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

History of Medicine.

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

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

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

What seems most probable on this subject therefore is, that religion and medicine came to be mixed together only in consequence of that degeneracy into ignorance and superstition which took place among all nations. The Egyptians, we know, came at last to be sunk in the most ridiculous and absurd superstition; and then, indeed, it is not wonderful that we should find their priests commencing physicians, and mingling charms, incantations, &c. with their remedies. That this was the case, long after the days of Joseph, we are very certain; and indeed it seems as natural for ignorance and barbarism to combine religion with physic, as it is for a civilized and enlightened people to keep them separate. Hence we see, that among all modern barbarians their priests or conjurors are their only physicians.

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

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

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

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

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

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

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

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

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

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

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

The time required for concoction depends on the differences among distempers mentioned above. In those which Hippocrates calls very acute, the digestion or crisis happens by the fourth day; in those which are only acute, it happens on the 7th, 11th, or 14th day; which last is the longest period generally allowed by Hippocrates in distempers that are truly acute: though in some places he stretches it to the 20th or 21st, nay, sometimes to the 40th or 60th day. All diseases that exceed this last term are called chronical. And while in those diseases that exceed 14 days, he considers every fourth day as critical, or at least remarkable, by which we may judge whether the crisis on the following fourth day will be favourable or not; so in those which run from 20 to 40 he reckons only the sevenths, and in those that exceed 40 he begins to reckon by 20. Beyond the 120th he thinks that the number of days has no power over the crisis. They are then referred to the general changes of the seasons; some terminating about the equinoxes; others about the solstices; others about the rising or setting of the stars of certain constellations; or if numbers have yet any place, he reckons by months, or even whole years. Thus (he says), certain diseases in children have their crises in the seventh month after their birth, and others in their seventh or even their 14th year.

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

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

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

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

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

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

Among his prognostics from the excretions by stool are the following:—Those that are soft, yellowish, of some consistence, and not of an extraordinary ill smell, that answer to the quantity of what is taken inwardly, and that are voided at the usual hours, are the best of all. They ought also to be of a thicker consistence when the distemper is near the crisis; and it ought to be taken for a good prognostic, when some worms, particularly the round and long, are evacuated at the same time with them. The prognosis, however, may still be favourable, though the matter excreted be thin and liquid, provided it make not too much noise in coming out, and the evacuation be not in a small quantity nor too often; nor in so great abundance, nor so often, as to make the patient faint. All matter that is watery, white, of a pale green or red colour, or frothy and viscid, is bad. That which is blackish, or of a livid hue, is the most pernicious. That which is pure black, and nothing else but a discharge of black bile, always prognosticates very ill; this humour, from what part ever it comes, showing the ill disposition of the intestines. The matter that is of several different colours, denotes the length of the distemper; and, at the same time, that it may be of dangerous consequence. Hippocrates places in the same class the matter that is bilious or yellow, and mixed with blood, or green and black, or like the dregs or scrapings of the guts. The stools that consist of pure bile, or entirely of phlegm, he also looks upon to be very bad.

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

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

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

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

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

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

Having thus seen in what Hippocrates makes the difference between health and sickness to consist, and likewise the most remarkable signs from whence he drew his prognostics, we must now consider the means he prescribed for the preservation of health, and the cure of diseases. One of his principal maxims was this, That, to preserve health, we ought not to overcharge ourselves with too much eating, nor neglect the use of exercise and labour. In the next place. That we ought by no means to accustom ourselves to too nice and exact a method of living; because those who have once begun to act by this rule, if they vary in the least from it, find themselves very ill; which does not happen to those who take a little more liberty, and live somewhat more irregularly. Notwithstanding this he does not neglect to inquire diligently into the articles which those who were in health used for food in his time. Here we cannot help taking notice of the prodigious disparity between the delicacy of the people in our days and in those of Hippocrates: for he takes great pains to tell the difference between the flesh of a dog, a fox, a horse, and an ass; which he would not have done if at that time they had not been used for victuals, at least by the common people. Besides these, however, Hippocrates speaks of all other kinds of provision that are now in use; for example, salads, milk, whey, cheese, flesh as well of birds as of four-footed beasts, fresh and salt fish, eggs, all kinds of pulse, and the different kinds of grain we feed on, as well as the different sorts of bread that are made of it. He also speaks very often of a sort of liquid food, or broth, made of barley-meal, or some other grain, which they steeped for some time, and then boiled in water. With regard to drink, he takes a great deal of pains to distinguish the good waters from the bad. The best, in his opinion, ought to be clear, light, without smell or taste, and taken out of the fountains that turn towards the east. The salt waters, those that he calls hard, and those that rise out of feney ground, are the worst of all; he condemns also those that come from melted snow. But though Hippocrates makes all these distinctions, he advises those who are in health to drink of the first water that comes in their way. He speaks also of alum waters, and those that are hot; but does not enlarge upon their qualities. He advises to mix wine with an equal quantity of water: and this (he says) is the just proportion; by using which the wine will expel what is hurtful to the body, and the water will serve to temper the acrimony of the humours.

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

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

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

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

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

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

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

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

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

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

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

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

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

When he found that diet and exercise were not sufficient to take nature of a burden of corrupted humours, he was obliged to make use of other means, of purgation, which purgation was one. By this word he understood all the contrivances that are made use of to discharge the stomach and bowels; though it commonly signifies only only the evacuation by stool. This evacuation he imagined to be occasioned by the purgative medicines attracting the humours to themselves. When first taken into the body, he thought they attracted that humour which was most similar to them, and then the others, one after another.—Most of the purgatives used in his time were emetics also, or at least were very violent in their operation downwards. These were the white and black hellebore; the first of which is now reckoned among the poisons. He used also the Cnidian berries, eneornum peplium, thapsia; the juice of hippophaë, a sort of rhamnus; elaterium, or juice of the wild cucumber; flowers of brais, coloquintida, scammony, the magnesian stone, &c.

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

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

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

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

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

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

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

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

Hippocrates had also a fourth intention for bleeding, and this was refreshment. So in the iliac passion, he orders bleeding in the arm and in the head; to the end, says he, that the superior venter, or the breast, may cease to be overheated. With regard to this evacuation, his conduct was much the same as to purging, in respect of time and persons. We ought, says he, to let blood in acute diseases, when they are violent, if the party be lusty and in the flower of his age. We ought also to have regard to the time, both in respect to the disease and to the season in which we let blood. He also informs us, that blood ought to be let in great pains, and particularly in inflammations. Among these he reckons such as fall upon the principal viscera, as the liver, lungs, and spleen, as also the quinsy and pleurisy, if the pain of the latter be above the diaphragm. In these cases he would have the patients bled till they faint, especially if the pain be very acute; or rather he advises that the orifice should not be close till the colour of the blood alters, so that from livid it turn red, or from red livid. In a quinsy he bled in both arms at once. Difficulty of breathing he also reckons among the distempers that require bleeding; and he mentions another sort of inflammation of the lungs, which he calls a swelling or tumor of the lungs arising from heat; in which case he advises to bleed in all parts of the body; and directs it particularly by the arms, tongue, and nostrils. To make bleeding the more useful in all pains, he directed to open the vein nearest the part affected; in a pleurisy he directs to take blood from the arm of the side affected; and for the same reason, in pains of the head, he directs the veins of the nose and forehead to be opened. When the pain was not urgent, and bleeding was advised by way of prevention, he directed the blood to be taken from the parts farther off, with a design to divert the blood infensibly from the seat of pain. The highest burning fevers, which show neither signs of inflammation nor pain, he does not rank among those distempers which require bleeding. On the contrary, he maintains that a fever itself is in some cases a reason against bleeding. If any one, says he, has an ulcer in the head, he must bleed, unless he has a fever. He says further, those that lose their speech of a sudden must be bled, unless they have a fever. Perhaps he was afraid of bleeding in fevers, because he supposed that they were produced by the bile and pituita, which grew hot, and afterwards heated the whole body, which is, says he, what we call fever, and which, in his opinion, cannot well be evacuated by bleeding. In other places also he looks upon the presence or abundance of bile to be an objection to bleeding; and he orders to forbear venefication even in a pleurisy, if there be bile. To this we must add, that Hippocrates distinguished very particularly between a fever which followed no other distemper, but was itself the original malady, and a fever which came upon inflammation. In the early ages of physic, the first only were properly called fevers: the others took their names from the parts affected; as pleurisy, peripneumony, hepatitis, nephritis, &c. which names signify that the pleura, the lungs, the liver, or the kidneys, are diseased, but do not intimate the fever which accompanies the disease. In this latter sort of fever Hippocrates constantly ordered bleeding, but not in the former. Hence, in his books on Epidemic Distempers, we find but few directions for bleeding in the acute distempers, and particularly in the great number of continual and burning fevers there treated of. In the first and third book we find but one single instance of bleeding, and that in a pleurisy; in which, too, he stayed till the eighth day of the distemper. Galen, however, and most other commentators on Hippocrates, are of opinion that he generally bled his patients plentifully in the beginning of acute disorders, though he takes no notice of it in his writings. But had this been the case, he would not perhaps have had the opportunity of seeing so many fevers terminate by cures, or natural evacuations, which happen of themselves on certain days. Hippocrates, in fact, laid so much weight upon the affluence of nature and the method of diet, which was his favourite medicine, that he thought if they took care to diet the patients according to rule, they might leave the rest to nature. These are his principles, from which he never deviates; so that his writings on Epidemical Diseases seem to have been composed only with an intention to leave to posterity an exact model of management in pursuance of these principles. With regard to the rules laid down by Hippocrates for bleeding, we must farther take notice, that in all diseases which had their seat above the liver, he bled in the arm, or in some of the upper parts of the body; but for those that were situated below it, he opened the veins of the foot, ankle, or ham. If the belly was too loofe, and bleeding was at the same time thought necessary, he ordered the loofenels to be stopp'd before bleeding.

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

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

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

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

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

Of the external remedies prescribed by Hippocrates, fomentations were the chief. These were of two kinds. The one was a sort of bath, in which the patient sat in a vessel full of a decoction of simples appropriated to his malady; so that the part affected was soaked in the decoction. This was chiefly used in distempers of the womb, of the arms, the bladder, the reins, and generally all the parts below the diaphragm. The second way of fomenting was, to take warm water and put it into a skin or bladder, or even into a copper or earthen vessel, and to apply it to the part affected; as, for example, in a pleurisy. They used likewise a large sponge, which they dipped in the water or other hot liquor, and squeezed out part of the liquor before they applied it. The same use they made of barley, vetches, or bran, which were boiled in some proper liquor, and applied in a linen bag. These are called moist fomentations. The dry ones were made of salt or millet, heated considerably, and applied to the part. Another kind of fomentation was the vapour of some hot liquor; an instance of which we find in his first book of the Distempers of Women. He cast, at several times, bits of red-hot iron into urine, and, covering up the patient close, caused her to receive the steam below. His design in these kinds of fomentations was to warm the part, to resolve or diffuse, and draw out the peccant matter, to mollify and assuage pain, to open the passages, or even to flat them, according as the fomentations were emollient or astringent. Fumigations were likewise very often used by Hippocrates. In the quinify, he burned hyssop with sulphur and pitch, and caused the smoke to be drawn into the throat by a funnel; and by this means he brought away abundance of phlegm through the mouth and through the nose. For this purpose he took nitre, marjoram, and cress-seeds, which he boiled in water, vinegar, and oil, and, while it was on the fire, caused the patient to draw in the steam by a pipe. In his works we find a great number of fumigants for the distemper of women, to promote the menstrual flux, to check it, to help conception, and to ease pains in the matrix, or the suffocation of it. On these occasions he used such aromatics as were then known, viz. cinnamon, cassia, myrrh, and several odoriferous plants; likewise some minerals, such as nitre, sulphur, and pitch, and caused the patient to receive the vapours through a funnel into the uterus.

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

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

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

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

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

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

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

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

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

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

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

Herophilus, the disciple of Praxagoras, and contemporary of Erafitratus, followed a less simple practice: he made no great use of medicines both simple and compound, that neither he nor his disciples would undertake the cure of any disorder without them. He seems also to have been the first who treated accurately of the doctrine of pulses, of which Hippocrates had but a superficial knowledge. Galen, however, affirms, that on this subject he involved himself in difficulties and advanced absurdities; which indeed we are not greatly to wonder at; considering the time in which he lived. He took notice of a disease at that time pretty rare, and to which he ascribes certain sudden deaths. He calls it a palsy of the heart; and perhaps it may be the same disease with what is now termed the angina pectoris.

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

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

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

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

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

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

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

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

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

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

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

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

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

Themison was old when he laid the foundation of the methodic sect; and it was only brought to perfection by Thephilus, who lived under the emperor Nero. Thephilus, Galen and Pliny accuse this physician of intolerable insolence and vanity, and report that he gave himself the air of despising all other physicians; and so intolerable was his vanity, that he assumed the title of the conqueror of physicians, which he caused to be put upon his tomb in the Appian way. Never was mountebank (says Pliny) attended by a greater number of spectators Thessalus, spectators than Thessalus had generally about him; and this circumstance is the less to be wondered at, if we consider that he promised to teach the whole art of medicine in less than fix months. In reality, the art might be learned much sooner if it comprehended no more than what the methodics thought necessary: for they cut off the examination of the causes of diseases followed by the dogmatics; and substituted in the room of the laborious obervations of the empirics, indications drawn from the analogy of diseases, and the mutual resemblance they bear to each other. The most skilful of all the methodic sect, and he who put the last hand to it, was Soranus. He lived under the emperors Trajan and Adrian, and was a native of Ephesus.

One of the most celebrated medical writers of antiquity was Celsus, whom we have already had occasion to mention. Most writers agree that he lived in the time of Tiberius, but his country is uncertain. It is even disputed whether or not he was a professed physician. Certain it is, however, that his books on medicine are the most valuable of all the ancients next to those of Hippocrates. From the latter, indeed, he has taken so much, as to acquire the name of the Latin Hippocrates; but he has not attached himself to him so closely as to reject the assistance of other authors. In many particulars he has preferred Asklepiades. With him he laughs at the critical days of Hippocrates, and ascribes the invention of them to a foolish and superstitious attachment to the Pythagorean doctrine of numbers. He also rejected the doctrine of Hippocrates with regard to venefication, of which he made a much more general use; but did not take away so much blood at a time, thinking it much better to repeat the operation than weaken the patient by too great an evacuation at once. He used cupping also much more frequently, and differed from him with regard to purgatives. In the beginning of disorders, he said, the patients ought to endure hunger and thirst: but afterwards they were to be nourished with good aliments; of which, however, they were not to take too much, nor fill themselves suddenly, after having fasted long. He does not specify how long the patient ought to practice abstinence; but affirms, that in this particular it is necessary to have a regard to the disease, the patient, the season, the climate, and other circumstances of a like nature. The signs drawn from the pulse he looked upon to be very precarious and uncertain. "Some (says he) lay great stress upon the beating of the veins or the arteries; which is a deceitful circumstance, since that beating is slow or quick, and varies very much, according to the age, sex, and constitution of the patient. It even sometimes happens that the pulse is weak and languid when the stomach is disordered, or in the beginning of a fever. On the contrary, the pulse is often high, and in a violent commotion, when one has been exposed to the sun, or comes out of a bath, or from using exercise; or when one is under the influence of anger, fear, or any other passion. Besides, the pulse is easily changed by the arrival of the physician, in consequence of the patient's anxiety to know what judgment he will pass upon his case. To prevent this, the physician must not feel the patient's pulse on his first arrival: he must first sit down by him, assume a cheerful air, inform himself of his condition; and if he is under any dread, endeavour to remove it by encouraging discourse; after which he may examine the beating of the artery. This, nevertheless, does not hinder us from concluding, that if the sight of the physician alone can produce so remarkable a change in the pulse, a thousand other causes may produce the same effect." But although Celsus thought for himself, and in not a few particulars differed from his predecessors, yet in his writings, which are not only still preferred, but have gone through almost innumerable editions, we have a compendious view of the practice of almost all his predecessors: and he treats of the healing art in all its branches, whether performed manu, visu, vel medicamentis. His writings, therefore, will naturally be consulted by every one who wishes either to become acquainted with the practice of the ancients prior to the fall of the Roman empire, or to read medical Latin in its greatest purity.

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

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

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

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

The second kind of disorders, relating to the organisical parts, results from irregularities of these parts, with respect to the number, bulk, figure, situation, &c. as when one has fix fingers, or only four; when one has any part larger or smaller than it ought to be, &c. The third kind, which is common both to the familiar and the organisical parts, is a solution of continuity, which happens when any familiar or compound part is cut, bruised, or corroded. Like Hippocrates, Galen distinguished diseases into acute and chronic; and, with respect to their nature and genius, into benign and malignant; also into epidemic, endemic, and sporadic.

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

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

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

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

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

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

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

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

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

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

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

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

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

In consequence of the general decay of learning in the western parts of the world, the Greek writers were entirely neglected, because nobody could read the language; and the Arabians, though principally copiers from them, enjoyed all the reputation that was due to the others. The Arabian physic was introduced into Europe very early, with the most extravagant applause: and not only this, but other branches of their learning, came into repute in the west; insomuch that in the 11th century, the studies of natural philosophy and the liberal arts were called the studies of the Saracens. This was owing partly to the crusades undertaken against them by the European princes; and partly to the settlement of the Moors in Spain, and the intercourse they and other Arabians had with the Italians. For, long before the time of the crusades, probably in the middle of the 7th century, there were Hebrew, Arabic, and Latin professors of physic settled at Salernum: which place soon grew into such credit, that Charles the Great thought proper to found a college there in the year 822; the only one at that time in Europe. Constantine the African flourished there towards the latter end of the 11th century. He was a native of Carthage; but travelled into the east, and spent 30 years in Babylon and Bagdad, by which means he became master of the oriental languages and learning. He returned to Carthage; but being informed of an attempt against his life, made his escape into Apulia, where he was recommended to Robert Guiscard, created in 1066 duke of that country, who made him his secretary. He was reputed to be very well versed in the Greek, as well as in the eastern tongues; and seems to have been the first who introduced either the Greek or Arabian physic into Italy. His works, however, contain nothing that is new, or material; though he was then accounted a very learned man.

From this time to the end of the 15th and beginning of the 16th century, the history of physic furnishes us with no interesting particulars. This period, however, is famous for the introduction of chemistry into medicine, and the description of three new distempers, the sweating sickness, the venereal disease, and the feverly. The sweating sickness began in 1485, in the army of Henry VII. upon his landing at Milford-haven, and spread itself at London from the 21st of September to the end of October. It returned there five times, and always in summer; first in 1495, then in 1506, afterwards in 1517, when it was so violent that it killed many in the space of three hours, so that numbers of the nobility died, and of the commonalty in several towns often the one-half perished. It appeared the fourth time in 1528, and then proved mortal in fix hours; many of the courtiers died of it, and Henry VIII. himself was in danger. In 1529, and only then, it infected the Netherlands and Germany, in which last country it did much mischief. The last return of it was in 1551, and in Weilminster it carried off 120 in a day. Dr Caius describes it as a pestilential contagious fever, of the duration of one natural day; the sweat he reckoned to be only a natural symptom, or crisis of the distemper. It first affected some particular part, attended with inward heat and burning, unquenchable thirst, relleflines, fickness at stomach, but seldom vomiting, headache, delirium, then faintness, and excessive drowsiness. The pulse was quick and vehement, and the breath short and laborious.—Children, poor and old people, were rarely subject to it. Of others, scarce any escaped the attack, and most of them died. Even by travelling into France or Flanders they did not escape; and what is still more strange, the Scots were said not to be affected; abroad the English only were seized, and foreigners in England were free. At first the physicians were much puzzled how to treat this disease. The only cure they ever found, however, was to carry on the sweat for a long time; for, if stopped, it was dangerous or fatal. The way, therefore, was for the patient to lie still, and not expose himself to cold. If nature was not strong enough to force out the sweat, it was necessary to assist her by art, with clothes, wine, &c. The violence of the distemper was over in 15 hours; but there was no security for the patient till 24 were passed. In some strong constitutions there was a necessity to repeat the sweating, even to 12 times. The removing out of bed was attended with great danger; some who had not sweated enough fell into very bad fevers.—No flesh-meat was to be allowed in all the time of the distemper; nor drink for the first five hours. In the seventh, the distemper increased; in the ninth the delirium came on, and sleep was by all means to be avoided. However terrible this distemper appeared at first, it seldom proved obstinate, if treated in the above-mentioned manner.

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

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

The revival of learning, which now took place throughout Europe, the appearance of these new distempers, and the natural fondness of mankind for novelty, contributed greatly to promote the advancement of medicine as well as other sciences. While at the same time, the introduction of the art of printing rendered the communication of new opinions as well as new practices so easy a matter, that to enumerate even the names of those who have been justly rendered eminent for medical knowledge would be a very tedious task. It was not, however, till 1628 that Dr William Harvey of London demonstrated and communicated to the public one of the most important discoveries respecting the animal economy, the circulation of the blood. This discovery, more effectually than any reasoning, overturned all the systems which had subsisted prior to that time. It may justly be reckoned the most important discovery that has hitherto been made in the healing art: for there can be no doubt that it puts the explanation of the phenomena of the animal body, both in a state of health and disease, on a more solid and rational footing than formerly. It has not, however, prevented the rise of numerous fanciful and absurd systems. These, though fashionable for a short time, and strenuously supported by blind adherents, have yet in no long period fallen into deserved contempt. And notwithstanding the abilities and industry of Stahl, Hoffman, Boerhaave, and Cullen, we may confidently venture to assert that no general system has yet been proposed which is not liable to innumerable and unanswerable objections. Very great progress has indeed been made in explaining the philosophy of the human body, from ascertaining by decisive experiment the influence of the circulating, the nervous, and the lymphatic systems in the animal economy. But every attempt hitherto made to establish any general theory in medicine, that is, to conduct the cure of every disease on a few general principles, has equally deviated from truth with those of Hippocrates and Galen; and has equally tended to mislead those who have adopted it. Many systems of our own days, such for example as that of Brown, though adopted with enthusiasm by the young and inexperienced, have evidently been attended with the most pernicious consequences in practice. Indeed we may with confidence venture to assert, that from the very nature of the subject itself, medicine does not admit of such simplicity. No one can deny that the human body consists of a very great number of different parts, both solids and fluids. It is, however, equally certain, that each of these is from many different causes liable to deviations from the sound state. And although some slight changes may take place without what can be called a morbid affection, yet we well know, that every change taking place to a certain degree in any one part will necessarily and unavoidably produce an affection of the whole. Hence we may without hesitation venture to affirm, that every general theory which can be proposed, attempting to explain the phenomena, and conduct the cure of all diseases on a few general principles, though for some time it may have strenuous advocates, will yet in the end be found to be both ill-grounded and pernicious.

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

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

Theory of Medicine, or an Account of the principal Functions of the Animal Body.

WHILE the functions of living animals, but particularly of the human species, are very numerous, the accounts given of these both in a state of health and disease are very various. Without, therefore, pretending to enumerate the contradictory opinions of different authors, we shall here present the reader with a view of this subject, Functions subject, chiefly extracted from the Conspicuous Medicine Theoretics of Dr James Gregory, who has collected from other writers the opinions at present most generally adopted.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sleep may be prevented both in healthy and sick people from various causes; such as strong light, noise, pain, anger, joy, grief, fear, anxiety, hunger, thirst, vehement desire, motion of the body, memory, imagination, intense thought, &c. On the other hand, sleep is brought on by a flight impression on the organs of sense, or none at all; by the humming of bees, the noise of falling water, cold and infipid discourse; or lastly, by such an exercise of the memory as is neither too laborious nor disturbing to the mind.—Too great an impulse of the blood towards the head, such as often happens in fevers, prevents sleep; but a free and equal distribution of the blood through the whole body, especially the extreme parts, frequently brings it on. Whatever weakens the body also favours sleep; and hence various kinds of evacuations, the warm bath, fomentations, sometimes heat itself, are useful for promoting it. It also comes on easily after taking food, or indulging venery; the violent sensation being then quieted, and the body itself somewhat weakened. Cold produces a deep sleep of long continuance, not easily disturbed, and often terminating in death. Lastly, There are certain substances which, when applied to the body, not only do not excite the nervous system, but plainly lay us asleep, and render us unfit for sensation; of this kind are those called narcotic, as opium and the like; among which also we may reckon wine taken in too great quantity. Lastly, Watching itself is often the cause of sleep; because while a man is awake he always more or less exercises the organs of his body, by which the nervous influence is diminished, and thus the more violently the body is exercised, in the same proportion is the person under a necessity of sleeping.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A too thin and watery blood makes the face pale, the body weak and languid. The solid parts become flaccid from want of nourishment, and having too great a quantity of water in their composition. It brings on hydropic effusions of water in all parts of the body, by reason of the increased exhalation of that thin fluid which moistens all the inward parts; partly by reason of the vessels being relaxed beyond their usual pitch, and not making a proper resistance. Besides, in this case, the lymphatics are so far from absorbing more than usual, that, partaking likewise of the general debility, they are scarcely fitted for performing their proper offices.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Practice of Medicine, or an Account of the principal Diseases to which the Human Body is subjected.

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

The Classes of Sauvages are,

1. Vitia. 2. Febres. 3. Phlegmasiae. 4. Spafmi. 5. Anhelationes. 6. Debilitates. 7. Dolores. 8. Vefanice. 9. Fluxus. 10. Cachexiae.

The Classes of Linnaeus are,

1. Exanthematici. 2. Critici. 3. Phlogistici. 4. Dolorosi. 5. Mentales. 6. Quietales. 7. Motorii. 8. Suppressorii. 9. Evacuatorii. 10. Deformes. 11. Vitia.

The Classes of Vogel are,

1. Febres. 2. Profuvia. 3. Epichenes. 4. Dolores. 5. Spafmi. 6. Adynamiae. 7. Hyperæstheses. 8. Cachexie. 9. Paranoiae. 10. Vitia. 11. Deformitates.

The Classes of Sagar are,

1. Vitia. 2. Palgae. 3. Cachexiae. 4. Dolores. 5. Fluxus. 6. Suppressiones. 7. Spafmi. 8. Anhelationes. 9. Debilitates. 10. Exanthemata. 11. Phlegmasiae. 12. Febres. 13. Vefanice. Besides these, two other systems have been presented to the public, which may be considered as deserving attention; those, viz. of the late learned Dr M'Bride of Dublin, and of the late ingenious Dr Darwin.

The Classes and Orders of M'Bride.

Class I. Universal Diseases. Or. 1. Fevers. 2. Inflammations. 3. Fluxes. 4. Painful diseases. 5. Spasmodic diseases. 6. Weaknesses or privation. 7. Asthmatic disorders. 8. Mental disorders.

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

Class III. Sexual Diseases. Or. 1. General proper to men. 2. Local proper to men. 3. General proper to women. 4. Local proper to women.

Class IV. Infantile Diseases. Or. 1. General. 2. Local.

The Classes and Orders of Darwin.

Class I. Diseases of Irritation. Or. 1. Increased irritation. 2. Decreased irritation. 3. Retrograde irritative motions.

Class II. Diseases of Sensation. Or. 1. Increased sensation. 2. Decreased sensation. 3. Retrograde sensitive motions.

Class III. Diseases of Volition. Or. 1. Increased volition. 2. Decreased volition.

Class IV. Diseases of Association. Or. 1. Increased associated motions. 2. Decreased associated motions. 3. Retrograde associated motions.

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

Cullen's Arrangement.

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

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

Sect. I. Intermitentes. Fevers arising from the miasma of marshes; with an apyrexia, or at least a very evident remission; but the disease returns regularly, and for the most part with a horror or trembling.

Genus I. Tertiana. Similar paroxysms after an interval of about 48 hours, coming on most commonly at mid-day. A tertian hath either; I. An apyrexia interposed. 1. Varying in the duration of the paroxysms. A, The tertian whose paroxysms are not extended beyond 12 hours. B, The tertian with paroxysms extended beyond 12 hours. 2. Varying in the return of paroxysms. C, The tertian returning every day with unequal paroxysms alternately similar to one another. D, The tertian returning every third day with two paroxysms on the same day. E, The tertian returning every day, with two paroxysms on every third day, and only one on the intermediate ones. F, The tertian returning every day, with an evident remission interposed between the odd and the even days, but a less remarkable one between the even and the odd days. 3. Varying in its symptoms. G, The tertian accompanied with a disposition to sleep. H, Accompanied with spasms and convulsive motions. I, Accompanied with an efflorescence on the skin. K, with phlegmata. 4. Varying in being complicated with other diseases. 5. Varying as to its origin. II. With the interposition only of a remission between the paroxysms. Genus II. Quartana. Similar paroxysms, with an interval of about 72 hours, coming on in the afternoon. I. With the interposition of an apyrexia. 1. Varying in the type. A, The quartan with single paroxysms, returning every fourth day, none on the other days. B, With two paroxysms every fourth day, and none on the other days. C, With three paroxysms every fourth day, and none on the intermediate days. D, Of the four days having only the third free from fever, with similar paroxysms every fourth day. E, The quartan coming on every day, with similar paroxysms every fourth day. 2. Varying in its symptoms. 3. Varying in being complicated with other diseases. II. With a remission only between the paroxysms. Genus III. Quotidiana. Similar paroxysms with an interval of about 24 hours, coming on commonly in the morning. I. With the interposition of an apyrexia. 1. Varies in being solitary. A. Universal. B. Partial. 2. Complicated with other diseases. II. With a remission only between the paroxysms. Sect. II. Continue. Fevers without evident intermission, and not occasioned by marsh miasmata; but attended with exacerbations and remissions, though not always very remarkable.

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

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

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

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

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

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

The species are, I. Phlogosis (phlegmone) of a vivid red colour; a swelling well defined, for the most part elevated to a point, and frequently degenerating into an abscess, with a beating or throbbing pain. The variations are, 1. In the form. 2. In the situation. II. Phlogosis (erythema) of a reddish colour, vanishing by pressure; of an unequal and creeping circumference, with scarce any swelling; ending in the scaling off of the cuticle, in pustules, or blisters. The variations are, 1. In the degree of violence. 2. In the remote cause. 3. In being complicated with other diseases. The consequences of a phlogosis are, an impoisthume, gangrene, sphacelus.

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

The species and varieties of the ophthalmia are, I. Idiopathic. 1. Ophthalmia (membranarum), in the tunica adnata, and the membranes lying under it, or the coats of the eye. A. Varying in the degree of the external inflammation. B. In the internal coats affected. 2. Ophthalmia (tarph), of the eye-lids, with swelling, erosion, and glutinous exudation.

II. Symptomatic. 1. From a disease of the eye itself. 2. From diseases of other parts, or of the whole body.

Genus IX. Phrenitis. Violent pyrexia; pain of the head; redness of the face and eyes; inability to endure the light or any noise; watchfulness; a furious delirium, or typhomania. I. Idiopathic. II. Symptomatic. Genus X. Cynanche. Pyrexia sometimes inclining to a typhus; difficulty of swallowing and breathing; with a fenestration of narrowness in the fauces.

The species are, I. Cynanche (tonfillaris) affecting the mucous membrane of the fauces, but especially the tonsils, with redness and swelling, accompanied with a synocha. II. Cynanche (maligna) affecting the tonsils, and mucous membrane of the fauces with swelling, redness, and mucous crusts of a whitish or ash-colour, creeping, and covering ulcers; with a typhous fever and exanthemata. III. Cynanche (trachealis) attended with difficult respiration, noisy and hoarse inspiration, loud cough, without any apparent tumor in the fauces, somewhat difficult deglutition, and a synocha. IV. Cynanche (pharyngea) attended with redness in the bottom of the fauces, very difficult and painful deglutition, respiration sufficiently free, and a synocha. V. Cynanche (parotidea) with great swelling in the parotids and maxillary glands appearing on the outside: the respiration and deglutition but little injured; a synocha, for the most part mild. Diseases of this genus are symptomatic, either from external or internal causes.

Genus XI. Pneumonia. Pyrexia, with a pain in some part of the thorax, difficult respiration, and cough. The species are, I. Peripneumony, with a pulse not always hard, but sometimes soft; an obtuse pain of the breast; the respiration always difficult; sometimes the patient cannot breathe unless in an upright posture; the face swelled, and of a livid colour; the cough for the most part moist, frequently bloody. 1. Simple idiopathic peripneumonies. Varying in degree. 2. Idiopathic peripneumonies complicated with fever. 3. Symptomatic peripneumonies. II. Pleurify, with a hard pulse; for the most part attended with a pungent pain of one side, augmented chiefly during the time of inspiration; an uneasiness when lying on the side; a most painful cough, dry in the beginning of the disease, afterwards moist, and frequently bloody. 1. Simple idiopathic pleurifies. 2. Pleurifies, complicated, (1.) With fever. (2.) With catarrh. 3. Symptomatic pleurifies. 4. False pleurifies. The consequences of pleurify are a vomica or empyema. Genus XII. Carditis. Pyrexia; pain about the heart; anxiety; difficulty of breathing; cough; unequal pulse; palpitation of the heart, and fainting. I. Idiopathic. II. Symptomatic.

Genus XIII. Peritonitis. Pyrexia; pain of the belly, exasperated by an upright posture, without the proper signs of other abdominal phlegmatis. I. Peritonitis (propria), situated in the peritoneum, properly so called, surrounding the inside of the abdomen. II. Peritonitis (omentalis), in the peritoneum extended through the omentum. III. Peritonitis (mesenterica), in the peritoneum spread through the mesentery.

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

I. Idiopathic. 1. From internal causes. A, Gastritis (phlegmonodea), attended with acute pain and violent pyrexia. 2. From external causes. B, Gastritis (erysipelatosa), with a less violent fever and pain; an erysipelatous redness appearing on the fauces.

II. Symptomatic.

Genus XV. Enteritis. Pyrexia of a typhous nature; pungent pain of the belly, stretching and twisting about the navel; vomiting; the belly obstinately bound. I. Idiopathic. 1. Enteritis (phlegmonodea), with acute pain, violent fever, vomiting, and constipation of the belly. 2. Enteritis (erysipelatosa), with less acute fever and pain, without vomiting; but accompanied with a diarrhoea.

II. Symptomatic.

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

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

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

Genus XIX. Cyfitis. Pyrexia; pain and swelling of the hypogastrium: frequent and painful discharge of urine, or ichuria; and tenesmus. The species are, I. Those arising from internal causes. II. Those from external causes.

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

Genus XXI. Rheumatismus. A disease arising from an external and frequently very evident cause; pyrexia; pain about the joints, frequently following the course of the muscles; infecting the knees and other large joints rather than those of the feet or hands; increased by external heat. The species are either idiopathic or symptomatic. The former varies in situation. A, In the muscles of the loins. B, In the muscles of the coxendix. C, In the muscles of the breast.

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

Genus XXIII. Podagra. An hereditary disease, arising without any evident external cause, but for the most part preceded by an unusual affection of the stomach; pyrexia; pain of a joint for the most part of the great toe of the foot, at least infecting chiefly the wrists and ankles; returning by intervals; and often alternated with affections of the stomach and other internal parts. I. Podagra (regularis), with a pretty violent inflammation of the joints remaining for some days, and by degrees going off with swelling, itching, and desquamation of the affected part. II. Podagra (atonica), with an atony of the stomach, or some other internal part; and either without the usual inflammation of the joints, or only with slight and wandering pains; and frequently alternated with dyspepsia, or other symptoms of atony. III. Podagra (retrograda), with the inflammation of the joints suddenly disappearing, and an atony of the stomach and other parts immediately following. IV. Podagra (aberrans), with the inflammation of an internal part either preceding or not, and suddenly disappearing.

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

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

Genus XXV. Erysipelas. A synocha of two or three days, for the most part attended with drowsiness, often with a delirium. In some parts of the skin, most frequently the face, appears a phlogosis. The species are, I. Erysipelas (vesiculo/um), with erythema, redness creeping, occupying a large space, and in some parts ending in large blisters. II. Erysipelas (phytienodes), with an erythema formed of a number of papulae, chiefly occupying the trunk of the body, ending in phlyctence or small blisters. The disease is also symptomatic.

