompanied with change of air and occasional bleedings, the patient will find his greatest security in a drain from a large scapulary influe, assisted by a diet of asses milk and vegetables."

GENUS XLI. DYSENTERIA.

The Dysentery.

Dysenteria, Sauv. gen. 248. Lin. 191. Vog. 107. Sag. 183. Hoffm. III. 151. Junck. 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 faeces seldom appear; and when they do, it is generally in a compact and hardened form, often under the form of small hard substances known by the name of fecula. 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 colitive, with an unusual fulness in the bowels. Sometimes, though more rarely, some degree of diarrhoea 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 among the mucus; but at other times is more copious, giving a tincture to 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 faeces, proceeding from gangrenous parts. There are very often mixed with the liquid matter some films of a membranous appearance, and frequently some small matters of a seemingly sebaceous matter. While the stools voiding these various matters are, in many instances, exceedingly frequent, quent, it is seldom that natural faeces appear in them; and when they do appear, it is, as we have said, in the form of scybala, 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 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 represented. In general it 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 connexion 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 being 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 Dysentery, the peculiar effect of inducing those symptoms which properly and essentially constitute 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 adopted; 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 constrictive; 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 constrictive. This is confirmed by almost all the dilatations 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, large portions of the great guts have been found affected with a very considerable constrictive.

The proximate cause of dysentery, or at least the chief part of the proximate cause, seems to consist in a preternatural constrictive 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 constrictive, and the frequent stagnation of faeces in the colon.

Cure. In the early periods of this disease, the objects chiefly to be aimed at are the following: The discharge of acrid matter deposited in the alimentary canal; the counteracting the influence of this matter when it cannot be evacuated; the obviating the effects resulting from such acrid matter as can neither be evacuated nor destroyed; and, finally, the prevention of any further separation and deposition of such matter in the alimentary canal. In the more advanced periods of the disease, the principal objects are, the giving a proper defence to the intestines against irritating causes; the diminution of the morbid sensibility of the intestinal canal; and the restoration of due vigour to the system in general, but to the intestines in particular.

The most eminent of our late practitioners, and Practice.

MEDICINE.

Prostuvia of greatest experience in this disease, seem to be of opinion, that it is to be cured most effectually by purging, affluently 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, 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 has found nothing more proper or convenient than tartar emetic, given in small doses, and at such intervals as may determine its operation to be chiefly by stool. To the tartarite of antimony, however, employed as a purgative, the great sickness which it is apt to occasion, and the tendency which it has, notwithstanding every precaution, to operate as an emetic, are certainly objections. Another antimonial, at one time considered as an almost infallible remedy for this disease, the vitrum antimonii ceratum, is no less exceptionable, from the uncertainty and violence of its operation; and perhaps the safest and best purgatives are the different neutral salts, particularly those containing fossil alkali; such as the soda vitriolata tartarifata or phosphorata. Rhubarb, so frequently employed, is, Dr Cullen thinks, in several respects, amongst the most unfit purgatives; and indeed from its astringent quality, it is exceptionable at the commencement of the affection, unless it be conjoined with something to render its operation more brisk, such as mild muriated mercury, or calomel as it is commonly called.

Vomiting has been held a principal remedy in this disease; and may be usefully employed in the beginning, with a view both to 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 contraction of the colon, and evacuating the retained faeces, clysters may sometimes be useful; but they are seldom so effectual as laxatives given by the mouth; and acrid clysters, 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 intestines, they favour the contraction 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 the fennecupium, or by 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, bloodletting, 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, bloodletting ought to be repeated. But, as the fever attending dysentery is often of the typhoid kind, or does, in the course of the disease, become soon of that nature, bloodletting 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 very pernicious. But although astringents may be hurtful at early periods of this affection, yet it cannot be denied, that where frequent loose stools remain after the febrile symptoms have subsided, they are often of great service for diminishing morbid sensibility, and restoring due vigour to the intestinal canal. Accordingly, on this ground a variety of articles have been highly celebrated in this affection; among others we may mention the quassia, radix indica lopeziana, verbacum, extractum catechu, and gum kino, all of which have certainly in particular cases been employed with great advantage. And perhaps also, on the same principles we are to account for the benefit which has been sometimes derived from the nux vomica, a remedy highly extolled in cases of dysentery by some of the Swedish physicians; but this article, it must be allowed, often proves very powerful as an evacuant. Its effects, however, whatever its mode of operation may be, are too precarious to allow its ever being introduced into common practice; and in this country, it has, we believe, been but very rarely employed. Whether an acid 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 the 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. Where, however, these are not acceptable to the patient's taste, those of the mucilaginous and farinaceous kind, as the decoctum hordei, potio cretacea, &c., are often employed with advantage.

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 acetic. Milk, in its entire state, is of doubtful quality in many cases; but even 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 astringent and septic powers, they may be hurtful; but in after periods they are often of advantage.

When this disease is complicated with an intermit- tent, and is protracted from that circumstance chiefly, it is to be treated as an intermittent, by administering the cinchona, 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. Order V.

Soporosis, Lin. Clas VI. Ord. II.

Adynamia, Vog. Clas VI.

Nervorum resoluciones, Hoffm. III. 194.

Affectus soporosis, Hoffm. III. 209.

Motum vitalium defectus, Junck. 114.

**Genus XLII. Apoplexia.**

*The Apoplexy.*

Apoplexia, Sauv. gen. 182. Lin. 101. Vog. 229.

Boerh. 1007. Junck. 117. Sag. gen. 288. Wepfer. Hist. apoplecticorum.

Carus, Sauv. gen. 181. Lin. 100. Vog. 231.

Boerh. 1045. Sag. gen. 287.

Cataphora, Sauv. gen. 180. Lin. 99. Vog. 232.

Boerh. 1045. Sag. gen. 286.

Coma, Vog. 232. Boerh. 1048.

Hæmorrhagia 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-ecstaticus, Hoffm. III. 44.

Ecstasis, 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.

This disease appears under modifications so various, as to require some observations with respect to each.

**Sp. I. The Sanguineous Apoplexy.**

*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, corrugations before the eyes, and redness of the face, usually precede. The distinguishing symptom of the disease is a deep sleep, attended with violent snoring; if any thing be 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 slumbering of the speech. Diseases sometimes show a rupture of some vessels of the meninges, or even vessels of the brain itself; though sometimes, if we may believe Dr Willis, no defect is to be observed either in the cerebrum or cerebellum.

*Cautions,* &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 has 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 be 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 this disease. 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.* The great object to be aimed at, is to restore the connexion between the sentient and corporeal parts of the system; and when interruption to this connexion proceeds from compression in the brain by blood, 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 sanguineous apoplexy, aforementioned. The body is to be kept in a somewhat erect posture, and the head supported in that situation.

**Sp. II. The Serous Apoplexy.**

Apoplexia pituitosa, Sauv. sp. 7. Apoplexia serosa.

Preysinger, sp. 4. Morg. de causis, &c. IV. LX.

Carus à hydrocephalo, Sauv. sp. 16.

Cataphora hydrocephalica, Sauv. sp. 6.

Cataphora somnolenta, Sauv. sp. 1.

Lethargus literaturum, Sauv. 7. Van Swieten in Aphor. 1010. 2 v and 3 a.

*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.

*Cautions,* &c. This may arise from anything 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, how- Practice.

Conata-

ever, follow, that the extravafated ferum above mentioned in the ventricles of the brain is always the cause of the disease, since the animal fluids 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 prognosis of the sanguineous, may also be said of that of the serous apoplexy.

Cure. In this species venesection can scarcely be admitted; acid purgatives, emetics, and stimulating clysters, are recommended to carry off the superabundant ferum; but in bodies already debilitated, they may perhaps be liable to the same exceptions with venesection itself. Volatile salts, cephalic elixirs, and cordials, are also prescribed; and in case of a hemiplegia supervening, the cure is to be attempted by aperient pills, cathartics, and sudorifics; gentle exercise, as riding in a carriage; with blisters and such stimulating medicines as are in general had recourse to in affections originally of the paralytic kind.

Sp. III. Hydrocephalic Apoplexy, or Dropsy of the Brain.

Hydrocephalus interior, Sauv. l.p. i. Hydrocephalus internus, Whytt's works, page 725. London Med. Obf. vol. iv. art. 3, 6, and 25. Gaudelius de hydrocephalo, apud Sandifort The- faur. vol. ii. Hydrocephalus acutus, Quin. Diff. de hydrocephalo, 1779. Asthena à hydrocephalo, Sauv. l.p. 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 unfortunate as to cure only one who laboured under the characteristic symptoms of the hydrocephalus; and he supposes 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 rendering 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 14 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 Apoplexia others.

When the disease appears under its most common form, the symptoms at different periods are so various as to lead Dr Whytt to divide the disease into three stages, which are chiefly marked by changes occurring in the condition of the pulse. At the beginning it is quicker than natural; afterwards it becomes uncommonly slow; and towards the conclusion of the disease it becomes again quicker than natural, but at the same time often very irregular.

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 headache 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 headaches alternately. From being perfectly well and sportive, some were in a few hours seized with those pains in the limbs, or with sickness, or headache, 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 lying 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 attack, 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 praecordia are always hot from the first attack. The sleeps are short and disturbed, sometimes interrupted by watchfulness; besides which there are startings.

In the first stage of the disease there seems to be a peculiar sensibility of the eyes, as appears from the intolerance of light. But in the progress of the disease a very opposite state occurs: The pupil is remarkably dilated, and cannot be made to contract by the action even of strong light; such, for example, as by bringing a candle very near to it. In many cases there is reason to believe that total blindness occurs: Often also the pupil of one eye is more dilated than that of another, and the power of moving the eyes is also morbidly affected. Those children, who were never observed to squint before, often become affected with Comata. with a very great degree of strabismus. The patients are 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 increases in its trembling undulations beyond the possibility of counting, till the vital motions entirely cease; and sometimes convulsions conclude 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 at its commencement. The most peculiar seem to be the pains in the limbs, with tickles and incessant headache; 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 colicive, but it is likewise with the greatest difficulty that stools can be procured. These are generally of a very dark greenish colour with an offensive 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 drank, and the time between the discharges of the urine. From their unwillingness to be moved, they often retain their water 12 or 15 hours, and sometimes longer. In complaints arising from worms, and in dentition, convulsions 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 24 hours incessantly, and till they expire.