Genus XXVI. Pestis. An exceedingly contagious typhus, with the highest debility. On an uncertain day of the disease buboes and carbuncles break forth. It is various in degree, but the species are uncertain. Genus XXVII. Variola; a contagious synoche, with vomiting, and pain on pressing the epigastrium. On the third day begins, and on the fifth is finished, the eruption of inflammatory pustules, which suppurate in the space of eight days, and at last go off in crusts; frequently leaving depressed cicatrices or pockpits in the skin. The species are, I. Variola (difficeta), with few, distinct, turpid, pustules, having circular bases; the fever ceasing immediately after the eruption. II. Variola (confluens), with numerous, confluent, irregularly shaped pustules, flaccid and little elevated; the fever remaining after the eruption. Genus XXVIII. Varicella. Synoche; papule breaking out after a short fever, similar to those of the smallpox, but hardly ever coming to suppuration; after a few days going off in small scales, without leaving any mark. Genus XXIX. Rubeola. A contagious synoche, with freezing, epiphora, and dry hoarse cough. On the fourth day, or a little later, break forth small, clustered, and scarcely elevated papulae; after three days going off in very small branny scales. I. Rubiola (oulgaritis), with very small confluent corymbose papulae, scarcely rising above the skin. Varying, 1. In the symptoms being more severe, and the course of the disease less regular. 2. In being accompanied with a cynanche. 3. With a putrid diathesis. II. Rubeola (variolodes), with distinct papulae, raised above the skin. Genus XXX. Miliaria. Synochus with anxiety, frequent sighing, unctuous sweat, and a sense of pricking as of pin points in the skin. On an uncertain day of the disease, break out red, small, distinct papules, spread over the whole body as well as the face; the spots of which, after one or two days, become very small white pustules, remaining for a short time. Genus XXXI. Scarlatina. A contagious synoche. On the fourth day of the disease the face swells a little; at the same time an universal redness occupies the skin in large spots, at length running together; after three days going off in branny scales; frequently succeeded by an anaeraea. The species are, I. Scarlatina (simplex), not accompanied with cynanche. II. Scarlatina (cynanchica), with an ulcerous cynanche. Genus XXXII. Urticaria. A quotidian fever. On the second day of the disease, red spots resembling the stinging of nettles, almost vanishing during the day, but returning in the evening with the fever, and after a few days going off altogether in very small scales. Genus XXXIII. Pemphigus. A contagious typhus. On the first, second, or third day of the disease, blisters break out in several parts of the body, of the bigness of a bean, remaining for many days, and at last pouring out a thin ichor. Genus XXXIV. Aphtha. Synochus; the tongue sometimes swelled and of a livid colour, as well as the fauces; often first appearing in the fauces, but at length occupying the whole internal parts of the mouth, of a white colour, sometimes distinct, often running together, quickly growing again when taken off; and remaining for an uncertain time. The species are, 1. Idiopathic. 2. Symptomatic. Order IV. Hæmorrhagie. Pyrexia, with a discharge of blood, without any external violence: the blood drawn from a vein hath the same appearance as in phlegmaæ. Genus XXXV. Epitaxis. Pain or weight of the head, redness of the face; a discharge of blood from the nose. I. Idiopathic. Varying according to the time of life. 1. Epitaxis of young people, with symptoms of an arterial plethora. 2. Epitaxis of old people, with symptoms of a venous plethora. II. Symptomatic. 1. From internal causes. 2. From external causes. Genus XXXVI. Hæmoptysis. Redness of the cheeks; a sensation of uneasiness, or pain, and sometimes of heat in the breast; difficulty of breathing; tickling of the fauces; either a severe or less violent cough, bringing up florid and frequently frothy blood. The idiopathic species are, 1. Hæmoptysis (plethorica), without any external violence, and without being preceded by any cough or suppression of any customary evacuation. 2. Hæmoptysis (violenta), from external violence applied. 3. Hæmoptysis (phthisica), after a long-continued cough, with a lameness and debility. 4. Hæmoptysis (calculus), in which some calculous molecules, for the most part of a calcareous nature, are thrown up. 5. Hæmoptysis (vicaria), after the suppression of a customary evacuation. Besides these, there are a number of symptomatic species mentioned by different authors. The consequence of an hæmoptysis is, a Phthisis. A wasting and debility of the body, with a cough, hectic fever, and for the most part a purulent expectoration. The species are, I. An incipient phthisis, without any expectoration of pus. II. A confirmed phthisis, with an expectoration of pus. Both species vary, 1. As to their remote cause. 2. As to the origin of the purulent matter. Genus XXXVII. Hæmorrhoides. Weight and pain of the head; vertigo; pain of the loins; pain of the anus; livid painful tubercles, from which for the most part blood flows out; which sometimes also drops out of the anus, without any apparent tumor. The species are, 1. Hæmorrhoides (tumens), external from mariscæ. Varying, A. Bloody. B. Mucous. 2. Hæmorrhoides (procident), external from a procidentia ant. 3. Hæmorrhoides (flues), internal, without any swelling, or procidentia ant. 4. Hæmorrhoides Practice.

4. Haemorrhoid (ceca), with pain and swelling of the anus, without any profusion of blood. Genus XXXVII. Menorrhagia. Pains of the back, belly, and loins, like those of child-birth; an unusual copious flux of the menses or blood from the vagina. The species are, 1. Menorrhagia (rubra), bloody in women neither with child nor in child-birth. 2. Menorrhagia (abortus), bloody in women with child. 3. Menorrhagia (lochialis), bloody in women after delivery. 4. Menorrhagia (vittorum), bloody from some local disease. 5. Menorrhagia (alba), serous, without any local disease, in women not pregnant. 6. Menorrhagia (Nabothi), serous in women with child.

Order V. PROFLUVIA. Pyrexia, with an increased excretion, naturally not bloody. Genus XXXIX. Catarthus. Pyrexia frequently contagious; an increased excretion of mucus, at least efforts to excrete it. The species are, 1. From cold. 2. From contagion. Genus XL. Dylenteria. Contagious pyrexia; frequent mucous or bloody stools, while the alvine faeces are for the most part retained; gripes; tenesmus. Varying, 1. Accompanied with worms. 2. With the excretion of small fleshy or sebaceous bodies. 3. With an intermittent fever. 4. Without blood. 5. With a miliary fever.

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

Order I. COMATA. A diminution of voluntary motion, with sleep, or a deprivation of the senses. Genus XLI. Apoplexia. Almost all voluntary motion abolished, with sleep more or less profound; the motion of the heart and arteries remaining. The idiopathic species are, 1. Apoplexia (anguinea), with symptoms of universal plethora, especially of the head. 2. A poplexia (fero/a), with a leucophlegmatia over the whole body, especially in old people. 3. Apoplexia (hydrocephalica), coming on by degrees; affecting infants, or those below the age of puberty, first with lassitude, a slight fever and pain of the head, then flowness of the pulse, dilatation of the pupil of the eye, and drowsiness. 4. Apoplexia (atrabilaria), taking place in those of a melancholic constitution. 5. Apoplexia (traumatica), from some external injury mechanically applied to the head. 6. Apoplexia (venenata), from powerful sedatives taken internally or applied externally. 7. Apoplexia (mentalis), from an affection or emotion of the mind.

8. Apoplexia (cataleptica), the muscles remaining contractile, by external motion of the limbs. 9. Apoplexia (suffocata), from some external suffocating power. The apoplexy is frequently symptomatic. 1. Of an intermittent fever. 2. Continued fever. 3. Phlegmaphia. 4. Exanthema. 5. Hyfteria. 6. Epilepsia. 7. Podagra. 8. Worms. 9. Ichuria. 10. Scurvy. Genus XLII. Paralysis. Only some of the voluntary motions impaired, frequently with sleep. The idiopathic species are, 1. Paralysis (partialis) of some particular muscles only. 2. Paralysis (hemiplegica) of one side of the body. Varying according to the constitution of the body. a. Hemiplegia in a plethoric habit. b. In a leucophlegmatic habit. 3. Paralysis (paraplegica) of one half of the body taken transversely. 4. Paralysis (venenata) from sedative powers applied either internally or externally. A symptom either of an Asthenia or Palsy is, Tremor; an alternate motion of a limb by frequent strokes and intervals. The species are, 1. Asthenic. 2. Paralytic. 3. Convulsive.

Order II. ADYNALE. A diminution of the involuntary motions, whether vital or natural. Genus XLIII. Syncope; a diminution, or even a total stoppage, of the motion of the heart for a short time. I. Idiopathic. 1. Syncope (cardiaca), returning frequently without any manifest cause, with violent palpitations of the heart during the intervals.—From a fault of the heart or neighbouring vessels. 2. Syncope (occasionalis) arising from some evident cause.—From an affection of the whole system. II. Symptomatic; of diseases either of the whole system, or of other parts besides the heart. Genus XLIV. Dyspepsia. Anorexia, nausea, vomiting, inflation, eructation, rumination, cardialgia, gastralgia, more or fewer of these symptoms at least concurring; for the most part with a constipation of the belly, and without any other disease either of the stomach itself or of other parts. I. Idiopathic. II. Symptomatic. 1. From a disease of the stomach itself. 2. From a disease of other parts, or of the whole body. Genus XLV. Hypochondriasis. Dyspepsia, with languor, sadness and fear, without any adequate causes, in a melancholy temperament. Genus XLVI. Chlorosis. Dyspepsia, or a desire of something not used as food; a pale or discoloured complexion; the veins not well filled; a soft tumor of the whole body; asthenia; palpitation; suppression of the menses.

Order III. SPASMI. Irregular motions of the muscles or muscular fibres. Sect. I. In the animal functions. Genus XLVII. Tetanus. A spastic rigidity of almost the whole body.

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

Genus XLVIII. Trifmus. A spastic rigidity of the lower jaw.—The species are, 1. Trifmus (naecentium), attacking infants under two months old. 2. Trifmus (traumaticus), attacking people of all ages either from a wound or cold.

Genus XLIX. Convulsio.—An irregular clonic contraction of the muscles without sleep. I. Idiopathic. II. Symptomatic. Genus L. Chorea, attacking those who have not yet arrived at puberty, most commonly within the 10th or 14th year, with convulsive motions for the most part of one side in attempting the voluntary motion of the hands and arms, resembling the gesticulations of mountebanks; in walking, rather dragging one of their feet than lifting it.

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

Genus LII. Epilepsia. A convulsion of the muscles, with sleep. The idiopathic species are, 1. Epilepsia (cerebralis), suddenly attacking without any manifest cause, without any sense of uneasiness preceding, excepting perhaps a flight vertigo or dimness of sight. 2. Epilepsia (sympathica), without any manifest cause, but preceded by the sensation of a kind of air rising from a certain part of the body towards the head. 3. Epilepsia (occasionalis), arising from a manifest irritation, and ceasing on the removal of that irritation.

Varying according to the difference of the irritating matter. And thus it may arise, From injuries of the head; pain; worms; poison; from the repulsion of the itch, or an effusion of any other acrid humour; from crudities in the stomach; from passions of the mind; from an immoderate hemorrhage; or from debility.

Sect. II. In the vital functions. In the action of the heart. Genus LIII. Palpitation. A violent and irregular motion of the heart. In the action of the lungs. Genus LIV. Asthma. A difficulty of breathing returning by intervals, with a sense of straitness in the breast, and a noisy respiration with hiffing. In the beginning of the paroxysm there is either no cough at all, or coughing is difficult; but towards the end the cough becomes free, frequently with a copious spitting of mucus.—The idiopathic species are, 1. Asthma (spontaneum), without any manifest cause or other concomitant disease. 2. Asthma (exanthematicum), from the repulsion of the itch or other acrid effusion. 3. Asthma (plethoricum), from the suppression of some customary fanguineous evacuation, or from a spontaneous plethora.

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

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

The symptomatic species of dyspnœa are consequences, 1. Of diseases of the heart or large vessels. 2. Of a swelling in the abdomen. 3. Of various other diseases. Genus LVI. Pertussis. A contagious disease; convulsive strangulating cough reiterated with noisy inspiration; frequent vomiting.

Sect. III. In the natural functions. Genus LVII. Pyrosis. A burning pain in the epigastrium, with plenty of aqueous humour, for the most part insipid, but sometimes acid, belched up.

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

The idiopathic species are, 1. Colica (spasmatica), with retraction of the navel, and spasms of the abdominal muscles. Varying, by reason of some symptoms superadded. Hence, a. Colica, with vomiting of excrements, or of matters injected by the anus. b. Colica, with inflammation supervening. 2. Colica (pietunum), preceded by a sense of weight or uneasiness in the belly, especially about the navel; then comes on the colic pain, at first slight and interrupted, chiefly augmented after meals: at length more severe and almost continual, with pains of the arms and back, at last ending in a palsy. Varying according to the nature of the remote cause; and hence, a. From metallic poison. b. From acids taken inwardly. c. From cold. d. From a contusion of the back. 3. Colica (fiercerea), in people subject to costiveness. 4. Colica (accidentalis), from acrid matter taken inwardly. 5. Colica (meconialis), in new-born children from a retention of the meconium. 6. Colica (callofa), with a sensation of stricture in some part of the intestines, and frequently of a collection of flatus with some pain; which flatus also passing through the part where the stricture is felt, gradually vanishes; the belly flow, and at last passing only a few liquid faeces.

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

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

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

II. Symptomatic. Genus LX. Diarrhea. Frequent stools; the disease not infectious; no primary pyrexia.

I. Idiopathic. 1. Diarrhea (crapulosa), in which the excrements are voided in greater quantity than naturally. 2. Diarrhea (biliosa), in which yellow faeces are voided in great quantity. 3. Diarrhea (mucofa), in which either from acrid substances taken inwardly, or from cold, especially applied to the feet, a great quantity of mucus is voided. 4. Diarrhea (celiac), in which a milky humour of the nature of chyle is discharged by stool. 5. Diarrhea (linteria), in which the aliment are discharged with little alteration soon after eating. 6. Diarrhea (hepatirrhcea), in which a bloody ferrous matter is discharged without pain.

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

I. Idiopathic. 1. Diabetes (mellitus), with urine of the smell, colour, and taste of honey. 2. Diabetes (insipidus), with limpid, but not sweet, urine.

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

The following are by Sauvages reckoned distinct idiopathic species; but, by Dr Cullen, only varieties of the same species. A. From a retention of the menfes. B. From a menorrhagia cruenta. C. From a menorrhagia ferofa, or fluor albus. D. From an obstruction of the viscera. E. From a fault of the stomach. F. From too great facility.

Genus LXIII. Hydrophobia. A dislike and horror at any kind of drink, as occasioning a convulsion of the pharynx; induced, for the most part, by the bite of a mad animal. The species are, 1. Hydrophobia (rabiofa), with a desire of biting the bystanders, occasioned by the bite of a rabid animal. II. Hydrophobia (simplex), without madness, or any desire of biting.

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

Genus LXIV. Amentia; an imbecility of judgement, by which people either do not perceive, or do not remember, the relations of things. The species are, 1. Amentia (congenita), continuing from birth. II. Amentia (senilis), from the diminution of the perceptions and memory through extreme old age. III. Amentia (acquisita), occurring in people formerly of a sound mind, from evident external causes. Genus LXV. Melancholia; a partial madness, without dyphemia. Varying according to the different subjects concerning which the person raves; and thus it is, 1. With an imagination in the patient concerning his body being in a dangerous condition, from flight causes; or his affairs in a deplorable state. 2. With an imagination concerning a prosperous state of affairs. 3. With violent love, without satyriasis or nymphomania. 4. With a superstitious fear of a future fate. 5. With an aversion from motion and all the offices of life. 6. With restlessness, and an impatience of any situation whatever. 7. With a weariness of life. 8. With a deception concerning the nature of the patient's species.

Dr Cullen thinks that there is no such disease as that called demonomania, and that the diseases mentioned by Sauvages under that title are either, 1. Species of melancholy or mania; or 2. Of some disease by the spectators falsely ascribed to the influence of an evil spirit; or 3. Of a disease entirely feigned; or 4. Of a disease partly true and partly feigned. Genus LXVI. Mania; universal madness. 1. Mania (mentalis), arising entirely from passions of the mind. 2. Mania (corporea), from an evident disease of the body. Varying according to the different disease of the body. 3. Mania (obscura), without any passion of mind or evident disease of the body preceding. The symptomatic species of mania are, 1. Paraphrofyne from poisons. 2. Paraphrofyne from passion. 3. Paraphrofyne febrils. Genus LXVII. Oneirodynia. A violent and troublesome imagination in time of sleep. 1. Oneirodynia (activa), exciting to walking and various motions. 2. Oneirodynia (gravans), from a sense of some weight incumbent, and pressing on the breast especially. Class III. CACHEXIAE; a depraved habit of the whole or greatest part of the body, without primary pyrexia or neurosis.

Order I. MARCORES; emaciation of the whole body.

Genus LXVIII. Tabes. Leannes, athenia, hectic fever. The species are, 1. Tabes (purulente), from an external or internal ulcer, or from a vomica. Varying in its situation: hence, 2. Tabes (scrophuloa), in scrophulous constitutions. 3. Tabes (venenata), from poison taken inwardly. Genus LIX. Atrophia. Leannes and athenia, without hectic fever. The species are, 1. Atrophia (inanitorum), from too great evacuation. 2. Atrophia (famelicorum), from a want of nourishment. 3. Atrophia (cacoachymica), from corrupted nourishment. 4. Atrophia (debilium), from the function of nutrition being depraved, without any extraordinary evacuation or cacoachymia having preceded.

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

Seçt. I. Adipose. Genus LXX. Polyfarcia; a troublesome swelling of the body from fat.

Seçt. II. Flatuosa. Genus LXXI. Pneumatosis; a tense elastic swelling of the body, crackling under the hand. The species are, 1. Pneumatosis (spontanea), without any manifest cause. 2. Pneumatosis (traumatica), from a wound in the breast. 3. Pneumatosis (veneneta), from poison injected or applied. 4. Pneumatosis (hylerica), with hysteria.

Genus LXXII. Tympanites; a tense, elastic, sonorous swelling of the abdomen; costiveness; a decay of the other parts. The species are, 1. Tympanites (intestinalis), with a tumor of the abdomen frequently unequal, and with a frequent evacuation of air relieving the tension and pain. 2. Tympanites (abdominalis), with a more evident noise, a more equable tumor, and a less frequent emission of flatus, which also gives less relief.

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

Seçt. III. Aquose or Dropies. Genus LXXIV. Anafarca. A soft, inelastic swelling of the whole body, or some part of it. The species are, 1. Anafarca (serosa), from a retention of serum on account of the suppression of the usual evacuations, or from an increase of the serum on account of too great a quantity of water taken inwardly. 2. Anafarca (apilata), from a compression of the veins.

3. Anafarca (exanthematica), arising after exanthemata, especially succeeding erysipelas. 4. Anafarca (anemia), from the thinness of the blood produced by hemorrhagy. 5. Anafarca (debilium), in weak people after long diseases, or from other causes.

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

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

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

Genus LXXVIII. Ascites. A tense, fierce elastic, but fluctuating swelling of the abdomen. The species are, 1. Ascites (abdominalis), with an equal swelling of the whole abdomen, and with a fluctuation sufficiently evident. Varying according to the cause. A. From an obstruction of the viscera. B. From debility. C. From a thinness of the blood. 2. Ascites (accutus), with a swelling of the abdomen, in the beginning at least, partial, and with a less evident fluctuation.

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

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

Seçt. IV. Solidae. Genus LXXXI. Phylconia. A swelling chiefly occupying a certain part of the abdomen, gradually increasing, and neither sonorous nor fluctuating. The species are, Phylconia hepatica. Phylconia splenica. Phylconia renalis. Phylconia uterina. Phylconia ab ovario. Phylconia mefentrica. Phylconia intestinialis. Phylconia omentalis. Phylconia polysplachna. Phylconia vilceralis. Phylconia externa lupialis. Phylconia externa schirrhodea. Phylconia externa hydatidofa. Phylconia ab adipe subcutaneo. Phylconia ab excrecentia.

Genus LXXXII. Rachitis. A large head, swelling most in the fore part, the ribs depressed; abdomen swelled, with a decay of the other parts. Varying, 1. Simple, without any other disease. 2. Joined with other diseases.

Order III. IMPETIGINES. Cachexies chiefly deforming the skin and external parts of the body. Genus LXXXIII. Scrophula. Swelling of the conglobate glands, especially in the neck; swelling of the upper lip and of the nose; the face florid, skin thin, abdomen swelled. The species are, 1. Scrophula (vulgaris), simple, external and permanent. 2. Scrophula (mefenterica), simple, internal, with paleness of the face, want of appetite, swelling of the abdomen, and unusual fetor of the excrements. 3. Scrophula (fugax), most simple, appearing only about the neck; for the most part proceeding from the resorption of the matter of ulcers in the head. 4. Scrophula (Americana), joined with the yaws.

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

Genus LXXXV. Scorbutus; in cold countries, attacking after putrefaction diet, especially such as is salt and of the animal kind, where no supply of fresh vegetables is to be had; athenia; stomacace; spots of different colours on the skin, for the most part livid, and appearing chiefly among the roots of the hair. Varying in degree. a, Scorbutus incipiens. b, Scorbutus crescens. c, Scorbutus inverteratus. Varying also in symptoms. d, Scorbutus lividus. e, Scorbutus petechialis. f, Scorbutus pallidus. g, Scorbutus ruber. h, Scorbutus calidus.

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

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

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

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

Genus XC. Icterus; yellowness of the skin and eyes; white feces; urine of a dark red, tinging what is put into it of a yellow colour. The idiopathic species are, 1. Icterus (calculosus), with acute pain in the epigastric region, increasing after meals; biliary concretions voided by stool. 2. Icterus (spasmodicus), without pain, after spasmodic diseases and passions, of the mind. 3. Icterus (hepaticus), without pain, after diseases of the liver. 4. Icterus (gravidaeum), arising during the time of pregnancy, and going off after delivery. 5. Icterus (infantum), coming on in infants a few days after birth.

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

Order I. Dysesthesiae. The senses depraved or destroyed, from a disease of the external organs. Genus XCI. Caligo. The sight impaired or totally destroyed, on account of some opaque substance interposed between the objects and the retina, inherent in the eye itself or the eyelids. The species are, 1. Caligo (lentis), occasioned by an opaque spot behind the pupil. 2. Caligo (corneci), from an opacity of the cornea. 3. Caligo (pupillae), from an obstruction of the pupil. Varying according to the different causes from which it proceeds. 4. Caligo (humorum), from a disease or defect of the aqueous humour. Varying according to the different state of the humour. 5. Caligo (palpebrarum), from a disease inherent in the eyelids. Varying according to the nature of the disease in the eyelids.

Genus XCII. Amaurosis. The sight diminished, or totally abolished, without any evident disease of the eye; the pupil for the most part remaining dilated and immovable. The species are, 1. Amaurosis (compressio), after the causes and attended with the symptoms of congestion in the brain. Varying according to the nature of the remote cause. 2. Amaurosis (atonica), after the causes and accompanied with symptoms of debility. 3. Amaurosis (phasmodica), after the causes and with the signs of spasm. 4. Amaurosis (venenata), from poison taken into the body or applied outwardly to it.

Genus XCIII. Dytopia. A depravation of the sight, so that objects cannot be distinctly perceived, except at a certain distance, and in a certain situation. The species are, 1. Dytopia (tenebrarum), in which objects are not seen unless they be placed in a strong light. 2. Dytopia (luminis), in which objects are not distinctly seen unless by a weak light. 3. Dytopia (diffusorium), in which distant objects are not perceived. 4. Dytopia (proximum), in which the nearest objects are not perceived. 5. Dytopia (lateralis), in which objects are not perceived unless placed in an oblique posture.

Genus XCIV. Pseudoblephisis; when the sight is defeated in such a manner that the person imagines he sees things which really do not exist, or sees things which do exist after some other manner than they really are. The species are, 1. Pseudoblephisis (imaginaria), in which the person imagines he sees things which really do not exist. Varying according to the nature of the imagination. 2. Pseudoblephisis (mutans), in which objects really existing appear somehow changed. Varying according to the change perceived in the objects, and according to the remote cause.

Genus XCV. Dyfecoae. A diminution or total abolition of the sense of hearing. The species are, 1. Dyfecoae (organica), from a disease in the organs transmitting sounds to the internal ear. Varying according to the nature of the disease and of the part affected. 2. Dyfecoae (atonica), without any evident disease of the organs transmitting the sounds. Varying according to the nature of the cause.

Genus XCVI. Paracufis; a depravation of the hearing. The species are, 1. Paracufis (imperfecta), in which though sounds coming from external objects are heard, yet it is neither distinctly nor in the usual manner. Varying, a. With a dulness of hearing. b. With a hearing too acute and sensible. c. When a single external sound is doubled by some internal causes. d. When the sounds which a person desires to hear are not perceived, unless some other violent sound is raised at the same time. 2. Paracufis (imaginaria), in which sounds not exciting externally are excited from internal causes. Varying according to the nature of the sound perceived, and according to the nature of the remote cause.

Genus XCVII. Anofmia; a diminution or abolition of the sense of smell. The species are, 1. Anofmia (organica), from a disease in the membrane lining the internal parts of the nostrils. Varying according to the nature of the disease. 2. Anofmia (atonica), without any evident disease of the membrane of the nose.

Genus XCVIII. Agheuffia; a diminution or abolition of the sense of taste. 1. Agheuffia (organica), from a disease in the membrane of the tongue, keeping off from the nerves those substances which ought to produce taste. 2. Agheuffia (atonica), without any evident disease of the tongue.

Genus XCIX. Anaesthesia; a diminution or abolition of the sense of feeling. The species from Sauvages, adopted by Dr Cullen, are, 1. Anaesthesia à spina bifida. 2. Anaesthesia plethorica. 3. Anaesthesia nascentium. 4. Anaesthesia melancholica.

Order II. Dysorexie; error or defect of appetite. Sect. I. Appetitus erronei. Genus C. Bulimia; a desire for food in greater quantities than can be digested. The idiopathic species are, 1. Bulimia (helluonum), an unusual appetite for food, without any disease of the stomach. 2. Bulimia (lyngopalis), a frequent desire of meat, on account of a sensation of hunger threatening syncope. 3. Bulimia (emeticus), an appetite for a great quantity of meat, which is thrown up immediately after it is taken.

Genus CI. Polydipsia; an appetite for an unusual quantity of drink. The polydipsia is almost always symptomatic, and varies only according to the nature of the disease which accompanies it.

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

Genus CIII. Satyriasis; an unbounded desire of venery in men. The species are, 1. Satyriasis (juvenilis), an unbounded desire of venery, the body at the same time being little disordered. 2. Satyriasis (furens), a vehement desire of venery with a great disorder of the body at the same time.

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

Genus CV. Noftalgia; a violent desire in those who are absent from their country of revisiting it. 1. Noftalgia (simplex), without any other disease. 2. Noftalgia (complicata), accompanied with other diseases.

Sect. II. Appetitus deficientes. Genus CVI. Anorexia. Want of appetite for food. Always symptomatic. 1. Anorexia (humoralis), from some humour loading the stomach. 2. Anorexia (atonica), from the tone of the fibres of the stomach being lost.

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

Genus CVIII. Anaphrodisia; want of desire for, or impotence to, venery. The true species are, 1. Anaphrodisia paralytica. 2. Anaphrodisia gonorrhoeica. The false ones are, 1. Anaphrodisia à mariscis. 2. Anaphrodisia ab urethrae vitio.

Order III. Dyscinesiae. An impediment, or deprivation of motion from a disorder of the organs. Genus CIX. Aphonía; a total suppression of voice without coma or syncope. The species are, 1. Aphonía (gutturalis), from the fauces or glottis being swelled. 2. Aphonía (trachealis), from a compression of the trachea. 3. Aphonía (atonica), from the nerves of the larynx being cut.

Genus CX. Mutitas; a want of power to pronounce words. The species are, 1. Mutitas (organica), from the tongue being cut out or destroyed. 2. Mutitas (atonica), from injuries done to the nerves of the tongue. 3. Mutitas (furdorum), from people being born deaf, or the hearing being destroyed during childhood.

Genus CXI. Paraphonia; a depraved sound of the voice. The species are, 1. Paraphonia (puberum), in which, about the time of puberty, the voice from being acute and sweet, becomes more grave and harsh. 2. Paraphonia 2. Paraphonia (rauca), in which, by reason of the dryness or faiced tumor of the fauces, the voice becomes rough and hoarse.

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

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

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

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

Genus CXII. Pfeffimus; a defect in the articulation of words. The species are, 1. Pfeffimus (hae/ians), in which the words, especially the first ones of a discourse, are not easily pronounced, and not without a frequent repetition of the first syllable. 2. Pfeffimus (ringens), in which the sound of the letter R is always aspirated, and, as it were, doubled. 3. Pfeffimus (lallans), in which the sound of the letter L becomes more liquid, or is pronounced instead of R. 4. Pfeffimus (emolliens), in which the hard letters are changed into the softer ones, and thus the letter S is much used. 5. Pfeffimus (balbutiens), in which, by reason of the tongue being large, or swelled, the labial letters are better heard, and often pronounced instead of others. 6. Pfeffimus (acheilias), in which the labial letters cannot be pronounced at all, or with difficulty. 7. Pfeffimus (lagoflomatum), in which, on account of the division of the palate, the guttural letters are less perfectly pronounced.

Genus CXIII. Strabifimus; the optic axes of the eyes not converging. The species are, 1. Strabifimus (habitualis), from a bad custom of using only one eye. 2. Strabifimus (commodus), from the greater debility or mobility of one eye above the other; so that both eyes cannot be conveniently used. 3. Strabifimus (nece/forius), from a change in the situation or shape of the parts of the eye.

Genus CXIV. Dyphagia; impeded deglutition, without phlegmata or the respiration being affected.

Genus CXV. Contratura; a long-continued and rigid contraction of one or more limbs. The species are, 1. Contratura (prinaria), from the muscles becoming contracted and rigid. a. From the muscles becoming rigid by inflammation. b. From muscles becoming rigid by spasm. c. From muscles contracted by reason of their antagonists having become paralytic. d. From muscles contracted by an irritating acrimony. 2. Contratura (articulare), from stiff joints.

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

Genus CXVI. Profusio; a flux of blood.

Genus CXVII. Ephidrosis; a preternatural evacuation of sweat.

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

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

Genus CXIX. Ptyalismus; a flux of saliva.

Genus CXX. Enuresis; an involuntary flux of urine without pain. The species are, 1. Enuresis (tonica), after diseases injuring the sphincter of the bladder. 2. Enuresis (irritata), from a compression or irritation of the bladder.

Genus CXXI. Gonorrhoea; a preternatural flux of humour from the urethra in men, with or without a desire of venery. The species are, 1. Gonorrhoea (pura), in which, without any impure venery having preceded, a fluid resembling pus, without dysuria or propensity to venery, flows from the urethra. 2. Gonorrhoea (impura), in which, after impure venery, a fluid like pus flows from the urethra with dysuria. The consequence of this is, Gonorrhoea (mucosa), in which, after an impure gonorrhoea, a mucous humour flows from the urethra with little or no dysuria. 3. Gonorrhoea (leavorum), in which an humour for the most part pellucid, without any erection of the penis, but with a propensity to venery, flows from the urethra while the person is awake. 4. Gonorrhoea (dormientium), in which the seminal liquor is thrown out, with erection and desire of venery, in those who are asleep and have lascivious dreams.

Order V. EPISCHESSES; suppressions of evacuations.

Genus CXXII. Obfitatio; the stools either suppressed, or flower than usual. The species are, 1. Obfitatio (debilitum), in lax, weak, and for the most part dyspeptic persons. 2. Obfitatio (rigidorum), in people whose fibres are rigid, and frequently of an hypochondriac disposition. 3. Obfitatio (obstructorum), with symptoms of the colica, 1st, 2d, 4th, and 7th, above-mentioned.

Genus CXXIII. Icthuria; an absolute suppression of urine. The species are, 1. Icthuria (renalis), coming after a disease of the kidneys, with pain, or troublesome sense of weight in the region of the kidneys, and without any swelling of the hypogastrium, or desire of making water. 2. Icthuria (ureterica), coming after a disease of the kidneys, with a sense of pain or uneasiness in some part of the ureter, and without any tumor of the hypogastrium, or desire of making water. 3. Icthuria (vesicalis), with a swelling of the hypogastrium, pain at the neck of the bladder, and a frequent stimulus to make water. 4. Icthuria (urethralis), with a swelling of the hypogastrium, frequent stimulus to make water, and pain in some part of the urethra.

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

Genus CXXIV. Dysuria; a painful, and somehow impeded emission of urine. The species are, 1. Dysuria 1. Dysuria (ardens), with heat of urine, without any manifest disorder of the bladder. 2. Dysuria (systmodica), from a spasim communicated from the other parts to the bladder. 3. Dysuria (compreffionis), from the neighbouring parts preffing upon the bladder. 4. Dysuria (phlogiftica), from an inflammation of the neighbouring parts. 5. Dysuria (irritata), with signs of a stone in the bladder. 6. Dysuria (mucofa), with a copious excretion of mucus.

Genus CXXXV. Dyspermatifimus; a flow, impeded, and insufficient emission of semen in the venereal act. The species are, 1. Dyspermatifimus (urethralis), from diseases of the urethra. 2. Dyspermatifimus (nodosus), from knots on the corpora cavernosa penis. 3. Dyspermatifimus (praeputialis), from too narrow an orifice of the prepuce. 4. Dyspermatifimus (mucosus); from mucus infarcting the urethra. 5. Dyspermatifimus (hypertonicus), from too strong an erection of the penis. 6. Dyspermatifimus (epilepticus), from a spasmodic epilepsy happening during the time of coition. 7. Dyspermatifimus (apractodes), from an imbecility of the parts of generation. 8. Dyspermatifimus (refluxus), in which there is no emission of semen, because it returns from the urethra into the bladder.

Genus CXXXVI. Amenorrhoea. The menfes either flowing more sparingly than usual, or not at all, at their usual time, without pregnancy. The species are, 1. Amenorrhoea (emansionis), in thole arrived at puberty, in whom, after the usual time, the menfes have not yet made their appearance, and many different morbid affections have taken place. 2. Amenorrhoea (suppressionis), in adults, in whom the menfes which had already begun to flow are suppressed. 3. Amenorrhoea (difficilis), in which the menfes flow sparingly, and with difficulty.

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

Genus CXXXVII. Aneurifima; a soft tumor, with pulsation, above an artery. Genus CXXXVIII. Varix; a soft tumor, without pulsation, above a vein. Genus CXXXIX. Ecchymoma; a diffused, little eminent, and livid tumor. Genus CXXX. Schirrus; an hard tumor of some part, generally of a gland, without pain, and difficultly brought to suppuration. Genus CXXXI. Cancer; a painful tumor of a febrinous nature, and degenerating into an ill conditioned ulcer. Genus CXXXII. Bubo; a suppurring tumor of a conglobate gland. Genus CXXXIII. Sarcoma; a soft swelling, without pain. Genus CXXXIV. Verruca; a harder scabrous swelling.

Genus CXXXV. Clavus; a hard, lamellated thicknes of the skin. Genus CXXXVI. Lupia. A moveable, soft tumor below the skin, without pain. Genus CXXXVII. Ganglion. A hard moveable swelling, adhering to a tendon. Genus CXXXVIII. Hydatis; a cuticular vesicle filled with aqueous humour. Genus CXXXIX. Hydarthus; a most painful swelling of the joints, chiefly of the knee, at first scarce elevated, of the fame colour with the skin, diminishing the mobility. Genus CXL. Exostosis; a hard tumor adhering to a bone.

Order VII. ECTOPIAE; tumors occasioned by the removal of some part out of its proper situation. Genus CXL. Hernia; an ectopia of a soft part as yet covered with the skin and other integuments. Genus CXLII. Prolapsus; a bare ectopia of some soft part. Genus CXLIII. Luxatio; the removal of a bone from its place in the joints.

Order VIII. DIALYSES. A solution of continuity; manifest to the sight or touch. Genus CXLIV. Vulnus; a recent and bloody solution of the unity of some soft part by the motion of some hard body. Genus CXLV. Uleus. A purulent or ichorous solution of a soft part. Genus CXLVI. Herpes; a great number of phlyctenae or small ulcers, gathering in clusters, creeping, and obfinate. Genus CXLVII. Tinca; small ulcers among the roots of the hair of the head, pouring out a fluid which changes to a white friable scurf. Genus CXLVIII. Flora. Itchy pustules and little ulcers of an infectious nature, chiefly infecting the hands. Genus CXLIX. Fractura; bones broken into large fragments. Genus CL. Caries; an ulceration of a bone.

Having thus presented to our readers Dr Cullen's general systematic view of all the diseases to which the human body is subjected, we come next to give a more particular account of the more important affections, treating of them in the order which Dr Cullen has arranged them.

CLASS I. PYREXIAE, or the Febrile Diseases.

ORDER I. FEBRES, OR FEVERS strictly fo called.

Sauvag. Clafs II. Vog. Clafs I. Sagar. Clafs XII. Morbi Febriles Critici, Lin. Clafs II.

SECT. I. INTERMITTENTS.

Intermittentes of many authors; Sauv. Clafs II. Order III. Lin. Clafs II. Order II. Vog. Clafs I. Order I. Sag. Clafs XII. Order III. The remittent of others, Sauv. Clas II. Order II. Sag. Clas XII. Order II. Exacerbantes, Lin. Clas II. Order III. Continue, Vog. Clas I. Order II.

Genus I. TERTIANA; the TERTIAN FEVER. (Tertiana, Sauv. G. 88. Lin. 16. Hoffm. Stahl. Cleghorn. Senac.)

The Genuine TERTIAN.

(Tertiana legitima, Senert. Hoffm. Cleghorn, Minore. Sauv. Sp. I.)

1. Description. This disease, in its most regular form, consists of repeated paroxyms, returning every second day, the patient during the intermediate period enjoying apparently a state of good health. This is the most common form of ague, as it is commonly called in Britain. Each paroxym consists of three parts, the cold, the hot, and the sweating stages. The paroxym commonly begins with a remarkable shivering, increasing frequently to a convulsive shaking of the limbs. The extremities are always cold, sometimes remarkably so. The cold for the most part is first perceived about the lumbar regions, from thence ascending along the spine it turns towards the pit of the stomach. Sometimes it begins in the first joint of the fingers and tip of the nose. Sometimes it attacks only a particular part of the body, as one of the arms, the side of the head, &c. This cold is often preceded by a heavy and sleepy torpor, languor, and lassitude, which we are partly to ascribe to real weakness and partly to mere languor. To these symptoms succeed yawning and stretching; after which the cold comes on as above described, not unfrequently with a pain of the back, and a troublesome sensation of tension in the precordia and hypochondria. To this succeed nausea and vomiting: and the more genuine the disease, the more certainly does the vomiting come on; by which a great deal of tough mucous matter, and sometimes bilious fluff or indigested food, is evacuated during the first paroxym. In some there is only a violent straining to vomit, without bringing up any thing: sometimes, instead of these symptoms, a diarrhea occurs, and this chiefly in weak, phlegmatic, and aged people, or where an indigested mucous taburra has long remained in the prime.

When these symptoms have continued for an hour or two, the cold begins to go off, and is succeeded by a lassitude, languor, and flaccidity of the whole body, but chiefly in the limbs, with an uneasy foreboding as if the parts had been bruised; excepting in those cases where the nausea continues for a longer time. After this languor, a heat comes on, the increase of which is generally slow, but sometimes otherwise, with pain of the head, thirst, and bitterness in the mouth. The pulse is quick and unequal; sometimes beating 130 strokes in a minute. As soon as this heat has abated, a little moisture or sweat is observed to break forth; not always indeed in the first, but always in the succeeding paroxyms, and the urine lets fall a quantity of latrititious sediment. The whole paroxym is seldom over in less than fix hours, more frequently eight, and in violent cases it extends to 12 hours; but that which exceeds 12 hours is to be reckoned a spurious kind, and approaching to the nature of continued fevers. All these symptoms, however, are repeated every second day, in such a manner that the patient is quite free from fever for at least 24 hours. The paroxyms return much about the same time, though sometimes a little sooner or later.

2. Causes of this disease and persons subject to it. The genuine tertian attacks men rather than women, young people rather than old: the latter being more subject to anomalous tertians. It likewise seizes the hasty and active, rather than the lazy and indolent. Those, however, who are apt to nauseate their meat fall easily into a tertian fever. The cause, according to Dr Cullen, is the miasma of marshes, and that only. Other physicians have taken in many more causes, almost every thing indeed which debilitates the body: but the Doctor denies that any of these, though they may dispose the body for receiving the disease, or may augment it, can by any means produce it without the concurrence of the marsh miasma; and it cannot be denied, that it is a disease almost peculiar to marshy situations. Thus we find it very frequent in the feney counties of Britain, although in other parts of this island it may be considered as a very rare disease; nay, in many it may perhaps be said that it never occurs. And it is also well known that intermittents have almost entirely disappeared in many parts of Britain, in which they were very common before the marshes of those places were drained.

3. Prognosis. The genuine simple tertian, unless improper medicines be administered, is generally very easily cured; nay, the vulgar reckon it of such a fatal nature, that after it they imagine a person becomes more strong and healthy than before. Hippocrates has observed, that these fevers terminate of their own accord after seven or nine paroxyms. Junker tells us, that it frequently terminates before the seventh paroxym, but rarely before the fourth. He also denies that anything critical is to be observed in its going off; but in this he differs from Vogel, who tells us, that the urine, for some days after the fever is quite gone off, appears flimy, and lets fall much sediment. The latter also informs us, that besides the common crisis by sweat and urine, the tertian hath one peculiar to itself, namely, dry scabby ulcers breaking out upon the lips. These sometimes appear about the third or fourth paroxym; and then we may venture to foretell that the disease will go off spontaneously after the seventh. But though the disease be never dangerous, in cold climates at least, when properly treated; yet the improper use of hot and stimulating medicines may change it into a continued fever, more or less dangerous according to the quantity of medicines taken and the constitution of the patient; in which case the prognosis must be regulated by the particular symptoms which occur. In warm climates, however, the tertian fever may be considered as a much more alarming disease; and unless the most powerful remedies be employed, the patient is in danger of falling a victim to every paroxym.

A variety of theories have been proposed for explaining the phenomena of this affection; but we may assert, that every thing hitherto said upon the subject is highly unsatisfactory. For although it be now almost universally admitted, that this fever does arise from the effluvia of marshes, yet in what manner the action of those effluvia induces fever, and particularly why this fever returns in regular paroxysms, are questions with regard to which we are still totally in the dark. Dr Cullen, with much ingenuity, attempted to prove, that the remote causes of this, as well as of other fevers, operate by inducing a state of debility; that this debility gives rise to spasm, which induces increased action, from which the phenomena are to be explained. But this theory is liable to no less numerous and unfurmountable objections than the exploded hypotheses which had before been propofed by others. For it is an undeniable truth, that debility often exists, even to the highest imaginable degree, without any fever; nay, that when fever has taken place, the debility is often much greater after it is entirely gone than at any period during its course. When spasm and increased action do take place, we have no reason to view them in any other light than merely as symptoms of the disease; and while they are often absent in this affection, they frequently occur in others where the sickness, anxiety, and other characterizing symptoms of fever are entirely absent: and, upon the whole, a probable or rational theory of intermittents, as well as of other fevers, still remains to be discovered.

Cure. The treatment of all genuine intermittents, whether tertians, quotidiens, or quartans, being almost precisely the same, the general method of cure applicable to all of them may be here given, to which it will be easy to refer when we come to describe the others.

In treating intermittent fevers, physicians have formed indications of cure according to their different theories. The followers of Boerhaave, Stahl, &c. who imagined that the disease proceeded from a lentor or other disorders in the blood, always thought it necessary to correct and evacuate these peccant humours by emetics and purgatives, before they attempted to stop the disease by the Peruvian bark or any other medicine. Cinchona indeed, among some, seems to be held in very little estimation: since Vogel affirms, that this medicine, instead of deserving to have the preference of all other febrifuge medicines, ought rather to be ranked among the lowest of the whole; and for this reason he ascribes the cures, said to be obtained by the use of the Peruvian bark, entirely to nature.

According to Dr Cullen, the indications of cure in interrupting fevers may be reduced to the following:

1. In the time of intermission, to prevent the return of the paroxysms.

2. In the time of paroxysms, to conduct these in such a manner as to obtain a final solution of the disease.

3. To take off certain circumstances which might prevent the fulfilling of the two first indications.

The first indication may be answered in two ways: 1. By increasing the action of the heart and arteries some time before the period of accession, and supporting that increased action till the period of accession be over, and thus preventing the recurrence of that atony and spasm of the extreme vessels, which he thinks give occasion to the recurrence of paroxysms. 2. By supporting the tone of the vessels, and thereby preventing atony and the consequent spasm, without increasing the action of the heart and arteries, the recurrence of paroxysms may be prevented.

The action of the heart and arteries may be increased, 1. By various stimulant remedies internally given Teriana, or externally applied, and that without exciting sweat. 2. By the same remedies, or by others, managed in such a manner as to excite sweating, and to support that sweating till the period of accession be for some time past. 3. By emetics, supporting for the same time the tone and action of the extreme vessels.

The tone of the extreme vessels may be supported without increasing the action of the heart and arteries, by various tonic medicines; as, 1. Astringents alone. 2. Bitters alone. 3. Astringents and bitters conjoined. 4. Astringents and aromatics conjoined. 5. Certain metallic tonics; and, 6. Opiates. A good deal of exercise, and as full a diet as the condition of the patient's appetite and digestion allow, will be proper during the time of intermission, and may be considered as belonging to this head. Although many particulars in this plan of cure are deduced from Dr Cullen's theory, yet there can be no doubt that the object chiefly to be aimed at is to employ such remedies during the intermissions as will prevent a recurrence of the paroxysm. Of all the remedies hitherto employed with this intention, the most celebrated, perhaps the most certainly effectual, is the Peruvian bark; or, to speak more properly, the bark of the Cinchona officinalis of Linnaeus. But it must be observed, that good effects are only to be expected from this medicine when employed in fulness and in large quantity; and for its use the following rules or observations have been given:

1. The cinchona may with safety be employed at any period of intermittent fevers, providing that at the same time there be neither a phlogistic diathesis prevailing in the system, nor any considerable or fixed congestion present in the abdominal viscera.

2. The proper time for exhibiting the cinchona in intermittent fevers is during the time of intermission, and it is to be abstained from in the time of paroxysms.

3. In the case of genuine intermittents, while a due quantity of cinchona is employed, the exhibition of it ought to be brought as near to the time of accession as the condition of the patient's stomach will allow.

4. In all cases of intermittents, it is not sufficient that the recurrence of paroxysms be stopped for once by the use of the cinchona; a relapse is commonly to be expected, and should be prevented by the exhibition of the cinchona repeated at proper intervals.

The advantage of administering the medicine as early as possible, was fully ascertained by Dr Lind in the years 1765, 1766, and 1767, during an uncommon prevalence of intermittents. When the disease was stopped by the cinchona immediately after the first or second fit, which was the case with 250 of the Doctor's patients as well as himself, neither a jaundice nor dropy ensued; whereas, when the cinchona could not be administered, on account of the imperfect intermission of the fever, or when the patient had neglected to take it, either a dropy, jaundice, or confluent headache, were the certain consequences, and the violence of the disease was in proportion to the number of the preceding fits, or to the continuance of the fever. By every paroxysm the dropical swellings were visibly increased, and the colour of the skin rendered of a deeper yellow. When the fever continued a few days without intermission, the belly and legs generally swelled; a violent headache, likewise, and vertigo, for the most part distressed the patient; patient; so that some, even after the fever had left them, were not able to walk across their chamber for a fortnight or three weeks. When the returns of the fever were regular and even, but flight, four or five fits of a simple tertian were sometimes followed by the most dangerous symptoms; especially in the year 1765, when these fevers raged with the greatest violence. If, as frequently happened, a dropical patient relapsed into the intermittent, there was an absolute necessity for putting an immediate stop to it by the cinchona; and in upwards of 70 such patients, Dr Lind observed the most beneficial effects to accrue from this practice. Without regard to a cough, or any other chronic indisposition, he ordered it to be given in large doses.

Cinchona has been often observed to fail in removing intermittents, from not continuing the use of it for a sufficient length of time, from administering it in too small a dose, or from giving it in an improper form. It was a prevailing opinion, that an ounce, or an ounce and a half, taken during one intermission, was sufficient to prevent the return of another paroxysm. But this is not always the case; for a fever fit will often attack a patient who has taken such a quantity. When this happens, the patient ought to persevere during the following intermissions, with an increase of the dose, till five or fix ounces at least have been taken. The medicine also ought not to be omitted as soon as one fit is stopped, but should be continued in a smaller dose, and after longer intervals, for at least ten days or a fortnight. Even for several months after the disease is entirely removed, it would be advisable to take a little occasionally in damp weather, or during an easterly wind, to prevent a relapse. Where the intervals between the fits are short, as in quotidian and double tertians, from one to two drams of it ought to be taken every two or three hours.

The form in which this medicine is administered is of some consequence. Mucilages and syrups have been recommended to conceal the taste of it; but, from various experiments, Dr Lind found nothing more effectual for this purpose than small beer or milk, especially the latter. A dram of bark mixed with two ounces of milk, and quickly drank, may easily be taken by a person of the most delicate taste, and by washing the mouth afterwards with milk, there will not remain the least flavour of the bark; but if the mixture be not drank immediately, the bark will impart a bitter taste to the milk. This medicine is commonly given in electuaries or boluses; but Dr Lind observes, that in these forms it proves much less efficacious than when administered in juleps or draughts, with the plentiful addition of wine or spirits. He has remarked, that six drams of powdered bark, given in a julep, consisting of one-fourth or one-third of brandy, is as effectual as an ounce of the powder in the form of an electuary, and proves less disagreeable to the stomach. For patients unaccustomed to wine or spirits, each draught should be warmed with spiritus ammoniae, or tinct. myrrh, by both of which the efficacy of the bark is he thinks increased. Dr Lind is also fully convinced that wine or spirits improve the virtues of the bark much more than elixir vitrioli, tinct. rogar, or such other medicines as have been recommended by different physicians.

For those who nauseate cinchona from a weakness of the stomach or other cause, he advises it to be given in clysters, in which form it is, he tells us, as efficacious as when taken by the mouth. For this purpose the extract is most proper with the addition of a sufficient quantity of the tinctura thebaica, in order to its being longer retained. For children labouring under intermittent fevers, Dr Lind orders the spine of the back to be anointed, at the approach of the fit, with a liniment composed of equal parts of tinctura thebaica and liniment. sapon, which has often prevented it. If this should not produce the desired effect, he informs us that two or three tea-spoonfuls of tyurpe & mecon, given in the hot fit, will generally mitigate the symptoms. But for the entire removal of the disease, after purging with magnesia alba, he prescribes a dram of the extract, cinchona with a few drops of tinct. thebaica, in a clyster, to be repeated every three hours for a child of about a year old. When the stomach is oppressed with phlegm, the magnesia frequently occasions vomiting, which should be promoted with warm water. The constant heaviness of the head occasioned by these fevers in such tender constitutions is best relieved by the application of a blitter to the back.

Cinchona has also proved effectual for the cure of intermittents in children, even when externally applied, by putting the powder of it into a quilted waistcoat. Of its efficacy in this way several instances are related by Dr Samuel Pye in the second volume of Medical Observations and Inquiries. In short, so effectual was it found in removing these fevers when properly applied, that of between four and five hundred afflicted with them in the year 1765, Dr Lind lost only two, neither of whom had taken this medicine.

In all these cases, a vomit was administered whenever the patient complained of a sickness and retching to vomit, or was seized with a spontaneous vomiting; and cinchona was never given till this sickness was removed, or a purgative taken to clear more perfectly the whole alimentary canal. In those patients who were troubled with a cough, attended with a pain in the side affecting the breathing, when the pain was not relieved by warm fomentations, the balsamum anodynum, or by a blitter, Dr Lind generally ordered a few ounces of blood to be taken away, and endeavoured to stop the fever as soon as possible by the administration of cinchona; having found that every return of the fever increased all such pains.—When the headache was very violent, and harassed the patient during the intermissions, the succefs of cinchona was rendered more complete by the application of a blitter to the back.—A giddiness of the head, which is the symptom most commonly remaining after even a slight intermittent fever, was generally relieved by the fal. C. C. and cinchona in wine. The former of these was administered in the following manner.

R. Aq. Alex. Simp. 3vii. Sal C. C. 5f. Svr. & Cort. Aurant. 3i. M. f. julep. Cap. cochlear. ij. subindè. If from the continuance of the fever the patient was distressed with a flatulence, distention of the abdomen, and a swelling of the legs, a spoonful of tinctura sacra, with the addition of 30 drops of the spirit. lavend. compof. was ordered to be taken every night.—A continuance of cinchona, a change of air, and the cold bath, were often found requisite to prevent a relapse.

Such is the method of cure recommended by this experienced author, who has also discovered the efficacy and success of opium in intermitting fevers. He informs us, that he has prescribed an opiate to upwards of 300 patients labouring under this disease; and he observed, that, if taken during the intermission, it had not the least effect either in preventing or mitigating the succeeding paroxysm: when given in the cold fit, it once or twice seemed to remove it; but when given half an hour after the commencement of the hot fit, it generally gave immediate relief.—When given in the hot fit, the effects of opium are as follow: 1. It shortens and abates the fit; and this with more certainty than an ounce of cinchona is found to remove the disease. 2. It generally gives a sensible relief to the head, takes off the burning heat of the fever, and occasions a profuse sweat. This sweat is attended with an agreeable softness of the skin, instead of the burning fenation which affects patients sweating in the hot fit, and is always much more copious than in those who have not taken opium. 3. It often produces a soft and refreshing sleep to a patient tortured in the agonies of the fever, from which he awakes bathed in sweat, and in a great measure free from all complaints.

Dr Lind has always observed, that the effects of opium are more uniform and constant in intermitting fevers than in any other disease, and are then more quick and obvious than those of any other medicine. An opiate thus given soon after the commencement of the hot fit, by abating the violence and lessening the duration of the fever, preserves the constitution fo entirely uninjured, that, since he used opium in agues, a droply or jaundice has seldom attacked any of his patients in those diseases. When opium did not immediately abate the symptoms of the fever, it never increased their violence. On the contrary, most patients reaped some benefit from an opiate given in the hot fit, and many of them bore a larger dose at that time than they could do at any other. He assures us, that even a delirium in the hot fit is not increased by opium, though opium will not remove it. Hence he thinks it probable, that many symptoms attending these fevers are spasmodic; but more especially the headache. However, if the patient be delirious in the fit, the administration of the opiate ought to be delayed until he recovers his senses, when it will be found greatly to relieve the weakness and faintness which commonly succeed the delirium. Dr Lind is of opinion, that opium in this disease is the best preparative for cinchona; as it not only produces a complete intermission, in which case alone that remedy can be safely administered; but occasions such a salutary and copious evacuation by sweat, as generally to render a much le's quantity of cinchona requisite. He commonly prescribes the opiate in about two ounces of tinctura laica, when the patient is convive, who is to take the cinchona immediately after the fit. By these means the paroxysm is shortened, and the intestines are cleansed, previous to the administration of cinchona; as the opiate doth not prevent, but only somewhat retards, the operation of the purgative. When a vomit is given immediately before the paroxysm, the administration of the opiate should be postponed till the hot fit be begun.

In the administration of cinchona, care should be taken that it be of a good quality. And different opinions have been entertained with respect to the choice, even where there is no reason to believe that it has been adulterated by the mixture of other articles. For a long time, the preference was given to small quilled pieces of pale-coloured bark; but of late the red bark, which is generally in larger masses, of an apparently coarser texture, and evidently of a more resinous nature, has been highly celebrated by Dr Saunders and others. And in cases where it does not disagree with the stomach or excite looseness, it is admitted by the most accurate observers to be more powerful in preventing the return of intermittents. Whether the red bark be the product of a different species of the cinchona, or be obtained as well as the pale quilled bark from the cinchona officinalis, is not yet ascertained with sufficient accuracy. Cinchona of a yellow colour has lately been imported into Britain and highly extolled. Its botanical history is not ascertained. It contains more bitter extractive matter, and more tannin and gallic acid, than either the pale or red; but less gum than the pale, and less resin than the red. It seems to produce the same medical effects in smaller doses. And it has sometimes succeeded in the cure of intermittents where the pale and red cinchona have before been employed in vain.

A species of cinchona, distinguished by the title of cinchona Jamaicensis, has been discovered in Jamaica and other islands in the West Indies. A very accurate description of it has been given by Dr Wright of Jamaica in the Philosophical Transactions of London. The bark of this species also has been recommended in the cure of intermittents; but the advantages of it have not hitherto been sufficiently confirmed by experience.

The barks of various trees readily cultivated in Britain, particularly different species of the falix, the prunus, the fraxinus, and the quercus, have by some been represented as no le's efficacious than the cinchona. But we may safely venture to assert, that although several of them may possess some power in stopping intermittents, yet that none hitherto tried can be considered as in any degree approaching to the cinchona in point of efficacy.

But although the Peruvian bark be the best cure for intermittents hitherto discovered, yet while it can by no means be represented as the only cure, it is very certain that other remedies have in different cases succeeded after the cinchona has failed. Cures have often been obtained by the use of different aromatics, bitters, and astringents. Many articles from the mineral kingdom also have been employed with advantage. And intermittents have unquestionably been in certain cases stopped by different preparations of iron, zinc, copper, lead, and mercury. But of all the articles of this nature, arsenic has of late been the most celebrated. Arsenic is on good grounds conjectured to be the basis of an article much employed in the cure of intermittents in some of the countries where they are most prevalent, and sold under the title of the tuffel'sague drop. The great success attending the use of this article, led Dr Fowler, an ingenious physician of Stafford, to examine it with particular attention. And in a treatise which he has lately published, entitled Medical Reports on the effects of arsenic in the cure of agues, he has given a formula for an arsenical solution, Febres. solution, which he has found very successful in affections of this kind, and which is probably very nearly the same with the taffle's ague drop. Dr Fowler's mineral solution, as he flies it, is found by diffusing 64 grains of arsenic and as much fixed vegetable alkaline salt in a pound of distilled water. This solution is given in doses from three to 12 drops, varied according to the condition of the patient, and repeated two or three times a-day. And where the cinchona has failed in stopping intermittents, it seems to be one of the most powerful remedies yet discovered. But after all remedies prove ineffectual, intermittents are often stopped by change of season and of situation.

But besides the remedies employed in tertians and other intermittents, with the view of preventing the return of paroxysms, it is often also necessary to employ powerful articles with other intentions, particularly to mitigate and shorten the paroxysm when present; to obviate urgent symptoms, especially those of an inflammatory or putrid nature; and to obtain a complete apyrexia or intermission from fever after the paroxysm has ceased. With these intentions, recourse is not unfrequently had to emetics, laxatives, blood-letting, blisters, opium, diluents, or sudorifics, as the circumstances of the case may require.

The Irregular or Spurious Tertian. Sp. I. var. 1. B. Tertiana notha five Ipuria, Sauv. Sp. 2. Sennert. Cleghorn. Hoffman.

The characteristic marks of this fever are, that its paroxysms last longer than 12 hours, and consequently it inclines more to the quotidian or continued fever than the former. Its paroxysms have no stated hour of attacking. The cure, however, is precisely the same with that above described, observing the proper cautions already mentioned with regard to the use of the cinchona.

The Double Tertian. Sp. 1. var. 2. C. Tertiana duplex, Sauv. Sp. 13. Vog. G. 12. Sennert. Cleghorn. Duplicata, Lin. 18.

The double tertian comes on every day; but differs from the quotidian in this, that its paroxysms do not answer to each other singly, but alternately. The first day, for instance, the fit will come on in the forenoon, in the second in the afternoon, the third in the forenoon, and the fourth in the afternoon.

Of these fevers we shall give the following description from Cleghorn's treatise on the diseases of Minorca: "They are called double tertians when there are two fits and two intervals within the time of each period. But commonly there is some difference between the two fits, either in respect of the hour they come at, the time of their duration, or the nature and violence of their concomitant symptoms. Some double tertians begin in this manner.—On the evening of Monday, for example, a flight fit comes on, and goes off early next morning; but on Tuesday, towards the middle of the day, a more severe paroxysm begins, and continues till night. Then there is an interval to Wednesday evening, when a flight fit commences a new period of the fever, which proceeds in the same manner as the first; so that according to the way physicians calculate the days of diseases, (by beginning to reckon from the first hour of their invasion), both paroxysms happen on the odd days, while the greatest part of the even days is calm and undisturbed." But in most double tertians the patient has a fit every day of the disease; the severe one commonly appearing at noon upon the odd days, the flight one towards evening on the even days; though sometimes the worst of two fits happen on the even days.

"There is a tertian fever sometimes to be met with, during each period of which there are three different fits, and as many intervals. For example, towards Monday noon the patient is seized with a paroxysm, which declines about five or fix o'clock the same evening; a few hours after, another fit begins, and continues until morning; from which time there is an interval to Tuesday evening, when a third fit comes on, and lasts most part of the night. On Wednesday there are again two paroxysms, as on Monday, and on Thursday like that of Tuesday; and thus the fever goes on with a double fit on each of the odd days, and a single fit on the even days.

"In double tertians, that interval is the most considerable which follows the severe fit; for the slight fit oftener ends in a remission than intermission, and frequently lingers till the other approaches: Hence it is, that the night preceding the vehement fit is much more restless than that which comes after it, as has been observed by Hippocrates. In double tertians, the vehement fit often comes on a little earlier in each period, while the flight fit returns at the same hour, or perhaps later and later every second day: so that the motions of one have no influence on those of the other; from whence it appears, that each of these fits hath its own proper independent causes."

Duplicated Tertian. Sp. I. var. 2. D. Tertiana duplicata, Sauv. Sp. 14. Jones. River.

This hath two fits on the same day, with an intermediate day on which there are none. This also does not differ in any remarkable particular from those already described.

The Triple Tertian. Sp. I. var. 2. D. Tertiana tripes, Sauv. Sp. 15. Cleghorn. Semiterteriana, Hoffman. Semiterteriana primi ordinis, Spig.

This differs from the former in having a single and double fit alternately: thus, for instance, if there be two fits the first day, there is only one the second, two the third, one the fourth, &c. Its cure is the same as before.

The Semi-Tertian. Sp. I. var. 2. F. Hemitritaeus, Celf. Semiterteriana, Cleghorn. Semiterteriana secundi ordinis, Spig. Amphimerina hemitritaeus, Sauv. Sp. 8. Amphimerina pseudo-hemitritaeus, Sauv. Sp. 9.

The femitertian is described by Dr Cullen as having only an evident remission between its paroxysms; more remarkable between the odd and even day, but less between the even and odd one. For this reason, he adds, that possibly some femitertians ought rather to be classed among the remittents; and owns that it is difficult to settle the boundaries between them. But Cleghorn, whom he quotes, describes it in the following manner. "A fit begins on Monday noon, for example, and goes off the same night. On Tuesday afternoon a second fit comes on, and gradually increases till Wednesday night, when it terminates. On Thursday morning there is such another interval as happened on Tuesday morning: But on Thursday afternoon another long fit like the preceding commences; and returning regularly every second day, leaves only a short interval of ten or twelve hours during the eight and forty.

Concerning the cure of these fevers Dr Cullen observes, that though no entire apyrexia occurs, cinchona may be given during the remissions: and it should be given even though the remissions be inconsiderable; if, from the known nature of the epidemic, intermittent or considerable remissions are not to be expected, and that great danger is apprehended from repeated exacerbations.

The Sleepy Tertian. Sp. I. var. 3. G. Tertiana catotica, Sauv. fp. 10. Werlhof. Tertiana hemiplegica, Sauv. fp. 20. Werlhof. Quotidiana soporosa, Sauv. fp. 8. Car. Pif. Febris caput impetens, Sydenham, ep. ad. R. Brady.

This, according to Vogel, is a most dangerous species, and very commonly fatal; for which reason he ranks it among those intermittents which he calls malignant. Sometimes he tells us the alarming symptom of a sleepiness comes on, not at the beginning of the disease, but will unexpectedly occur during the third, fourth, fifth, or sixth paroxysm. It commonly begins with the cold fit, and continues during the whole time of the paroxysm, and, becoming stronger at every succeeding one, at last terminates in a mortal apoplecty. Sometimes fevers of this kind rage epidemically. Vogel relates, that he saw a simple tertian changed into one of these dangerous fevers. The patient was a woman of a delicate constitution, and the symptoms appeared in consequence of her being put in a violent passion: however, it occurred but once, and she recovered. Hoffman mentions a carus in a double tertian occurring seven times without proving mortal; though Vogel says, that the powers of nature are very seldom sufficient to conquer the disease.

In 1678, Dr Sydenham tells us that intermittents raged epidemically at London, where none had appeared before from 1664. Of them "it is to be noted (says he), that though quartans were most frequent formerly, yet now tertians or quotidians were most common, unless the latter be entitled double tertians: and likewise, that though these tertians sometimes began with chilneas and shivering, which were succeeded first by heat, and soon after by sweat, and ended at length in a perfect intermission, returning again after a fixed time; yet they did not keep this order after the third or fourth fit, especially if the patient was confined to his bed and used hot cardias, which increase the disease. But afterwards this fever became so unusually violent, that only a remission happened in the place of an intermission; and approaching every day nearer the species of continued fevers, it seized the head, and proved fatal to abundance of persons."

From this description of Sydenham's we may have an idea of the nature of the dicathe. As to its cure he strongly recommends cinchona; telling us, that, even in the most continued kind of intermittents, "the nearer the intermittent approaches to a continued fever, either spontaneously, or from using too hot a regimen, so much the more necessary is it to exhibit a larger quantity of the bark; and that he took advantage of a remission, though ever to fail."

The Spasmodic or Convulsive Tertian. Sp. I. var. 3. H. Tertiana athmatica, Sauv. fp. 6. Bonnet. Tertiana hysterica, Sauv. fp. 8. Wedel. A. N. C. Dec. I. A. II. obf. 193. Hysteria febricola, Sauv. G. 135. fp. 8. A. N. C. Dec. I. Ann. II. Tertiana epileptica, Sauv. fp. 16. Calder. Lautter. Quotidiana epileptica, Sauv. fp. 3. Edinb. Eflays, vol. v. art. 49. Eclampsia febricola, Sauv. G. 139. fp. 17. Epilepsia febricola, Sauv. G. 134. fp. 9. Tertiana tetanodes Med. Beobacht I. Band. Tetanus febricofus, Sauv. G. 122. fp. 10. Stork. Ann. Med. II.

Tertians of this kind occur with very different symptoms from those of the true ones, and sometimes even with those which are very extraordinary. In some they are attended with symptoms of asthma, in others with those of hysterics, in others with convulsions. Where the symptoms of asthma occur, the disease must be treated with diuretics and antiphlogistics joined with cinchona. In the hysteric asthma the fit comes on with cold, yawning, cardialgia, terror and dejection of mind. The disease is to be removed by mild aperients and antihysterics joined with cinchona.

Of the convulsive tertian we have a most remarkable instance in the Edinburgh Medical Essays, vol. v. The patient was a farmer's son about 26 years of age, of a strong plethoric habit of body. He had laboured under an ague half-a year, and had taken a great deal of Peruvian bark. While he was telling his case to the surgeon (Mr Baine of Pembroke), he was suddenly taken with a violent flapping of his feet; and the convulsions gradually ascended from the soles of the feet to his legs, thighs, belly, back, and shoulders. His head was then most violently convulved, with a total deprivation of speech; but he had a most dismal vociferation, which might have been heard at a considerable distance, his abdomen and thorax working and heaving violently and unusually in the mean time. This fit having lasted half an hour, a profuse sweat broke out over all his body, which relieved him; and he then became capable of answering such questions as were put. These extraordinary fits, he said, had been occasioned by a fright, and his neighbours had concluded that he was bewitched. They returned sometimes twice a-day, and always at the times the ague used to return. During the paroxysm his pulse was very high and quick, his face much inflamed, and his eyes ready to start out of his head. After Febres. the fit was over, he complained of a most torturing pain of the bowels. His tongue was generally moist, and he had a suppression of urine.—This formidable disease, however, was totally subdued by the use of cinchona, mercurials, antipathodics, opiates, and saline draughts.

The Eruptive Tertian. Sp. I. var. 3. 1. Tertiana petechialis, Sauv. sp. 3. Donat. Lautter. Tertiana scorbutica, Wedel. A. N. C. Dec. I. A. II. obf. 193. Tertiana urticata, Sauv. sp. 22. Planchon. Journ. de Med. 1765. Cleghorn. Tertiana miliaris, Sauv. sp. 21. Walthieri de Med. Ger.

This species of tertian is accompanied with red or livid blotches on the skin, or an eruption like that occasioned by the stinging of nettles. In the latter case Dr Cleghorn says the disease is very dangerous; and as the former indicates an incipient dissolution and putrefaction of the blood, it must also be reckoned of very dangerous tendency.

The Inflammatory Tertian. Sp. I. var. 3. K. Tertiana pleuritica, Sauv. sp. 4. Valef. Lautt. Pleuritis periodica, Sauv. G. 103. sp. 14. Tertiana arthritica, Sauv. sp. 5. Morton. Lautt.

Sauvages informs us, that he has seen a true and genuine pleurisy having all the pathognomonic signs of the disease, but assuming the form of an intermittent; that is, the patient is one day affected with the pleurisy, and the next seemingly in perfect health. He also tells us, that in the month of May 1760, a tertian raged epidemically, which after the third fit imitated a pleurisy, the pain of the side, and difficulty of breathing coming regularly on, and the fever from an intermittent becoming remittent; the blood had also the same appearance with that of pleuritic persons, and the distemper yielded to bleeding and gentle cathartics.—Morton also informs us, that he has observed similar disorders an hundred times, which were always certainly and safely cured by the Peruvian bark.

The Tertian complicated with other Disorders. Sp. I. var. 4. Tertiana scorbutica, Sauv. sp. 9. Etmuller, Timeus. Tertiana syphilitica, Sauv. sp. 17. Deidier. Tertiana verminosa, Sauv. sp. 18. Stiffer. in act. Helmstad. Lancif. de noxius palud. Pringle. Ramazzini. Van den Bosch. de cont. vermin.

The scorbutic tertian, according to Sauvages, is exceedingly anomalous, its periods being sometimes much anticipated, and sometimes much postponed. It is exceedingly obtinate, and will return if the body be not cleared of its scorbutic taint. The patient is affected with lancinating pains of a wandering nature. The urine lets fall a dusky red sediment, or a thick branny matter is copiously scattered up and down in it, seemingly tinged with blood. The usual symptoms of fever, viz. livid spots, and rotten fetid gums, also frequently occur. For this the Peruvian bark is very useful, both as a febrifuge and antiscorbutic.

A tertian accompanied with worms is taken notice of by Sir John Pringle in his treatise on the diseases of Tertiana. The worms, he tells us, were of the round kind; and though we are by no means to reckon them the cause of the fever, they never failed to make it worse, occasioning obstinate gripings or sickness at stomach. In these cases stitches were frequent; but, being flatulent, were not often relieved by bleeding. The worms were discharged by vomiting as well as by stool. For discharging these worms, he commonly gave half a dram of rhubarb with 12 grains of calomel; without observing any inconvenience from such a large dose of mercury. Anthelmintics, which act slowly, had little chance of doing good; for though worms will sometimes lie long in the bowels without giving much uneasiness to a person otherwise well, yet in a fever, especially one of a putrid kind (to which his intermittents always seemed to incline), the worms being disturbed by the increase of heat, and the corruption of the humours in the prime viva, begin to move about, and struggle to get out. Lancifius, who makes this remark, adds, that upon opening the bodies of some who had died at Rome of fevers of this kind, wounds were found in the intestines made by the biting of the worms; nay, that some of them had even pierced through the coats of the guts, and lay in the cavity of the abdomen. Pringle never had any instance of this; but knew many cases in which the worms escaped by the patient's mouth, though there had been no previous retching to bring them up. One soldier was thrown into violent convulsions, but was cured by the above-mentioned powder.

The Tertian varied from its Origin. Sp. I. var. 5. Tertiana accidentalis, Sauv. sp. 12. Sydenham. Tertiana à scabie, Sauv. sp. 12. Juncker, tab. 8o. Hoffman, II. p. 12.

The existence of fevers of this kind, as we have already observed, is denied by Dr Cullen; the accidental fever of Sauvages was said to arise from any slight error in the non-naturals, and consequently was very easily cured. That which arose from the repulsion of the itch, was cured as soon as the eruption returned.