Causes. The causes of internal hydrocephalus are very much unknown. Some suppose it to proceed from a rupture of some of the lymphatic vessels of the brain. But this supposition is so far from being confirmed by any anatomical observation, that even the existence of such vessels in the brain is not clearly demonstrated. That lymphatics, however, do exist in the brain, cannot be doubted; and one of the most probable causes giving rise to an accumulation of water in the brain is a diminished action of these. Here, however, as well as in other places, accumulation may also be the consequence of augmented effusion; and in this way, an inflammatory dilution, as some have supposed, may give rise to the affection. But from whatever cause an accumulation of water in the ventricles of the brain be produced, there can be no doubt that from this the principal symptoms of the disease arise, and that a cure is to be accomplished only by the removal of it. It is, however, probable, that the symptoms are somewhat varied by the position of the water, and that the affection of vision in particular is often the consequence of some morbid state about the thalami nervorum opticorum; at least, in many cases, large collections of water in the ventricles have occurred, without either strabismus, intolerance of light, or dilatation of the pupil. And in cases where these symptoms have taken place to a remarkable degree, while upon dissection after death but a very small collection of water was found in the ventricles, it has been observed, that a peculiar tumid appearance was discovered about the optic nerves, which upon examination was found to arise from water in the cellular texture. This may have given compression producing a state of insensibility; but it may have been preceded, or it may even have originated from some inflammatory affection of these parts, producing the intolerance of light.

Prognosis and Cure. Till very lately this disorder was reckoned totally incurable; but of late it has been alleged, that mercury, if applied in time, will remove every symptom. This remedy was first suggested by Dr Dobson of Liverpool, and afterwards employed apparently with success by Dr Percival, Dr Makie, and others. But the practice has by no means been found to be generally successful. In a great majority of instances, after mercury has had the fairest trial, the disorder has proved fatal. And it is a very remarkable circumstance, that in this disease, after great quantities of mercury have been used both externally and internally, it rarely affects the mouth. But even in cases where salivation has been induced, a fatal conclusion has yet ensued.

Of late the digitalis purpurea has been thought, in some cases of hydrocephalus, as well as in other obliterative disorders, to be employed with benefit. But this also, in the hands of most practitioners, has very generally failed. Perhaps there is no remedy from which benefit has more frequently been observed than from blisters. But we may conclude with observing, that the cure of the apoplexia hydrocephalica still remains to be discovered.

Sp. IV. Apoplexy from Atrabilis.

Apoplexia atrabilariarum, 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 has been found quite tinged brown. It cannot be thought to admit of any cure.

Sp. V. Apoplexy from External Violence.

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.

Sp. VI. Apoplexy from Poisons.

Apoplexia temulenta, Sauv. sp. 3. Carus à narcoticis, Sauv. sp. 14. Lethargus à narcoticis, Sauv. sp. 3. Carus à plumbagine, Sauv. sp. 10. Apoplexia mephistica, Sauv. sp. 14. Asphyxia à mephitide Sauv. sp. 9. Asphyxia à multo, Sauv. sp. 3. Catalepsis à fumo, Sauv. sp. 3. Asphyxia à fumis, Sauv. sp. 2. Asphyxia à carbone, Sauv. sp. 16. Asphyxia foricariorum, Sauv. sp. 11. Asphyxia sideratorum, Sauv. sp. 10. Carus ab infestatione, Sauv. sp. 12. The poisons which bring on an apoplexy when taken internally may be either of the stimulant or 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 stertor.—To enumerate all the different symptoms which affect the unhappy persons who have swallowed opium, or any of the stronger vegetable narcotics, is impossible, as they are scarcely 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 has 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 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 stand 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, halted 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.

"Cælius Aurelianus says, that those who are injured by the fumes of charcoal become cataleptic. And Hoffman 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 doffs of cotton impregnated with various matter, was, immediately on the introduction, afflicted with an 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 opprobrious 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 breast 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 dilodge 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 as practicable, get the patient to drink some cold water. But if the case be too far gone to be thus relieved, let a healthy person breathe into the mouth of the patient; and gently force air into the mouth, throat, and nostrils. Frictions, cupping, bleeding, and blisters, are likewise indicated. And if, after the instant danger is removed, a fever be excited, the method of cure must be adapted to the nature and prevailing symptoms of the fever."

With regard to the poison of opium, Dr Mead recommends the following method of cure. Besides evacuations by vomiting, bleeding, and blistering, acid medicines and lixivial salts are proper. These contract the relaxed fibres, and by their diuretic force make a depletion of the vessels. Dr Mead says he has given repeated doses of a mixture of salt of wormwood and juice of lemons, with extraordinary success. But nothing perhaps is of greater consequence, than to use proper means for the prevention of sleep, by rousing and stirring the patient, and by forcing him to walk about; for if he be once permitted to fall into a sound sleep, it will be found altogether impossible to awake him.

Of a kind somewhat akin to the poison of opium seems to be that of laurel-water, a simple water distilled from the leaves of the lauro-cerasus or common laurel. The bad effects of this were particularly observed in Ireland, where it had been customary to mix it with brandy for the sake of the flavour; and thus two women were suddenly killed by it. This gave occasion to some experiments upon dogs, in order to ascertain the malignant qualities of the water in question; and the event was as follows: All the dogs fell immediately into totterings and convulsions of the limbs, which were soon followed by a total paralysis, so that apoplexy, no motion could be excited even by pricking or cutting them. No inflammation was found upon dissection, in any of the internal membranes. The most remarkable thing was a great fulness and distention of the veins, in which the blood was so fluid, that even the lymph in its vessels was generally found tinged with red. The same effects were produced by the water injected into the intestines by way of clyster.

To make the experiment more fully, Dr Nicholls prepared some of this water so strong, that about a dram of heavy essential oil remained at the bottom of three pints of it, which by frequent shaking was again quite incorporated with it. So virulent was this water, that two ounces of it killed a middle-sized dog in less than half a minute, even while it was passing down his throat. The poison appeared to refer entirely in the above-mentioned essential oil, which comes over by distillation, not only from the leaves of laurel, but from some other vegetables; for ten drops of a red oil distilled from bitter almonds, when mixed with half an ounce of water, and given to a dog, killed him in less than half an hour.

Volatile alkalies are found to be an antidote to this poison; of which Dr Mead gives the following instance. About an ounce of strong laurel-water was given to a small dog. He fell immediately into the most violent convulsions, which were soon followed by a total loss of his limbs. When he seemed to be expiring, a phial of good spirit of sal ammoniac was held to his nose, and a small quantity of the same forced down his throat; he instantly felt its virtue; and by continuing the use of it for some time, he by degrees recovered the motion of his legs; and in two hours walked about with tolerable strength, and was afterwards quite well.

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 following 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 a 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 cinchona, by strengthening the fluids, 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.

Sp. VII. APoplexy from Passions of the Mind.

Carus à pathemate, Sauv. sp. 11. Asphyxia à pathemate, Sauv. sp. 7. Ecstasis catoque, Sauv. sp. 1. Ecstasis resoluta, Sauv. sp. 2.

Apoplexies Sp. VIII. The Cataleptic Apoplexy.

Catalepsis, Sauv. gen. 176. Lin. 129. Vog. 230. Sag. gen. 281. Boerh. 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 paroxysms. The patients are said to be 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 be 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 that can be depended upon among medical writers.

Sp. IX. Apoplexy from Suffocation.

Asphyxia suspensorum, Sauv. fp. 4. Asphyxia immerorum, Sauv. fp. 1.

This is the kind of apoplexy which takes place in those who are hanged or drowned. For the treatment of those persons, see the articles DROWNING and HANGING.

Besides the species above mentioned, the apoplexy is a symptom in many other distempers, such as fevers both continued and intermittent, exanthemata, hysteria, epilepsy, gout, worms, ichuria, and feverly.

GENUS XLIII. PARALYSIS.

The Palsy.

Paralysis, Boerh. 1057. Hemiplegia, Sauv. gen. 170. Lin. 103. Vog. 220. Paraplexia, Sauv. gen. 171. Paraplegia, Lin. 102. Vog. 227. Paralysis, Sauv. gen. 169. Lin. 104. Vog. 226. Junck. 115. Atonia, Lin. 120.

Sp. I. The Partial Palsy.

Paralysis, Sauv. gen. 169. Lin. 104. Vog. 226. Junck. 115. Paralytic plethorica, Sauv. fp. 1. Paralytic ferula, Sauv. fp. 12. Paralytic nervosa, Sauv. fp. 11. Mutitas à glottolyse, Sauv. fp. 1. Aphonia paralytica, Sauv. fp. 8.

Sp. II. Hemiplegia, or Palsy of one side of the Body.

Hemiplegia, Sauv. gen. 170. Lin. 108. Vog. 228. Sag. gen. 276. Hemiplegia ex apoplexia, Sauv. fp. 7. Hemiplegia spasmodica, Sauv. fp. 2. Hemiplegia ferula, Sauv. fp. 10.

Sp. III. Paraplegia, or Palsy of one half of the Body taken transferredly.

Paraplexia, Sauv. gen. 171. Sag. gen. 277. Paraplegia, Lin. 102. Vog. 227. Paraplexia sanguinea, Sauv. fp. 2. Paraplexia à spina bifida, Sauv. fp. 3. Paraplexia rheumatica, Sauv. fp. 1.

Description. The palsy under all the different forms here mentioned as particular species, shows itself by a sudden loss of tone and vital power in a certain part of the body. In the lighter 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 of 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 be 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. Whether the disease be more or less extended, many different varieties may be observed in its form. Sometimes there occurs a total loss of sense while motion is entire; in others a total loss of motion with very slight or even no affection of sense; and in some cases, while a total loss of motion takes place in one side, a total loss of sense has been observed on the other. This depends entirely on the particular nerves or branches of nerves in which the affection is situated; loss of sense depending on an affection of the subcutaneous nerves; and loss of motion on an affection of those leading to the muscles.

Causes, &c. Palpitations most commonly supervene upon 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. Palpitations are also the infallible consequences of injuries to the large nerves.

Prognosis. Prognosis. Except in the lighter cases of palsy, we have little room to hope for a cure; however, death does not immediately follow even the most severe paralytic affections. In hemiplegia it is not uncommon to see the patients live several years; and even in the paraplegia, if death do 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 itching 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 lighter cases, medicines seldom prove effectual; and before any plan 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 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 down the spine: but in habits where the blood is rather inclined to the watery state, it will be necessary to give entities from time to time; to apply blisters, and infuse fluids.

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 scouring them with nettles, have also been recommended, and may do service, as well as volatile and stimulating medicines taken inwardly. And it is probably by operating in this manner, that the use of camphor, or a mercurial course continued for some length of time to such a degree as gently to affect the mouth, have been found productive of a cure in obstinate cases of this affection. Of late years, an infusion of the arnica montana or German leopard's bane, has been highly extolled in the cure of this disease, by some foreign writers: but the trials made with it in Britain, particularly at Edinburgh, have been by no means equally successful with those related by Dr Collins, who has strongly recommended this medicine to the attention of the public. Another remedy has of late been highly extolled in palsy, the rhus toxicodendron or poison oak. It has been employed with some success in France by Mr Freinot; and Dr Alderson of Hull, in a late dissertation on this plant, has published several cases, even of very obstinate palsy, in which its use was attended with wonderful success. In some cases also at Edinburgh, it has been used with apparent advantage, but in a much greater number without any benefit.

In certain cases of palsy, unexpected cures have been accomplished both by electricity and by galvanism. But in a considerable majority of instances, palsy from which the patient has not what may be called a natural recovery, will be found incurable by any remedies which have hitherto been recommended.

Sp. IV. The Palsy from Poisons.

Paralysis metallariorum, Sauv. fp. 22. Hemiplegia saturnina, Sauv. fp. 14.

This kind of palsy arises most frequently from lead taken into the body, and is a consequence of the colic pleuron, under which it is more particularly treated.

Tremor, or Trembling.

Tremor, Sauv. gen. 129. Lin. 139. Vog. 184. Sag. 236.

This by Dr Cullen is reckoned to be always symptomatic either of palsy, athetia, or convulsions; and therefore need not be treated of by itself.

ORDER II. ADYNAE.

Adynamiae, Vog. Clas. VI. Defectivi, Lin. Clas. VI. Order I. Leiopathymiae, Sauv. Clas. VI. Order IV. Sag. Clas IX. Order IV.

GENUS XLIV. SYNCOPE.

Fainting.

Syncope, Sauv. gen. 174. Sag. 94. Vog. 274. Sag. 280. Junck. 119. Leiopathymia, Sauv. gen. 173. Lin. 93. Vog. 273. Sag. 279. Asphyxia, Sauv. gen. 175. Lin. 95. Vog. 275. Sag. 281. Virium lapsus et animi deliquia, Hoffm. III. 267.

Sp. I. The Cardiac Syncope.

Syncope plethorica, Sauv. fp. 5. Senac. Tr. de Coeur, p. 540. Syncope à cardiogmo, Sauv. fp. 7. Senac. de Coeur, 414. Morgagn. de Sed. XXV. 2. 3. 10. Syncope à polypo, Sauv. fp. 8. Senac. p. 471. Syncope ab hydrocardia, Sauv. fp. 12. Senac. 533. Schreiber Almag. L. III. § 196. Syncope Lanzoni, Sauv. fp. 18. Lanzon. Op. II. p. 462. Asphyxia Vallalviana, Sauv. fp. 13.

Sp. II. Occasional Syncope.

Leiopathymia à pathemate, Sauv. fp. 1. Senac. p. 544. Syncope pathetica, Sauv. fp. 7. Syncope ab antipathia, Sauv. fp. 9. Senac. p. 544. Syncope à veneno, Sauv. fp. 10. Senac. p. 546. Syncope ab apothezis, Sauv. fp. 11. Senac. p. 554. Syncope à sphacelo, Sauv. fp. 14. Senac. p. 553. Syncope ab inanitione, Sauv. fp. 1. Senac. p. 536. Syncope à phlebotomia, Sauv. fp. 4. Syncope à dolore, Sauv. fp. 2. Senac. p. 583. Asphyxia Asphyxia traumatica, Sauv. sp. 14. Asphyxia neoplyterum, 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, senses, and motion, all at once. In those cases which physicians have distinguished by the name of leipothymia, 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 asphyxia, not the smallest sign of life can be perceived; the face has a death-like pallor, 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 flight 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 by this means the patient may escape.

Cure. When persons of a full habit faint through excess of passion, they ought to be bled 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 tinctura opii camphorata, 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 saburra, occasions a leipothymia, 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 flannel; very strong vinegar, aromatic vinegar, or salt of hartshorn, or volatile alkaline spirit, are to be held to the nostrils, and rubbed 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 asphyxia, 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 cinchona joined with chalybeates.

GENUS XLV. DYSPEPSIA.

Depraved Digestion.

Dyspepsia, Vog. 277. Apepsia, Vog. 276. Diaphora, Vog. 278. Anorexia, Sauv. gen. 162. Lin. 116. Sag. gen. 286. Cardialgia, Sauv. gen. 202. Lin. 48. Vog. 157. Sag. gen. 160. Gastrodynia, Sauv. gen. 203. Sag. gen. 161. Soda, Lin. 47. Vog. 161. Nausea, Sauv. gen. 250. Lin. 182. Vog. 159. Sag. gen. 185. Vomitus, Sauv. gen. 251. Lin. 183. Vog. 214. Sag. gen. 186. Flatulentia, Sauv. gen. 272. Lin. 165. Vog. 127. Sag. gen. 207.

The idiopathic species are,

Anorexia pituitosa, Sauv. sp. 2. Anorexia à saburra, Sauv. sp. 9. Anorexia exhaustorum, Sauv. sp. 8. Amoresia paralytica, Sauv. fp. 1. Nausea ex cacochylia, Sauv. fp. 11. Vomitus putitulosus, Sauv. fp. 26. Vomitus ruminatus, Sauv. fp. 6. Vomitus à saburra, Sauv. fp. 2. Vomitus à crapula, Sauv. fp. 1. Vomitus lacteus, Sauv. fp. 3. Flatulentia infantilis, Sauv. fp. 5. Flatulentia acida, Sauv. fp. 1. Flatulentia nitrofa, Sauv. fp. 2. Cardialgia bradypepta, Sauv. fp. 9. Cardialgia à saburra, Sauv. fp. 2. Cardialgia lactantium, Sauv. fp. 11. Cardialgia flatulenta, Sauv. fp. 3. Cardialgia paralytica, Sauv. fp. 7. Gastrodynia saburrallis, Sauv. fp. 1. Gastrodynia flatulenta, Sauv. fp. 2. Gastrodynia periodynia, Sauv. fp. 7. Gastrodynia affringens, Sauv. fp. 9. Gastrodynia atterens, Sauv. fp. 10. Gastrodynia à frigore, Sauv. fp. 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, as 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; diffusion of the stomach when no food has been taken for some time before; flight 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 sickness; 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 staggers as if he was drunk. From the too great ascendency 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 afflicted as well as the body, and he 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 anaeroma or afecies.

Causes, &c. The causes of dyspepsia may be anything which debilitates the system in general, but in a 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; and without this we cannot expect a complete removal of the affection; but when it frequently returns, with symptoms of great debility, hectic fever, or dropsy, we have great reason to dread the event.

Cure. A radical cure of dyspepsia is only to be expected by removing from the stomach and system that debility on which the disease depends. On this ground, the objects chiefly to be aimed at in the cure are, 1st, The avoiding whatever will tend to diminish the vigour of the stomach; 2d, The employing such remedies as have influence in increasing that vigour; and, in the third place, The obviating urgent symptoms, particularly those which tend to increase and support the affection. Of the avoiding causes, which tend to diminish the vigour of the stomach, after what has already been said of the causes inducing the disease, it is unnecessary to make any farther observations; and indeed every dyspeptic patient will be taught by experience what is to be done with this intention. The medicines chiefly employed with the view of increasing vigour are those of the tonic kind; but, previous to their use, it will be necessary to evacuate the contents of the alimentary canal by vomits or purgatives. If there be 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 terebinthine powders, as being purgative while dissolved in an acid, when 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 hardly doubt of its efficacy in slighter degrees of the disorder. But although acidity may often be successfully obviated in this manner, yet the best way of counteracting this symptom, as well as of obviating coliciveness, flatulence, and a variety of others, is by retarding the tone of the stomach in particular, and indeed of the system in general. With this intention, recourse is had to a variety of tonics both from the mineral and vegetable kingdom; particularly chalybeates in different forms, gentian, colombo, and the like; but of all the tonics which can be employed in this affection, none are attended with greater benefit than exercise and cold bathing; and the proper and prudent employment of these is no less effectual in removing the disease, than in preventing the return of it after it is once removed.

GENUS XLVI. HYPOCHONDRIASIS.

HYPOCHONDRIAC Affection.

Hypochondriasis, Sauv. gen. 220. Lin. 76. Vog. 218. Sag. 332. Morbus hypochondriacus, Boerh. 1098. Malum hypochondriacum, Hoffm. III. 65. Junck. 36.