The Tertian with only a remission between the fits. Sp. II. Remittent tertian. Tritaeophya, Sauv. Gen. 85. Sag. p. 695. Tritaeus, Lin. 21. Hemitritea, Lin. 23. Tertiane remittentes et continue Auctorum. Tertiane subintrantes, proportionate, subcontinue, Torti. Tertiana subcontinua, Sauv. sp. 19. Quotidiana deceptiva, Sauv. sp. 2. Amphimerina semiuintana, Sauv. sp. 24. Tritaeophya deceptiva, Sauv. sp. 10. Causus Hippocratici. Tritaeophya causus, Sauv. sp. 2. Febris ardens Boerhaavii, aph. 738. Tertiana perniciosa, que simulata tertiani circuitus effigie lethalis, et mille accidentibus periculoosissimis implicata, exsiftit. Lud. Mercatus. Tertiana pestilens, P. Sal. Diversus. Tertiana maligna pestilens, Rivieri. Morbus Hungaricus. Lang. Lemb. Sennert. Jordan. Languor Pannonicus, Cober. Amphimerina Hungarica, Sauv. sp. 10. Hemitriteus pestilens, Schenck. ex Corn. Gamma. Febres pestilentes Aegyptiorum, Alpin. Febres tertiae epidemica, Bartholin. Febres epidemicæ, autumni 1657 et 1658, Willis. Febres synchae epidemicæ, ab anno 1658 ad 1664. et postea ab anno 1673 ad 1691, Morton. Febres autumnales incipientes, Sydenham. Affectus epidemicus Leidenfis, Fr. Sylvi. Morbus epidemicus Leidenfis, 1660, Fanoi. Tertiane pernicientes et pestilentes, et febres castrennes epidemicæ, Lancif. Febres intermittentes anomalæ et mali moris, Hoffman. Febres cholerica minus acuta, Hoffman. Febres epidemicæ Leidenfis, anno 1719, Koker apud Haller, Disp. tom. v. Amphimerina paludosa, Sauv. sp. 19. Febres paludum, Pringle. Bononiensis constitutio hiemalis 1729, Beccari in A. N. C. vol. iii. Amphimerina biliosa, Sauv. sp. 22. Febres castrennes, Pringle. Febres putrida epidemicæ, Huxham de æcre ad ann. 1729. Febres biliosa Laufanensis, Tiffot. Triteophya Wratislaviensis, Sauv. sp. 3. Hahn. Epidemia verna Wratislavi. in App. ad A. N. C. vol. x. Triteophya Americana, Sauv. sp. 12. Febres anomala Batava, Greinger. Morbus Naronianus, Pujati. Febres continua remittens, Hillary's diseases of Barbadoes. Febres remittens Indiæ Orientalis, Lind. diff. inaug. 1768. Febres critica et febr. biliosa æstatis, Rouppe. Febres remittens regionum calidarium, Lind on the diseases of hot climates. A. Tertiana cholerica five dysenterica, Tort. Therap. Special. lib. iii. cap. 1. Lautter. Hist. Med. caf. 6. 16. 17. 20. Morton, App. ad Exerc. II. B. Tertiana subcruenta five atrabilariis, Tort. ibid. Never seen by Cleghorn. C. Tertiana cardiaca, Tort. ibid. Lautter. Hist. Med. caf. 15. 16. 23. Amphimerina cardiaca, Sauv. sp. 5. Triteophya affodes, Sauv. sp. 6. Febres continua affodes, Vog. 27. D. Tertiana diaphoretica, Tort. ibid. Triteophya typhodes, Sauv. sp. 4. Triteophya elodes, Sauv. sp. 5. Febres continua elodes, Vog. 21. E. Tertiana syncopalis, Tort. ibid. Lautter. caf. 11. 12. 13. 15. 16. Triteophya syncopalis, Sauv. sp. 1. Amphimerina syncopalis, Sauv. sp. 4. Amphimerina humorosa, Sauv. sp. 6. Febres continua syncopalis, Vog. 29. F. Tertiana algida, Tort. ibid. Lautter. caf. 13. Amphimerina epiala, Sauv. sp. 3. Amphimerina phricoides, Sauv. sp. 7. Triteophya leipyria, Sauv. sp. 9. Tertiana leipyria, Sauv. sp. 23. Valcarenghi Med. Ration. p. 18. Febres continua epiala et leipyria, Vog. 19. et 24. G. Tertiana lethargica, Tort. ib. Triteophya carotica, Sauv. sp. 7. Lautter. 1. 7. 14. Tertiana apoplectica, Morton. Exerc. I. cap. ix. hift. 25. Tertiana suporosa, Werlhof. de febr. p. 6. Febres epidemicæ Urbcvetana, Lanef. de noxiis pal. effluv. I. II. c. 3.

The remittent fevers are much more dangerous than the true intermittents, as being generally attended with much greater debility of the nervous system and tendency to putrefaction in the fluids than the latter. Sauvages divides his triteophya, a remittent tertian into the following species:

1. Triteophya syncopalis, or that attended with fainting. It begins like a tertian, with cold succeeded by heat and profuse sweating; but attended with much more dangerous symptoms, such as cardialgia, enormous vomiting, great weakness, small contracted pulse, coldness of the extremities, and, unless timely assistance be given, kills during the second or third paroxysm.

2. The causus, or burning fever of Hippocrates, returns every third day without any new sensation of cold; and is attended with great thirst, heat, but without diarrhoea or sweat, and continues only for one week or two at the utmost. It attacks chiefly young people of a robust and bilious habit of body, who have been accustomed to much exercise, and exposed to the sun during the heats of summer, and have also used a phlogistic regimen. The tongue is dry, sometimes black; the urine of a red or flame colour; together with pain of the head, anxiety, and sometimes other symptoms still more dangerous.

3. Triteophya Wratislaviensis, was a pestilential disease occasioned by famine, during which the people fed on putrid aliment: the air was infected by the vast numbers of bodies of those slain in battle, and the inhabitants were also dejected by reason of being deprived of their harvest, and other calamities; to all which was added the continuance of a calm in the atmosphere for a long time. It began with an acute fever, leipyria or coldness of the external parts and a sensation of burning heat inwardly; general weakness; pain of the head and precordial; serous, or bilious diarrhoea; a delirium, in some furious, and accompanied with a dread of being exposed to the air; on the second day the thirst was violent, attended with a bilious vomiting, as well as diarrhoea, tough viscid spitting, fainting, burning heat in the bowels, the tongue dry and seeming as if burnt with a hot iron, a suppression of the voice, anxiety, stupor, after which quickly followed convulsions and death. In some fevers leipyria came on with an exceeding great cold of the extremities, presently followed by an intolerable heat of the viscera, with symptomatic sweats, violent diarrhoea, followed by a very itchy miliary eruption. On the fourth day came on copious sweats, spasms of the lower jaw, nausea, involuntary passing of urine, slight delirium, a flux of ichorous matter from the nostrils, an exceeding tough spitting, an epilepsy, and death. Professor Hahn, who gives gives the history of this disease, was himself attacked by it, and suffered in the following manner: On the first day was a violent feverish paroxysm without rigor, a sharp pain in the occiput, and immediately an inflammatory pain over the whole head; the feet were extremely cold, and the extremities rigid with spasms. The pain continued to increase daily to such a degree, that the contact of the air itself became at last intolerable; a dejection of mind and incredible weakness followed; he passed restless nights with continual sweating, heavy and pained eyes, and an universal sensation of rheumatism over the whole body. On the third day the pains were afflaged, but he had a very bad night. On the fourth day all the symptoms were worse, the feet quite chilled, the hands very red and agitated with convulsive motions; he was terrified with apprehensions of death, and had a vomiting every now and then: this day sponges dipped in cold water were applied over the whole body, and he used cold water for his drink. On the eighth day the pulse was convulsive; and the pains were so violent that they made him cry out almost continually. On the ninth day he was delirious, and threw up some grumous blood. On the 11th his pulse was more quiet, and he had a sweat; a decoction of cinchona was given: his voice was broken, his speech interrupted, and his teeth chattered upon one another. On the 12th his jaw was convulsed, he had a risus fardonicus, and deafness; after which the paroxysms returned less frequently, and only towards night. On the 14th he had a chilling cold over the whole body, a cold sweat; frequent lotions were applied, and all the symptoms became milder. On the 18th he had a quick delirium, but fainted as soon as taken out of bed; a sensation of hunger, followed by copious sweats; profound sleep; an aversion from noise; every thing appeared new and extraordinary. On the 36th a cholera; on the 48th a scalding off of the skin, and falling off of the nails. This epidemic carried off above 3000 people at Warsaw. Frequent lotions of the body either cold or tepid, watery glysters, and the copious introduction of watery fluids under the form of drink, were of service. But the most favourable crisis was under the form of some cutaneous eruption.

4. Tritaeophya typhodes. The principal symptom of this fever was a continual sweat with which the patients were almost always wet; with paroxysms returning every third day. Sauvages tells us, that he had twice an opportunity of observing this fever; one was in the teacher of an academy, about 40 years of age, and of a melancholic temperament. He sweated every second night so plentifully, that he was obliged to change his linen nine times; and even on the intermediate days was never perfectly free of fever, and had his skin moistened with sweat. The other was of a woman who went about in man's clothes, and was discovered only after her death. The disease began with a flight sensation of cold, after which she sweated for eight hours. It was attended with the highest debility, anxiety, and at the same time an infatiable hunger.

5. Tritaeophya elodes, was an inflammatory epidemic, but not contagious, terminating about the 14th or 21st day. The disease came on in the night time, with disturbed rest, universal weakness, watchings, great heat and sweat, redness of the face and almost of the Tertiana. whole body, sparkling eyes, the tongue dry and white; a hard, tense, and turgid pulse: about the third day a kind of frenzy frequently came on with the feverish paroxysm, the forerunner of an universal miliary eruption; or, what was worse, with purple spots so close together, that they looked like an erysipelas of the whole body. Sometimes blisters of the size of small pearls, filled with acrid serum, appeared on the neck, armpits, and trunk of the body, which were of all the symptoms the most dangerous. There was a variety of the disease, which Sauvages calls the humoralis, and in which the pulse was soft and feeble, with greater weaknesses over the whole body, and the disposition to sleep more frequent than in the other; the eyes languid; the tongue very white, but not dry; and worms were sometimes discharged.

6. Tritaeophya affodes. This species arose from a foulness of the prime viae, and the effluvia of waters in which hemp had been steeped. It began with rigor, followed by great heats, restlessness, tossing of the limbs, faintings, immoderate thirst, dryness of tongue, delirium, and at length excessive watchings; these last, however, were less dangerous than vertigo or a catatonic disposition, which brought on convulsions or apoplectics.

7. Tritaeophya carotica. This had exacerbations every other evening; and its distinguishing symptom was an excessive inclination to sleep, preceded by a severe headache, and followed by delirium, and sometimes convulsions; the tongue was black, and the patient insensible of thirst after the delirium came on. In those cases where the disease proved fatal, a subful tus tendinum and other alarming symptoms, came on.

8. Tritaeophya leipryia is only a variety of the tritaeophya caulis, already described.

9. Tritaeophya deceptiva. This species at first affumes the appearance of a continued fever; but afterwards degenerates into a remittent, or even an intermittent. It is described by Sydenham, but attended with no remarkable symptoms.

10. The last of Sauvages's species of Tritaeophya belonging to the remitting tertian is the Americana. This, according to Sauvages, is the ardent fever with which the Europeans are usually seized on their first arrival in America, and generally carries off one half of them. Of this there are two varieties, the very acute and the acute. The very acute ends before the seventh day. It comes on a few days after the person's arrival, with loss of appetite, with dyspnoea and sighing from weakness, headache, lassitude, and pain of the loins: a pyrexia succeeds, with great thirst, sweat, and heat; the sickness increases, nausea comes on, with vomiting of porraceous bile; the tongue rough, the extremities often cold; watching, furious delirium; and the patient frequently dies on the third day. Copious sweats, and a plentiful hemorrhagy from the nose on the fifth day, but not sooner, are serviceable; but a bilious diarrhea is the best crisis of all.

The acute kind terminates most frequently on the ninth, but very rarely goes beyond the fifteenth day. Death frequently comes on between the fourth and seventh days. It begins with headache, pain in the loins, and sometimes shivering; great lassitude, dyf- pncea, thirst; burning fever, increasing every third day; inflation of the abdomen, pain at the pit of the stomach, nausea, and bilious vomiting. Such is the state of the disease within twenty-four hours. The eyes are red, and full of tears; the urine pellucid; there is a low delirium, and continual anxiety; the tongue is dry and red, and sometimes, though rarely, black, which is a still worse sign; the pulse, formerly strong and full, sinks about the fourth day, and becomes tensive and spasmodic: if a carus then comes on, the patient dies the fifth or sixth day; but if the pulse keeps up, and no carus comes on, a crisis is to be expected by sweat, by a copious hemorrhagy from the nose, or, which is still more safe, by a bilious diarrhoea, which is never fatalary if it comes on before the fifth day.

To the remitting tertian also belong the following species mentioned by Sauvages, viz.

1. Tertiana subcontinua. This begins like a genuine tertian, and at first hath distinct paroxysms; but these grow gradually more and more obscure, the disease acquiring daily more of the appearance of continued fever, by which it is to be distinguished from the other varieties of this species. It is not unfrequently joined with those symptoms which attend the fatal fever already mentioned; as cardialgia, cholera, syncope, &c., but in a much less degree. The disease commonly begins with little or no sense of cold, but rather a sensation of heat; when the tertian is doubled, it has first a lighter and then a more severe fit; and thus goes on with an exacerbation on the even days: and though it should change from a double into a single tertian, we are still to suspect it, if a weak fit is the forerunner of a very strong one. This change of the tertian into a continued fever is also to be prognosticated if a heat remarkable to the touch is perceived on the day of intermission, together with some disturbance of the pulse, thirst, and dryness of the tongue; all of which show a tendency to inflammation: the fame is foretold by the urine being in small quantity, and very red, or of a saffron colour; also an ulcerous or aphthous inflammation of the throat, with difficulty of swallowing, or any very severe symptom coming on in the beginning of the disease, excepting only a delirium, which is easily removed.

2. Quotidiana deceptiva. This is a disorder of an inflammatory kind, with a strong tendency to putrefaction, and sometimes assumes the form of a quotidian. In it the patient frequently complains of cold when he really is hot, and the remission is very indistinct. The disease is known by the great languor of the patient and the foulness of his tongue.

3. Amphimerina cardiaca is an acute malignant fever, with daily exacerbations, attended with fainting and vomiting of green bile. Afterwards, the weakness increasing, the patient's extremities grow cold, and a profuse sweat comes on, which is frequently succeeded by death on the fourth day. Another species resembling this Sauvages calls the syncopalis; but the cardiaca differs from it in being attended with cardialgia.

4. Amphimerina pululofa. This is the fever described by the British physicians under many different names, and appearing under various forms, according to the different constitutions of the patients. This fever in the East Indies, according to Dr Lind of Windsor, generally comes on suddenly, and begins with a sense of debility and a very great lowness of spirits. These tertiana symptoms are attended with a greater or less degree of chilliness, vertigo, nausea, very acute pains in the head and loins, and a trembling of the hands; the countenance is pale, the skin commonly very dry and corrugated, the eyes dull and heavy, the pulse quick and small, the breath generally difficult, and interrupted with hiccough.

As the paroxysm increases, the chillsiness now and then gives way to irregular heats, which soon become violent and permanent; the nausea likewise increases; and in some there comes on a vomiting, in which they throw up a great deal of bile. Sometimes bile is likewise voided by stool. The skin grows red; the eyes appear small, and sometimes not a little inflamed. The pulse becomes fuller, and the breath more difficult, attended with great restlessness and a troublesome thirst; notwithstanding which (so great is the nausea) the patient cannot endure any kind of liquids. The tongue becomes foul, and the pain of the head and loins more violent; a delirium then follows; a slight moisture appears on the face, and from thence spreads to the other parts; whilst the violence of the other symptoms abates, and shows the beginning of a remission, which is completed by plentiful sweats.

On the fever's remitting, the pulse returns almost to its natural state; the pains of the head and loins still continue, though somewhat less violent, as likewise the nausea and want of appetite. When the disease gains strength, the remission is scarcely obvious, and is immediately followed by another paroxysm; which begins, not indeed with so great a flurrying, but is attended with a greater pain of the head, the greatest anxiety, a heartburn, nausea, vomiting, and bilious stools. The matter most commonly evacuated by vomit and stool is whitish like chalk and water, or curdled milk which is vomited by sucking children, when the curd is much broke down. A heat, immoderate thirst, and delirium now come on. The tongue becomes more foul; the teeth and inside of the lips are covered with a black crust; the breath grows hot and fetid; another remission ensues, attended with a sweat; but this remission is both shorter and less obvious than the first.

This second remission is succeeded by a paroxysm, in which the symptoms are far more violent than in the former; that which the patient discharges by vomiting and purging is more fetid; the mouth, teeth, and inside of the lips, are not only covered with a black crust, but the tongue becomes so dry and stiff, that the patient's voice can scarce be heard. Violent delirium, with restlessness and anxiety, come on chiefly during the paroxysm; nor do these symptoms abate till the fever remits, and the patient sweats.

When the fever becomes so violent, during the third fit, as to end in death, which is often the case, some of the sick have a coma; in others the delirium becomes more violent. The discharges now become more fetid, and have a cadaverous smell; the stools are involuntary; the pulse is so quick, small, and irregular, that it is scarce to be counted, or even felt; a cold sweat is diffused over the whole body, especially the head and neck: the face becomes Hippocratic and convolled; the patient picks the bed-clothes; a subfultus tendinum comes on; the sick lie constantly on their backs, and insensibly slide down to the foot of the bed; their extremities grow cold; they are then feized with convulsions, with which the scene closes.

In this fever, the urine, which at the beginning is pale, becomes of a deeper colour by degrees, but without depositing any sediment. There seldom or never appear any petechiae, and the prickly heat which was before on the skin vanishes on the first appearance of the fever. But though these were the general symptoms of this disorder, they varied in the different subjects, and at different seasons of the same year. The pulse, for example, in some, was quick in the beginning of the disorder; in others, it varied with the other symptoms. The skin was generally dry in the beginning of the fit; but in some it was moist, and covered with sweat from the very beginning of the disease. In the month of September, when the disorder raged most, the remissions were very imperfect and obscure; but, on the return of winter and the healthy season, they became more regular, and the disease assumed the appearance of an intermitting fever, to such a degree as at length not to be distinguished from it. In some the remissions could scarce be perceived, and the fever continued for two weeks without any material change for the better or the worse. At this time numbers were feized with it. When the disorder continued for any time without a change, it generally ended in death; while the weather grew better, it sometimes, in the space of a few days, from a common fever became an intermitting one, and the patient recovered, unless his liver, which was sometimes the case, happened to be affected. The cure of an inflammation of the liver proved uncertain and tedious; as it was commonly followed by a colligative diarrhea, which generally endangered the patient's life.—Every succeeding paroxysm was observed to be more dangerous than the preceding; the third generally proved fatal; some died during the first. When this happened, the fever, in the language of the country, was called a puca, that is a strong fever.

This disease, according to Dr Lind of Haslar hospital, is the autumnal fever of all hot countries, the epidemic disease between the tropics, and the disease most fatal to Europeans in all hot and unhealthy climates. All authors agree that intermittents in general, but particularly this dangerous kind of them, are produced by heat and moisture, but particularly the evaporation of moisture from marshes. Dr Lind of Windsor remarks, that the European seamen are very subject to the fever above mentioned when they happen to arrive at Bengal in autumn. They are predisposed to it from the nature of their food, their confinement on board, the very great heats to which they are exposed during the voyage, and their lying for hours together exposed to the night colds.

Most of the meat used by the crews of those ships is salted, and often in a putrid state, without any fresh vegetables, they having only biscuits, and some other farinaceous matters. The quantity of the vinous or spirituous liquors allowed them is, in his opinion, by far too small to subdue the putrefic disposition of their animal-food. Their fluids consequently become, from day to day, more and more putrescent, and of course more apt to breed and contract this disorder. This disposition is likewise induced by their being flowed very close together, and that for a considerable length of time, and in a foul air, especially when the weather happens to be too stormy to permit the hatches and port-holes to be kept open.

Though the heats they endure in the voyage to India are less considerable than those of the country itself, yet they are too much for an European constitution to bear. The general heat at sea within the tropics is about 84° of Fahrenheit's thermometer, which is sufficient to relax them, and promote a corruption of their humours, especially when it coincides with the above causes. It likewise creates a languor and indolence, which alone are sufficient to increase that putrefaction. These causes are apt to be considerably aggravated by the men's being often exposed, when on duty, for hours together, to rain, damp, and cold air; a circumstance which frequently happens to them when working their ships up the river Ganges in the night-time. Hence the perspiration is checked, and the excrementitious fluid which used to be discharged by the skin being retained in the body, contributes, he thinks, very much towards the predisposition to this disease.

But the most powerful of all the remote causes is justly thought to be the effluvia of marshes replete with putrid animal-substances. We have not, however, been able to determine from what kind of putrid animal-substances these effluvia derive their virus. For that every kind of putrefaction has not such an effect appears from this, that neither practical anatomists, nor those who by their trades are exposed to the putrid effluvia of animals, for instance such tanners and butchers as keep their shops and stalls very dirty, are more subject than others to putrid diseases. Nor are the ship-stewards and their servants, whose business it is to deliver out the provisions to the ships crews, and who spend the most of their time amongst the putrid and rank effluvia of the places in which those provisions are kept, more subject to putrid fevers than their ship-mates. But whatever be in this, we are well assured that some particular putrid fermentations produce noxious vapours, which, united with those of marshes, render them more pernicious. Hence evidently proceeds the extreme unhealthfulness of a place called Culpi, on the eastern bank of the Ganges. The shores about it are full of mud, and the banks covered with trees. Opposite to the place where the ships lie there is a creek, and about a mile from its entrance stands the town of Culpi: the ships lie about a mile from the shore. None of the sailors on board the ships stationed at this place enjoyed their health. The burying ground also contributed not a little to spread the infection. The ground being marshy, the putrid water flowed from the old graves into the new ones, which infected the grave-diggers and those that attended the funerals; and from this cause many were suddenly feized while they were performing the last duty to their companions. This place has ever been remarkable for the unhealthfulness of its air. It was once customary to send some of the Company's servants here to receive the cargoes of the ships, and send them to Calcutta; but so many of them died on this duty, that the Company was at length obliged to dispense with it.

Hence it plainly appears, how apt putrid animal and vegetable substances are to render the effluvia of fenny places more pernicious than they would otherwise be. The reason why great inundations of the Nile and Ganges are followed by a healthy season is, that by this means the putrid animal and vegetable substances dispersed over the contiguous countries are carried off into the sea.—The noxious vapours arising from fens spread but a little way. Dr Lind has often known ships crews at a very little distance from the shore quite free from this disorder. But although these marsh misfortune first bring on the disease, yet contagion particularly spreads it, and renders it more epidemic. Thus the Drake East Indian continued free from the disorder for two weeks together, when she had no communication with the other ships; but as soon as the disorder was brought on board, many were seized with it within a few days in such a manner as to leave no room to entertain the least doubt concerning its contagious nature.

Dr Lind of Hallar hospital has given a very curious and learned account of the appearance of this fever throughout the various parts of the globe. It was very common in England in the years 1765 and 1766, one obvious cause of which was the prevalence of the easterly wind. This wind in England is often said to bring with it a fog from the sea; but the truth of the matter is, that in many places of this island the easterly wind frequently raises a copious vapour from water, mud, and all marshy or damp places. To this exhalation quality of the easterly wind Dr Lind has often been an eye-witness. When the wind changes to the east, the mud sometimes sends up a vapour as thick as smoke; and the doctor has observed two fish-ponds in his neighbourhood, one of fresh and the other of salt-water, which on the approach of an easterly wind sometimes also emit a dense vapour, as from a pot of boiling water. In order to view this phenomenon distinctly, the person should stand at about 100 yards distance from the mud or ponds. If the sun shines when the wind changes to the east, he will observe a constant stream of vapours arising out of the ponds, from about five to ten yards in height, while the air about him remains serene. As the vapour or fog arising from other bodies glides along the surface of the earth, and is brought by the easterly wind to the ponds, he will still be able, for some time, to distinguish the vapours ascending perpendicularly out of the ponds from those which are carried in an horizontal direction by the wind; especially if the sun continues to shine, though faintly.

This evaporating quality of the east-wind seems to manifest itself also by its effects both on the thermometer and the human body; for a thermometer hung over a damp piece of ground during the fogs or exhalations arising from it, will often indicate a degree of cold below the freezing point. The chilliness of the body, so sensibly perceived when in this situation, seems to proceed from the same cause, and to produce nearly the same sensations, which the damp arising from the wet floor of a chamber communicates to those who happen to be in it.

Winds are not constant in their effects. As we have sometimes warm weather with a north-wind, and sometimes very little heat with one blowing from the south; so the fogs attending an east-wind are not constant, neither is the evaporation above mentioned at all times to be perceived. It is possible, however, that in all this Tertiana, there may be a deception; and that instead of supposing the quantity of vapours exhaled to be increased by an easterly wind, the coldness of that wind may only condense and render visible the vapours in the air at that time. But even this supposition is liable to great objections, as our coldest north-winds seldom or never produce such an effect, but on the contrary are attended with dry and serene weather.

Be this as it will, however, an east-wind is usually accompanied with a cold, damp, and unwholesome vapour, which is observed to affect the health both of animals and vegetables, and in many places to produce obstinate intermitting fevers, and also to occasion frequent relapses. In particular spots of the low damp island of Portsea, the ague frequently prevails during the autumnal season, and in some years is much more frequent and violent than in others. It is also observable, that this disease always attacks strangers, or those who have formerly lived on a drier soil, and in a more elevated situation, with greater severity than those who are natives of the island.

The year 1765 was remarkable, not only for the long continuance of the easterly winds, but for an excessive degree of heat, which produced a more violent and general appearance of those diseases than had been known for many years before. In the month of August the quicksilver in Fahrenheit's thermometer often rose to 82° in the middle of the day. This considerable addition of heat, together with the want of refreshing rains, greatly spread the fever, increased its violence, and even changed its form in many places. At Portsmouth, and throughout almost the whole island of Portsea, an alarming continual or remitting fever raged, which extended itself as far as Chichester. At the same time, the town of Gosport, though distant only one mile from Portsmouth, enjoyed an almost total exemption from sickness of every kind; whereas in the neighbouring villages and farm-houses, a mild regular tertian ague affected whole families. The violence of the fever, with its appearances in a continued, remitting, or intermitting form, marked in some measure the nature of the soil. In Portsmouth the symptoms were bad, worse at Kington, and still more dangerous and violent at a place called Half-way Houses; a street so named, about half a mile from Portsmouth, where scarcely one in a family escaped this fever, which generally made its first attack with a delirium. In the large suburb of Portsmouth called the Common, it seemed to rage with more violence than in the town, some parts excepted; but even whole streets of this suburb, together with the houses in the dock-yard, escaped its attack.

The marines, who were three times a-week exercised early in the morning on South-sea beach, suffered much from the effect of the stagnant water in an adjoining morass. Half a dozen of them were frequently taken ill in their ranks when under arms; some being seized with such a giddiness of their head, that they could scarcely stand; while others fell down speechless, and upon recovering their senses complained of a violent headache. When such patients were received into the hospital, it was observed that some few had a regular ague, but that far the greater number laboured under a remitting fever, in which sometimes indeed there was no perceptible remission for several days. A constant pain and giddiness of the head were the most inseparable and distressing symptoms of this disease. Some were delirious, and a few vomited up a quantity of bile; but in all the countenance was yellow. A long continuance of the fever produced a dropy or jaundice, or both. Even a flight attack reduced the most robust constitution to a state of extreme debility; and this weakness, together with the giddiness, continued for a long time after the fever. A facbby eruption now and then made its appearance on the lips and the corners of the mouth: but dry itchy spots over the whole body, resembling much the common itch, and seeming to partake of the nature of that disease, were more frequently observed in the patients at Portsmouth, where there was not the least reason to suspect any infection.

Such is the appearance of the remitting fever occasioned by marsh miasmata in England. In the Netherlands its symptoms are not much different. Dr Lind informs us, that at Middleburg, the capital of West Zealand, a sickness generally reigns towards the latter end of August, or the beginning of September, which is always most violent after hot summers. It commences after the rains which fall in the end of July; the sooner it begins the longer it continues, and it is only checked by the coldness of the weather. Towards the end of August and beginning of September it is a continual burning fever, attended with a vomiting of bile, which is called the gall-sickness. This fever, after continuing three or four days, intermits, and affumes the form of a double tertian; leaving the patient in a fortnight, or perhaps sooner. Strangers that have been accustomed to breathe a dry pure air do not recover so quickly. Foreigners in indigent circumstances, such as the Scots and German soldiers, who are garrisoned in the adjacent places, are apt after those fevers to have a swelling in their legs and a dropy; of which many die.

These diseases, the doctor observes, are the same with the double tertians common within the tropics. Such as are seized with the gall-sickness have at first some flushes of heat over the body, a loss of appetite, a white foul tongue, a yellow tinct in the eyes, and a pale colour in the lips. Such as live well, drink wine, and have warm clothes and good lodgings, do not suffer so much during the fickle season as the poor people; however, these diseases are not infectious, and seldom prove mortal to the natives.

Sir John Pringle observes, that the prevailing epidemic of autumn in all marshy countries, is a fever of an intermitting nature, commonly of a tertian form, but of a bad kind; which, in the dampest places and worst seasons, appears as a double tertian, a remitting, or even an ardent fever. But however these fevers may vary in their appearance according to the constitution of the patient and other circumstances, they are all of a similar nature. For though, in the beginning of the epidemic, when the heat or rather the putrefaction in the air is the greatest, they affume a continued or a remitting form, yet by the end of autumn they usually terminate in regular intermittents.

In Zealand where the air is more corrupted than in other parts of the Netherlands, this distemper is called the gall-sickness; and indeed both the redundancy and depravation of the bile is sometimes so great, that it has been generally ascribed to the corruption and overflow- ing of that humour. But though it cannot with justice be laid to originate from corrupted bile, it is certain that the disease may be continued, and the symptoms aggravated, by an increased secretion and putrefaction of the bile occasioned by the fever. In proportion to the coolness of the season, to the height and dryness of the ground, this distemper is milder, remits or intermits more freely, and removes further from the nature of a continued fever. The higher ranks of people in general are least liable to the diseases of the marshes; for such countries require dry houses, apartments raised above the ground, moderate exercise, without labour in the sun or evening damps, a just quantity of fermented liquors, plenty of vegetables, and fresh meats. Without such helps, not only strangers, but the natives themselves, are sickly, especially after hot and close Summers. The hardiest constitutions are very little excepted more than others; and hence the British in the Netherlands have always been liable to fevers.

By this distemper the British troops were harassed throughout the whole of the war from 1743 to 1747. It appeared in the month of August 1743; the paroxysms came on in the evening, with great heat, thirst, a violent headache, and often a delirium. These symptoms lasted most of the night, but abated in the morning, with an imperfect sweat, sometimes with a hemorrhage from the nose or a looseness. The stomach from the beginning was disordered with a nausea and sense of oppression, frequently with a bilious and offensive vomiting. If evacuations were either neglected, or too sparingly used, the patient fell into a continued fever, and sometimes grew yellow as in a jaundice. When the season was further advanced, this fever was attended with a cough, rheumatic pains, and fizzy blood. The officers being better accommodated than the common men, and the cavalry who had cloaks to keep them warm, were not so subject to it: and others who belonged to the army, but lay in quarters, were least of all affected; and the less in proportion to their being little exposed to heats, night-damps, and the other fatigues of the service.

In this manner did the remitting fever infest the army for the remaining years of the war; and that exactly in proportion to their distance from the marshy places, of which we have several notable instances in Pringle's observations. In Hungary the same disease appears with still more violence, and is readily complicated with fevers of a truly pestilential nature, by which means it becomes extremely dangerous. Hungary is acknowledged to be the most sickly climate in Europe, and indeed as bad as any in the world. Here it was where the crusaders in only marching through the country to invade Affa, often lost half their number by sickness; and where the Austrians not long since buried, in a few years, above 40,000 of their best troops, who fell a sacrifice to the malignant disposition of the Hungarian air. The reason of this uncommon malignity is, that Hungary abounds with rivers, which, by often overflowing, leave that low flat country overspread with lakes and ponds of stagnating water, and with large unwholesome marshes. So great is the impurity of these stagnated waters, that by them the rivers, even the Danube, whose course is flow, become in some places corrupted and offensive. The air is moist, and in summer quite sultry. In the nights of harvest, Kramer tells us, it was so very damp, that the Austrian soldiers could not secure themselves from the moisture even by a triple tent-covering. Here epidemical distempers begin constantly to rage during the hottest months of the year; which are July, August, and September: and these complaints, according to the observations of the physician above mentioned, are the same with those which are epidemic upon the coast of Guinea, and in the sickly climates of the East and West Indies, of which malignant fevers of the remitting and intermitting kind are the most common and dangerous.

The heat of the sun in Hungary is more intense than in any other country of Europe; and in proportion to the heat is the pestilential quality of the marshy exhalations. It is constantly observed, that the nearer any city or fort is to a morass or a large river with foul and oozy banks, the more unhealthy are the inhabitants. At such seasons and places, the air swarms with numberless insects and animalcules, a sure sign of its malignant disposition; and the hotter the summer, the more frequent and mortal are the diseases. In short, this country, on account of its unhealthiness, has been termed the grave of the Germans; and in Italy, the Campania of Rome is almost equally unhealthy. Lanctius, physician to Pope Clement XI. furnishes us with a very striking instance of the malignant quality of the air of Campania. Thirty gentlemen and ladies of the first rank in Rome having made an excursion, upon a party of pleasure, towards the mouth of the Tyber, the wind suddenly shifting, blew from the south over the putrid marshes, when 29 were immediately seized with a tertian fever, only one escaping.

The island of Sardinia is annually visited with an epidemical sickness, which rages from June to September; and is called by the natives the intemperies. In some years there is a want of rain for four or five months; and then it is that this sickness exerts its utmost violence, being always more fatal in some places than in others, and in particular to foreigners. Of this the British had a severe proof in 1758.—Admiral Broderick, in the Prince ship of war, anchored in the bay of Orifagni, where 27 of his men, sent ashore on duty, were seized with the epidemical distemper of this island; twelve of them in particular, who had slept on shore, were brought on board delirious. All of them in general laboured under a low fever, attended with great oppression at the breast; and, at the pit of the stomach, a constant retching, and sometimes a vomiting of bile; upon which delirium often ensued. These fevers changed into double tertians, and terminated in obstinate quartan agues. It is worthy of remark, that in this ship, which lay only two miles from the land, none were taken ill but such as had been on shore, of whom seven died. The prior of a convent, making a visit to the English officers, informed them, that the intemperies of the island was a remitting or intermitting fever, and that he himself had suffered several attacks of it. Sardinia was formerly so remarkable for its unholyfome air, that the Romans used to banish their criminals thither; and it is at present but thinly peopled, owing to the mortality occasioned by this annual sickness. For although it is about 140 miles long, and in several places 75 miles broad, yet it is computed that the whole number of its inhabitants does not exceed 250,000: an inconsiderable number, when compared with the inhabitants of the lesser, but comparatively more healthful, island of Corsica; though even there the French lost a number of their troops by intermitting and remitting fevers. In the island of Minorca, too, Dr Cleghorn informs us, that fevers of this kind prevail exceedingly; that their types are various, their symptoms violent, the intermissions fallacious, and that they frequently and suddenly prove fatal. It is more than probable, he adds, from the accounts of several physicians and travellers, that epidemical tertians are not wholly confined to the coasts and islands of the Mediterranean, but that they are equally frequent and destructive in many other parts of the globe; and perhaps may be deemed the anniversary autumnal distempers of most hot countries in the world. And though in the mild climate of Britain, a tertian may easily be cured when it is discovered; yet in warm climates, such is the rapid progress of the distemper, that it is necessary to know it in the very beginning, which is very difficult for those who have never seen any but the tertians usually met with in Britain.

From Dr Cleghorn's account of Minorca, however, it doth not appear why that island should be so much infested with fevers of this kind, since it is far from being a marshy country; nay, on the contrary, is very dry. The fourth wind, he observes, is very unhealthy; and it is the prevalence of this wind which brings on the fever: but still the difficulty is not removed, because the sea air is so far from bringing on such dangerous diseases, that it is one of the greatest preservatives against them. As to the moisture which must necessarily accompany an insular situation, that cannot reasonably be admitted as a cause of this or any other disease. In the London Medical Observations we find a paper on a subject very similar to the present, namely, the mischiefs produced by lying in damp fleets, or being exposed to moist vapour. The author tells us, that he hardly knows a distemper the origin of which has not by some been ascribed to lying in a damp bed, or sitting in a wet room; and yet he does not know any one which will certainly be produced by these causes, and people frequently expose themselves to such causes without suffering any ill effects. "It must be owned indeed," (says he,) "that the vapours arising from the bilge-water of ships tend to produce a feverous." The swampy plains also near the mouths of great rivers which are often overflowed, and low grounds which cannot readily be drained, and those tracts of land where the thickness and extent of the woods keep the ground moist and half putrid for want of ventilation, are destructive to the neighbouring inhabitants, by occasioning obstinate intermittents in the colder climates, and pestilential fevers in the hotter regions. But all this mischief arises not merely from moisture, but from an unventilated and putrid moisture; for the innocuousness of mere wetness, untainted with putridity, may be reasonably inferred from the following considerations. The air is often fully saturated with moisture; and yet neither is any epidemical distemper produced by it, nor are those remarkably aggravated with which the sick happen at that time to be afflicted. The air from rivers and from the sea is probably more replenish- ed with vapours than inland countries cleared of their woods: yet the most celebrated of the ancient physicians recommended the bank of a running river for the situation of a house, on account of its peculiar healthfulness; and many invalids are sent by the modern physicians to the sea side, only for the benefit of the sea air.

"Where the sailors are cleanly, and not too much crowded, they are often as healthy during long voyages at sea, as they would have been upon any part of the land. Venice is not observed to be less healthy than London or Paris.

"Those who are much disposed to sweat, lie many hours in bedclothes impregnated probably with a less wholesome moisture than would have been left in the sheets half-dried after washing; and there is no reason to think that any remarkable injury was done to the health by the continuance of such sweats almost every night for weeks, and for months, except what arose from the too great copiousness of this evacuation.

"Children, and such as are troubled with the stone, and those who, from other infirmities or age, constantly wet their beds with their urine, do not appear to suffer in their health on this account.

"It is a common practice, in some disorders, to go to bed with the legs or arms wrapped in linen cloths thoroughly soaked in Malvern water, so that the sheets will be in many places as wet as they can be; and I have known these patients and their bedfellows receive no harm from a continuance of this practice for many months. Nor can it be said that the Malvern water is more innocent than any other water might be, on account of any ingredients with which it is impregnated; for the Malvern water is purer than that of any other spring in England which I ever examined.

"The greatest valetudinarians do not scruple to sprinkle lavender-water upon their sheets; and yet, when the spirit is flown off, there is left what is as truly water as if it had been taken from the river.

"Is it observed, that laundresses are peculiarly unhealthy above other women, though they live half their time in the midst of wet linen, in an air fully saturated with vapours? Many other employments might be mentioned, the persons occupied in which are constantly exposed to wet floors or pavements, or to be surrounded with watery vapours, or to have their clothes often wet for many hours together.

"Is it the coldness of wet linen which is to be feared? But shirts and sheets, colder than any unfrozen water can be, are safely worn and lain in by many persons, who, during a hard frost, neither warm their shirts nor their sheets.—Or does the danger lie in the dampness? But then how comes it to pass, that a warm or cold bath, and long-continued fomentations, can be used, without the destruction of those who use them? Or is it from both together? Yet we have long heard of the thickness and continuance of the cold fogs in the seas north-west of England, but have never yet been told of any certain ill effect which they have upon those that live in these countries."

With regard to the causes of fevers, however, Dr. Lind is of opinion, that noxious vapours arising from the earth are for the most part to be blamed. Even in countries seemingly dry, and where violent rains are not frequent, he thinks that the air may load itself with putrid exhalations from the ground; and that, except in the burning deserts of Arabia or Africa, Tertiana people are nowhere exempt from diseases occasioned by putrid moiture. In most of the hot countries the pernicious effects of the putrid vapours are by no means equivocal. In Guinea, they seem to be more extraordinary than anywhere else in the world; neither indeed can it be supposed, that a hot and moist atmosphere can be without putrefaction. It may in general be remarked, that in fultry climates, or during hot weather, in all places subject to great rains, where the country is not cleared and cultivated, but is overrun with thickets, shrubs, or woods, especially if there are marshes or stagnating waters in the neighbourhood, feckness may be dreaded, and particularly the remitting fever of which we now treat. The fens, even in different counties of England, are known to be very prejudicial to the health of those who live near them, and still more so to strangers; but the woody and marshy lands in hot countries are much more pernicious to the health of Europeans. In all those unhealthy places, particularly during fogs or rains, a raw vapour, disagreeable to the smell, arises from the earth, and especially in the huts or houses. But of all the vapours which infect the torrid zone, the most malignant and fatal are the har-mattans: They are said to arise from the conflux of several rivers in the king of Dormeo's dominions at Benin (the most unwholesome part of Guinea), where travellers are obliged to be carried on men's backs for several days journey, through swampy grounds, and over marshes, amidst stinking ooze, and thickets of mangrove trees which are annually overflowed. These vapours come up the coast to a surprising distance, with the south-east and north-east winds: and it has been observed, that in their progress they have often changed both the course of the winds and of the sea-currents. The times of their appearance at Cape Coast are the months of December, January, or February. The north-east and south-east winds are always unhealthy, but particularly so during the harmattan season. In some years this vapour is scarcely perceptible; but in others it is thick, noxious, and destructive to the blacks as well as whites.—The mortality is in proportion to the density and duration of the fog. It has a raw putrid smell; and is sometimes so thick, that a person or house cannot be discerned through it at the distance of 15 or 20 yards: and it continues so for 10 or 14 days; during which it opens the seams of ships, splits or opens the crevices of wood as if shrunk or dried with a great fire, and destroys both man and beast. In the year 1754 or 1755, the mortality-occasioned in Guinea by this stinking fog was so great, that in several negro towns the living were scarce sufficient to bury the dead.—Twenty women brought from Holland by a new governor to the Castle del Mina, perished, together with most of the men in the garrison. The gates of Cape Coast castle were shut up for want of centinels to do duty; the blacks dying at this time as well as the white people. It is lucky that it is only in some years that harmattans are so very thick and noxious, otherwise that part of the country would be depopulated. It is observed that all fogs are extremely unhealthy in those parts, particularly before and after the rainy seasons; but the above account of the harmattans appeared so very extraordinary and incredible to some of Dr Lind's readers, that he thought proper to publish. publish a further corroboration of the facts above mentioned. "A gentleman (fays he), who had long resided at Cape Coast castle, informed me, that during the time of this fog, being in the upper chambers of the fort, the boards of the floor shrank so much, that he could discern the candles burning in the apartments below him (there are no plaster ceilings used in those hot countries), and that he could then even distinguish what people were doing in the apartments below; the seams of the floor having opened above half an inch while the fog lasted, which afterwards, upon its being dispelled, became close and tight as before."

In Africa the rains and dews seem to be possessed of qualities almost equally pernicious with the fogs. This much is certain, that in Guinea, many of the principal negroes, and especially of the mulatto Portuguese, take the utmost precaution to avoid being wet with those rains, especially such as fall first. At the setting in of the rainy season, they generally shut themselves up in a close well-thatched hut, where they keep a constant fire, smoke tobacco, and drink brandy, as preservatives against the noxious quality of the air at that time. When wet by accident with the rain, they immediately plunge themselves into salt-water, if near it. Those natives generally bathe once a day, but never in the fresh water rivers when they are overflowed with the rains: at such times they prefer for that purpose the water of springs. The first rains which fall in Guinea are commonly supposed to be the most unhealthy. They have been known, in 48 hours, to render the leather of the shoes quite mouldy and rotten, they stain clothes more than any other rain; and soon after their commencement, even places formerly dry and parched swarm with frogs. At this time Ikins, part of the traffic of Senegal, quickly generate large worms; and it is remarked, that the fowls, which greedily prey on other insects, refuse to feed on these. It has been farther observed, that woollen cloths wet in those rains, and afterwards hung up to dry in the sun, have sometimes become full of maggots in a few hours.—It is also probable, that as in some of those countries the earth, for fix or eight months of the year, receives no moisture from the heavens but what falls in dews, which every night renew the vegetation, the surface of the ground in many places becomes hard and incrusted with a dry scurf, which pens up the vapours below; until, by the continuance of the rains for some time, this crust is softened, and the long pent up vapours set free. That these dews do not penetrate deep into the earth is evident from the constant dryness and hardness of such spots of ground in those countries as are not covered with grass and other vegetables. Thus the large rivers in the dry season being confined within narrow bounds, leave a great part of their channel uncovered, which having its moisture totally exhaled, becomes a solid hard crust; but no sooner the rains fall than by degrees this long parched up crust of earth and clay gradually softens, and the ground, which before had not the least smell, begins to emit a stench, which in four or five weeks becomes exceedingly noisome, at which time the sickness is generally most violent.

This sickness, however, is not different from the remitting fever which has been described under so many various forms and names. An inflammatory fever is seldom observed, during the season of sickness, in this part of the world; and we shall conclude our description of the amphimerina paludosa with some extracts from the surgeon's journal in a ship that sailed up the rivers of Guinea.

"On the 5th of April we failed up the river of Gambia, and found all the English in the fort in perfect health. The surgeons of the factory informed me, that a relaxation of the stomach, and consequently a weakened digestion, seemed to bring on most of the diseases fatal to Europeans in the fickle season. They were generally of a bilious nature, attended with a low fever, sometimes of a malignant, at other times of a remitting kind.—On the 12th of April, after sailing 30 miles up the river St Domingo, we came to Catoucha, a town belonging to the Portuguese in Lat. 20° N. In this town were only four white people, the governor, and three friars. The number of whites in the trading ships was 51. One morning, towards the latter end of April, a little rain fell. On the 13th of May there was a second shower, accompanied with a tornado. On the 18th of May it rained the whole day; and the rain continued, with but short intervals, until the beginning of October.

"In the month of June almost two-thirds of the white people were taken ill. Their sickness could not be well characterized by any denomination commonly applied to fevers: it however approached nearest to what is called a nervous fever, as the pulse was always low, and the brain and nerves seemed principally affected. It had also a tendency to frequent remissions. It began sometimes with a vomiting, but oftener with a delirium. Its attack was commonly in the night; and the patients, being then delirious, were apt to run into the open air. I observed them frequently recover their sensibility for a short time, by means of the heavy rain which fell upon their naked bodies. But the delirium soon returned: they afterwards became comatose, their pulse sunk, and a train of nervous symptoms followed; their skin often became yellow; bilious vomitings and stools were frequent symptoms. The fever reduced the patient's strength so much, that it was generally fix weeks or two months before he was able to walk abroad. A consumming flux, a jaundice, a dropy or obstructions in the bowels, were the consequences of it. Of 51 white men, being the companies of four ships which were at Catoucha, one-third died of the fever, and one-third more of the flux, and other diseases consequent upon it; and of these not one was taken ill till the rains began.

"I believe, on the whole face of the earth, there is hardly to be found a more unhealthy country than this during the rainy season: and the idea I then conceived of our white people was by making a comparison of their breathing such a noxious air, with a number of river-fish put into stagnating water; where, as the water corrupts, the fish grow less lively, they droop, pine away, and many die.

"Thus some persons became dull, inactive, slightly delirious, at intervals; and, without being so much as confined to their beds, they expired in that delirious and comatose state in less than 48 hours after being in apparent good health. The white people in general became yellow; their stomach could not receive much food without loathing and retchings. Indeed it is no wonder that this sickness proved so fatal, that recove- ries from it were so tedious, and that they were attended with fluxes, dropsey, the jaundice, ague-cakes, and other dangerous chronical distempers. It seems more wonderful to me that any white people ever recover, while they continue to breathe so pestiferous an air as that at Catchou during the rainy season. We were, as I have already observed, 30 miles from the sea, in a country altogether uncultivated, overflowed with water, surrounded with thick impenetrable woods, and overrun with slime. The air was vitiated, noisome, and thick; insomuch that the lighted torches or candles burnt dim, and seemed ready to be extinguished: even the human voice lost its natural tone. The smell of the ground and of the housetops was raw and offensive; but the vapour arising from putrid water in the ditches was much worse. All this, however, seemed tolerable, when compared with the infinite numbers of insects swarming every where, both on the ground and in the air; which, as they seemed to be produced and cherished by the putrefaction of the atmosphere, so they contributed greatly to increase its impurity. The wild bees from the woods, together with millions of ants, overran and destroyed the furniture of the housetops; at the same time, swarms of cockroaches often darkened the air, and extinguished even candles in their flight; but the greatest plague was the musquitoes and land-flies, whose incessant buzz and painful stings were more insupportable than any symptom of the fever. Besides all these, an incredible number of frogs on the banks of the river made such a constant and disagreeable croaking, that nothing but being accustomed to such an hideous noise could permit the enjoyment of natural sleep. In the beginning of October, as the rains abated, the weather became very hot; the woods were covered with abundance of dead frogs, and other vermin, left by the recess of the river; all the mangroves and shrubs were likewise overspread with flinging lime."

After so particular a description of the remitting fever in many different parts of the world, we presume it will be needless to take notice of any little varieties which may occur in the warm parts of America, as both the nature and cure of the distemper are radically the same: neither shall we lengthen out this article with further descriptions of remitting fevers from the works of foreign authors, as, from what we have already said, their nature cannot easily be mistaken.

Cure. The great difficulty in the cure of remitting fevers arises from their not being simple diseases, but a complication of several. Fevers, properly speaking, have but three or four different appearances which they can assume without a complication. One is, when they are attended with a phlogistic diathesis; another is, when they assume the form of genuine intermittents; a third is, when they produce a great debility of the nervous system; and the fourth is, when along with this debility there is also a rapid tendency to putrefaction. If, therefore, all these species happen to make an attack at once, the most dangerous fever we can imagine will be produced; and however contrary it may be to our theories to admit the possibility of such an attack, the truth of the fact is too often confirmed by fatal experience. In the beginning of remittent fevers, for instance, the symptoms indicate a high degree of inflammation: but if the practitioner attempts to remove this inflammation by blood-letting or other evacuations, the pulse sinks irrecoverably, and the person dies with such symptoms as show that the nervous system has been from the beginning greatly affected; at the same time the high stimulants and cordials, or cinchona, which would have conquered the nervous part of the disease, increase the inflammatory part of it to such a degree, that, by a too early exhibition of them, the patient also dies, but after another manner.

In the remitting fever of the East Indies, Dr Lind of Windsor formed the following indications of cure. 1. To allay the violence of the fever. 2. To evacuate the putrid humours, and take great care to prevent the body from inclining to putrefaction. 3. To keep up the strength of the patient as much as possible during the disorder. 4. To lose no time in preventing the return of the paroxysms.

To allay the violence of the fever, everything that can contribute to increase it ought to be carefully avoided or removed; such as great heat, too strong a light falling on the eyes, noise, and motion. If during the paroxysm the head and loins be affected with violent pains, the pulse be full and hard, and the heat intense, bleeding may be used, but with the greatest caution: for, however useful this operation may be in cold climates, the success of it in warm ones is so far from being certain, that the lives of the patients have been often very much endangered, nay even destroyed by it. Dr Badenoch, and the surgeon of the Penhorne, endeavoured each of them to relieve two patients by blood-letting; and the consequence was, that each of them lost one patient. Dr Lind bled two patients; one of whom was Mr Richardion, the first mate of the ship, who complained of a most violent pain in his head, with a full hard pulse. About four or five ounces of blood were taken from him, by which he was greatly relieved: nor was the cure retarded by it; nay, the fever afterwards became less irregular. At the time the other patient was bled, the disease was exceedingly frequent and violent. He was so earnest for bleeding, that he fired all the rest with the same desire, fearing, that by refusing them this only remedy, every one of them would be sent to their graves. To quiet them, therefore, and get quit of their importunities, the doctor complied with their request, and took about five or fix ounces from him who had been the first to require it. The consequence was, that he immediately lost his strength; and in less than an hour, during which time he made his will, was carried off by the next fit. It is necessary, however, to observe, and indeed the doctor himself makes the observation, with regard to this patient, that he was bled at an improper time, namely, between the fits; whereas, had he been bled in the hot fit, it is possible he might have been relieved.

In support of the advantages to be derived from bleeding under proper circumstances, we have the authority both of Cleghorn and Pringle. As Dr Cleghorn practised in a very hot country, his observations must in the present case have greater weight than those of Pringle, who practised in a colder one. The former acquaints us, that if he was called in early enough, unless there was a strong contra-indication, he always used to take away some blood from people of all ages; namely, from robust adults, 10 or twelve ounces; from others a smaller quantity, in proportion to their strength and years. And further, if a violent headache, obtinate delirium, and heat or pains of the bowels, were urgent, the bleeding was repeated within a day or two. By this reasonable evacuation, he found the vehemence of all the paroxysms somewhat diminished; the apyrexia became more complete; the operation of emetics and cathartics rendered safer and more successful; and the terrible symptoms which happened about the height of the distemper, such as raving sopor, difficulty of breathing, inflammations of the abdominal viscera, &c. were either prevented or mitigated. But if the fever had continued for some time before he was called, and the mass of blood appeared to be too much melted down or inclined to a putrid dissolution, he either abstained from bleeding entirely, or took away a very small quantity, though some urgent symptoms might seem to require a larger evacuation. As to the time of performing the operation, he acquaints us, that it is safe enough, except when the cold fit lasts or is soon expected, or while the skin is covered with critical sweats; and that he usually opened a vein in the beginning of the hot fit; by which means the sick were relieved, the immoderate heat of the body, which is often productive of fatal effects, was diminished, and the critical sweats brought on sooner and in greater abundance.

But though Dr Lind found venesection to be of such pernicious tendency in his patients, cooling acidulated liquors were of the utmost service, as they corrected the putrid humours, lessened the heat and thirst, and of course prevented the fever from arriving at so great an height as it would otherwise have done. Those cooling liquors are the best which are made up with some farinaceous substance, as they most easily unite with our fluids. Fossil acids too, and crystals of tar- tar, especially the latter, are of considerable use, not only in this, but in other fevers. The neutral salts, prepared with the juice of lemons, were likewise given with success during the heat of the fever. They lessen the nausea, the fits become more regular, and the remissions more full; and they are particularly grateful when given in a state of effervescence. The good effects of these draughts we are in a great measure to attribute to the antiseptic quality of the fixed air extracted from them during the effervescence.

During the remission, it is proper to evacuate the putrid humours by small doses of ipecacuanha, or rather tartar emetic. The tartar emetic indeed appears to be endowed with some kind of febrifuge virtue, which Dr Cullen thinks is owing to its relaxing the febrile spasm taking place in the capillary vessels. But should there appear any symptoms of a topical inflammation in some of the abdominal viscera, a thing which never happens unless the disorder has been of some standing, vomiting is to be avoided, and we are to depend upon purgatives alone for the evacuation of the putrid bile. These are always useful in the cure of this disorder. But all acid and strong purgatives are to be carefully avoided, and only the mild antiseptic ones made use of, such as crystals of tar- tar, or tamarinds made up with manna or with Glauber's salt.

Though in these diseases there is a great quantity of putrefied bile collected in the body, yet it seems much more probable that this is the effect than the cause of the disorder; and therefore, though we carry off the quantity collected ever so often, more of the same kind will still be produced by the putrefied disposition of the other fluids, at the same time that the strength of the patient must necessarily be diminished by repeated evacuations, when it ought rather to be kept up by all possible means. We ought well to observe, however, that the mineral acids have not that property of sweetening putrid bile which the vegetable ones have; and therefore the same relief will not be given by them which might reasonably be expected from vinegar or lemon juice.

In order to keep up the strength of the patient, good food is absolutely necessary. Dr Lind allowed the sick small mashes of panada made with boiled rice and barley mixed with currants or raisins and prunes, seasoned with sugar and a little wine, especially claret. During the paroxysms, they had gruel made of flour and rice, with sugar and the juice of acid fruit; and when the fit went off, a little wine was added to this mixture.

The shirts and bedding must be very often changed and well aired; their stools, and all filth and nastiness, are to be immediately removed; the places where they are lodged should be well aired and frequently sprinkled with vinegar; and, in the last place, the sick must be exceedingly well nurfed. Blisters, according to Dr Lind, should never be used till the fever has been of long continuance, or the spirits and pulse of the patient have begun to flag. But here our author has implicitly followed Dr Huxham, whose theory concerning the use of blisters is now found to be erroneous. According to that celebrated author, blisters are capable of doing considerable hurt in all cases where there is a tendency to inflammation, by increasing the motion of the fluids and the oscillatory power of the vessels, both of which are already too great. They are also improper, according to him, where there is a considerable tendency of the fluids to putrefaction; because he supposes the salts of these flies to operate in the same manner with volatile alkalies, that is, by dissolving and putrefying the blood still farther. But Sir John Pringle has shewn, that, in inflammatory fevers as well as those of the putrid kind, both blisters and volatile salts may be of service; the latter, particularly, he hath experimentally proved to be so far from promoting putrefaction, that they are exceedingly strong antiseptics.

In the East Indies, Dr Lind found it absolutely necessary to exhibit the Peruvian bark in large quantities, and as early as possible. By this method he not only secured the patient from the imminent danger of death to which he was exposed at every fit, but likewise conquered those obstructions which were apt to ensue in the abdominal viscera, and which are to be attributed to the continuance of the disorder, and not to the bark employed to cure it. He always gave the cinchona during the second remission, as all his care was during the first to cleanse the prime vie. He observes, however, that it is no purpose to give the bark till the necessary purgations are over; but affures us, that it never fails, unless from the coming on of a vomiting or diarrhoea it cannot be taken in sufficient quantities before the return of a paroxyfm. To prevent the medicine from vomiting or purging, he mixed a few drops of liquid laudanum with every dose of it. Half a dram was given every half hour in some convenient vehicle, beginning as soon as the fever had considerably abated, and the pulse was returned nearly to its natural state; both which generally happened before the sweats were over. An ounce of the bark was sometimes found too little to check the fever, but an ounce and a half never failed. It must be continued daily in small doses till the patient has recovered his strength, and then a greater quantity must be given, especially at the season when the rivers overflow the country.

Dr Pringle found the autumnal remittents in the Netherlands complicated with a great many inflammatory symptoms; for which reason it was generally found necessary to open a vein in the beginning. The vernal and later autumnal remitting fevers are accompanied with pleuritic and rheumatic pains from the coldness of the weather, and on that account require more bleeding. A physician unacquainted with the nature of the disease, and attending chiefly to the paroxyfms and remissions, would be apt to omit this evacuation entirely, and give the cinchona too soon, which would bring on a continued inflammatory fever. In these countries a vein may be safely opened either during the remission or in the height of a paroxyfm; and our author also found good effects resulting from bleeding in the hot fits of the marsh fever, even after it had almost come to regular intermissions. After bleeding, a purgative was usually exhibited, of which he gives us the following formula.

R. Infus fennae commun. 3ij. Elec. Lenitiv. 3s. Nitr. pur. 5i. Tinct. fen. 3vi. M.

Of this only one half was taken at once; and if it did not operate twice in four hours, the remainder was then taken. This potion agreed with the stomach, purged plentifully, and therefore was a very useful composition. Next morning, when there was almost always some remission, he gave one grain of emetic tartar rubbed with 12 grains of crabs-eyes, and repeated the dose in two hours, if the first had little or no effect; or at any rate in four hours. This medicine was intended not only to vomit, but also to operate by stool, and excite a sweat. If these evacuations were procured, the fever generally became easier, and was even sometimes cured. This he prefers to the ipecacuanha, and therefore in the latter years of his practice difused that root entirely. The same medicine was repeated next day or the day following; or if not, a laxative clyster was thrown up: and this method was continued till the fever either went off altogether, or interrupted in such a manner as to be cured by the cinchona.

A similar method was followed by Dr Huck in the remitting fevers of the West Indies and North America. In the beginning he let blood; and in the first remission gave four or five grains of ipecacuanha, with from half a grain to two grains of emetic tartar. This powder he repeated in two hours, taking care that the patient should not drink before the second dose; for then the medicine more readily passed into the bowels after it had operated by vomiting. If, after two hours more, the operation either way was small, he gave a third dose, which commonly had a good effect in opening the first passages; and then the fever either went quite off, or interrupted in such a manner as to yield to the bark. On the continent, he found little difficulty after the interruption; but in the West Indies, unless he gave the cinchona upon the very first interruption, though imperfect, the fever was apt to assume a continued and dangerous form.

In the remitting fevers of hot countries, however, it must be observed, that the lancet must in all cases be much more sparingly used than in similar diseases of the colder regions; and we must also be sparing of venefaction in those countries where the marsh effluvia are very strong and prevail much. For this reason Dr Lind of Haslar greatly condemns the practice of indiscriminate bleeding when people first arrive in hot climates. The first diseases indeed which occur in a voyage to the southward are, for the most part, of an inflammatory nature, and owing to a sudden transition from cold to hot weather. This occasions a fulness and diffusion of the veffels; whence all Europeans, on their first arrival under the tropic, bear evacuations much better than afterwards. The practice of indiscriminately bleeding, however, a number of the ship's company when they first come into a warm latitude, is by no means found to answer the purpose of a preventive. In such cases, indeed, as plainly indicate a plethoric disposition brought on by the heat, blood-letting is certainly useful. The signs of this are a pain and giddiness in the head; a heaviness and dulness of the eyes, which sometimes appear slightly inflamed: there is also commonly a fenfe of weight and fulness in the breast, the pulse at the fame time being quick and oppressed.

But the case is quite different after a longer continuance of filthy weather, and when the constitution is in some measure habituated to the hot climate. For it is then observed, that the symptoms of inflammations in the bowels, even the most dangerous, are not near so severe in such climates as in cold countries; nor can the patients bear such large evacuations. The physician, however, must take care not to be misled by the apparent mildness of the symptoms: for he will find, notwithstanding such deceitful appearances, that the inflammation makes a more rapid progress in hot countries than in cold, suppurations and mortifications being much more suddenly formed; and that in general all acute distempers come sooner to a crisis in the warm than in colder regions. Hence it is an important rule of practice in those climates, to feize the most early opportunity, in the commencement of all threatening inflammations, to make frequent though not copious evacuations by blood-letting. For by delay the inflammation quickly passes from its first to its last or fatal stage; at least, an imperfect crisis in such inflammatory fevers ensues, which fixes an obstruction in the viscera extremely difficult to remove.

It is indeed a general maxim with some physicians in the West Indies, that in most acute distempers bleeding in that country is prejudicial. This is founded upon a supposition that the crafamentum of the blood Fever is thinned, and the solids greatly weakened, by the heat of the climate. It is therefore objected, that bleeding in such an habit of body weakens the powers of nature, and withdraws the strength which is requisite to support the patient until the crisis of the fever.

This reasoning is partly just; but, like all general maxims, will admit of exceptions. First, with regard to sailors, it is to be remembered, that they are more exposed to quick vicissitudes of heat, cold, damps, and to various changes of the air and weather, than most of the other inhabitants of the Torrid Zone. Add to this, that their intemperance, and the excesses they are apt to fall into whenever it is in their power to commit them, render them more liable to inflammations than any other set of people. Hence their diseases require more plentiful evacuations than the land-inhabitants of those parts of the world, and generally they bear them better. But with regard to the natives of the country, or those who have remained long there, it must be proper to bleed them very sparingly, making allowance for the different seasons of the year, the temperature of the air, and the situation of the places where they reside. Thus, in some parts, even on the island of Jamaica, at particular seasons, the weather is cool; wherefore, in these places, and at such seasons, the inhabitants having their fibres more rigid, and a firmer crisis of their blood, bear venesection much better.

In cold countries the state of the air greatly assists in restoring the impaired spring of the fibres; whereas every thing almost in warm weather, such as heat, moisture, &c. concur to relax and weaken the habit of body. Thus we may daily see persons in Britain, after having suffered a most severe fit of sickness, recover their strength and spirits in a few days, and in a very short time their natural constitution. But the case is very different in the fultry regions of the Torrid Zone, or indeed in any part of the world where the heat of the season causes the mercury to stand for any length of time at the 77th degree and upward of Fahrenheit's thermometer. During such an excess of heat, debility after fevers is apt to remain with European constitutions for several months. In Jamaica, the convalescents are sent to the cool summits of the mountains; but a retreat to a more northern climate is often absolutely necessary to recover their wonted tone and vigour of body. It is a well-established observation, that the negroes and aborigines of the Torrid Zone cannot bear plentiful evacuations by the lancet. They commonly mix the most stimulating poignant spices with their ordinary light food, and this is found by experience suitable to their constitutions.

As proper preventives for the dangerous fevers of which we are treating, Dr Lind on all occasions recommends the avoiding of stagnant water, or putrid marshes; the use of proper food, cleanliness, and sobriety. Of the propriety of removing from the neighbourhood of those places whose pestilential effluvia produce the disorders, we cannot possibly entertain a doubt; and of the efficacy of proper food in preventing putrid disorders he gives a remarkable instance in the Sheernefs man of war, bound to the East Indies. As they went out, the men being apprehensive of sickness in so long a voyage, petitioned the captain Tertiana, not to oblige them to take up their salt provisions, but rather to permit them to live upon the other species of their allowance. It was therefore ordered, that they should be served with salt-meat only once a-week; and the consequence was, that after a passage of five months and one day, the ship arrived at the Cape of Good Hope without having a single person sick on board. As the use of Sutton's pipes had been then newly introduced into the king's ships, the captain was willing to ascribe part of such an uncommon healthfulness to their beneficent effects; but it was soon discovered, that, by the neglect of the carpenter, the cock of the pipes had all this while been kept shut. This ship remained in India some months, where none of the men, except the boats crew, had the benefit of going on shore; notwithstanding which, the crew continued to enjoy the most perfect state of health; they were, however, well supplied with fresh meat. On leaving India, knowing they were to stop at the Cape of Good Hope, and trusting to a quick passage, and the abundance of refreshments to be had there, they ate their full allowance of salt meats, during a passage of only 10 weeks; and it is to be remarked the air-pipes were now opened. The effect of this was, that when they arrived at the Cape, 20 of them were afflicted in a most miserable manner with scorbutic and other disorders. These, however, were speedily recovered by the refreshments they met with on shore. Being now thoroughly sensible of the beneficial effects of eating, in these southern climates, as little salt meat as possible when at sea, they unanimously agreed, in their voyage home from the Cape, to refrain from their too plentiful allowance of salt flesh. And thus the Sheernefs arrived at Spithead, with her full complement of 160 men in perfect health and with unbroken constitutions, having in this voyage of 14 months and 15 days buried but one man, who died in a mercurial falivation.

Thus we see, that a free and pure air is not a sufficient preservative against a putrefied state of the fluids, without proper food; and, on the other hand, we have a very remarkable instance of the inefficacy of the most salutary food to prevent putrid diseases, in a very noxious state of the atmosphere. In the year 1717, at the siege of Belgrade in Hungary, the fever of the country, and the flux, occasioned a most extraordinary mortality among the troops. The dread of these diseases caused every one, as may naturally be supposed, to have recourse to different precautions for self-preservation. Prince Eugene, the commander in chief, had water and the provisions for his table sent him twice a-week from Vienna. The pure stream of the river Kahlenberg was regularly brought to him: he avoided all excesses, and lived regularly, or rather abstemiously; refreshed himself often by eating a cool melon; and mixed his usual wine, which was Burgundy, with water. Yet, notwithstanding his utmost care, he was seized with a dysentery; which would have quickly put an end to his life, had not the speedy conclusion of that campaign permitted him to make a quick retreat.

At this unhealthy season, when hardly one imperial officer, much less their several domestics, escaped those malignant diseases, the renowned Count Bonneval and his his numerous retinue continued in perfect health, to the surpise, or to use the words of Dr Kramer, to the envy, of all who beheld them. The only remedy he used, was to take, two or three times a-day, a small quantity of brandy in which the Peruvian bark was infused; and he obliged all his attendants and domestics to follow his example. It is no less remarkable that the count, placing his certain preservation in the use of this single medicine, lived for many years afterwards in the most unhealthy spots of Hungary, without any attack or apprehension of disease; and continued to enjoy a perfect state of health during the hottest and most sickly seasons. And thus, with an unbroken and sound constitution, which is seldom the case of those who reside long in such climates, he lived to a great age. There is an instance produced by the same author, of a whole regiment in Italy having been preserved by the use of cinchona from the attack of these malignant diseases, viz. the flux, and bilious fever as it is frequently called, when the rest of the Austrian army, not pursuing that method, became greatly annoyed with them.

The intemperance and irregular living of those Europeans who visit the hot climates is frequently accused as the cause of their destruction; but, our author thinks, without sufficient reason; for though intemperance will make the body more liable to receive such diseases, it will not bring them on. It must by no means, however, be imagined, that in those climates Europeans may with impunity be guilty of excesses in eating or drinking; for the least error in that way will often prove fatal by debilitating the body, whose utmost strength in time of full health was perhaps scarce sufficient to resist the pestilential miasma of the atmosphere.

It appears, therefore, from the concurrent testimony of the most eminent physicians, that the most proper medicine to be used, either as a preventive or cure for remitting and intermitting disorders, is the Peruvian bark, administered with proper precautions and after the prime vic have been evacuated of the putrid bilious matter collected in them. In those species of triteophya, &c. belonging to this class, enumerated by Sauvages, the same remedies only were useful; but in that pestilential distemper which he calls triteophya Vratiflaviensis, he tells us, that washing the body with water sometimes hot, sometimes cold, watery clysters, and plenty of aqueous drink, were likewise of use.

GENUS II. QUARTANA; the QUARTAN FEVER.

Quartana auctorum, Sauv. Gen. 89. Lin. 17. Vog. 3. Sag. 71. Hoffm. II. p. 23. Junck. tab. 81.

The Genuine Quartan. Sp. I. var. 1. A. Quartana legitima, Sauv. Sp. I. Sydenham de morb. acut. cap. v.

Description. The genuine quartan, according to Juncker, keeps its form more exactly than other intermittents; scarcely coming on at any other time than four or five in the afternoon. The cold is less violent than in the tertian; but is very perceptible, though it doth not proceed to such a height as to make the limbs shake; it continues for about two hours. It is preceded and accompanied by a languor both of body and mind. There is seldom any vomiting unless when the stomach is manifestly overloaded with aliment; neither is there any diarrhea, but the belly in general is rather bound, not only on the days on which the paroxyism takes place, but also on the intermediate ones. The heat, which slowly succeeds the cold, is less troublesome to the patient by its violence than by the uneasy dryness of the skin, which is scarcely ever moistened with sweat. This heat rarely continues longer than four or five hours, unless perhaps at the first or second paroxyism. It is accompanied also with a giddiness and dull pain of the head. On the termination of the paroxyism, the patient returns to a middling state of health, and continues in the same for the rest of the intermediate days; only there remains somewhat of a loathing, and a deep-seated pain as if the person was all over bruised or broken, which kind of sensation the physicians are wont to call obfocopus. The fit returns every fourth day, and that precisely at the same hours, being rarely postponed.

Causae of, and persons subject to, this disorder. The same general causes concur in producing this as other intermittents, namely marsh miasmata, and whatever can dispose the body to be easily affected by them. Studious people, and those of a melancholic turn, are said to be particularly subject to quartans; but what are the immediate causes which produce a return of the fits every fourth day, instead of every day, or every third day, must probably lie for ever concealed, as depending upon the secret and inexplicable mechanism of the human body.

Prognosis. A simple quartan, where there is no reason to dread any induration of the viscera, may very certainly admit of a cure; and the prognosis can never be unfavourable, unless in cases of extreme weakness, or where the distemper hath been unskilfully treated.

Cure. This does not in the least differ from that which hath been fully laid down for the simple tertian, and which it is therefore needless to repeat here.

The Duplicated Quartan. Sp. I. var. 1. B. Quartana duplicata, Sauv. Sp. 4. Bonet.

This is entirely similar to the duplicated tertian already mentioned; proper allowance being made for the difference between the type of a tertian and quartan.

The Triplicated Quartan. Sp. I. var. 1. C. Quartana triplicata, Sauv. Sp. 16.

This hath three paroxysms every fourth day, while the intermediate days are entirely free from fever.

The Double Quartan. Sp. I. var. 1. D. Quartana duplex, Sauv. Sp. 3. Vog. Sp. 13.

In the double quartan, the fits come on every day except the third; but so that the first paroxyism answers to the third, the second to the fourth, and so on.

The Triple Quartan. Sp. I. var. 1. E. Quartana triplex, Sauv. Sp. 5. Vog. Sp. 14. Bartholin. H. anat. c. 1. 95.

This comes on every day, but the quartan type is still still preserved by the times of accession; that is, the time of the fourth paroxysm's coming on answers to that of the first, the fifth to the second, the sixth to the third, &c.

The QUARTAN, accompanied with Symptoms of other diseases. Sp. I. var. 2.

Quartana cataleptica, Sauv. sp. 7. Bonet. polyalth. vol. i. p. 825. Quartana comatosa, Sauv. sp. 15. Werholf. de febr. C. Pifonis Observ. de morbis à colluvie scrof. obf. 166, 167, 168, 169, 171, 172, 173, 174. Quartana epileptica, Sauv. sp. 8. Schozai Conf. 379, 383. Quartana hysterica, Sauv. sp. 10. Morton, Pyrct. exerc. i. cap. ix. H. 10. 11. Quartana nephralgica, Sauv. sp. 9. Quartana metastatica, Sauv. sp. 17. Quartana amens, Sauv. sp. 12. Sydenham de morb. acut. cap. v. Quartana splenetica, Sauv. sp. 2. Etmuller, Coll. consult. caf. 25.

The QUARTAN complicated with other Diseases. Sp. I. var. 3.

Quartana syphilitica, Sauv. sp. 6. Plateri, observ. L. III. p. 676. Edin. Eff. art. xlvii. obf. 8. Quartana arthritica, Sauv. sp. 11. Musfr. de Arthr. sympt. cap. ix. H. 4. et 5. Arthritis febrifeca, Sauv. sp. 10. Arthritis febricofa, Sauv. sp. 10. Werholf. de febr. Cockburn de morbis navigantium, obf. 19. Quartana scorbutica, Sauv. sp. 14. Barthol. de med. Dan. diff. iv. Tim. L. VIII. caf. 18.

The Remitting QUARTAN. Sp. II.

Tetartophya, Sauv. gen. 85. Sag. 699. Lin. 21. Quartana remittens auctorum.