Although some of the nomenclatural writers, particularly Sauvages, have considered this genus as consisting of different species, Dr Cullen is of opinion, that there is only one idiopathic species, the hypochondriasis melancholica. He considers not only the hypochondriasis hysterica, phthisica, and asthmatica, but also the biliosa, fanguinea, and pituitosa, as being only symptomatic; but he views the true melancholic hypochondriasis as being a proper idiopathic disease, perfectly distinct from hysteria, with which it has often been confounded.

Description. The symptoms of hypochondriasis are, stretching, prefling, griping, and tormenting pains, under the ribs, and chiefly in the left side; which sometimes are exasperated, and become pungent, burning, or lancinating. Frequently there is an inflation of the left hypochondrium, which sometimes becomes stationary, and by Hippocrates was taken for a symptom of an enlarged spleen. When these symptoms take place in the right hypochondrium, they are commonly attended with colic pains, uncertain flying heats, especially in the head, with a transient redness of the face, and very frequently an oedematous swelling of the feet succeeds. To these are superadded almost all the affections of the stomach occurring in dyspepsia, besides a variety of other symptoms, such as palpitations, sleepless nights, and the like. But besides these, there occurs also a particular depression of spirit and apprehension of danger, which may be considered as one of the great characterizing symptoms of the disease.

Causes, &c. The general causes of the hypochondriac affection are said to be a plethora, and supernatural thickness of the blood; suppressions of customary evacuations; high and full diet, together with a sparing quantity of drink; an hereditary disposition; indolence; atony of the intestines; violent passions of the mind, &c.

Prognosis. The hypochondriac affection, when left to itself, is more troublesome than dangerous; but, if improperly treated, it may bring on various diseases of a more fatal tendency, such as the melancholy, bloody urine and nephritis, jaundice, vertigo, palsy, apoplexy, &c.

Cure. This is to be attempted by such medicines as counteract occasional causes, and obviate urgent symptoms, which may be all comprehended under bleeding, gentle evacuants, chalybeates, the cinchona, and exercise, especially riding on horseback, which in this disease is greatly preferable to any other. When the circumstances of the patient can afford it, a voyage to Spain, Portugal, or some of the warmer countries in Europe, will be of great service.

GENUS XLVII. CHLOROSIS.

GREEN SICKNESS.

Chlorosis, Sauv. gen. 309. Lin. 222. Vog. 305. Sag. gen. 135. Boerh. 1285. Hoffm. iii. 311. Junck. 86.

Of this genus also Dr Cullen thinks there is but one idiopathic species: viz. what some distinguish by the title of chlorosis virginea, others of 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 more than 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 leucoplegmasia, anaearca, atrophy, and death, succeed.

Causes. 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 does 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... lating also the vessels of the uterus; and for this reason indulgence in venery has sometimes been said to produce a cure, particularly with love-sick maids. The cold bath is also extremely proper.

**ORDER III. SPASMI.**

SPASMI, Sauv. Clas IV. Vog. Clas V. Sag. Clas VIII. Motorii, Lin. Clas VII. Morbi spasmodici et convulsiivi, Hoffm. III. 9. Spasmi et convulsiones, Junk. 45, 54. Epilepsia, Boerh. 1071, 1088.

**GENUS XLVIII. TETANUS.**

Tetanus, Sauv. gen. 122. Lin. 127. Vog. 180. Sag. gen. 228. Catochus, Sauv. gen. 123. Lin. 128. Vog. 183. Sag. gen. 229. Opifhotonos, Vog. 181. Epilhotonos, Vog. 182.

On this distemper Dr Lionel Chalmers has published a dissertation in the first volume of the Medical Observations, which being superior to any thing that has 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 opifhotonos and tetanus, either with regard to the variety of painful symptoms which almost without intermission afflict 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 opifhotonos 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 tetanus next morning.

"These diseases so rarely appear as originals in Europe, that a good history of them cannot be expected from the physicians who practise in that part of the world; nor has anything 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 opifhotonos 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 show 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 clas of spasmodic diseases, there are three which distinguish themselves in a very particular manner, on which the names of emprophotonos, opifhotonos, 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 to 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 emprophotonos. 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 opifhotonos; 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 emprophotonos; and shall only speak of the opifhotonos and tetanus, the first being by far the most common, and in the last stage of which the tetanus frequently supervenes. 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 opifhotonos 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 opifhotonos, contrary to what Bontius affirms, often comes on gradually and by flight approaches, the patient complaining rather of an uneasy stiffness in the back-part of the neck and about the shoulders, than of any acute pain, with some degree of a general latitude. 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 cartilago ensiformis, which strikes through to 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;" Practice.

Spasms. lence; 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 opilhotos, 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 invades the unfortunate person with the whole train of its mischiefous symptoms in a few hours: in which case, the danger may truly be eliminated from the violence of the first attack; for such generally die in 24, 36, or 48 hours, and very rarely survive the third day. But when it is less acute, few are lost after the ninth or eleventh; which number of days it would not be possible for them to complete, unless the violence of the disease was in a good measure subdued; although I had one who recovered, after having been subject to its tyrannical attacks daily for six weeks. In this stage the pulse is slow, and very hard, and the belly is bound; blood taken away seems not to be altered from the natural state, so that no indication can be deduced therefrom, and it only varies with regard to laxity or compaction, according to the age of the person and season of the year.

"Stage II. The spasm under the sternum (which is the pathognomonic symptom of this disease) becomes more violent, returning every 10 or 15 minutes; and never fails to be instantly succeeded by a stronger retraction of the head, with great rigidity and pain all round the neck, and along the spine to the lower extremities, which are suddenly put to the stretch. The countenance is very pale and contracted; the jaws are at that moment snapped together, and cannot afterwards be opened so wide as to receive the end of one's little finger; an attempt to do which, by way of experiment, almost constantly hurries on the spasm. The mastoid, coraco-hyoid and sternohyoid muscles, as well as all the others concerned in deglutition, and the deltoid and pectorals, are most violently contracted, so that the shoulders are strongly raised forward, and the arms are stretched out or drawn across the body; but the wrists and fingers seem not to be affected.

"Such is the condition of the patient in the time of the spasm, which ceases in a few seconds: after which the shoulders and arms recline, and the inferior extremities relax; yet not so entirely, but that such a degree of rigidity for the most part remains as will not permit them to bend when this is attempted by another person; for as to the sick himself, he cannot at all move them. The muscles on the sides and forepart of the neck continue still contracted, although not so strongly; but their action is overcome by the number and strength of the posterior ones; so that the retraction of the head constantly remains. The patient breathes quick for some minutes, as if he had been excessively exercised; and the pulse is small, fluttering, and irregular, but both become more calm and slow. The face is sometimes pale in the intervals, but oftener flushed; and the whole countenance expresses strong appearances of the most melancholy distress, as well Tetanus, because of the dread he has of a return of the spasm, which he is sure will soon happen, as from the pain he suffers by the present contractions, and the more general and severe ones which he has lately sustained. The tongue is stiff and torpid; but so far as it can be seen, is not foul. The belly is always bound, and cannot easily be loosed. In drinking, the liquid passes with great difficulty to the stomach, even in the smallest quantity; and if the spasm should seize him at that time, which an attempt to swallow for the most part occasions, the liquor returns through the nose with force. The patients desire to lie still as much as possible; and avoid drinking, speaking, or being moved, either of which are apt to occasion a return of the spasm.

"Stage 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 bed, 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 deflected in the time of the spasms, that were it not for the standers by, the patient 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 exceedingly quick, small, and irregular, although the heart throbs so strongly, that its motions may be plainly seen, and a palpitating fulsibitory 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 anything that was put into his mouth. In this state patients are commonly delirious: and as they cannot submit many hours under so great a fulsibition of the vital and natural functions, a mortal anxiety ensues and relieves." releases them; oftener a continued and severe spasm finalizes 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 opiphotonos, 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 opiphotonos, and its contents seem to be thrust up into the thorax, which at the same 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. As in cases of tetanic affections, the disease often arises from some particular irritation, the removal of this must necessarily be an important object in the cure: But where it cannot be removed, benefit may often be obtained by the prevention of its influence being communicated to the brain. When, however, that influence is communicated to the brain, a cure is to be expected only by diminishing and obviating it. This is principally brought about by the use either of those means which have a general tendency to diminish action, or of those which induce a different state of action. On these grounds the operation of those remedies which are employed with greatest success in this affection, may, we apprehend, be explained. Fortunately it has been found, that opium is capable of giving some relief, if administered in proper time, and if 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 polyphren, 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 extraction thebaicum, or 20 drops of the tincture, every second or third hour; and it will be safest not to Tetanus. trust to the thebaic tincture which is kept ready prepared in the shops, but to 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 clysters; for during the whole course of the disease it will be of service to order emollient clysters 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 weakness and relaxation of the muscular fibres. In order to perfect the recovery, a course of the cinchona 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, in the opinion of some practitioners, be omitted, since all of them as well as blisters have been alleged to exacerbate 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 with children in Britain, viz. from 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 excretions; or from something taken in by the mouth which is over acid, or too hard to digest, which irritates their tender bowels, and produces startings and convulsive spasms, with all the other symptoms which precede and accompany convulsions in young children in Britain. And this shows 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 Britain, 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 to increase 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, and the disease is but seldom cured in such young children when it arrives at that state: 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 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 so 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, Dr Hillary thinks Practise.

MEDICINE.

Spasms thinks it is never cured. But if the physician be 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 by proper antipyretics, and correcting the remaining acrimony of the nutritious juices in the prime of life.

To answer these intentions, the following method, with variations pro re nata et pro ratione etatis, as the cause is different, has been found to answer the desired effect the best: R. Seri lactis 3ij. Sipon. Venet. 3j. Mannz Calab. 3ij. vel iij. Ol. amygd. dul. 3ls. Ol. feniculi dul. gul. ij. Balf. Peruvi. gut. v. Mifce. Fi enema quam primum injiciendum.

And if the symptoms of the approaching tetanus will permit, he gives something of the following nature to assist the operation of the clyster, and to carry off the acrimony the sooner: R. Ag. fem. feniculi 3ij. Magnes. albus 3ls. Ocul. cancer. prep. 3j. Syr. e eichor. cum rheo. Rofar. foliat. ana 3ij. Mifce. Or. R. Ag. fem. feniculi 3ij. Sapon. amygdal. 3ls. Magnes. albus 3ls. Syr. e eichor. cum rheo. Mannz opt. ana 3ij. Ol. amygd. dul. 3ij. Mifce: Exhibe cochl. parvo. vel duo pro ratione etatis, omni semihora, vel omni hora, donec responda. alvus.

Two or three stools being obtained by these, the following is exhibited in order to abate the convulsive twitchings, and prevent the tetanus from coming on: R. Ag. fem. feniculi 3ij. Magnes. albus 3ls. Ocul. cancer. prep. 3j. Moschi orient. gr. ij. Spir. C. C. gut. xv. Syr. e mecon. 3ls. Mifce: Exhibe cochl. parvo. (a child's spoonful) ter quaterve de die, vel si pusius, urgent, convuls. vel spasms.

But if the symptoms show that the tetanus is more immediately coming on, so that we have no time to wait till the operation of the clyster and opening laxative be over, something of the following nature must be immediately given; or the tetanus will come on, and most probably prove fatal to such tender babies. R. Ag. fem. feniculi 3ij. Moschi orient. gr. j. Tinct. thebaica. gut. iiiij. Syr. e mecon. 3ij. Mifce pro duobus doj. de quibus exhibe unam quamprimum, et alteram si convuls. spasms. redemit.

This, Dr Hillary observes, may be thought a bold attempt, to give tinct. thebaica to such a tender young infant; but it is to be considered that the little patient will certainly die if the tetanus seize it, and that it will come on if this do not prevent it; and he has known a bold ignorant old midwife give four or five drops of that tincture to a very young infant without any prejudice more than its doing three or four hours, though not in this case, but in one much less violent.

The clyster may be given at the same time, and the opening laxative not long after it; though it may retard the operation of that for some time, yet it operates soon after, and gives relief; after which the other medicines, and fomenting the body and anointing it as before, may be used, if the physician finds it necessary; also a little of the laxative mixture may be given once or twice a day, if the above julep does not answer the intention of keeping the child's body open for a few days afterwards, which in this case is generally found necessary to be observed.

These methods and medicines may be varied according to circumstances. For neither the same method nor the same medicines will answer in all cases, though the disease be the same; but they must be changed as the causes differ, or the constitution of the sick, or the time of the disease, or as some other circumstances may require; which is a thing of great importance, not only in this, but in the cure of most other diseases.

When proper medicines are thus timely and judiciously given in this case, they seldom fail to carry off the irritating cause, quiet and ease the nerves, remove the convulsions and spasms; and consequently prevent the tetanus from coming on, and the death of the patient. But if calling in the physician be deferred till the tetanus has already strongly seized the child, as is too often the case here, neither warm bathing, fomenting, nor any other methods or medicines whatever, will remove it or its causes, nor save the life of the little tender patient.

Dr Chalmers gives an account of his having cured one child feigned with a tetanus, by purging with an infusion of rhubarb; to which a few grains of musk, and a little ol. tartar. per deliq. were added, together with the warm bath, and the frequent injection of clysters made with an infusion of chamomile 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 affluence 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 feigned 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 titioners 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 no 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 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 Dr William Carter of Canterbury, by means very different from any of those above related.—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 an wound on the inner ankle of his right leg, which he had received five 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 spine dorfi, 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 daytime, entire, though sometimes wandering in the night. As to his pulse, it 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 Silvester, in the first volume 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 thebaicum 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 milk, 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 thebaicum 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; the jaw to be anointed with the oleum latertium; and a purge, consisting of the tinctura facra, tinctura jalapae, and the syrupus de rhanno cathartic, 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 fuscini, the fetid gum, and the oleum amygdalimum. Of the first he took 30 drops, of the gum 20 grains, and of the last four ounces, in 24 hours. 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.

For 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 show 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 Edinburgh Medical Commentaries we have an account of the cold bath being used as a remedy, by Dr Thomas Cochrane, at that time physician 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. Dr Cochrane 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 clysters and laxatives; it is by no means easy to say what share the cold bath had in his cure. Dr Cochrane, however, says he has heard of some cases being treated successfully by cold water and cinchona. Spasm. cinchona in St Eustatia and St Kitt's, and in another letter mentions his having used the cold bath in other cases of tetanus with success. But since Dr Cochrane's publication, a more full and satisfactory account of the benefit of this practice has been communicated in a paper published by Dr Wright, in the fifth volume of the London Medical Observations. Dr Wright gives a particular account of five cases, in which the best effects were obtained from dashing cold water upon the patient; and he observes, that since he first used this method of cure he never failed in one instance to effect a recovery, and that in a shorter time than by any other method hitherto proposed. This practice has on some occasions been adopted by practitioners in Britain, although here the disease is a much less frequent occurrence. It has particularly been employed with success by Dr Currie of Liverpool; and we hope that still more extensive practice will confirm the benefit to be derived from it, although not in every instance, yet in many cases of this affection. We are, however, sorry to say that we have of late heard of several cases in which it has been tried in Britain, and which, notwithstanding the use of it, had a fatal termination.

Very lately a different mode of cure in this affection has been recommended by Dr Ruth, professor of medicine in Philadelphia, in a paper entitled Observations on the Cause and Cure of Tetanus, published in the second volume of the Transactions of the American Philosophical Society. Dr Ruth, viewing tetanus as being a disease occasioned by relaxation, thinks the medicines indicated to cure it are such only as are calculated to remove this relaxation, and to restore tone to the system. On this ground he recommends the liberal use of wine and cinchona; and tells us, that he has employed them with success in actual practice. When the disease arises from an wound of any particular place, he recommends stimulants to the part affected; such as dilatation of the wound, and filling it with oil of turpentine. How far this practice will be confirmed by more extensive experience, we cannot take upon us to determine. We may only observe, that a very contrary practice has been recommended as highly successful by some practitioners in Spain, where tetanic affections are a very frequent occurrence in consequence of slight accidents. There gentle emollients are strongly recommended, particularly immersing the wounded part in tepid oil for the space of an hour or so at a time, and repeating this application at short intervals. By this mode many cases, after very alarming appearances had taken place, are said to have been completely and speedily removed. While the practice is very simple, it appears at the same time in many respects very rational, and may perhaps be considered as well deserving a trial in the first instance.

Among other remedies employed in tetanus it has been said that the spasms have sometimes been allayed by a strong electric shock. And in obstinate cases electricity or galvanism certainly well deserve a trial.

GENUS XLIX. TRISMUS.

The Locked Jaw.

Trismus, Sauv. gen. 117, Lin. 124. Sag. gen. 223. Capitulum, Vog. 208.

Sp. I. Trismus nascentium.

Locked jaw in children under two months old.

Trismus nascentium, Sauv. sp. 1. Heffler Comp. Med. Pract. cap. xv. § 10. Cleghorn on the Diseases of Minorca, Introd. p. 33. Hofzer. in Acta 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. And nothing need now be added to what has been said respecting tetanus.

Sp. II. The Trismus from Wounds or Cold.

Trismus traumaticus, Sauv. sp. 2. Lond. Med. Obs. vol. i. art. 1, 7. Vol. ii. 34. Vol. iii. 31. Vol. iv. 7.

Angina spasmodica, Sauv. sp. 18. Zwingeri, Acta Helvet. tom. iii. p. 319.

Convulso à 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. But of this also we have offered some observations under the head of Tetanus; and, indeed, trismus may be considered as being merely an incipient tetanus, or rather a slight degree of that disease.

GENUS L. CONVULSIO.

Convulsions.

Convulso, Sauv. gen. 128. Lin. 142. Vog. 191. Sag. gen. 235.

Convulso universalis, Sauv. sp. 11.

Hieranofos, Lin. 144. Vog. 190.

Convulso habituatus, sp. 12.

Convulso intermittens, Sauv. sp. 16.

Convulso hemitotonos, Sauv. sp. 15.

Convulso abdominis, Sauv. sp. 10.

Convulso ab inanitione, Sauv. sp. 1.

Convulso ab omnimodo, 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 flutters of the tendons, the picking of the bedclothes, &c., in acute diseases, are all of them convulsive disorders. Convulsions, even when most generally extended, differ from epilepsy in not being attended with any mental affection or abolition of sense, and not followed by the same torpid state.

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 pend 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, and 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 smallpox, 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 be very evident, a cure is hardly to be expected, especially after the disease has been of long continuance.

Cure. The treatment is very much the same with that of epilepsy, afterwards to be considered; but a recovery is most frequently obtained by the removal of the existing cause.

GENUS LI. CHOREA.

St Vitus's Dance.

Scelotyrbe, Sauv. gen. 136. Sag. 243. Chorea, Lin. 139. Scelotyrbe chorea Viti, Sauv. sp. 1. Chorea St Viti, Sydenh. Sched. Monit.

Description. This disease shows itself first by a kind or 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 be 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, though generally the disorder is easily removed before that time.

Chorea, however, in some instances, proves an obstinate affection; but is hardly in any instance attended with danger.

Cure. It has hitherto been almost universally the common practice to treat this disease with antispasmodics and tonics, particularly opium, hyoscyamus, valerian, cinchona, preparations of iron, zinc, and copper, and cold bathing; and under the use of these the disease has, in general, been removed. But Dr James Hamilton, senior physician to the Royal Infirmary of Edinburgh, in a treatise which he has lately published on the use of purgative medicines, has recommended a very different practice in this disease, the use, viz. of brisk cathartics; these he advises to be repeated daily for some time. The great object, however, which he has in view, is not to evacuate from the system, but to produce a thorough and complete evacuation of the intestinal canal. He finds, that by the first doses, large quantities of black-colored matter are discharged; and he recommends that the use of the purgatives should be persisted in till the stools assume a natural appearance. In confirmation of the utility of this practice, he has related several cases in which it produced a speedy and complete cure; and equal success has attended this practice when directed by several others. There can therefore be no hesitation in recommending it at least in every obdurate instance of chorea.