Var. 1. Tetartophya simplex, Sauv. sp. 1. 2. Amphimerina semiquartana, Sauv. sp. 23. 3. Tetartophya semiteriana, Sauv. sp. 5. 4. Tetartophya maligna, Sauv. sp. 6. Lautter. Hift. med. caf. 21. M. Donat. L. III. cap. 14. ex M. Gatenaria Horfh. L. I. obf. 15. 5. Tetartophya carotica, Sauv. sp. 4. Werholf. de febr. Bianchi Hift. hep. pars III. confit. ann. 1718, p. 751. 6. Tetartophya splenalgica, Sauv. sp. 2. 7. Tetartophya hepatalgica, Sauv. 3. Car. Pif. in prefat. p. 33. 8. Amphimerina splamodica, Sauv. sp. 16.

To the tertian or quartan fevers also belong the Erraticae of authors. As all thofe above mentioned differ only in the flight circumstance of the type from the intermitting and remitting tertians already defcribed at length, it is unnecessary here to take up time in describing every minute circumstance related by physicians concerning them, efpecially as it could contribute nothing towards the laying down a better method of cure than what hath been already suggested.

GENUS III. QUOTIDIANA; the QUOTIDIAN FEVER.

Quotidiana auctorum, Sauv. gen. 86. Lin. 15. Vog. I. Hoffm. II. 33. Junck. tab. 79.

The Genuine QUOTIDIAN. Sp. I. var. 1. A.

Quotidiana simplex, Sauv. sp. 1. Quotidiana legitima, Sennert. de febr. cap. 18.

Description. This kind of fever generally comes on about fix or seven o'clock in the morning, beginning with a considerable degree of cold and shivering, which lasts for about an hour; and is often accompanied with vomiting or spontaneous diarrhoea, or both. It is succeeded by a pretty strong heat, accompanied with thirst, restlessness, and pain of the head. When the heat abates a little, a spontaneous sweat commonly follows, and the whole paroxysm rarely exceeds fix hours. It returns, however, every day almost always at the fame hour, unless it be evidently disturbed.

Caufes of, and perfon's subject to, the disease. The fame general caufes are to be assigned for the quotidian as for other intermittents. This kind occurs but rarely; and is said to attack people of a phlegmatic temperament rather than any other: alfo old people rather than young, and women rather than men.

The prognosis and method of cure are not different from thofe of tertians and quartans.

The Partial QUOTIDIAN. Sp. I. var. 1. B.

Quotidiana partialis, Sauv. sp. 16. Cnoffel. E. N. C. D. I. A. III. obf. 205. Edin. Med. Eff. vol. i. art. 31 vol. ii. art. 16.

Quotidiana cephalalgica, Sauv. sp. 6. Mort. pyretol. exerc. i. hift. 27. Van Swieten in Boerh. p. 534. Cephalalgia intermittens, Sauv. sp. 7. Cephalalgia febricofa, Sauv. sp. 4. Quotidiana ophthalmica, Morton, ibid. hift. 17. Van Swieten, ibid. Ophthalmia febricofa, Sauv. sp. 23.

Thefe diftempers attack only fome particular part of the body, as the head, the eye, arm, &c. producing periodical affections of thofe parts returning once in 24 hours; they are to be cured by cinchona, as other intermittents. They are known to belong to this clas, by the evident intermiffion of the pain or other affection of the part. The quotidiana hysterica, Sauv. sp. 3. quotidiana catarrhalis, Sauv. sp. 9. and quotidiana frangurifca, Sauv. sp. 11. feem to be symptomatic diftempers.

The Remitting QUOTIDIAN. Sp. II.

Amphimerina, Sauv. gen. 84. Lin. 2c. Quotidiana continua, Vog. 15. Quotidiane remittentes et continue auctorum. Amphimerina latica, Sauv. sp. 1. Febris continua lymphatica, Etmuller, Coll. conf. caf. 32. Rver. Obf. cent. 1. obf. 57. Amphimerina finguftuofa, Sauv. sp. 14. Febris continua Lyngodes, Vog. 26.

Concerning thefe also nothing remains neceffary to be mentioned in this place, having already fo fully difcuffed the remitting fevers in all the different parts of the world. Many other varieties of these fevers mentioned by different authors are to be accounted merely symptomatic.

SECT. II. CONTINUED FEVERS.

Continuas, Sauv. clafs ii. ord. 1. Vog. clafs i. ord. 2. Sag. 666. Boerk. 727. Continentes, Lin. clafs ii. ord. 1. Stahl. Caf. mag. 35. Caf. min. 87. Junck. 58. Sennert. de febr. L. ii. cap. 2. et 10.

GENUS IV. SYNOCHA.

Synocha, Sauv. gen. 80. Lin. 12. Junck. 58. Synocha, five febris acuta fanguinea, Hoffm. II. 105. Synochus, Vog. 16. Continua non putris, Boerk. 720. Ephemera, Sauv. g. 79. Boerk. 728. Junck. 57. Diaria, Lin. 11. Febris inflammatoria auctorum.

Description. The most simple kind of synocha is the ephemera or diary fever. It begins without any sensation of cold or shivering, unless there be some internal inflammation, or the smallpox or measles happen to be present. A continual heat without any intermission constitutes the essence of this disease. The heat, however, is more tolerable than in the synocha properly so called. In some, the pains of the head are pungent and throbbing, answering to the pulsations of the arteries; but in others they are dull and heavy. The face is red and bloated; and there is a remarkable latitude of the limbs, with a strong, full, and frequent pulse. The urine is red, and deposits a sediment almost of the colour of orange-peel; and in the very first day of the disease, signs of concoction (according to the Hippocratic phrase) appear. The fever commonly goes off with a gentle sweat; but sometimes, though more rarely, with a hemorrhagy by the nose. Its shortest period is 24 hours: but if it goes beyond the fourth day, it is then a synocha properly so called.

The simple synocha, according to Vogel, begins with cold and shivering, succeeded by vehement heat, redness, and dryness of the skin. The face, especially, is very red, and the thirst intense. The head is either pained or heavy. The patient either doth not sleep at all, or is disturbed with dreams. A moist sweat then breaks out all over the skin. The pulse is full, quick, and frequent; the judgment is sometimes a little disturbed; young people are apt to be terrified with imaginations; and they for the most part incline to sleep; the respiration is difficult, and the belly coltive; at the same time that a tenitive kind of latitude is perceived over the whole body. A complete crisis takes place either on the fourth or at the farthest on the eleventh day. The characteristic marks of the simple synocha, therefore, are, A redness of the face, moisture of the skin, a strong and frequent pulse.

Causes of, and persons subject to, this disease. As we have already remarked of intermittents, so must we also now remark of continued fevers, that it is impossible to discover those minute causes which occasion the difference of type betwixt one inflammatory fever and another, though most authors pretend to enumerate these with great certainty. Thus Juncker tells us, that the cause of the simple ephemera is plethora, together with any immoderate agitation and commotion of the fluids while in that state. Vogel reckons among the causes of his febris diaria, passions of the mind, pain, want, exposure to the sun, &c.; a repulsion or abstraction of certain humours; wounds, fractures, luxations, &c.; so that in general we may reckon every thing tending to increase the action of the arterial system to be in certain circumstances a cause of inflammatory fever.—Hence we find those are most subject to the synocha whose constitution is either naturally robust, or who are exposed to those causes which tend to produce an increased action of the arterial system; such as hard labour, high living, &c.

Prognosis. The most simple kind of synocha, that is, the ephemera or diary fever, is commonly cured without the assistance of medicine, and therefore the prognosis is for the most part favourable: yet, if it be improperly treated by heating medicines, it may easily be converted into the other kind; or, if there be a putrid disposition of the fluids, into a fever of a very dangerous nature. The same thing is to be understood even of the most violent kind; for simple inflammatory fevers are not dangerous unless complicated with an affection of some particular part, as the pleura, stomach, &c.

Cure. Dr Cullen objects to the plan of those who are for leaving the cure of continued fevers to the operations of nature; because these operations are neither certain in themselves, nor are they so well understood as to enable us to regulate them properly; and it is likewise possible to supercede them by art. The plan therefore on which he proceeds is, to form his indications of cure upon the means of obviating the tendency to death in fevers; and these he reduces to three. 1. To moderate the violence of re-action.—2. To remove or obviate the causes of debility; and, 3. To obviate or correct the tendency of the fluids to putrefaction.

The first indication may be answered, 1. By all those means which diminish the action of the heart and arteries. 2. By those which take off the spasm of the extreme veffels, which, according to his theory, is the chief cause of violent re-action.

1. The action of the heart and arteries may be diminished, 1. By avoiding or moderating those irritations which, in one degree or other, are almost constantly applied to the body. 2. By the use of certain sedative powers. 3. By diminishing the tension or tone of the arterial system.

[1.] The irritations above-mentioned are the impressions made upon our senses, the exercise of the body and mind, and the taking in of aliment. The avoiding of these as much as possible, or the moderating their force, makes what is properly called the antiphlogistic regimen, proper to be employed in almost every continued fever. This regimen is to be directed in the following manner.

1. Impressions on the external senses, as stimulant to the system, and a chief support of its activity, should be avoided as much as possible; especially such as are of a stronger kind, and which give pain and uneasiness. No impression is to be more carefully guarded against than that of external heat; and at the fame same time every other means of increasing the heat of the body is to be shunned. Both these precautions are to be taken as soon as a hot flagge is fully formed; and to be attended to during its continuance, except in certain cases, where a determination to sweating is necessary, or where the stimulant effects of heat may be compensated by circumstances which determine it to produce relaxation and revulsion.

2. All motion of the body is to be avoided as much as possible, and that posture only chosen which employs the fewest muscles, and keeps none of them long in a state of contraction. Speaking, as it accelerates respiration, is particularly to be avoided. It must also be observed, that every motion of the body is more stimulant in proportion as the patient is weaker.

3. The exercise of the mind is also to be avoided, as being a stimulus to the body; but here an exception is to be made in the case of a delirium coming on, when the presenting of accustomed objects may divert the irregular train of ideas then arising in the mind.

4. The presence of recent aliment in the stomach proves always a stimulus to the system, and ought therefore to be as moderate as possible. A total abstinence for some time may be of service; but as this cannot be long continued with safety, we must avoid the stimulus of aliment by choosing that kind which gives the least. Alimentary matters are also to be accounted more stimulant in proportion to their alkaline qualities; and this leads us to avoid all animal, and use only vegetable food. For the same reason, aromatic and spirituous liquors are to be avoided; and in answering the present indication, we must abstain from all fermented liquors except those of the lowest quality. Other stimuli are, the sensation of thirst, crudities or corrupted humours in the stomach, a preternatural retention of the faeces in the intestines, and a general acrimony of all the humours, which is in most fevers to be suspected. These are to be removed by such methods as the urgency of the symptoms require, by diluting liquors, vomiting, the use of acids, laxative clysters, and large quantities of antiseptic drinks.

[2.] The second method of moderating the violence of reaction is by the employment of certain sedative powers, with a view to diminish the activity of the whole body, and particularly that of the sanguineous system. The first of these to be mentioned is the application of cold. Heat is the chief support of the activity of the animal-system; and the system is therefore provided with a power of generating heat: but at the same time we may observe, that this would go to excess, were it not constantly moderated by a cooler temperature in the surrounding atmosphere. When, therefore, the generating power of heat in the system is increased, as is commonly the case in fevers, it is necessary not only to avoid all further means of increasing it, but also to apply air of a cooler temperature; or at least to apply it more entirely and freely than in a state of health. This is shown, from some late observations, to be a very powerful means of moderating the violence of reaction: but what is the mode of its operation, to what circumstances of fever it particularly applies, or what limitations it requires, are not yet fully ascertained.

Another sedative power very frequently employed in fevers, is that of certain medicines known in the materia medica by the name of refrigerants. The chief of these are acids of all kinds when sufficiently diluted, and which are, in several respects, remedies adapted to continued fevers. Those especially in use are the sulphuric and vegetable; and on many accounts the latter are to be preferred. Another set of refrigerants are the neutral salts formed of the sulphuric, nitrous or vegetable acids, with alkalis either fixed or volatile. All these neutrals, while they are diffused in water, generate cold; but as that cold ceases soon after the diffusion is finished, and as the salts are generally exhibited in a diffused state, their refrigerant power in the animal body does not all depend upon their power of generating cold with water. Nitre is the refrigerant chiefly employed; but all the others, compounded as above mentioned, partake more or less of the same quality. Besides these neutrals, some metallic salts have also been employed in fevers, particularly the acetite of lead: but the refrigerant powers of this salt are by no means ascertained, and its deleterious qualities are too well known to admit of its being freely used.

[3.] The third general method of diminishing the reaction, is by lessening the tension, tone, and activity of the sanguineous system. As the activity of the system in a great measure depends upon the tone, and this again upon the tension, of the vessels, given to them by the quantity of fluids they contain, it is evident, that the diminution of the quantity of these must diminish the activity of the sanguineous system. The most efficacious means of diminishing the quantity of fluids is by the evacuations of blood-letting and purging. The former is evidently one of the most powerful means of diminishing the activity of the whole body, and especially of the sanguineous system; and it must therefore be the most effectual means of moderating the reaction in fevers. When the violence of reaction, and its constant attendant a phlogistic diathesis, are sufficiently evident; when these constitute the principal part of the disease, and may be expected to continue through the whole of it, as in the cases of synochia; then blood-letting is the principal remedy, and may be employed as far as the symptoms of the disease may seem to require, and the constitution of the patient will bear. It must, however, be remarked, that a greater evacuation than is necessary may occasion a slower recovery, and render the person more liable to a relapse, or bring on other diseases. It is also to be observed, that this evacuation is the more effectual, as the blood is more suddenly drawn off, and as the body is at the same time more free from all irritation, and therefore when it is in a posture in which the fewest muscles are in action.

With regard to purging, when we consider the quantity of fluids constantly present in the cavity of the intestines, and the quantity which may be drawn off from the innumerable excretories that open into this cavity, it will be obvious, that a very great evacuation may be made in this way; and if this be done by a stimulus that is not at the same time communicated to the rest of the body, it may, by emptying both the cavity of the intestines and the arteries which furnish the excretions poured into it, induce a considerable relaxation in the whole system; and is therefore suited to moderate the violence of reaction in fevers. But it is to be observed, that as the fluid drawn from the excretories opening into the intestines is not all drawn immediately from the arteries, and as what is even more immediately drawn from these is drawn off slowly; so the evacuation will not, in proportion to its quantity, occasion such a sudden depletion of the red vessels as blood-letting does; and therefore cannot act so powerfully in taking off the phlogistic diathesis of the system.

At the same time this evacuation may induce a considerable degree of debility; and therefore, in those cases in which a dangerous state of debility is likely to occur, purging is to be employed with a great deal of caution; and this caution is more difficult to be observed than in the case of blood-letting: and it is further to be noticed, that as purging takes off in some measure the determination of the blood to the vessels on the surface of the body, it seems to be less adapted to the cure of fevers.

II. The other method of moderating the violence of reaction in fevers is by the exhibition of those remedies suited to take off the spasm of the extreme vessels, supposed to be the irritation which chiefly supports the reaction. The means to be employed for this purpose are either internal or external.

First, The internal means are, 1. Those which determine the force of the circulation to the extreme vessels on the surface of the body, and by restoring the tone and activity of those vessels, overcome the spasm on their extremities. 2. Those medicines which have the power of taking off spasm in any part of the system, and which are known under the title of Anti-spasmodics.

(1.) Those remedies which are fit to determine to the surface of the body are, 1. Diluents. 2. Neutral salts. 3. Sudorifics. 4. Emetics.

1. Water enters, in a large proportion, into the composition of all the animal fluids, and a large quantity of it is always diffused through the whole of the common masts. In a sound state, the fluidity of the whole mass depends upon the quantity of water present in it. Water therefore is the proper diluent of our mass of blood, and other fluids are diluent only in proportion to the quantity of water they contain.

In a healthy state, also the fulness of the extreme vessels and the quantity of excretion are in proportion to the quantity of water present in the body. But in fever, though the excretions be in some measure interrupted, they continue in such quantity as to exhale the more fluid parts of the blood; and, while a portion of them is at the same time necessarily retained in the larger vessels, the smaller, and the extreme vessels, both from the deficiency of fluid and their own contracted state, are less filled, and therefore allowed to remain in that condition. To remedy this contracted state, nothing is more necessary than a large supply of water or watery fluids taken in by drinking or otherwise; for as any superfluous quantity of water is forced off by the several excretories, such a force applied may be a means of dilating the extreme vessels, and of overcoming the spasm affecting their extremities. Accordingly, the throwing in a large quantity of watery fluids, has been, at all times, a remedy much employed in fevers; and in no instance more remarkably than by the Spanish and Italian physicians, in the use of what they call the dieta aquosa. This practice consists in taking away every other kind of aliment and drink, and in giving, in divided portions, every day for several days together, fix or eight pounds of plain water, generally cold, but sometimes warm. This, however, is to be done only after the disease has continued for some time, and at least for a week.

2. A second mean of determining to the surface of the body, is by the use of neutral salts. These neutrals, in a certain dose, taken into the stomach, produce soon after a sense of heat upon the surface of the body; and, if the body be covered close and kept warm, a sweat is readily brought out. The same medicines taken during the cold stage of a fever, very often put an end to it, and bring on the hot one; and they are also remarkable for stopping the vomiting which so frequently attends the cold stage of fevers. All this shows, that neutral salts have a power of determining the blood to the surface of the body, and may therefore be of use in taking off the spasm which subsists there in fevers. The neutral most commonly employed in fevers, is that formed of an alkali with the native acid of vegetables. But all the other neutrals have more or less of the same virtue; and perhaps some of them, particularly the ammoniacal salts, possess it in a stronger degree. As cold water taken into the stomach often shows the same diaphoretic effects with the neutral salts, it is probable that the effect of the latter depends upon their refrigerant powers.

3. A third method of determining to the surface of the body, and taking off the spasm subsisting there, is by the use of sudorifics and by sweating. The propriety of this practice has been much disputed; and many specious arguments may be adduced both for and against it. In its favour may be urged, 1. That in healthy persons, in every case of increased action of the heart and arteries, a sweating takes place, and is, seemingly, the means of preventing the bad effects of such increased action. 2. That, in fevers, their most usual solution and termination is by spontaneous sweating. 3. That, even when excited by art, it has been found useful at certain periods and in certain species of fever.—On the other hand, it may be urged against the practice of sweating, 1. That in fevers, as a spontaneous sweating does not immediately come on, there are some circumstances different from those in the state of health, and which may render it doubtful whether the sweating can be safely excited by art. 2. That in many cases the practice has been attended with bad consequences. The means commonly employed have a tendency to produce an inflammatory diathesis; which, if not taken off by the sweat succeeding, must be increased with much danger. Thus sweating employed to prevent the accessions of intermittent fevers has often changed them into a continued form, which is always dangerous. 3. The utility of the practice is doubtful; as sweating, when it happens, does not always give a final termination, as must be manifest in the case of intermittents, and in many continued fevers which are sometimes in the beginning attended with sweatings which do not prove final; and, on the contrary, whether they be sponta- neous or excited by art, they seem often to aggravate the disease.

From these considerations, it is doubtful if the practice of fweating can be admitted very generally; but, at the same time, it is also very doubtful if the failure of the practice, or the mischiefs said to arise from it, have not been owing to the improper conduct of the practitioner. With respect to the last, it is almost agreed among physicians, 1. That fweating has been generally hurtful when excited by stimulant, heating, and inflammatory medicines. 2. That it has been hurtful when excited by much external heat, and continued with a great increase of the heat of the body. 3. That it is always hurtful when it does not relieve; and rather increases the frequency and hardness of the pulse, the anxiety and difficulty of breathing, the headache, and delirium. 4. That it is always hurtful if it be urged when the sweat is not fluid, and when it is partial and on the superior parts of the body only.

In these cases, it is probable, that either an inflammatory diathesis is produced, which increases the spasm on the extreme vessels; or that, from other causes, the spasm is too much fixed to yield easily to the increased action of the heart and arteries: and upon either supposition it must be obvious, that urging the sweat may produce determinations to some of the internal parts, with very great danger.

Notwithstanding these doubts, however, it still remains true, 1. That fweating has been often useful in preventing the accessions of fevers when they have been certainly foreseen, and a proper conduct employed. 2. That even after fevers have in some measure come on, fweating has interrupted their progress when properly employed, either at the very beginning of the disease, or during its approach and gradual formation. 3. That even after pyrexia have continued for some time, fweating has been successfully employed in curing them, as is particularly exemplified in the case of a rheumatism. 4. That certain fevers produced by a very powerful sedative contagion, have been generally treated most successfully by fweating.

These instances are in favour of fweating, but give no general rule; and it must be left to farther experience to determine how far any general rule can be established in this matter. In the mean time, if the practice of fweating is to be attempted, the following rules may be laid down for the conduct of it: 1. That a sweat should be excited without the use of stimulant inflammatory medicines. 2. That it should be excited with as little external heat, and with as little increase of the heat of the body, as possible. 3. That, when excited, it should be continued for a due length of time; not less than 12 hours, and sometimes for 24 or 48 hours; always, however, supposing that it proceeds without the dangerous circumstances already mentioned. 4. That for some part of the time, and as long as the person can easily bear, it should be carried on without admitting of sleep. 5. That it should be rendered universal over the whole body; and therefore particularly that care should be taken to bring the fweating to the lower extremities. 6. That the practice should be rendered safer by moderate purging excited at the same time. 7. That it should not be suddenly checked by cold anyhow applied to the Synocha body.

When attention is to be given to these rules, the fweating may be excited, 1. By warm bathing, or a fomentation of the lower extremities. 2. By frequent draughts of tepid liquors, chiefly water, rendered more grateful by the addition of a light aromatic, or more powerful by that of a small quantity of wine. 3. By giving some doses of neutral salts. 4. Most effectually, and perhaps most safely, by a large dose of an opiate, joined with a portion of neutral salts, and of an emetic.

The fourth mean of determining to the surface of the body, and thereby taking off the spasm affecting the extreme vessels, is by the use of emetics. These, particularly of the antimonial kind, have been employed in the cure of fevers ever since the introduction of chemical medicines; but though of late their use has become very general, their efficacy is still disputed, and their manner of operating is differently explained.

Vomiting is in many respects useful in fevers: as it evacuates the contents of the stomach, as it emulges the biliary and pancreatic ducts, and evacuates the contents of the duodenum, and perhaps also of a large portion of the intestines; as it agitates the whole of the abdominal viscera, it expedites the circulation in them, and promotes their several secretions; and, lastly, as it agitates also the viscera of the thorax, it has like effects there.

It is not to this cause, however, that we are to impute the effect vomiting has in determining to the surface of the body. This must be attributed to the particular operation of emetics upon the muscular fibres of the stomach, whereby they excite the action of the extreme arteries on the surface of the body, and by this means effectually determine the blood to these vessels, remove the atony, and take off the spasm affecting them. For this purpose they are exhibited in two different ways; that is, either in such doses as may excite full and repeated vomitings, or in such doses as may excite sickness and nausea only, with little or no vomiting at all.

Full vomiting is well suited to determine to the surface of the body, and thereby to obviate the atony and spasm which lay the foundation of fever. Thus, vomiting excited a little before the expected accession of the paroxysm of an intermittent, has been found to prevent the paroxysm altogether. It has been observed also, that when contagion has been applied to a person, and first discovers its operation, an emetic given has prevented the fever which might otherwise have been expected.

These are the advantages to be obtained by exciting vomiting at the first approach of fevers, or of the paroxysm of fevers; and they may also be applied after fevers are formed, to take off, perhaps entirely, the atony and spasm, or at least to moderate these, so that the fever may proceed more gently and safely. It is seldom, however, that vomiting is found to produce a final solution of fevers; and after they are once formed, it is commonly necessary to repeat the vomiting several times; but this is attended with inconvenience, and sometimes with disadvantage. The operation of full vomiting is transitory, and the exercise of vomiting is a debilitating power; and therefore, when the vomiting does not remove the atony and spasm very entirely, it may give occasion to their recurrence with greater force. For these reasons, after fevers are fully formed, some physicians have thought proper to employ emetics in nauseating doses only. These are capable of exciting the action of the extreme vessels, and their operation is more permanent. At the same time they often show their power by exciting some degree of sweat, and their operation is rendered more safe by their commonly producing some evacuation by stool. But nausea continued for any great length of time, is to most patients a sensation highly distressing, and almost insufferable.

The emetics chiefly in use at present are, ippecacuanha and antimony. The former may be employed for determining to the surface of the body: but, even in very small doses, it so readily excites vomiting, that it is with difficulty employed for the purpose of nauseating only; and in whatever manner employed, there is reason to suspect that its effects are less permanent, and less powerfully communicated from the stomach to the rest of the system, than those of antimony. This last is therefore generally preferred; and its preparations, seemingly various, may all be reduced to two heads; one comprehending those in which the reguline part is in a condition to be acted upon by acids, and therefore on meeting with acids in the stomach it becomes active; and another, comprehending those preparations in which the reguline part is already joined with an acid, rendering it active. Of each kind there are great numbers, but not differing essentially from one another; the two most worthy of notice are, the calx nitrata antimonii, and emetic tartar, or tartrite of antimony, of the Edinburgh Dispensatory. Both these are very efficacious medicines; but the latter seems preferable, because its dose is capable of being better ascertained; though the former, on account of its slower operation, may have some advantages, and in certain cases be more efficacious as a purgative and sudorific.

The calx nitrata antimonii, when first introduced into the pharmacopoeia of the Edinburgh college was supposed to be very nearly, if not precisely, the same with a medicine which has of late been highly celebrated in the cure of fevers, Dr James's powder. But from more accurate observations, there is now reason to believe that the pulvis antimonialis of the London Pharmacopoeia, formed by the calcination of antimony with hartshorn, approaches more nearly to that celebrated arcanum. But at any rate, the calx antimonii nitrata, the pulvis antimonialis, and James's powder, are probably not essentially different from each other. The two latter, however, have the most near resemblance; and accordingly the Edinburgh college, in their Pharmacopoeia, have introduced an article under the title of antimonium calcareo-phosphoratum, which they consider as so much similar to James's powder, that they have used as a synonyme for it, the title of pulvis Jacobi.

The time most proper for exhibiting these medicines is a little before the accession, when that can be certainly known. In continued fevers the exacerbations are not always very observable; but there is reason to believe, that one commonly happens about noon or soon after it; and that these, therefore, are the most proper times for exhibiting emetics.

With respect to the manner of administration, that of the calx nitrata is simple, as the whole of what is thought a proper dose may be given at once; and no more can be properly given till the next accession. The administration of the emetic tartar is different. It is to be given in small doses, not sufficient to excite vomiting; and these doses are to be repeated after short intervals for several times, till sickness, nausea, and some, though not much, vomiting come on. The difference of administration must depend upon the dose, and the length of the interval at which it is given. If it be intended that the medicine should certainly operate by stool, the doses are made small, and the intervals long. On the contrary, when vomiting is proper, or when much purging ought to be avoided, and therefore some vomiting must be admitted, the doses are made larger, and the intervals shorter. With respect to both kinds of preparations, the repetition is to be made at the times of accession, but not very often: for if the first exhibitions, duly managed, have little effect, it is seldom that the after exhibitions have much; and it sometimes happens that the repeated vomiting, and especially repeated purging, does harm by weakening the patient.

(2.) The other set of internal medicines which are supposed useful in taking off the spasm of the extreme vessels, are those named anti/spa/modics. But whatever may be the virtues of some of them in this way, such is their power of stimulating at the same time, that very few of them can with safety be administered in fevers of an inflammatory nature. Almost the only one which can with safety be exhibited in these cases is camphor; and the operations of this are by no means well ascertained. Dr Huxham mentions it as a corrector of the acrimony of cantharides; and assures us, that it very effectually promotes a diaphoresis. But from the remarks of other practitioners, we have no just reason to suppose that it acts perceptibly in a dose of five or six grains, though in 15 or 20 it produces a particular kind of intoxication.

Secondly, The external means suited to take off the spasm of the extreme vessels, are blistering and warm bathing.

1. What are the effects of blistering so frequently employed in fevers is not yet agreed among physicians. Dr Cullen is of opinion, that the small quantity of cantharides absorbed from a blistering plaster, is not sufficient to change the consistence of the mass of blood; and therefore, that such a quantity can neither do good by reviving phlogistic lentor if it exists, nor do harm by increasing the diffusion of the blood arising from a putrid tendency in it. The effects of cantharides upon the fluids, therefore, may be entirely neglected. The inflammation produced by the application of cantharides to the skin, affords a certain proof of their stimulant power: but in many persons the effect of that stimulus is not considerable; in many it is not communicated to the whole system; and even when it does take place in the whole system, it seems to be taken off very entirely by the effusion and evacuation of serum from the blistered part. It may be concluded, therefore, that neither much good is to be expected, nor much harm to be apprehended, from the stimulant power of blistering; and the certainty of this conclusion is established by the great benefit arising from the proper practice of blistering in inflammatory diseases. Much has been imputed to the evacuation made by blistering; but it is never so considerable as to affect the whole system; and therefore can neither, by a sudden depletion, relax the sanguineous system, nor by any revulsion affect the general distribution of the fluids. The evacuation, however, is so considerable as to affect the neighbouring vessels; and the manifest utility of blistering near the part affected in inflammatory diseases leads us to think, that blistering, by deriving to the skin, and producing an effusion there, relaxes the spasm of the deeper seated vessels. It is in this manner, most probably, that the tumor of a joint, from an effusion into the cellular texture under the skin, takes off the rheumatic pain formerly affecting that joint. Analogous to this, probably, is the good effect of blistering in continued fevers, arising from the relaxation of the spasm of the extreme vessels by a communication of the blistered part with the rest of the skin. A blisters may be employed at any period in continued fevers; but it will be of most advantage in the advanced state of such fevers, when, the reaction being weaker, all ambiguity from the stimulating power of blistering is removed, and when it may best concur with other circumstances tending to a final solution of the spasm.

From this view of the matter, it will appear, that the part of the body to which blisters ought to be applied is indifferent, except upon the suspicion of topical affection, when the blistering is to be made as near as possible to the part affected. Whether sinapisms and other rubefacientia act in a manner analogous to what has been supposed of blistering may be doubtful; but their effects in rheumatism and other inflammatory diseases render it probable.

2. The other external means of taking off the spasm of the extreme vessels is warm bathing. This was frequently, and in different circumstances, employed by the ancients; but has, till very lately, been neglected by modern physicians. As the heat of the bath stimulates the extreme vessels, and, with the concurrence of moisture, also relaxes them, it seems to be a safe stimulus, and well suited to take off the spasm affecting these vessels. It may be applied to the whole body by immersion; but this is in many respects inconvenient. From extensive experience it appears, that most of the purposes of warm bathing can be obtained by a fomentation of the legs and feet, if properly administered, and continued for a due length of time, not less than an hour. The marks of the good effects of such a fomentation are, the patient's bearing it easily, its relieving delirium, and inducing sleep.

GENUS V. TYPHUS; the Typhous FEVER. Typhus, Sauv. gen. 82. Sag. 677.

I. Typhus mitior, or the Slow Nervous FEVER. Sp. i. var. 1.

Febris maligna hectica convulsviva, five lues nvgadns, Willis de morb. convulsv. cap. 8. Febris pestilens, Fracastor. de morb. contag. lib. ii. cap. 4.

Febris pestilens, sine charactere veneni, Foreft, i. vi. Typhus, obf. 26. Febris hectica pestilens, Foreft, i. vi. obf. 32. Febris nova ann. 1685, Sydenham, Sched. monitor. Febris putrida nervosa, Wintringh. Com. Nofolog. ad ann. 1720, 1721. Febris lenta nervosa, Huxham on fevers, chap. 8. Febris contagiosa, Lind on fevers and infection, paflum. Typhus nervosus, Sauv. Sp. 2. Typhus comatosus, Sauv. Sp. 3. Tritteophya typhodes Mangeti, Sauv. Sp. 11. Raym. Fort. de febribus.

Description. Of all the descriptions we have of the nervous fever, that of Dr Huxham is perhaps the best. According to him, the patient at first grows somewhat listless, and feels slight chills and shudders, with uncertain flushes of heat, and a kind of weariness all over, like what is felt after great fatigue. This is always attended with a sort of heaviness and dejection of spirit, and more or less of a load, pain, or giddiness of the head; a nausea or difficulty of every thing soon follows, without any considerable thirst, but frequently with retching to vomit, though little but insipid phlegm is brought up. Though a kind of lucid interval of several hours sometimes intervenes, yet the symptoms return with aggravation, especially towards night; the head grows more giddy or heavy; the heat greater; the pulse quicker, but weak; with an oppreßive kind of breathing. A great torpor, or obtuse pain and coldness, affects the hinder part of the head frequently, and oftentimes a heavy pain is felt on the top all along the coronary sutura; this, and that of the back part of the head, generally attend nervous fevers, and are commonly succeeded by some degree of a delirium. In this condition the patient often continues for five or fix days, with a heavy, pale, sunk countenance; seemingly not very sick, and yet far from being well; restless, anxious, and commonly quite void of sleep, though sometimes very drowsy and heavy; but although he appears to those about him actually to sleep, he is utterly insensible of it. The pulse during all this time is quick, weak, and unequal; sometimes fluttering, and sometimes for a few moments slow; nay, even intermitting, and then, with a sudden flush in the face, immediately very quick, and perhaps soon after surprisingly calm and equal; and thus alternately. The heats and chills are as uncertain and unequal; sometimes a sudden colour and glow arise in the cheeks, while the tip of the nose and ears is cold, and the forehead at the same time in a cold dewy sweat. Nay, it is very common, that a high colour and heat appear in the face, when the extremities are quite cold. The urine is commonly pale, and often limpid; frequently of a whey colour, or like vapid small beer, in which there is either no manner of sediment, or a kind of loose matter like bran irregularly scattered up and down in it. The tongue at the beginning is seldom or never dry or discoloured, but sometimes covered with a thin whitish mucus: at length, indeed, it often appears very dry, red, and chapped, or of the colour of pomegranate rind; but this chiefly at the close of the disease: yet, however dry the tongue and lips seem, the patient seldom complains of thirst, though sometimes of a heat in the tongue. About the seventh or eighth day, the giddiness, pain, or heaviness of the head become much greater, with a constant noise in it, or tinnitus aurium; which is very disturbing to the sick, and frequently brings on a delirium. The load on the precordia, anxiety and faintness, grow much more urgent; and patients often fall into an actual delirium, especially if they attempt to sit up; cold sweats suddenly come out on the forehead, and on the backs of the hands (though at the same time there be too much heat in the cheeks and palms), and as suddenly go off. If the urine now grow more pale and limpid, a delirium is certainly to be expected, with universal tremors and jubilatus tendinum; the delirium is seldom violent, but as it were a confusion of thought and action, muttering continually and faltering in their speech. Sometimes they awake only in a hurry and confusion, and presently recollect themselves, but forthwith fall into a muttering dozy state again. The tongue grows often very dry at the height, especially in its middle part, with a yellowish lift on each side, and trembles greatly when the sick attempts to put it out. Frequently profuse sweats pour forth all at once, about the ninth, tenth, or eleventh day, commonly coldish and clammy on the extremities; oftentimes very thin stools are discharged, and then nature sinks apace; the extremities grow cold, the nails pale or livid; the pulse may be said to tremble and flutter, rather than to beat, the vibrations being so exceedingly weak and quick that they can scarce be distinguished; though sometimes they creep on surprizingly slow, and very frequently intermit. The sick become quite insensible and stupid, scarce affected with the leastest noise or the strongest light; though, at the beginning, strangely susceptible of the impressions of either. The delirium now ends in a profound coma, and that soon in death. The stools, urine, and tears, run off involuntarily, and denounce a speedy dissolution, as the tremblings and twitchings of the nerves and tendons are preludes to a general convulsion, which at once snaps the thread of life. In one or other of these ways are the sick carried off, after having languished for 14, 18, or 20 days; nay, sometimes much longer. Most patients grow deaf and stupid towards the end of this disease (some extremely deaf), though too quick and apprehensive at the beginning; insomuch that the least noise or light greatly offended them. Many from their immoderate fears seem to hurry themselves out of life, where little danger is apparent at the beginning: nay, some will not allow themselves to sleep, from a vain fear of dozing quite away; and others from the vast hurry, anxiety, and confusion of which they are sensible either during sleep or at their waking.

Causes of, and persons subject to, this disorder. The nervous fever is most frequently the consequence of contagion. It most commonly attacks persons of weak nerves, a lax habit of body, and a poor thin blood; those who have suffered great evacuations, a long dejection of spirits, immoderate watchings, studies, fatigue, &c.; also those who have used much crude unwholesome food, vapid impure drinks, or who have been confined long in damp foul air; who have broken the vigour of their constitutions by falsifications, too frequent purging, immoderate venery, &c. Hence we see how the disease is connected with an extreme debility of the nervous system; for when people are prepared for this fever by having their nerves already weakened, the contagious particles immediately attack the nervous system, without so much affecting the state of the blood or juices, though the latter are greatly affected in the putrid malignant fevers.

Prognosis. In nervous fevers, the prognosis is very much the same with that of the putrid malignant kind. And although death be not so frequent as in that modification of fever, yet it may justly be considered as a very fatal disease.

Cure. As this fever is produced by contagion affecting the nervous system of a person already debilitated, and thus producing weakness in an extreme degree, we have now occasion to consider Dr Cullen's two indications of cure omitted under the Synocha; namely, to remove the cause and obviate the effects of debility, and to correct the putrefactive tendency of the fluids; for though, in the beginning of nervous fevers, the tendency to putrefaction be not remarkable, it becomes exceedingly great towards their conclusion.

[1.] In answering the first indication, Dr Cullen observes, that most of the sedative powers inducing debility cease to act soon after they have been first applied; and therefore the removing them is not an object of the present indication. There is only one which may be supposed to continue to act for a long time, and that is the contagion applied; but we know nothing in the nature of contagion that can lead us to any measures for removing or correcting it. We know only its effects as a sedative power inducing debility, or as a ferment inducing a tendency to putrefaction in the fluids, the former of which at present falls under our consideration.—The debility induced in fevers by contagion, or other causes, appears especially in the weaker energy of the brain; but in what this consists, or how it may be restored, we do not well know; but as nature, seemingly for this purpose, excites the motion of the heart and arteries, we must ascribe the continuance of the debility to the weaker re-action of the sanguiferous system: the means, therefore, which we employ for obviating debility, are immediately directed to support and increase the action of the heart and arteries; and the remedies employed are tonics or stimulants.

In contagious diseases we know, both from the effects which appear, and from dissections, that the tone of the heart and arteries is considerably diminished; and that tonic remedies are therefore properly indicated. We are to consider these remedies as of two kinds; 1. The power of cold; 2. That of tonic medicines.

The power of cold as a tonic in fevers may be employed in two ways: either as thrown into the stomach, or as applied to the surface of the body. As we have already observed that the power of cold may be communicated from any one part to every-other part of the system, so it will be readily allowed that the stomach is a part as fit as any other for this communication, and that cold drink taken into the stomach may prove an useful tonic in fevers. This the experience of all ages has confirmed, but at the same time it has been frequently observed, that, in certain circumstances, cold drink taken into the stomach has proved very hurtful; and therefore that its use in fevers requires some limitations. tations. What these limitations should be, and what are all the circumstances which may forbid the use of cold drink, it is difficult to determine; but it seems clearly forbidden in all cases where a phlogistic dia- thesis prevails in the system, and more especially when there are topical affections of an inflammatory nature.

The other method of employing cold as a tonic, is by applying it to the surface of the body, as a re- frigerant power fit to moderate the violence of reaction; but probably it may here also be considered properly as a tonic, and useful in cases of debility.— Not only cool air, but cold water also may be applied to the surface of the body as a tonic. The ancients frequently applied it with advantage to particular parts as a tonic; but it is a discovery of modern times, that, in the case of putrid fevers attended with much debility, the body may be washed all over with cold water. This was first practised at Breslaw in Silesia, as appears from a dissertation under the title of Epidemia Verna, que Wratilaviann, anno 1737 af- fixit, to be found in the Acta Nat. Curiof. vol. x. And from other writers it appears, that the practice has passed into some of the neighbouring countries. But in Britain the use of cold water externally applied has of late been more extensively introduced than into any other country of Europe. For this we are chiefly indebted to the late ingenious Dr Currie of Liverpool. He has recommended the dashing cold water over the whole surface of the body, as a means not only of obvi- ating heat, delirium, and other symptoms most urgent; but of putting an immediate stop to the disease. And there can be no doubt that the practice has often been attended with the most salutary consequences. But it is by no means so generally advantageous as Dr Currie and some others are inclined to believe. It is in but very rare instances that an artificial termination of fever can thus be obtained; and even as obviating symptoms, it is not unfrequently attended with bad con- sequences. It can never be employed with safety un- less where the heat is very urgent. And perhaps all the advantages of cold immersion may be obtained merely from cold bathing, a practice now very common in Britain.

The medicines which have been employed in fevers as tonics are various. If the acetite of lead hath been found useful, it is probably as a tonic rather than as a refrigerant; and the ens veneris, or other prepara- tions of iron which have been employed, can act as tonics only. The preparations of copper, from their effects in epilepsy, are presumed to possess a tonic power; but whether their use in fevers be founded on their tonic or emetic powers, is uncertain. And upon the whole there may no doubt occur some instances of fevers being cured by tonics taken from the fossil kingdom; but the vegetable tonics are the most efficacious, and among these the cinchona certainly holds the first place.

The cinchona has commonly been considered as a specific, or a remedy of which the operation was not understood. We must observe, however, that, as in many cases the effects of the bark are perceived soon after its being taken into the stomach, and before it can possibly be conveyed to the mats of blood, we may conclude, that its effects do not arise from its operating on the fluids; and must therefore depend upon its acting on the nerves of the stomach, and being there- by communicated to the rest of the nervous system. This operation seems to be a tonic power, the bark being a remedy in many cases of debility, particularly in gangrene; and if its operation may be explained from its possessing a tonic power, we may easily perceive why it is improper when a phlogistic diathesis prevails; and from the same view we can ascertain in what cases of continued fever it may be admitted. These cases are either where considerable remissions have appeared, when it may be employed to prevent the return of exacerbations, on the same footing as it is used in intermitting fevers; or in the advanced state of fevers, when all fulsion of an inflammatory condition is removed, and a general debility prevails in the system; and its being then employed is sufficiently agreeable to the present practice.

Another set of medicines to be employed for ob- viating debility and its effects, are the direct stimu- lants. These, in some measure, increase the tone of the moving fibres; but are different from the tonics, as they more directly excite and increase the action of the heart and arteries. This mode of operation renders their use ambiguous; and when an inflammatory dia- thesis is present, the effects of the stimulants may be very hurtful; but it is still probable, that in the ad- vanced state of these fevers, when debility prevails, they may be useful.

Of all the stimulants which may be properly em- ployed, wine seems to be the most eligible. It has the advantage of being grateful to the palate and stomach, and of having its stimulating parts so much di- luted, that it can be conveniently given in small doses; and therefore it may be employed with sufficient safety.—It may be suspected that wine has an operation ana- logous to that of opium; and on good grounds. But we can distinctly remark its stimulating power only; which renders its effects in the phrenetic delirium manifestly hurtful; and in the mild delirium depending on debili- ty, as remarkably useful.

[2.] We must now proceed to the other indication of cure, namely, to correct or obviate the tendency in the fluids to putrefaction. This may be done, 1. By avoiding any new application of putrid or putrefient matter. 2. By evacuating the putrid or putrefient matter already present in the body. 3. By correcting the putrid or putrefient matter remaining in the body by diluents and antipathies. 4. By supporting the tone of the vessels, and thereby resisting further putrefaction, or obviating its effects. 5. By moderating the vio- lence of reaction, considered as a means of increasing putrefaction.

The further application of putrid or putrefient mat- ter may be avoided, 1. By removing the patient from places filled with corrupted air. 2. By preventing the accumulation of the patient's own effluvia, by a constant ventilation, and by a frequent change of bedclothes and body linen. 3. By the careful and speedy removal of all excremental matters from the patient's chamber. 4. By avoiding animal food.

The putrid or putrefient matter already present in the body, may be evacuated partly by frequent evacu- ations of the contents of the intestines; and more effectually still by supporting the excretions of perspi- ration and urine by the plentiful use of diluents. That which remains in the body may be rendered more mild and innocent by the use of diluents, or may be corrected by the use of antipathics. These last are of many and various kinds; but which of them are conveniently applicable, or more particularly suited to the case of fevers, is not well ascertained. Those most certainly applicable and useful are acetic aliments, particularly fruits, acids of all kinds, and neutral salts.

The progress of putrefaction may be considerably retarded, and its effects obviated, by supporting the tone of the vessels; and this may be done by tonic medicines, of which the chief are cold, and the Peruvian bark, as already mentioned. The violence of reaction increasing the tendency to putrefaction, may be moderated by the means already mentioned under Synocha.

These are the proper indications to be observed in the cure of the slow nervous fever; and they are chiefly fulfilled by cleanliness, cool air, and diluents; which, perhaps, upon the whole, are more useful in fevers, than all other practices put together. Dr Huxham observes, that evacuations (especially bleeding), are improper even at the beginning. Even a common purgative given at this time hath been followed by surpurring languors, syncope, and a train of other ill symptoms. It may, however, sometimes be necessary to cleanse the stomach and prime vie by a gentle emetic, or a mild laxative. Indeed, where nausea, tickness and load at stomach are urgent, as is frequently the case in the beginning of this fever, a vomit is necessary. Clysters of milk, sugar, and salt, may be injected with safety and advantage every second or third day, if nature wants to be prompted to stool. The temperate, cordial, diaphoretic medicines, are certainly, according to our author, most proper in these fevers; and a well-regulated, supporting, diluting diet is necessary. The latter of itself, judiciously managed, will go a great way in the cure, especially if assisted by well-timed and well-applied blisters, and a due care to keep the patient as quiet as possible both in body and mind. But it should be noted, that strong opiates are commonly very pernicious, however much the want of sleep and restlessness may seem to demand them. Mild diaphoretics, such as neutral draughts or elixir paregoricum, have much better effects; which, by raising a gentle easy sweat, or at least a plentiful perspiration, calm the hurry of the spirits, and a refreshing sleep ensues. Where the confusion and dejection of spirits are very considerable, blisters have been advised to be applied to the neck, occiput, or behind the ears; and during all this a free use of thin wine whey, some pleasant pifian or gruel, with a little pure wine, must be directed. Indeed the patients, in this case should drink frequently: though such quantities may not be necessary as in the ardent or even putrid malignant fevers; yet they should be sufficient to carry on the work of dilution, support the sweats, and supply the blood with fresh and wholesome fluids, in place of that noxious matter which is continually passing off. In this view also a thin chicken-broth is of service, both as food and physic, especially towards the decline of the disease; and for the same reason thin jellies of hartshorn, fago, and panada, are useful, adding a little wine to them, and the juice of orange or lemon.

It is observable, that the sick are never so easy as Typhus, when they are in a gentle sweat; for this soon removes the hurry of spirits, exacerbations of heat, &c. But profuse sweats should never be encouraged, much less induced, by very strong heating medicines, especially in the beginning or advance of the fever; for they too much exhaust the vital powers, and are followed by a vast dejection of spirits, tremors, startings of the tendons, and sometimes end in rigors, cold clammy sweats, syncope, or a comatose disposition. Sometimes irregular partial heats and flushes succeed, with great anxiety, rattleheats, delirium, difficulty of breathing, and a vast load and oppression in the precordia; so as to incline the least cautious observer to think there may be something pneumonic in it; but even here we must beware of bleeding, as the pulse will be found very small and unequal, though very quick. Nor is bleeding contraindicated only by the weakness and fluttering of the pulse, but also by the pale, limpid, and watery urine which is commonly attendant. These symptoms denote the load, anxiety, and oppression on the precordia to proceed from an affection of the nervous system, and not from a pneumonic obstruction or inflammation. The breathing in this case, though thick and laborious, is not hot, but a kind of sighing or sobbing respiration, nor is there often any kind of cough concomitant; so that it has been conjectured to proceed from some spasm on the vitals. Here therefore the nervous cordial medicines are indicated, and blisters to the thighs, legs, or arms.

The above-mentioned difficulty of breathing, anxiety, and oppression, many times precede a military eruption, which often appears on the seventh, ninth, or eleventh day of the fever, and sometimes later. Indeed great anxiety and oppression on the precordia always precede puticular eruptions of any kind in all sorts of fevers. This eruption should be promoted by soft easy cordials and proper diluents; to which should be sometimes added some gentle aromatics. These tend to calm the universal uneasiness commonly complained of, and also very effectually promote a diaphoresis, with which the military eruptions freely and easily advance. But however advantageous these commonly are, profuse sweats are seldom or never fo, even though attended with a very large eruption. Two or three crops of these military pustules have been known to succeed one another, following profuse sweats, not only without advantage, but with great detriment to the patients, as they were thereby reduced to an extreme degree of weakness; so that they may justly be reckoned symptomatic rather than anything else, and the consequent eruption is often merely the symptom of a symptom.

In these profuse colligative sweatings a little generous red wine (diluted somewhat, if necessary) may be given with the greatest advantage; as it presently moderates the sweats, supports the patient, and keeps up the military papulae if they happen to attend. Towards the decline of the fever also, where the sweats are abundant and weakening, small doses of the tincture of cinchona with saffron and snakeroot may be given with the greatest advantage, frequently interposing a dose of rhubarb to carry off the putrid colliquies in the first passages; which withal makes the remissions or intermissions that often happen in the decline of nervous fevers Febres. fevers more distinct and manifest, and gives a fairer opportunity of throwing in the bark; for in the proper exhibition of this medicine we are to place our chief hope of curing both the nervous and putrid malignant fevers.

11. Typhus gravior, or the putrid, pestilential, or maligni FEVER. Sp. I. var. 2. Febris pestilens, P. Sal. Diverf. de febre pestilenti. Febris pestilens Ægyptiorum, Alpin. de med. Ægypt. i. i. cap. 14. Typhus Ægyptiacus, Sauv. fp. 6. Febris pestilens maligna, Sennert. de febribus, L. iv. cap. 10. Febris maligna pestilens, River. l. xvii. sect. iii. cap. 1. Febris pestilens maligna, ann. 1643, Willis, de febribus, cap. 14. Typhus carcerum, Sauv. fp. 1. Febris nautica pestilentialis, Huxham de æcre ad ann. 1740. Miliaris nautica, Sauv. fp. g. Febris putrida contagiosa in carceribus genita, Huxham de æcre ad ann. 1742. Miliaris purpurata, Sauv. fp. h. Febris carcerum et nofocomiorum. Pringle, Difcaes of the army, p. 294. Van Swieten, Maladies des armés, p. 136. Typhus caffenfis, Sauv. fp. 5. Febris caffenfis, quam vulgo cephalalgiam epidemicam vocant, Henr. Mai et A. Ph. Koph. Diff. apud Hallerum, tom. v. Febris Hungarica five caffenfis, Juncker, 74 et plurium außerum. Febris caffenfis Gallorum in Bohemiâ, ann. 1742, Scriene. Diff. apud Haller. tom. v. Febris petechialis, Sennert. l. iv. cap. 13. River. prax. l. xvii. sect. iii. cap. 1. Hoffm. ii. p. 84. Juncker, 73. Huxham on fevers, chap. 8. Ludwog. Infl. med. clin. N° 146. Schreiber von erkentnifs, und cur der Krank heiten, p. 126. Monro, Difcaes of military hopitals, p. 1. Febris catarrhalis maligna petechianis, Juncker, 72. Hoffm. ii. 75. Eller de cogn. et cur. morb. sect. vi. Febris que lenticulas, puncticula, aut pelliculas vocant, Fracaforius de morb. contag. lib. ii. cap. 6. Febris peticularis Tridenti, ann. 1591. Roboretus de febr. peticul. Febris petechialis epidemica Coloniae, ann. 1672. Donckers, Idia febris petechialis. Febris petechialis epidemica Pofomii, 1683, C. F. Locu in App. ad. A. N. C. vol. ii. Febris petechialis epidemica Mutinæ, 1692. Ramazzini. Confl. Mutinensis, oper. p. 177. Febris maligna petechianis, ann. 1698. Hoffm. ii. p. 80. Febris petechialis Wratilaviae, ann. 1699. Helwich, Ephem. Germ. D. III. A. VII. et VIII. obf. 132. p. 616. Febris epidemica Lipfæ, 1718. M. Adolph. A. N. C. III. obf. 131. p. 296. Febris endemica et epidemica Corcagienfis, ann. 1708, 1718, et seq. Rogers, Effay on Epidemic Typhus, difeases. Febris continua epidemica Corcagienfis, ann. 1719. et seq. M. O'Connel, Obf. de morbis. Febris petechialis epidemica Cremonæ, 1734. Valcarenghi Med. ration. sect. 3. Febris petechianis Petropolii, 1735. Weitbrecht. Diff. apud Haller, tom. v. Febris petechialis, ann. 1740, 1741, in Hassia. Ritter. A. N. C. vol. vii. obf. 4. Febris maligna petechialis Rintelli, 1741. Furstenau, A. N. C. vol. vii. obf. 5. Febris petechialis epidemica Silefiae, 1741, et seq. Bandhorfl. Diff. apud Haller, tom. v. Febris petechialis epidemica Vienne, 1757. Hafenrohrl. Hift. med. cap. 2. Febris petechialis epidemica Lipfæ, 1757. Ludwig. Adverf. tom. i. pars 1. Febris petechialis epidemica variis Germaniae locis ab ann. 1755 ad 1761. Strack de morbo cum petechiis.

Description. This disease has been supposed to differ from the former in degree only; and there are many circumstances which would lead us to conclude, that both frequently originate from a contagion precisely of the same nature. In the same manner we fee, during different feasons, and in different circumstances, various degrees of malignity in smallpox. Though every instance of the disease depends on the introduction of a peculiar and specific contagion into the body, yet this contagion in particular epidemics evidently produces peculiar malignancy. The fame is probably the case with the typhoid fever: But whether this observation be well founded or not, there cannot be a doubt that the typhus gravior or putrid fever is a disease of the most dangerous nature, as, besides the extreme debility of the nervous system, there is a rapid tendency of the fluids to putrefaction, which sometimes cuts off the patient in a few days, nay, in the warm climates, in 12 or 14 hours; or if the patient recovers, he is for a long time, even in this country, in an exceedingly weak state, and requires many weeks to recover his former health.

The putrid fevers, according to Huxham, make their attack with much more violence than the slow nervous ones; the rigors are sometimes very great, though sometimes scarce felt; the heats much sharper and permanent; yet, at firft, sudden, transient, and remittent: the pulse more tenfe and hard, but commonly quick and small; though sometimes flow, and seemingly regular for a time, and then fluttering and unequal. The headach, nausea, and vomiting, are much more confiderable even from the beginning. Sometimes a fevere fixed pain is felt in one or both temples, or over one or both eyebrows; frequently in the bottom of the orbits of the eyes. The eyes always appear very dull, heavy, sometimes yellowish, and very often a little inflamed. The countenance seems bloated, and more dead-coloured than usual. Commonly the temporal arteries throb much, and a tinnitus aurium is very troublesome: a strong vibration alo of the carotid arteries frequently takes place in the advance of the fever, though the pulse at the wrist may be small, nay even flow: this is a certain sign of an impending delirium, Feverium, and generally proceeds from some considerable obstructions in the brain.

The prostration of spirits, weakness, and faintness, are often surprisingly great and sudden, though no immediate evacuation happens; and this too sometimes when the pulse seems tolerably strong. The respiration is most commonly laborious, and interrupted with a kind of sighing or sobbing, and the breath is hot and offensive.

Few or none of these fevers are without pain in the back and loins; always an universal weariness or foreboding is felt, and often much pain in the limbs. Sometimes a great heat, load, and pain, affect the pit of the stomach, with perpetual vomiting of porraceous or black bile, and a most troublesome flegmus; the matter discharged is frequently of a very nauseous smell. The tongue, though only white at the beginning, grows daily more dark and dry; sometimes of a shining livid colour, with a kind of dark bubble at top; sometimes exceeding black; and so continues for many days together; nor is the thirst to be got off many times for several days, even after a favourable crisis: at the height of the disease, it generally becomes very dry, stiff, and black, or of a dark pomegranate colour. Hence the speech is very inarticulate, and scarce intelligible. The thirst in the increase of the fever is commonly very great, sometimes unquenchable; and yet no kind of drink pleases, but all seem bitter and mawkish; at other times, however, no thirst is complained of, though the mouth and tongue are exceedingly foul and dry; this is always a dangerous symptom, and ends in a frenzy or coma. The lips and teeth, especially near the height, are covered with a very black tenacious froth. At the commencement of the fever, the urine is often crude, pale, and vapid, but grows much higher coloured in the advance, and frequently resembles a strong lixivium, or citrine urine, tinged with a small quantity of blood; it is without the least sediment or cloud, and so continues for many days together: by degrees it grows darker, like dead strong high-coloured beer, and smells very rank and offensive. In petechial fevers, the urine has often been seen almost black and very fetid. The stools, especially near the height, or in the decline of the fever, are for the most part intolerably fetid, green, livid, or black, frequently with severe gripes and blood. When they are more yellow or brown, the less is the danger; but the highest when they run off insensibly, whatever their colour may be. It is likewise a very bad symptom when the belly continues tense, swollen, and hard, after profuse stools; for this is generally the consequence of an inflammation or mortification of the intestines. A gentle diarrhoea is often very beneficial, and sometimes seems to be the only way which nature takes to carry off the morbid matter.

Sometimes black, livid, dun, or greenish spots appear on different parts of the skin, particularly on the breast, which always indicate a high degree of malignity; but the more florid the spots are, the less danger is to be feared. It is also a good sign when the black or violet petechiae become of a brighter colour. The large, black, or livid spots, are almost always attended with profuse hemorrhagies; and the small, dusky, brown spots, like freckles, are not much less dangerous than the livid or black; though they are seldom accompanied with fluxes of blood: excessively profuse, cold, clammy sweats are often concomitant, by which also they sometimes vanish, though without any advantage to the patient. The eruption of the petechiae is uncertain; sometimes they appear on the fourth or fifth day, though sometimes not till the eleventh, or even later. The villices, or large dark blue or greenish marks, seldom appear till very near the fatal period. Frequently also we meet with an efflorescence like the maceles in malignant fevers, but of a much more dull and livid hue; in which the skin, especially on the breast, appears as it were marbled or variegated. This in general is an ill symptom, and is often attended with fatal consequences.

Sometimes about the 11th or 14th day, on the occurrence of profuse sweats, the petechiae disappear, and vast quantities of white miliary pustules break out. This is seldom found of any considerable advantage; but an itching, smarting, red rash, commonly gives great relief; and so do the large, fretting, watery bladders, which many times rise upon the back, breast, shoulders, &c. A scabby eruption likewise about the lips and nose is one of the salutary symptoms; and the more hot and angry it is, so much the better. But of much more uncertain and dangerous event are the brown-coloured aphthae; nor are those that are exceeding white and thick, like lard, of a very promising aspect. They are soon succeeded by great difficulty of swallowing, pain and ulceration of the fauces, oesophagus, &c. and with an incessant flegmus: the whole prime vie become at last affected; a bloody dysentery comes on, followed by a phaeclation of the intestines; as is evident from the black, fumous, and bloody stools, extremely fetid and infectious. Vibices, or large black and bluish marks resembling bruises, are frequently seen towards the close of the fever; and, when attended with lividity and coldness of the extremities, are certain tokens of approaching death. In some cases, the blackness has been known to reach almost to the elbows, and the hands have been dead-cold for a day or two before the death of the patient.

Such are the general appearances of the putrid malignant fever in this country, among those who enjoy a free air, and are not crowded together, or exposed to the causes of infection: but in jails, hospitals, or other places where the sick are crowded, and in some measure deprived of the benefit of the free air, the symptoms are, if possible, more terrible. Sir John Pringle, who had many opportunities of observing it, tells us, that the jail or hospital fever, in the beginning, is not easy to be distinguished from a common fever. The first symptoms are slight interchanges of heat and cold, a trembling of the hands, sometimes a sense of numbness in the arms, weakness of the limbs, loss of appetite; and the disorder increasing towards night, the body grows hot, the sleep is interrupted, and not refreshing. With these symptoms, for the most part, there is some pain or confusion in the head; the pulse at first is a little quicker than natural, and the patients find themselves too much indisposed to go about business, though too well to be wholly confined. When the fever advances, the above-mentioned symptoms are in a higher degree; and in particular the patient complains of a lassitude, nausea, pains in his back, a more constant pain and confusion in his head, attended with an uncommon dejection of spirits. At this time the pulse is never sunk, but beats quick, and often varies in the same day both as to strength and fulness. It is little affected by bleeding, if a moderate quantity of blood be taken away; but if the evacuation be large, and especially if it be repeated, to answer a false indication of inflammation, the pulse, increasing in frequency, is apt to sink in force, and often irrecoverably, whilst the patient becomes delirious. But we must observe, that, in every case, independent of evacuations, the pulse sooner or later sinks, and then gives certain evidence of the nature of the disease. The appearance of the blood is various; for though it be commonly little altered, yet sometimes it will be fizzy, not only on the first attack, but after the fever is formed. The worst appearance is when the sanguineum is dissolved; though this does not happen till the advanced state of the fever: indeed this seems not easy to be ascertained, as blood has been so seldom taken away at that time. The urine is also various. Sometimes it is of a reddish or flame colour, which it preserves a long time; but it is oftener pale, and changes from time to time in colour as well as crudity, being sometimes clear, sometimes clouded: towards the end, upon a favourable crisis, it becomes thick, but does not always deposit a sediment. If the sick lie warm, and have had no preceding flux, the belly is generally bound; but when they lie cold, as they often do in field-hospitals, the pores of the skin being shut, a diarrhoea is a common symptom, but is not critical. In the worst cases, a flux appears in the last stage; then the stools are involuntary, colligative, ichorous, or bloody, and have a cadaverous smell; the effects of a mortification of the bowels, and the sign of approaching death. When the hospitals are filled with dysenteric patients, some of the nurses will be infected with the flux only, and others with this fever, ending in these bloody and gangrenous stools.

In the beginning the heat is moderate; and even in the advanced state, on first touching the skin, it seems inconsiderable: but upon feeling the pulse for some time, we are sensible of an uncommon heat (the calor mordicans, as it has been called), leaving an unpleasant sensation on the fingers for a few minutes. A day or two before death, if care be not taken, the extremities become cold, and the pulse is then hardly to be felt. The skin is generally dry and parched; though sometimes there are longer or shorter sweats, especially in the beginning. Such as are produced by medicine are of no use, except on the first attack, at which time they will often remove the fever; and natural sweats are never critical till the temper begins to decline. These last are rarely profuse, but gentle, continued, and equally diffused over the body: sometimes the disease will terminate by an almost imperceptible moisture of the skin; the sweats are usually fetid, and offensive even to the patient himself.

The tongue is commonly dry; and, without constant care of the nurse, becomes hard and brown, with deep chops: but this symptom is common to most fevers. At other times, though rarely, the tongue is soft and moist to the last, but with a mixture of a greenish or yellowish colour. The thirst is sometimes great, but more frequently moderate. In the advanced state, the Typhus breath is offensive, and a blackish furring gathers about the roots of the teeth.

Some are never delirious, but all lie under a stupor or confusion; few retain their senses till death: many lose them early, and from two causes: either from immoderate bleeding, or the premature use of warm and spirituous medicines. They rarely sleep; and, unless delirious, have more of a dejected and thoughtful look than what is commonly seen in other fevers. The face is late in acquiring either a ghastly or a very morbid appearance; yet the eyes are always muddy, and generally the white is of a reddish cast as if inflamed. The confusion of head commonly rises to a delirium, especially at night; but, unless by an unseasonable hot regimen, it seldom turns to rage, or to those high flights of imagination common in other fevers. When the delirium comes to that height, the face is flushed, the eyes red, the voice is quick, and the patient struggles to get up. But when that symptom is owing to large evacuations, or only to the advanced state of the disease, the face appears meagre; the eye-lids in slumbers are only half shut; and the voice, which is commonly low and flow, sinks to a degree scarce to be heard. From the beginning there is generally a great dejection and failure of strength. A tremor of the hands is more common than a starting of the tendons; and if the subful tus occurs, it is in a lesser degree than in many other fevers. In every stage of the disease, as the pulse sinks, the delirium and tremors increase; and in proportion as the pulse rises, the head and spirits are relieved. Sometimes in the beginning, but for the most part in the advanced state, the patient grows dull of hearing, and at last almost deaf. When the fever is protracted, with a slow and low voice, the sick have a particular craving for something cordial, and nothing is so cordial or so acceptable as wine. They long for no food, yet willingly take a little panada if wine be added. But such as are delirious, with a quick voice, wild looks, a subful tus tendimus, or violent actions, though their pulse be sunk, yet bear neither hot medicines, wine, nor the common cordials.

Vomiting, and complaints of a load and sickness at stomach, though usual symptoms, are not essential to the disease; nor are pleuritic stitches, difficulty in breathing, or flying pains, to be referred so much to it as to the constitution of the patient, or to a preceding cold.

A petechial efflorescence is a frequent, though not an inseparable, attendant of this fever. It sometimes appears of a brighter or paler red, at other times of a livid colour, but never rises above the skin. The spots are small; but generally so confluent, that at a little distance the skin appears only somewhat redder than ordinary, as if the colour was uniform; but upon a nearer inspection interfaces are seen. For the most part this eruption is so little conspicuous, that unless it be looked for attentively, it may escape notice. The spots appear thickset on the back and breast, less on the legs and arms, and Sir John Pringle never remembers to have seen any on the face. As to the time of their appearance, he agrees entirely with Dr Huxham. These spots are never critical, nor are they reckoned among the mortal symptoms; but only concur with other signs to ascertain the nature of the disease. The nearer they they approach to purple, the more they are to be dreaded. In a few cases, instead of spots, purple streaks and blotches were observed. Sometimes the petechiae did not appear till after death; and there was one case in which, after bleeding, the petechiae were seen only on the arm below the ligature, and nowhere else on the skin.

The hospital fever, though accounted one of the continued kind, yet has generally some exacerbations at night, with a remission and often partial sweats in the day; and after a long continuance it is apt to change into a hectic, or an intermittent form. The length of the disease is uncertain. Sometimes it was terminated, either in death or recovery, in seven days after the patient took to his bed; but in the hospitals it generally continued from 14 to 20, and some died or recovered after four weeks. From the time of the sinking of the pulse until death or a favourable crisis, there is perhaps less change to be seen from day to day in this than in most other fevers. When its course is long, it sometimes terminates in suppurations of the parotid or axillary glands; and when these do not appear, it is probable that the fever is kept up by the formation of some internal abscess. The parotid glands themselves do not suppurate, but only some of the lymphatic glands that lie over them. Sir John Pringle observed one instance of a swelling of this kind on both sides, without any previous indisposition, when the person, not suspecting the cause, and applying diluent cataplams, was, upon the tumour subsiding, seized with the hospital-fever. Many patients after the crisis of this fever complain of a pain in the limbs and want of rest; and almost all of them mention great weakness, confusion in their head, vertigo, and a noise in their ears.

Ten of the bodies of those who died of this distemper in Houghton's regiment were opened. In some, all the cavities were examined; in others, only the brain and the bowels. In some of them, the brain appeared to be suppurrated. The first of this kind Sir John Pringle met with at Ghent; but the man being brought into the hospital from the barracks no earlier than two days before he died, he could only conjecture from the symptoms and the imperfect accounts he had of him, that his death was owing to a fever of this kind, after lingering near a month in it. About three ounces of purulent matter were found in the ventricles of the brain, and the whole cortical and medullary substance was uncommonly flaccid and tender; nay, some of the same kind of matter was found in the substance of the upper part of the cerebellum: yet this person, with some stupor and deafness, had his senses till the night before he died; so far, at least, that he answered distinctly when roused and spoken to; but about that time the muscles of his face began to be convolled. Of two other instances of men who undoubtedly died of this fever, in one the cerebrum was suppurrated, in the other the cerebellum. In the former case, the patient was under a stupor, with deafness from the beginning; but was never delirious, nor altogether insensible. His pulse sunk early; and about ten days before his death his head began to swell, and continued very large till within two days before he died, when it subsided a little. For several days before his end, he would taste nothing but cold water, and during his illness he lay constantly upon one side. The head being opened, an abscess as large as an egg was found in the substance of the forepart of the right hemisphere of the brain, full of thin matter like whey. At that time five more, ill of the same fever, had the like swelling of their heads, but recovered. In the other case, the abscess in the cerebellum was about the size of a small pigeon's egg, and contained also a thin ichorous matter; nor had this patient ever been so thoroughly insensible as not to answer reasonably when spoken to. Two days before he died his urine turned pale.

These suppurations, however, were not constant; for another who died about the same time, and had been ill about the same number of days with the like symptoms, the pale water excepted, had no abscess either in the brain or cerebellum. Two were opened afterwards, in whom the cortical substance of the brain had an inflammatory appearance, but no suppuration. In one of them the large intestines were corrupted; that man went off with a loofeness; and just before he died, an ichorous matter was discharged from his nose. In the military hospital at Ipswich, one who unexpectedly died of this fever after having been seemingly in a fair way of recovery, had no suppuration in his brain; but in another, who died after an abscess in both orbits, the brain was found flaccid, and about two ounces of a thin serum in the ventricles.

Causes of, and persons subject to, this disorder. The cause of this fever, as well as that of the slow nervous fever, is an infection or contagion from some diseased animal-body, or from corrupted vegetables; and therefore is very little, if at all, different from those pestilential disorders which have arisen after battles, where great numbers of dead bodies were allowed to lie above ground, and infect the air with their effluvia. This is confirmed by an observation of Foretus, who was eyewitness to a distemper of this kind (which indeed he calls a plague) owing to the same cause, attended with buboes and a high degree of contagion. The same author also gives an account of a malignant fever breaking out at Egmont in North-Holland, occasioned by the rotting of a whale which had been left on the shore. We have a like observation of a fever affecting the crew of a French ship, by the putrefaction of some cattle which they had killed on the island of Nevis in the West Indies. These men were seized with a pain in their head and loins, great weakness, and a disorder of the stomach, accompanied with fever. Some had carbuncles; and on others purple spots appeared after death.

Galen assigns two causes for pestilential fevers: 1. The great heat of the weather, when the humours happen to be in a more putrefied state than usual. 2. A putrid state of the air, arising either from a multitude of dead bodies left unburied, as after a battle, or from the evaporation of corrupted lakes and marshes.

One of the most remarkable diseases incident to an army is related by Diodorus, as breaking out among the Carthaginians at the siege of Syracuse. That author not only relates some of its most distinguishing symptoms, but reasons well about its cause. He observes, that pains in the back and eruptions (φλυκταιναι) were common; that some had bloody stools; that others were seized with a delirium, so as to run about and beat all that came in their way; that the physi- cians knew no cure; and that it was the more fatal as the sick were abandoned by every body on account of the contagion. As to the cause, the author takes notice of the multitude of people confined within a narrow compass; of the situation of the camp in low and wet ground; of the scorching heats in the middle of the day, succeeded by the cold and damp air from the marshes in the night-time; to these he adds, the putrid fleas arising first from the marshes, and afterwards from the bodies of those who lay unburied.—This distemper seems to have been a compound of the marsh and pestilential fever.

Forelius remarks, that, from the putrefaction of the water only, the city of Delft, where he practised, was scarce ten years together free from the plague or some pestilential distemper. He adds, that the magistrates, upon his representation of the cause, erected a wind-mill for moving and refreshing the water. At that time Holland was much more subject to inundations and the stagnation of water than at present. In 1694, a fever broke out at Rochfort in France, which, on account of the uncommon symptoms and great mortality, was at first believed to be the plague. But M. Chirac, who was sent by the court to inquire into its nature, found the cause to arise from some marshes that had been made by an inundation of the sea; and observed, that the corrupted fleas, which smelled like gun-powder, were carried to the town by the wind, which had long blown from that quarter. About two-thirds of those who were taken ill died. In such as were opened, the brain was found either inflamed or loaded with blood; the fibres of the body were uncommonly tender; and the bowels had either suppurated or were mortified.

It is needless to mention more instances of pestilential fevers being brought on by the fleas of corrupted substances, whether animal or vegetable. In general it may be remarked, that the putrefaction of these substances in a dry air is more apt to bring on a fever of the continued form; but in a moist air has a greater tendency to produce remitting fevers. But it must also be observed, that, even in cases where the most malignant fevers prevail, all persons are not equally disposed to receive the infection, though equally exposed to it with others. Some, through mere vigour of body and mind, cannot be infected with the most contagious diseases; while, on the other hand, those whose bodies are debilitated by a former disease, by study, low diet, or want, or those who have laboured under any of the depressing passions of the mind for some time, seldom or never escape. Men, therefore, who have been weakened by accidents (as those who have undergone a mercurial salivation) are very apt to fall into this distemper. Those who are taken into crowded hospitals, ill of the smallpox, however good the fort may be, fall readily into this fever, and run a greater risk of dying of it than others. The second fever is attended with double danger, fixing the patient has been so much weakened by the first. A sure sign of the corruption of the air in an hospital is when many of the nurses fall sick.