GENUS LII. RAPHANIA.

Raphania, Lin. 155. Vog. 143. Lin. Amoen. Acad. vol. vi. Convulvio raphania, Sauv. sp. 7. Eclamplia typhodes, Sauv. sp. 1. Sennert. de febr. l. iv. cap. 16. Gregor. Horst. Oper. tom. ii. l. viii. obs. 22. Brunner in Ephem. Germ. D. iii. A. ii. obs. 224. Willisch. ibid. cent. vii. obs. 13. Wepfer. de Affect. Capitis, obs. 120. Breslauer Sammlung 1717, Julio, Septembri, et Decembr. Ibid. 1723, Januar. A. N. C. vol. vii. obs. 41. Bruckmann. Comb. 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 precordia. Then come on palpable throbings 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 exanthema; 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 the disease takes its name. It is also, however, a very common opinion, that this disease depends on the rye used in diet being of a bad quality, and particularly containing a large proportion of what is called spurred rye.

Cure. In this affection, the cure, as far as it has yet been discovered, is very much the same with that of epilepsy, the disease next to be considered. But from what has been laid of the advantages derived from the use of purgatives in chorea, analogy would lead us to make a trial of them also in cases of raphania. GENUS LIII. EPILEPSIA.

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.

Sp. I. The CERERALIS, or Epilepsy depending on an affection of the Brain.

Epilepsia plethorica, Sauv. sp. 1. Eclampsia plethorica, Sauv. sp. 7. Epilepsia cachectica, Sauv. sp. 2.

Sp. II. The SYMPATHICA, or Sympathetic Epilepsy, with a sensation of something rising from a certain part of the body towards the head.

Epilepsia sympathica, Sauv. sp. 8. Epilepsia pedilymptomatica, Sauv. sp. 6.

Sp. III. The OCCASIONALIS, or Epilepsy arising from various irritating causes.

Epilepsia traumatica, Sauv. sp. 13. Eclampsia traumatica, Sauv. sp. 9. Epilepsia à dolore, Sauv. sp. 10. Epilepsia rachialgica, Sauv. sp. 14. Eclampsia à doloribus, Sauv. sp. 4. a, Rachialgica. b, Ab otalgia. c, A dentitione. Eclampsia parturientium, Sauv. sp. 3. Eclampsia verminosa, Sauv. sp. 2. Eclampsia ab atrope, Sauv. sp. 11. Eclampsia ab cenanthie, Sauv. sp. 12. Eclampsia à cicuta, Sauv. sp. 13. Eclampsia à coriaria, Sauv. sp. 14. Epilepsia exanthemata, Sauv. sp. 11. Epilepsia cachectica, Sauv. sp. 2. Epilepsia stomachica, Sauv. sp. 3. Eclampsia à saburra, Sauv. sp. 5. Epilepsia à 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, inasmuch that by no smell, noise, or otherwise, nor even by pinching the body, can they be brought to themselves; they foam 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 epilepsy 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, or heaviness of the head, with a laxitude of all the joints.

Causes, &c. The disease 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 bony 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 found. 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 has 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 has sometimes, however, been observed, that epilepsies have been removed by the appearance of cutaneous diseases, as the itch, smallpox, measles, &c. While the disease is recent, therefore, we are not to despair of a cure; but if it be of long standing, or hereditary, there is very little reason to expect that it can be removed.

Cure. From the symptoms occurring in epilepsy, which consists of involuntary convulsive motions, and an affection of the mental powers, there is reason to conclude that the fit immediately depends on the induction of some peculiar action of the brain; but that convulsions may ensue from this cause, it would seem necessary that there should also occur a peculiar disposition to action in the moving fibres. On this ground, then, we may suppose the cure to be chiefly expected on one of two principles; either by our being able to prevent the peculiar action of the brain, or to remove the disposition to action in the moving fibres. The first is chiefly to be accomplished by the removal of irritating causes, by preventing their influence from being propagated to the brain, when they are applied to remote parts; or by counteracting their influence, from inducing in the brain a state of action different from that to which they give rise. The second end is chiefly to be obtained by diminishing the mobility of the nervous energy, and by strengthening... enging the tone of the moving fibres. It must, however be allowed, that 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, caltor, musk, opium, the febrile gums, cinchona, 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 slighter, or symptomatic cases, may often be removed by them.

Of late the calx or oxide, improperly called the flowers, of zinc, have obtained such reputation in convulsive disorders as to be received into the Edinburgh Pharmacopoeia under the title of oxidum zinci. They were proposed by Dr Gaubius as an antispasmodic, in his Adversaria; and their efficacy has 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 of the eyes from acid lymph. Glauber first proposed the internal use of them; and Gaubius discovered them to be the remedy of a celebrated empiric Luddemannus, which he styled his luna fixata. After this he exhibited them with success in convulsive and spasmodic diseases. Dr Hart supposes, that they act either as absorbents, 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 years of age was seized with a slight chorea from a fright; and when the disease had continued six days, she 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 zinc. 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 venesection 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 chincough, hysterical 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. But it does not appear that he ever saw a confirmed epilepsy cured by this medicine.

In the first volume of the Edinburgh Medical Commentaries, 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.

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; excepting 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 the oxide of zinc as an antispasmodic are also attested by Dr Haygarth of Chester and Dr White of York. The former gives a test 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 cate of hieranofoos, or strange convulsions of almost all the muscles of the body, cured by zinc, after a number of other remedies had failed. But, although from these and other respectable authorities, there can be no doubt that zinc has often been successful in epilepsy; yet it is equally certain, that in many others it has had a fair trial, without producing any benefit.

In Dr Home's clinical experiments and histories, also, oxide of zinc is 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. Venesection. Not to be depended on in convulsions.

3. Electricity. In two convulsive cases was of no service.

4. Epiphaetis. Do not seem to be powerful antispasmodics.

5. Valerian. In nine convulsive cases, for which this remedy has 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. Though much used at present, he tells us it has always appeared to him a weak, often a hurtful, medicine.

6. Musk. Six convulsive patients treated with large doses of this remedy, were neither cured nor in the least relieved.

7. Caltor 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. Mafastida has 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... and vomiting: but this can be known only after the exhibition of the medicine.

9. Cinchona. 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 guercinum, 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 hysteric affection, without the least good effect.

13. Folia aurantiacum were exhibited with the like bad success. Five drams 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. Ammoniacetum cupri made no cure in four cases of epilepsy in which it was tried.

That in many cases all these remedies have been employed without success, is not to be denied; and indeed it may with confidence be asserted, that a great majority of cases of epilepsy are incurable by any remedy that has yet been discovered. At the same time, as there is incontrovertible evidence that some of them have succeeded at least in certain cases, the more powerful may always be considered as deserving a fair trial. The ammoniacetum cupri, in particular, seems well entitled to the attention of practitioners; for though it be a medicine of great activity, yet under prudent administration it may be employed even with very young subjects without any hazard; and in several inveterate cases, which had obstinately resisted other medicines, it has brought about a complete recovery.

GENUS LIV. PALPITATIO.

PALPITATION OF THE HEART.

Palpitatio, Sauv. gen. 130. Lin. 132. Vog. 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 polypous concretions or obstructions 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 be plethoric, bleeding will probably remove the disorder, at least for the present.

GENUS LV. ASTHMA.

Asthma, Sauv. gen. 145. Lin. 161. Vog. 268. Sag. gen. 282.

Asthma convulsionum, et spasmodico-flatulentum, Hoffm. III. 94.

Asthma spasticum, Junck. tab. 51.

Sp. I. Spontaneous Asthma.

Asthma humidum, Sauv. sp. 1. Flatulentum, Floyer on the Asthma, chap. i.

Asthma convulsionum, Sauv. sp. 2. Willis Pharm. rat. P. II. sect. i. cap. 12.

Asthma hystericum, Sauv. sp. 3. Floyer on the Asthma, chap. i.

Asthma stomachicum, Sauv. sp. 8. Floyer, Scheme of the Species of Asthma. Periodic Asthma, 6.

Orthopnea spasmodica, Sauv. sp. 3.

Orthopnea hysterica, Sauv. sp. 4.

Sp. II. The Exanthematic Asthma.

Asthma exanthematicum, Sauv. sp. 11.

Asthma cachecticum, Sauv. sp. 13.

Sp. III. The Plethoric Asthma.

Asthma plethoricum, Sauv. sp. 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 thirty 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. 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 flatusulence, 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 will 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 feebly 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 atrafetida, must be immediately injected; and if the violence of the symptoms should not speedily abate, it will be proper to apply a blistering plaster to the neck or breast.

In the height of the paroxysm, an emetic might be followed 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 saburra. A very strong infusion of roasted coffee has been found to give ease in an asthmatic paroxysm.

Sir John 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 Muffgrave in his treatise de Arthritide anomala; but he first heard of it from a physician in Litchfield, who had been informed 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 fit, 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 said to be very serviceable in some asthmatic cases; but its operation is both too distressing and too dangerous, that it will never probably be introduced into common use as an emetic. Smoking or chewing the same has been known to prevent the frequency and severity of the paroxysms. Asthmatic patients may also use the lac ammoniaci, with a due proportion of oxymel scillitum and vinum antimoniale, with a view to promote expectoration; or the gum ammoniac, and others of similar virtues, may be formed into pills, and combined with soap, as mentioned for the dyspnea pituitosa; or a mafs may be composed of asafoetida and balsam of Tolu, with syrup of garlic; 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 coptive habit should prevail, it will be necessary, from time to time, to give a few grains of pills of aloes and myrrh, soap and aloes, or a mass 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 ipecacuanha 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. Iliums 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 often highly serviceable.

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 asthma arthriticum, liniments 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 febriculorum, and invades at regular intervals, we must have recourse to the Peruvian bark. The asthma exanthematicum will require blisters or iliums, to give vent to the acrid matters which were repelled from the surface of the body; and courses of sulphureous waters, goats whey, and sweetening diet drinks, or perhaps mercurial alternatives, in order to correct the sharpness of the juices.

**GENUS LVI. DYSPNEA.**

**Habitual Difficulty of Breathing.**

*Dyspnea, Sauv. gen. 144. Lin. 160. Vog. 267. Sag. 251. Junck. 32.*

**Sp. I. The Catarrhal Dyspnea.**

*Asthma catarrhale, Sauv. sp. 16.*

*Asthma pneumonicum, Willis Pharm. rat. P. II. sect. i. cap. 12.*

*Asthma pituitosum, Hoffm. III. sect. ii. cap. 2. § 3.*

*Asthma pneumodes, Sauv. sp. 17.*

This is readily known by the symptoms of pneumonia and catarrh attending it, and to the removal of these symptoms the care of the physician must be principally directed.

**Sp. II. The Dry Dyspnea.**

*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. Sauvages doth not mention any particular remedy. Shortness of breath arising from tubercles, as they are termed, or a scirrhus enlargement of the lymphatic glands which are dispersed through the lungs, is com- Spasm. monly found in scrophulous habits, and may be distin- guished by the concomitancy of those external swellings and appearances which particularly mark the scrophula. This species of dyspnoea generally ends in a phthisis. Courses of goats' whey, and of sea water, have been known to do service; but it must be confessed, that a perfect cure is seldom obtained. Iffues are of use in these cases, as they appear to prevent the ill effects of over fulness, if it should happen at any time to super- vene.

Sp. III. Dyspnoea from Changes in the Weather. (Sauv. p. 12.)

This seems to be a disease entirely spasmodic, and the antispasmodics already related are accordingly indi- cated.

Sp. IV. The Dyspnoea from Earthy Substances formed in the Lungs.

Sauvages mentions this disease as much more com- mon 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 a dyspnoea, and threatened with consumption. In three cases of this kind which fell under Dr Cullen's inspec- tion, there was no appearance of earthy or flinty con- cretions 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 exquisite 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 pulmo- nary calculi than mankind, is that they very seldom cough, and thus the stagnating mucus or lymph con- cretes into a kind of gypseous matter.

Sp. V. The Watery Dyspnoea.

Dyspnea pituitosa, Sauv. p. 1.

Orthopnoea ab hydropneumonia, Sauv. p. 12.

This may arise from too great a defluxion of mucus on the lungs, or from an effusion of serum, as is men- tioned under the pneumonia. The treatment of the disease may be gathered from what has been already said under the heads of Pneumonia, Catarrh, Empye- ma, &c.

Sp. VI. The Dyspnoea from Corpulency.

Orthopnoea a pinguedine, Sauv. p. 6.

There have been many instances of suffocation and death occasioned by too great corpulency. These fa- tal 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 showed itself externally, nor could be removed by any medicines.

Other species of dyspnea have been considered un- der Phthisis. It is frequently symptomatic of diseases of the heart and large vessels, or swellings of the abdo- men, &c.

GENUS LVII. PERTUSSIS.

Crincough.

Pertussis, Sydenham, Ed. Leid. p. 200, 311, 312. Huxham de aere, ad ann. 1732. Tussis convulsa, tive ferina, Hoffm. III. iii. Tussis ferina, Sauv. sp. 10. Sag. sp. 10. Tussis convulsa, Sauv. sp. 11. Sag. sp. 11. Amphitherina 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 cat- arrh, and there is a remarkable affection of the eyes, as if they were swollen, and a little pulled 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 thrill 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 an- other inspiration of the same kind; and thus it conti- nues for some time, very often till the patient vomit, which puts an end to the paroxysm at that time. These paroxysms are attended with a violent determin- ation of the blood towards the head, so that the ves- sels become extremely turgid, and blood not unfre- quently flows from the mouth and nose. The disease is tedious, and often continues for many months. It is not commonly attended with fever, unless at the com- mencement.

Causes, &c. The chincough is an infectious disor- der, and very often epidemic; but the nature of the contagion is not understood; at least it is no farther un- derstood than that of smallpox, measles, or similar epi- demics. We well know that it is from a peculiar and specific contagion alone that this disease, as well as the others above-mentioned, can arise. But with regard to the nature of any of them, we are totally in the dark. It generally attacks children, or adults of a lax habit, making its attack frequently in the spring or autumn; at the same time, when this contagion is introduced in- to any town, village, or neighbourhood, it will rage epi- demically at any season. Those alone are affected with this disease who had never before been subjected to it. For in this affection, as well as in smallpox, having had the disease once, gives defense against future contagion. Every individual, however, does not seem to be equally readily affected with this contagion; like other con- tagious diseases occurring only once in a lifetime, it may naturally be expected to be more frequent among children than at any other period of life. But many, though frequently exposed to contagion, are yet not affected with the disease; and those children who live upon unwholesome watery food, or breathe unwhole- some air, are most liable to its attacks, or at least suffer medicinE.

mofl from them. In general it has been concluded, that whatever weakens the foids, or tends to bring on a dissolution of the fluids, predisposes to this disease, and increases its severity.

Prognosis. The cincough is not very often fatal. During one epidemic, however, it is often observed to be much more dangerous and more severe than during another. This is also remarked with regard even to particular periods of the same epidemic; and it is also observed, that on certain families this disease is much more severe than on others. Its danger, however, is still more connected with the period of life at which it occurs. In children under two years of age it is most dangerous; and kills them by producing convulsions, suffocation, inflammation, and suppuration of the brain or in the lungs, ruptures, and incarceration 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 scrofulous. It is generally reckoned a good sign when a fit terminates by vomiting; for in this disease there seems to be a great increase of the secretion of mucus, and the vomiting affords great relief.

Cure. Pertussis is one of those diseases which, after the contagion has exerted its influence, can be terminated only by running a certain course; but it is much less limited in its course than smallpox and measles, and often it runs on to a very great length, or at least it is very difficult to distinguish certain sequelae of this disease from the disease itself. And when it exists in the former of these states, it admits of an artificial termination. In the treatment of this affection, therefore, the objects at which a practitioner chiefly aims, are, in the first place, the obviating urgent symptoms, and forwarding the natural termination of the disease; and secondly, the inducing an artificial termination. With these intentions various practices are employed on different occasions. The most approved remedies 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 calomel and cinchona; 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, relates 20 cases of it cured by the extract of hemlock. He directs half a grain daily 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 have not two stools daily, he advises magnesia or the sulphur potash cum sulphure, 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, has by no means become universal in consequence of this publication, nor indeed has this remedy been found equally successful with others who have given it a fair trial.

The remedy most to be depended upon in this disease is change of air. The patient, as soon as the disease is fully formed, ought to be removed to some other part of the country: but there is no occasion for going to a distant place; a mile or two, or frequently a smaller distance, will be sufficient; and in this new habitation, the frequency of the cough is almost instantly diminished to a most surprising degree. After remaining there for some time, however, the cough will often be observed to become again more frequent, and the other symptoms increased. In this case, another change of air, or even a return to the former habitation, becomes necessary. Manifest benefit has even been derived by changing a patient from one room of a house to another. But although change of air has thus been advantageous, it must also be remarked, that when it has been had recourse to at very early periods it has often done mischief, particularly by aggravating the febrile and inflammatory symptoms. If the disease be attended with fever, bleeding and other antiphlogistic remedies are proper. Dr Buchan recommends an ointment made of equal parts of garlic and hog's lard applied to the soles of the feet; but if it have any effect, it is probably merely as an emplastrum calidum. It ought to be put on a rag and applied like a plaster. Opiates may sometimes be useful, but in general are to be avoided. They are chiefly serviceable where the cough is very frequent, with little expectoration. In these cases benefit has sometimes also been derived from sulphuric ether, and sometimes from the tincture of cantharides. An almost instantaneous termination has on some occasions been put to this disease by exciting a high degree of fear, or by inducing another febrile contagion: But the effects of both are too uncertain and too dangerous to be employed in practice.

GENUS LVIII. PYROSIS.

The Heart-Burn.

Pyrosis, Sauv. gen. 200. Sag. 158. Soda, Lin. 47. Vog. 154. Scotis, the Water-Brash. Pyrosis Suecica, Sauv. sp. 4. Cardialgia sputatoria, Sauv. sp. 5.

This disease, whether considered as primary or symptomatic, has already been fully treated under Dyspepsia.

GENUS LIX. COLICA.

The Colic.

Colica, Sauv. gen. 204. Lin. 50. Vog. 160. Sag. 162. Funck. 106. Colica spasmodica et flatulenta, Hoffm. II. 284. Rachialgia, Sauv. gen. 211. Sag. 168. Ileus, Sauv. gen. 252. Vog. 162. Sag. gen. 187. Iliaca, Lin. 185. Dolor et spasmus iliacus, Hoffm. II. 263. Passio iliaca, Funck. 107.

Sp. I. The Spasmodic Colic.

Colica flatulenta, pituitosa, &c. Sauv. sp. 1, 2, 5, 6, 7. Ileus 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, twisting, boring, a ligature drawn very tight, &c. The belly is generally colitive, 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 coughiness; and if purgatives be 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; and hiccup comes on, which continues obstinately; till at last a cessation of pain and fetid breath indicate a mortification of the intestines and approaching death. Sometimes the peristaltic motion of the intestines is so totally inverted, that all their contents are evacuated by the mouth, and even clutters 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 austere, 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 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 intestines have sometimes been found twisted; but more commonly there hath been an introflection 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 constrictive 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 the sides 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 introflection 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 happen 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, has 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 cæcum. 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 cæcum. This cord formed a circle with the mesentery, large enough to admit a hen's egg to pass through it. The cord 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 be free, even though their peristaltic motion should be inverted, and clutters evacuated by the mouth, there is much more hope of a cure, than when the belly is obstinately colitive, and there is some fixed obstruction which seems to bid defiance to all remedies.

Cure. In the cure of the spasmodic colic, the recovery must ultimately depend on producing a resolution of the spasmodic affection. In order to accomplish this, it is in general necessary to evacuate the contents of the intestines, and to remove morbid irritability existing in that part of the system. But in order to preserve the life of the patient from the most imminent hazard, it is still more necessary to prevent and remove those inflammatory affections which often occur in this disease. 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 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 glysters of various kinds, to procure a stool. In obstinate cases, where stimulating cathartics have proved ineffectual, the milder kinds, such as manna, senna, oleum ricini, &c., will sometimes succeed; but when 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; 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 this 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 farther on. The same thing may be said of quicksilver: not to 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. There are, however, some late cases on record, particularly one by Mr William Perry, published in the sixteenth volume of the Edinburgh Medical Commentaries, in which the hydrargyrum, swallowed in great quantities, was attended with the happiest effects, after every other remedy had been tried in vain.

Another method has been proposed, in the Medical Essays, for relieving the miserable patients in this disorder, which in many cases has 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, baths of cold water are to be doused on his feet, legs, and thighs; and this must be continued for an hour or longer, if a stool be not procured before that time, though this will generally be the case much sooner. The exercise does 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 a habitual coliciveness, 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 glysters 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 coliciveness had continued for a much longer time. Other remedies are, the blowing air into the intestines by means of a bellows, and the injecting glysters 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. In some obstinate cases, however, benefit has certainly been derived from tobacco-smoke injections, and likewise from injections of tepid water to the extent of several pounds. For putting in practice these modes of cure, a particular apparatus has been contrived; and in cases even apparently desperate, neither should be neglected. The cold water gives a general and very considerable shock to the system, checks the peripatetic, 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 glyster. But when all methods have failed, the only chance the patient can have for life is by a manual operation.

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. Even there also, however, it is necessary that the belly should be moved; and for this purpose injections, containing a solution of salaciata, which operate powerfully as antispasmodics, are preferable to most other modes of cure.

Sp. II. Colica Pictonum. The Colic of Poitou.

Rachialgia Pictonum, Sauv. sp. 1. Rachialgia metallica, Sauv. sp. 3. Colica Pictonum Citefi.

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 some solution or fume of it, received into the body. 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 is received into the body dissolved in cider, the common drink of the inhabitants of that country. This has been proved by experiment; for lead has 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-ach 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 distension, as with wind; and frequent retchings 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 Spasms, 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. 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 *scybala*, 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, inasmuch 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 peritallatic 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.

**Cure.** 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 sulphate of copper. 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 be ended, it has 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 panada; 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 has found this very efficacious in obstinate affections of the bowels, and that it generally proves a cure in the lighter cases of the colica pictonum. 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. Mercury also, particularly under the form of calomel, has often been employed with success. And much benefit has been derived from combining the calomel with opium. From this combination there is often obtained, in the first instance, an alleviation of the pain, and afterwards a free discharge by the belly.

**Sp. III. The Colic from Coffiveness.**

*Colica stercorea*, Sauv. fp. 3.

*Ileus a faecibus induratis*, Sauv. fp. 2.

For the treatment of this species, see above.

**Sp. IV. The Accidental Colic.**

*Colica Japonica*,—accidentalis,—laetentium,—à veneno, Sauv. fp. 10. 14. 18. 20.

*Cholera ficca auriginosa*, à fungis venenatis, ejusfl. fp. 2.

When colics arise from acid poisonous matter taken into the stomach, the only cure is either to evacuate the poison itself by vomiting, or to swallow some other substance which may decompose it, and thus render it inactive. The most common and dangerous substances of this kind are corrosive mercury and arsenic. The former is easily decomposed by alkaline salts; and therefore a solution of lixivial salt, if swallowed before the poison has 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 has been recommended as efficacious; and lately a solution of *hepar sulphuris*. The latter may possibly do service; as arsenic unites readily with sulphur, and has its pernicious qualities more obviated 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.

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 large quantity of the shell-fish known by the name of mussels (the Mytilus). Some of the fungi, doubtless, may have an inherent poisonous quality; but generally they as well as the mussels act on a different principle. Their pernicious effects happen most commonly when they are taken on an empty stomach; and are then supposed to be 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 has taken place, it cannot be removed till either vomiting be excited, or the stomach has recovered itself in such a manner as to throw off the adhering matter.

Sp. V. Colic of New-born Infants from a Retention of the Meconium. (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, or a drop or two of antimonial wine. By these means the stomach is cleaned by vomiting, and the belly is generally loosed; but if this last effect does not happen, some gentle purge will be necessary.

Sp. VI. Colic from a Callosity of the Colon.

It is often impossible to discover this distemper before the patient's death; and though it should, it does not admit of a cure.

Sp. VII. The Colic from Intestinal Calculi. (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 particular method of cure. In the Medical Essays we have an instance of colics for five 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. Vog. 110. Sag. 188. Hoffm. II. 165. Diarrhoea cholérica, Junck. 112.

Sp. I. The Spontaneous Cholera, coming on without any manifest cause.

Cholera spontanea, Sauv. sp. 1. Sydenh. lect. iv. cap. 2. Cholera Indica, Sauv. sp. 7.

Sp. II. The Accidental Cholera, from acrid matter taken inwardly.

Cholera crapulosa, Sauv. sp. 11. Cholera à venenis, Sauv. sp. 4. 5.

The cholera shows itself by excessive vomiting and purging of bilious matters, with violent pain, irritation 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, a small and unequal pulse, cold sweats, fainting, coldness of the extremities, and hiccup; and death frequently ensues in 24 hours.

In this disease, as a great quantity of bile is deposited in the alimentary canal, particularly in the stomach, the first object is to counteract its influence, and to promote an easy discharge of it. It is next necessary to restrain that increased secretion of bile, by which a fresh deposition in the alimentary canal would otherwise be soon produced. And, in the last place, measures must often be employed to restore a sound condition to the alimentary canal, which is frequently much weakened by the violence of the disease.

On these grounds, 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 be 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 or good simple mint-water is also said to be very efficacious in the same case.

The tincture of opium is sometimes retained when given in conjunction with a portion of the sulphuric acid properly diluted. But when it cannot be retained in a fluid form by the aid of any addition, it will sometimes sit upon the stomach when taken in a solid state.

After the violence of the disease is overcome, the alimentary canal, and the stomach in particular, requires to be braced and strengthened. With this view recourse is often had with advantage to different vegetable bitters, particularly to the use of the colombo root; which, while it strengthens the stomach, is also observed to have a remarkable tendency in allaying a disposition to vomiting, which often remains for a considerable time after the cholera may be said to be overcome. GENUS LXI. DIARRHOEA.

Looseness.

Diarrhoea, Sauv. gen. 253. Lin. 187. Vog. 103. Sag. gen. 189. Junck. 112. Hepatirrhoea, Sauv. gen. 246. Cholerica, Lin. 190. Celiaca, Sauv. gen. 255. Lin. 189. Vog. 109. Sag. gen. 199. Lienteria, Sauv. gen. 256. Lin. 188. Sag. gen. 191. Vog. 108. Pituitaria, et leucorrhoeis, Vog. 111. 112.

Sp. I. The Feculent Diarrhoea.

Diarrhoea stercorosa et vulgaris, Sauv. sp. 1. 2.

This is occasioned by too great a quantity of matter thrown into the alimentary canal; and what is discharged has not the appearance of excrements, but is much whiter, and of a thinner consistence. Voracious people who do not sufficiently chew their food, gormandizers, and even those who stammer in their speech, are said to be liable to this disease. In slighter cases it is removed without any medicine, or by a dose of rhubarb; but where the matters have acquired a putrid taint, the disorder may be much protracted and become dangerous. In this case lenient and antifeptic purgatives are to be made use of, after which the cure is to be completed by astringents.

Sp. II. The Bilious Diarrhoea.

(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 intermitting or bilious fever. When the fever is gone, the diarrhoea is to be removed by acidulated and cooling drinks, with small doses of nitre.

Sp. III. The Mucous Diarrhoea.

Diarrhoea lactentium, Sauv. sp. 19. Dysenteria Pariflava, Sauv. sp. 3. Diarrhoea ab hypercatharisi, Sauv. sp. 16. Dysenteria a catharticis, Sauv. sp. 12. Pituitaria, Vog. 111. Leucorrhoeis, Vog. 117. Diarrhoea pituitola, Sauv. sp. 4. Celiaca mucosa, Sauv. sp. 3. Diarrhoea feroa, 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 ipé-cacuana, 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 spirit of cinnamon, to which was added seven ounces of common water, and two drachms of tincture of catechu. Of this the patient took two spoonfuls once in four or five hours, and sometimes also an opiate at bedtime. He recommends the same medicine in obstinate diarrhoeas of all kinds. A decoction of simaruba bark was also found effectual, when the dysenteric symptoms had gone off. Dr Huck, who used this article in North-America, also recommends it in diarrhoeas. Two or three ounces of the simaruba 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.

Sp. IV. The Coeliac Passion.

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 Arretus, 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 flatus 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 Arretus, 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. Sp. II. DIABETES with insipid Urine.

M. Lister Exerc. Medicin. II. de Diabete. Diabetes legitimus, Sauv. sp. 1. Aretaeus de Morb. diurnum 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 though the patients drink much, the quantity of urine always exceeds what is drank. In Dr 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 discharged from 12 to 15 pints of urine in the 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, feet, and scrotum; in this disease 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 deprived of an animal nature, and to be largely impregnated with a saccharine matter scarcely distinguishable from that obtained from the sugar-cane. This discovery was first made by Dr Dobson of Liverpool, who made some experiments on the urine of a person labouring under a diabetes, who discharged 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 aside, fell into a spontaneous effervescence, changed first into a vinous liquor, and afterwards into an acetous one, before it became putrid and offensive. Eight ounces of blood taken from the same patient, separated into albumen 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 drams 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 winous 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 albumen was