Prognosis. In these fevers we cannot draw a prognostic from any symptom by itself; and perhaps all of them together are more fallible than in others. Generally the following are good: To have little delirium; the strength little impaired; turbid urine in the decline of the distemper; and at that time a gentle sweat or moisture diffused over the body, or even the skin soft and the tongue moist; or to have some loose stools succeeded by a diaphoresis; the pulse to rise by wine or cordials, with an abatement of the stupor, tremor, and other affections of the brain. Deafness is rather a good sign. A sediment in the urine, without other changes for the better, is no sure sign of recovery; and some have recovered in whose urine there was no sediment.—The bad signs are, a subitus tendinum; the eyes much inflamed and staring; the speech quick, and the sound of the voice altered; a high delirium; perpetual watchfulness; constant ficksness at the stomach, and vomitings; frequent stools, with a sinking pulse, and the disorder of the head increased; coldness of the extremities, and a tremulous motion of the tongue. It is observed to be among the worst signs when the patient complains of blindness; when he swallows with difficulty, or cannot put out his tongue when desired to do it; when he can lie on his back only, and pulls up his knees; or when insensible he endeavours to uncover his breast, or makes frequent attempts to get out of bed without affixing any reason. If to any of these are added ichorous, cadaverous, and involuntary stools, it is a sign of a mortification of the bowels and approaching death. It will not seem strange to find most of these prognostics common to the advanced state of other fevers, when we consider, that from whatever cause fevers begin, by a long continuance the humours are corrupted, and the brain and nerves affected much in the same manner as in those which arise from infection.

Prevention and cure. As distempers of the putrid kind never arise without an infection received from some quarter or other, the methods of prevention must evidently be reduced to two general heads. 1. To avoid receiving the infection into the body; and, 2. To put the body in such a situation as may enable it to resist the infection when received. On both these methods scarce any writer hath equalled Dr Lind of Hafar, whose opinions and directions therefore we shall give pretty fully.

As putrid diseases are very common and violent in the hot countries, it is very necessary for Europeans who visit these climates to be well informed, in the first place, of the signs of an unhealthy country, that they may be upon their guard as soon as they enter any foreign region. These signs are by this author enumerated as follows.

1. A sudden and great alteration in the air, at sunset, from intolerable heat to a chilling cold. This is perceived as soon as the sun is down, and is for the most part accompanied with a very heavy dew: it shows an unhealthy swampy soil, the nature of which is such, that no sooner the sun-beams are withdrawn, than the vapours emitted from it render the air damp, raw, and chilling, in the most fultry climates; so that even under the equator, in some unhealthy places, the night-air is very cold to an European constitution.

2. Thick noisome fogs, chiefly after sunset, arising from the valleys, and particularly from the mud, slime, or other impurities. In hot countries, the smell of these Practice.

Febres. these feogs may be compared to that of a new-cleaned ditch. Difeases, therefore, arising from this caufe, generally take place in the night, or before sunrise.

3. Numerous swarms of flies, gnats, and other insects which attend stagnated air and unhealthy places covered with wood.

4. When all butchers meat soon corrupts, and in a few hours becomes full of maggots; when metals are quickly corroded on being exposed to the air; and when a corpse becomes intolerably offensive in less than six hours; these are proofs of a close, hot, and unwholesome country. And in such places, during excessive heats and great calms, it is not altogether uncommon for Europeans, especially such as are of a gross habit of body, to be seized at once with the most alarming and fatal symptoms of what is called the yellow-fever, without even any previous complaint of sickness or other symptoms of the disease. There has first been perceived an uneasy itching sensation, commonly in the legs; and upon pulling down the stockings, streams of thin dissolved blood followed, a ghastly yellow colour quickly diffused itself over the whole body, and the patient has been carried off in less than forty-eight hours.

5. A sort of sandy soil, commonly a small, loose, white sand, as that at Penfcola, Whydah, and the island of Bonavifa, which is found by experience to be injurious to health. The pestiferous vapour arising, during the summer months and in the heat of the day, from such a sandy soil, is best characterized by its effects in the extensive deserts of Asia and Africa. It there constitutes what is called the Samiel-wind; a blast which, in the parched desert, proves instantly fatal both to man and beast; but when it passes over a soil well covered with grass and vegetables, has its effects greatly mitigated; it is, however, even then, productive of sickness: thus the lusherly winds, while they blow from the deserts of Libya during the summer, at Algiers, Tunis, and Tripoli, produce an unhealthy season; and at Madras the winds, which, in the months of April and May, pass over a large tract of sand, are always hot, disagreeable, and unwholesome.

During these land-winds, sudden gusts of a more hot and suffocating nature are often observed to come from these sands once or twice, or even more frequently, in a day, which seem to be this vapour in a purer form. These gusts pass very quickly, and affect persons who happen to stand with their faces towards them in the same manner as the hot air which rises from a burning furnace, or from a heated oven, and obliges them immediately to turn away from it in order to recover breath. The effect of this hot suffocating blast or vapour on the human body, even when mitigated by passing through a moist atmosphere, is the same as that of intense cold; it shuts up every pore of the skin, and entirely stops the perspiration of such as are exposed to it. These blasts come only in the daytime, and always from the deserts. Water is the only known corrector or antidote against them: hence, coarse thick cloths, kept constantly wet, and hung up at the windows or doors, greatly mitigate their violence. A house so built as to have no windows or doors towards the deserts, is an excellent protection against their pernicious effects. The hot land-winds constantly blow at Madras and other places on the coast of Coromandel, at that season, from midnight till noon; the sea-breezes then begin, which relieve the difficulty in breathing, and the obstructed perspiration, which the former occasioned.

That the heat of these land-winds, as also of the sudden gusts which accompany them, proceeds from large tracts of sand heated by the sun, is evident from the increased heat and suffocating quality of those winds, in proportion as the day advances, and as the heat of the season is increased. The opposite winds, blowing from each side of the Balagate mountains, are a further proof of this. These mountains running from north to south, divide the farther Peninsula of India into two equal parts, and separate what is called the Malabar from the Coromandel coast. To the former they are very near, but at a great distance from the latter. The winds blowing from those hills are on the Malabar coast always remarkably cool; but on the coast of Coromandel, in the months of April, May, June, and July, are extremely hot and suffocating, as they pass over a large tract of intermediate sand, heated during those months by an almost vertical fun. Hence the Malabar coast is always covered with an agreeable verdure; whereas the Coromandel coast, during the continuance of these hot winds, seems a barren wilderness, nothing appearing green except the trees. On the contrary, the winds that pass over these sands, after being wet with the rains, are the coldest which blow at Madras. Bottles of liquor inclosed in bags of coarse cloth, kept constantly wet, and suspended in the shade, where those hot winds may have access to them, become as cold as if they had been immersed in a solution of nitre; an effect owing undoubtedly to the constant evaporation of water from the surface.

It is an observation of the natives on the coast of Coromandel, which is confirmed by the experience of many Europeans, that the longer the hot land-winds blow, the healthier are the ensuing months; these winds, as they express it, purifying the air. Are not the winds therefore the cause why the air on the coast of Coromandel, except during their continuance, is more healthy than in other parts of India where these winds do not blow? Does not this also suggest a very probable reason, why the plague in Egypt generally ceases in the beginning of June; the periodical hot winds which come from the deserts of Nubia and Ethiopia having then rendered the air of Egypt pure and wholesome? Many have ascribed that effect to the north winds; as the plague not only ceases when they blow, but all infected goods, household-furniture, and wearing apparel, are then said to become entirely free from the contagion: these, however, cannot be the cause, as the most destructive plague is abated in its violence, if not wholly eradicated, before they set in. With equal propriety we may reject the opinion that the overflowing of the Nile is productive of that salutary effect, as the plague generally ceases before the increase of that river is perceptible.

Thus the plague, the greatest calamity which can afflict mankind, seems to be destroyed by those hot winds, which are otherwise so pernicious to animal and vegetable life. And although, during the continuance of these winds, the most fruitful fields wear the aspect of a parched desert, yet no sooner the rains fall, but vegetation is restored, the plants revive, and a beautiful verdure is again spread over the face of the country.

Having thus given an account of the signs of an unhealthy country, Dr Lind next proceeds to mention such employments as are particularly dangerous to Europeans on their first arrival. One of these is the cutting down of trees, shrubs, &c. or clearing the ground, as it is called. Of the unhealthiness of this employment he gives two instances. At the conclusion of the late peace, the captain of a ship of war went on shore at the island of Dominica, with 12 of his men, to cut down the wood, and to clear a piece of ground which he intended to have purchased: but, in a few days, sickness obliged him to desist from this dangerous work; the captain and 11 of his men being feized with violent fevers, which terminated in obstinate intermittents, and of which several died. The survivors suffered so much in their constitutions, that, even after they came to England, the return of an east-wind was apt to bring on a violent fit of the ague. The Ludlow-Castle, a ship of war of 40 guns, in a voyage to the coast of Guinea, lost 25 of her men at Sierra Leon, who were employed in cutting down wood for the ship. This is an occupation which has often proved destructive to Europeans in those climates, and in which they ought never to be employed, especially during the rainy season; there being numberless instances of white persons, when cutting down the woods at that season, who have been taken ill in the morning, and dead before night.

Another evil, less known, and less suspected, but no less dangerous, is the fending Europeans in open boats after sunset, where the soil is swampy, or where there are great night-fogs. The single duty alone of fetching fresh-killed butchers meat at night for the use of our ships companies in the East and West Indies, has destroyed every year several thousand seamen. In those parts of the world, butchers meat must be brought on board at night immediately after it is killed, otherwise it will not be fit for use the next day; but a contract made with the natives to send it on board at that time, which might be done for a trifling sum, would be the means of preserving many useful lives. During the sickly season at Batavia, a boat belonging to the Medway, which attended on shore every night, was three times successively manned, not one having survived that service. They were all taken ill in the night, when on shore, or when returning on board; so that at length the officers were obliged to employ none but the natives on that business. Great numbers of men have perished from being employed in this manner at Bengal, where the European ships often anchor in the most unhealthy spots of the river; and even when the great night-fogs arise, after the rainy season, the men are often obliged to perform such night-services in boats. Now since it is so dangerous for Europeans in unhealthy countries, particularly during a season of sickness, to be exposed in an open boat to the foggy night-air, it must appear that fending them unsheltered, in open boats, far up rivers, in unhealthy southern climates, for the sake of wood, water, trade, or other purposes, must be attended with the most destructive and fatal consequences.

Burying the dead in swampy countries is another Typhus occupation which has proved fatal to many, and which ought to be entrusted to negroes or the natives of the country. The effluvia from the ground when newly opened, whether from graves or ditches, are far more dangerous than from the same swampy foil when the surface is undisturbed; nay, in some places, it has been found almost certain death for an European to dig a grave, unless long seafoned to the country. In such a place, the attendance of friends at funerals ought to be dispensed with.

In all cases where it is practicable, the ships which visit these unhealthy countries should anchor at as great a distance as possible from shore; or if obliged to anchor near marshy grounds or swamps, especially during summer or in hot weather, and when the wind blows directly from thence, the gun-ports which would admit the noxious land-breeze ought to be kept shut, especially at night. Or if the ship rides with her head to the wind, a thick sail ought to be put upon the fore-mast, along which the smoke from the fire-place might be made constantly to play and ascend. If the sail should occasion a little smoke between decks, this inconvenience will be sufficiently compensated by its keeping off the direct stream of the swampy shore effluvia; which now being obliged to form a curve before they reach the more distant parts of the vessel, must needs be greatly diverted and scattered.

The best preservative against the mischievous impressions of a putrid fog, or of a marshy exhalation, is a cloe, sheltered, and covered place; such as the lower apartments in a ship, or a house in which there are no doors or windows facing the swamps. If in such places a fire be kept either at the doors and other inlets to a house, or in the chambers, as is practised in some unhealthy countries during the rainy or foggy season, it will prove an excellent and effectual protection against the injuries of a bad air. On board of ships also fires may be made at the hatchways; and of the good effects of this we have the following example. When the Edgar, a ship of war of 60 guns, was upon the coast of Guinea in the year 1768, her men were very sickly, and many of them died: however it was observed, that in a floop of war, which was constantly in company with her, few were taken ill, and not one died during the whole voyage. This could be ascribed to no other cause, but that in the floop the fire-place for cooking victuals was on the same level with the deck where the men lay; and every morning when the fire was lighted, especially when there was but little wind, the smoke from the cook-room spread itself all over the ship, and particularly over those parts where the men lay; but from the construction of the fire-place of the Edgar, no smoke from it ever came between her decks.

Persons on board any ship whatever, are much more safe, and their situation is much preferable to that of those who make distant inland excursions in small boats upon the rivers, and who are for the most part ignorant of the cause of those maladies which destroy them. The intolerable heat at noon often obliges such persons to go in a manner half naked; while a free and plentiful perspiration issues from every pore. A near approach to putrid swamps at this time is apt to produce an immediate sickness, vomiting, and afterwards Fever, afterwards, a low nervous or malignant fever. If they happen to pass them at night, or lie near them in an open boat, the air from those swamps is perceived to be quite chill and cold; in so much that warm thick clothing becomes absolutely requisite to guard the body against the impressions of so great an alteration in the air, and against its cold and inclement quality: for the effects of it then, even on the most healthy and vigorous constitution, is frequently a chilling cold fit of an ague, terminating in a fever with delirium, bilious vomitings, and purging, or even death itself.

Where such exposure becomes unavoidable, the only method is to defend the body as much as possible against the pernicious misfumata with which the air abounds.—All those who are employed in cutting down woods, or in other laborious and dangerous services in hot climates, during the heat of the day, ought to have their heads covered with a bladder dipt in vinegar, and to wash their mouths often with the same liquor; never to swallow their spittle, but rather to chew a little rhubarb or some other bitter, and spit it out frequently; to stop their nostrils with a small bit of linen or tow dipped in camphorated vinegar; and to infuse some Peruvian bark, garlic, and rhubarb, in brandy, of which a dram is to be taken, either by itself or diluted with water, morning and evening.

In the evening before sunset they should leave off work, and not return to their labour in the morning till the sun has dispersed the unwholesome dews and vapours. Those who must of necessity remain on shore, and sleep in dangerous places, should take care not to sleep upon the ground exposed to the dews, but in hammocks in a close tent, standing upon a dry sand, gravel, or chalk, near the sea shore, and where there is no subterraneous water for at least four feet below the surface of the ground. The door of this tent should be made to open towards the sea; and the back part of it, which receives the land breeze, must be well secured by double canvas, or covered with branches of trees. But in such circumstances, a hut, when it can be procured, is preferable to a tent, especially if it be well thatched, so as to prove a defence both against the excessive heat of the sun by day, and the noxious dews which fall at night. Here the men may be enjoined to smoke tobacco. When the air is thick, moist, and chill, the earth being overspread with cold dew, a constant fire must be kept in and about the tent or hut, as the most excellent means of purifying such unwholesome air, and of preserving the health of those who either sleeping or waking are exposed to its influence. The sentinels who guard the water-casks, ought likewise at such a time to have a fire burning near them. All old and forsaken habitations, natural caves and grottos in the earth, where the men may be induced to take up their abode, must before their admission be perfectly dried and purified with sufficient fires. Fire and smoke are undoubtedly the great purifiers of all tainted and unwholesome air, and the most excellent preservatives against its noxious influence. It is the custom of the negroes in Guinea, and also of some Indians (who both sleep for the most part on the ground), to have a fire, producing a little smoke, constantly burning in their huts where they sleep. This not only corrects the moisture of the night, but also, by occasioning more smoke than heat, Typhus, renders the damp from the earth less noxious; of which Dr Lind gives the following remarkable instance. A Guinea ship being up one of the rivers for the sake of trade, it was found to be very dangerous to sleep on shore: without which their trade could not be conveniently carried on. First the captain, then the mate, and two or three of the seamen, were taken ill; each of them the morning after they had lain on shore. By these accidents the men were greatly intimidated from lying ashore; till the surgeon boldly offered to try the experiment on himself. Next morning when he waked, he found himself feized, as the rest, with a giddiness and pain in the head. He immediately acquainted one of the negroes with his condition, who carried him to his hut, and set him down in the smoke of it; when his shiverings and giddiness soon left him. He then took a dram of the bark bitter; and found himself greatly relieved, especially by breathing fume time in the smoke.—Thus instructed by the negro he ordered a large fire to dry the hut he slept in; and afterwards had every night a small fire sufficient to raise a gentle smoke without occasioning a troublesome heat: and by this means he and several others, using the same precautions, slept many nights on shore without any inconvenience.

Fire and smoke indeed are found to be certain correctors, or rather destroyers, of infection in all cases, whether arising from the noxious effluvia of marshes, or from the contagion of diseased bodies. Even those most extraordinary and fatal damps called harmattans, are unable to resist the salutary effects of smoke. In other cases, Dr Lind remarks, that, under some circumstances, the source of an infection in a sick chamber, or any other place, may be removed or destroyed by accidental means, for which we cannot account, and which we often cannot ascertain. But it oftener happens, that it is very difficultly rooted out; and that exact cleanliness, with the benefit of a pure air, often proves insufficient to remove the evil. Smoke, however, has never been known to fail. It is not to be doubted, that, excepting the true plague, there has been an infection fully as pestilential and as mortal in some ships as in any other place whatever; yet it has never been heard, that any ship, after having been carefully fumoked, did not immediately become healthy: and if afterwards they turned sickly, it was easy to trace that sickness from other infected ships, jails, and the like places.

There are three methods practised for purifying vessels after the men have been removed out of them. The first is by burning of tobacco. A quantity of tobacco is spread on several fires, made with fresh old pieces of rope as are called junk. These are dispersed into different places of the ship, and their heat and smoke afterwards closely confined below for a considerable time.—The second method is by charcoal fires strewed with brimstone. The heat and steam of these burning materials must also be long and close shut up; but, although this fume, properly applied, has been found by experience to purify most effectually tainted apartments, ships, clothes, &c. yet there are some kinds of vermin which it will not destroy, particularly lice. The third method of purification is performed by the addition of arsenic to the materials of the second pro- cess, in the following manner. After carefully stopping up all the openings and every small crevice of the ship (as was also necessary in the preceding processes), a number of iron pots, properly secured, are to be placed in the hold, orlop, gun-deck, &c. Each of these is to contain a layer of charcoal at the bottom, then a layer of brimstone, and so alternately three or four layers of each, upon which the arsenic is to be sprinkled, and on the top of it some oakum dipped in tar is to be laid to serve as a match. The men, upon setting fire to the oakum, must speedily leave the place, shutting close the hatchway by which they came up.

From the known and experienced efficacy of these processes, it appears, that fire and smoke are powerful agents for annihilating infection; and, it may be presumed, even the plague itself. This is in some measure agreeable to what we learn from the ancient records of physic. But the preposterous use, or rather abuse, of fire on such occasions, has caused its effects to be disregarded by some, and to be suspected of mischief by others. The modern practice of burning large fires in the open air, in the streets, and about the walls of towns infected with the plague or other contagion, is founded on principles groundless and erroneous; and has therefore been found by experience not only unsuccessful, but hurtful. But though this must be allowed, it does not thence by any means follow, that when once a house has been infected, and the patients removed from it, the doors and windows at the same time being shut, that such fires will then prove hurtful; or that, by this method of purification, all the seeds of contagion may not be effectually destroyed. Whenever, therefore, persons die of a spotted fever, a malignant sore throat, the small pox, or any distemper found to be communicable from the sick to the sound, the corpse ought quickly after death to be removed into another room; that in which the person died should be well aired, by having the windows opened, till a charcoal fire be kindled, with some rolls of sulphur upon it; after which, both doors and windows should be kept shut for a considerable time, not less than eight or ten hours, till the room be thoroughly smoked. In several ships, where there are the fairest opportunities of trying and judging things of this nature, the contagion of the small-pox has been entirely stopped by wood-fires, sprinkled with brimstone, kept burning and closely confined in the infected place. In a word, a judicious and proper application of fire and smoke is a powerful agent for the destruction and utter extinction of the most malignant sources of disease; and they are besides great purifiers of all bad and tainted air.

Next to the smoke of wood for purifying a tainted air, that of gun-powder is to be esteemed the best; and it has this further good property, that it is entirely inoffensive to the lungs. The eucarilla bark, when burning, gives a most agreeable scent to the chamber of the sick; thus it is at least an elegant preservative, and may prevent bad smells from taking effect. The steam of camphorated vinegar, warmed, is still more powerful for this purpose. But, besides correcting the ill quality of the air, and purifying the chamber, another good effect is produced from such fumes and smoke as are inoffensive to the lungs. As soon as the vapour becomes dense, the nurses and patients become desirous of the admission of fresh air by the doors or windows.

Now it is certain, that the air in the chambers of the sick cannot be too often changed, provided the patient be well covered, and the curtains of his bed, if necessary, be drawn close. No argument is so forcible to obviate the danger of foul air in a room or ward (occasioned by the obstinacy of nurses and relations), as ordering it to be frequently fumigated or smoked: A practice more frequent in other countries than in this, but of great benefit to the sick.

Lastly, with regard to the method of purifying goods, moveables, clothes, &c. which are supposed to harbour infection, it must be observed, that the usual custom of only unpacking and exposing such materials to the open air, is in many instances insufficient to destroy the latent seeds of disease. It is certain indeed, that in most cases the contagious particles are more readily and fatally communicated from the clothes of a sick person than from his body. The spreading abroad, therefore, of contaminated clothes to dry or to be aired, without a previous fumigation of them, may be of dangerous and fatal consequence. All such suspected substances should be first fumigated in a close place, and in the same manner as an infected chamber, after which they may be spread abroad and exposed to the air. In infectious diseases, especially fevers, the linen of the sick, or such clothes about them as will admit of being washed, ought never at first to be put in warm water, as it is dangerous to receive the steam that may hence arise. It is necessary to steep them first either in cold water or in cold soap-lesse for several hours, that the filth may be washed off.

But although the destruction of contagion by smoke is unquestionably a very important practice, yet it cannot now be said, that it is the most powerful agent for this purpose. By the ingenious observations and experiments of M. Morveau in France, and of Dr Smyth Carmichael in England, it is now ascertained, that we possess still more powerful means of destroying contagions, either in the muriatic or nitrous acid gas. The former may easily be detached from common sea salt, and the latter from nitre, by means of the sulphuric acid. Rooms may, with the utmost safety and ease, be filled with these fumes, although the sick be not removed from them. But for disinfecting a room, ward, or ship, when empty, the most powerful article yet discovered is the oxygenated muriatic acid gas, detached from a mixture of manganese and sea salt, by means of the sulphuric acid.

We must now proceed to give an account of the method of cure, after these means of preventing the infection from being received into the body have either been neglected or proved ineffectual. Here it is of the utmost importance to take the disease in the very beginning, before it has time to corrupt the fluids to such a degree as to endanger life. In flight degrees of infection, a vomit properly administered, especially if succeeded by a blister, never fails to remove the disorder, and prevent the fever which would otherwise unavoidably follow. Of this Dr Lind gives the following instances. A lady afflicted with the bilious cholic, had intolerably fetid discharges of corrupted matters upwards and downwards. A gentlewoman, only in passing the room, was immediately seized with a retching and sickness, which continued 24 hours. The nurse who attended was suddenly fei- Februes zed with a giddiness and vomiting from the bad smell, which, as he expressed it, reached into her stomach. The vomiting became more severe at night, accompanied with a purging and frequent shiverings. By means of an emetic both evacuations were stopped; notwithstanding which, for some days afterwards, she continued to have frequent tremors, and a violent headache, with a low irregular pulse; and did not recover so soon as the patient.

Such slight degrees of infection have been often observed to be derived from patients of a gross habit of body when labouring under inflammatory distempers, and even other complaints. A man was sent to Hal-lar Hospital, supposed to have a fever. He was furiously delirious, with a quick full pulse. Notwithstanding plentiful evacuations, this delirium continued for two months with short intervals: when the case was found to be plainly maniacal. A nurse, upon raising this person up in her arms, perceived an intolerably bad smell, and was instantly feized with shiverings, sickness, and headache. Finding herself very ill, she took a vomit in fix hours afterwards, and passed the night in profuse sweats by means of a sudorific draught. Next morning the violence of the headache was but little abated; upon every attempt to move, she complained of a burning heat and pain in her forehead, and became giddy. Her inclination to drink was frequent, and her pulse low and quick. A blister was immediately applied to the back; as soon as the blister took effect, the headache and thirst entirely left her, and the pulse was calm. Next day the aforesaid was well.

Many similar instances of infection have been observed from putting the dead into their coffins. In particular, one man, from performing that duty to his mistress, was so ill, even after the operation of the vomit, as to require a blister. In the course of one week two nurses were infected by a person in the smallpox. Both were feized in like manner with shiverings, sickness, and headache; the one upon receiving the patient's breath, the other upon making his bed. In one, a pain darted into her breast; in the other, into the breast and in the small of the back. The complaints of the former were speedily removed by a vomit, though he continued to have irregular returns of shiverings for three days afterwards. But in the latter, though the headache, sickness, and rigors, were greatly abated by the vomit, yet a constant heat and thirst, with a low pulse, and a violent pain in the breast, indicated the necessity of applying a blister to the affected parts, which next morning removed all her complaints.

A person is often immediately sensible of his having received infection from the first attack: they generally compare the first impression to an earthy disagreeable smell, reaching down, as they express it, into their stomach, as from a grave newly opened, but not quite so raw as the cadaverous stench; and the effects of it, shivering and sickness, are instantaneous. It is a smell difficult to describe; but it is well known to the nurses and attendants about the sick, as it usually accompanies fevers of extreme malignity, and, with the peculiar discharges from the blistered parts, may be reckoned among the most constant symptoms of a bad fever. Some compare the smell to that of rotten straw.

It often resembles the disagreeable smell of a person labouring under the confluent smallpox at their turn, though not so strong. One person, on receiving the infection, was sensible of something like an electric shock through his body. But many are not sensible of any effect from infection at first; and an infection from a fever will sometimes continue for many days, nay weeks, discovering itself chiefly by irregular shiverings, sometimes to fever as to oblige the patients to have recourse to their beds once or twice a-day; sometimes every other day. Among a number thus affected, it also appears, that such as are put into unseafed chambers, or have fat down on the cold ground, lain in raw damp apartments, &c. are immediately feized with a sickness at stomach, sometimes with a dangerous purging, and often with fevers accompanied with bad symptoms, which others have entirely escaped.

It now remains to consider the proper method of curing putrid fevers, on the supposition that the infection has been allowed to operate till the blood becomes radically tainted, and of consequence the nervous system affected to such a degree, that its power cannot be restored by any of the simple practices above mentioned. Here all authors agree, that a change of air, when it can be effected, is highly advantageous, and often contributes more towards the removing the disease than all the medicines that can be exhibited. The utility of this change will appear from what has been formerly said; and we shall only further mention one instance from Dr Lind, in which the effects of bad air appear to a degree almost incredible. "It is remarkable (says he), that, in the last war, the English ships which touched at Batavia suffered more by the malignant and fatal diseases of that climate, than they did in any other part of India, if we except a fatal fever which once raged in that fleet at sea. Soon after the capture of Manilla, the Falmouth, a ship of 50 guns, went to Batavia, where she remained from the latter end of July to the latter end of January; during which time she buried 100 soldiers of the 79th regiment, and 75 of the ship's company; not one person in the ship having escaped a fit of sickness, except her commander Captain Brereton. The Panther, a ship of 65 guns, was there in the years 1762 and 1764; and both times during the rainy season. In the former of these years, she buried 70 of her men; and 92 of them were very ill when she left the place. In the year 1764, during a short stay, 25 of her men died. The Medway, which was in company with her, lost also a great number of men. Nor was the sickness at that time confined to the ships: the whole city afforded a scene of disease and death: streets crowded with funerals, bells tolling from morning to night, and horses jaded with dragging the dead in heaves to their graves. At that time a slight cut of the skin, the least scratch of a nail, or the most inconsiderable wound, turned quickly to a spreading putrid ulcer, which in 24 hours consumed the flesh even to the bone. This fact is so extraordinary, that upon a single testimony, credit would hardly be given to it; yet on board the Medway and Panther they had the most fatal experience of it, and suffered much from it."

But where a change of air is impracticable or ineffectual, and where the fever has already made some progress, Sir John Fringle generally took away some blood if the pulse was full. When the symptoms run high, high, a plentiful evacuation of that kind seemed indicated; yet it was observed, that large bleedings generally did harm, by finking the pulse, and affecting the head. Nor was a moderate bleeding to be repeated without caution; even though whose blood was fizzy, unless their lungs were inflamed, were the worse for a second bleeding. If the head only suffered, it was much safer to use leeches than to open a vein in the arm; but in the delirium with a sunk pulse, even leeches were hurtful. Many recovered without letting blood, but few who lost much of it.

Emetics also must be used with caution; for though they may be of service by way of prevention, yet in the advanced state of the disease, when the patient has all along complained of a sickness at stomach, they are evidently unsafe. Here the antiseptic quality of fixed air is of much use, and the neutral draughts given in the act of effervescence are generally attended with happy effects. Nay, clysters of fixed air itself have been found very serviceable. Even in very bad stages of the distemper, where a putrid and colligative looseness has taken place, clysters of fixed air have been known to alleviate the symptoms. We must not, however, put too much confidence in medicines of this kind. Mild tonic cordials, especially wine and cinchona, are the only resources in these disorders. Concerning the former, Sir John Pringle observes, in the low state of these fevers, and in great sinkings, which either come after unseasonable bleedings or long want of nourishment, it was a most grateful and efficacious cordial, to which nothing was comparable. The common men had an allowance, from a quarter to half a pint in a day, of a strong kind made into whey, or added to the panada which was their ordinary food. But to others out of the hospital, he usually prescribed Rhineith or a small French wine, whereof some consumed near a quart per day, and part of that undiluted. Nay, so great was the virtue of wine in this stage of the fever, that several were known to recover from the lowest condition, when, refusing the bark on account of its taste, they took nothing but a little panada with wine, and a volatile diaphoretic mixture, every two or three hours by turns. Perhaps there is no rule more necessary in this state, than not to let the patient when low remain long without taking something cordial and nourishing; as many have been observed past recovery, by being suffered to pass a whole night without any support about the time of the crisis. In the advanced state of this fever the sick are remarkably low; and therefore Hoffman advises in such cases, that they should be constantly kept in bed, and not permitted even to sit up in it. In the last stage of this fever, as well as in that of the fea-furry, it would seem that the force of the heart was too small to convey the blood to the brain, except when the body is in a horizontal posture.

But, however necessary wine and cinchona may be in the low stage of this fever, we must remember, that these remedies are to be administered only as antiseptics and supporters of the vis vitae, without aiming at thoroughly raising the pulse or relieving the head, or at forcing a sweat by them, before nature points that way, and which Sir John Pringle seldom observed before the 14th day.

In the low state of the hospital fever, a stupor was a constant attendant, which was very apt, in the evening, to change to a flight delirium. If this was all, nothing was done. But if the delirium increased upon using wine, if the eyes looked wild, or the voice became quick, there was reason to apprehend a phrenitis; and accordingly it was observed, that at such times all internal heating medicines aggravated the symptoms; and in these cases, blisters were of the greatest service. Fomentations of vinegar and warm water for the feet, Sir John Pringle is of opinion, would answer better than either fumapills or blisters, provided they were long enough and often enough applied. In the inflammatory fevers, he has known these fomentations have little effect for the first hour, and yet succeed afterwards. For internal medicine, cinchona was omitted for some time, but the patient was continued with an acidulated drink, viz. barley-water and vinegar; and treated also with amphire, pulvis contrayerae compositus, and nitre, as was usual in the beginning of the fever. If the delirium was of the low kind, a decoction of cinchona and wine were the only remedies; for in no instance was the delirium perfectly removed till the time of the crisis. It must also be observed, that a delirium may arise in putrid fevers from two opposite errors; one from large and repeated bleedings, and the other from wine and the cordial medicines being taken too early. It appears, therefore, how nice the principles are that regard the cure; as neither a hot nor a cool regimen will answer with every patient, or in every state of the disease.

If a diarrhoea came on in the decline of the fever, it was moderated, but not suppressed, by adding an opiate to the usual medicines. For though the looseness may be considered as critical; yet as the sick were too low to bear evacuations, there was a necessity for restraining it in some measure; and it has often been observed, that when it has been treated in this manner, about the usual time of the crisis, the patient has fallen into a gentle sweat, which has carried off the disease. In the worst cases of this fever, and especially when it coincides with the dentery, the stools are frequently bloody; in which dangerous state, if any thing could be done, it was attempted by medicines of the same kind. In proportion to the putrid nature of the stools, opiates and astringents were used with the greater caution.

If the disease terminate in a suppuration upon one of the parotid glands, the abscess was opened without waiting for a fluctuation, which might never happen; the pus being often here to viscid, that after it was ripe, the part felt nearly as hard as if the suppuration had not begun.

Almost every patient, after the fever, complained of want of rest, frequently of a vertigo or confusion of the head, of a continuation of the deafness, or of other symptoms commonly called nervous. An opiate was then given at night; and in the day some strengthening medicines, such as cinchona and the sulphuric acid. In these cases, the bark was found not only to be the best strengthener, but the surest preservative against a return of the disease. For this last intention the convalescent was ordered about three drams a-day for fix or seven days together; and afterwards, if he remained longer in the hospital, some smaller quantity daily. But if there was any appearance of a hectic tic fever from an inward abscess, the case was treated accordingly. Upon comparing some of the remaining symptoms of those who recovered, with the condition of the brain in those who died and were opened, Sir John Pringle was induced to think, that some part even of that substance might suppurate, and yet the person recover.

Sometimes the patient falls into an irregular intermittent; which, if not of a hectic nature from an internal abscess, may proceed from neglecting to clear the prime vi.e. For it is easy to conceive, that after a long fever of such a putrid nature, often attended with languor of the bowels, the feces may be so much accumulated, and so corrupted, as to occasion new disorders. In such cases, after proper evacuation by a purge, cinchona was almost an infallible remedy.

The Yellow Fever.

Typhus cum flavedine cutis. Typhus icteroides, Sauv. Sp. 7. Febris flavia Indie Occidentalis, Warren. Malignant Fever of Barbadoes, Hillary's Diseases of Barbadoes. Lining on the Yellow Fever of South Carolina, Edin. Phyf. and Liter. Essays, vol. ii. McKitterick de Febre Flavà Indie Occidentalis, Edin. 1766.

Description. This is one of the most fatal diseases to which the inhabitants of warm climates are subject, and is the same with that called, from one of its worst symptoms, the black vomit, which is to terribly destructive in some of the warm parts of America, particularly at Carthagena ; and which of late has proved so fatal in Philadelphia, New York, and the British West India islands, as described by Drs Rush, Chisholm, Clerk, and other late writers. This, though by some considered as a new disease, is evidently from the same contagion which has produced fatal fevers on many former occasions.

The yellow or putrid bilious fever has been in particular minutely described by Dr Hillary. It most commonly seizes the patient at first with a faintness, then with a sickness at stomach, accompanied in general with a giddiness of the head; and soon after with a flight chills and horror, very rarely with a rigor. These symptoms are soon followed by a violent heat and high fever, attended with acute darting pains in the head and back. A flushing in the face, with an inflamed redness and a burning heat in the eyes, great anxiety and oppression about the precordia, are the pathognomonic signs of the distemper, especially when attended with sickness at stomach, violent retchings, and bilious yellow vomitings, with frequent sighing. The pulse is now generally very quick, high, soft, and sometimes throbbing, but never hard : in some it is very quick, soft, low, and oppressed; the respiration quick, full, and sometimes difficult; the skin very hot, and sometimes dry, though more frequently moist. Blood taken from the patient, even at the very beginning of the disease, is often of an exceeding florid red colour, without the least appearance of size; and the crassamentum, when it has stood till it is cold, will scarce cohere, but fluctuates; the serum is often yellow.

Most of the above-mentioned symptoms continually increase, and are much aggravated: the retching and vomiting become almost incessant; the anxiety great, and sighing frequent; great restlessness; continual tossing; no ease in any posture; little sleep, and that disturbed and uneasy, and without any refreshment to the sick. When they are fainting, they turn yellow about the face and neck, instead of turning pale; and as the fainting goes off, they recover their natural colour. These symptoms generally continue to the third day, though sometimes not longer than the first or second; in others to the end of the fourth: the first shows the greater diffusion of the blood, and the greater malignity of the disease; the last, the contrary; which the improper manner of treating the disease sometimes hampers and increases, or the proper method retards. This may be called the first stadium of the disease, and generally ends on the third day.

Blood taken from the sick on the second or third day, is much more diffused, the serum more yellow, and the crassamentum florid, loose, scarcely cohering, but undulates like fizzy water when shaken, and sometimes has dark blackish spots on its surface, showing a strong gangrenecent diathesis.

About the third day, the pulse, which was quick and full before, now generally sinks greatly, and becomes very low: though sometimes it remains very quick, yet in others it is not much quicker than when the patient was in health, but is always low; the vomiting becomes almost incessant if not so before, and the matter thrown up is black; the patient then becomes comatose, with interrupted delirium. The thirst in some is very great, in others but little; the pulse still low and quick, attended with cold clammy sweats, and sometimes with delirium. The eyes, which were inflamed and red before, and began to be of a more dusky colour, now turn yellow; and this yellowness also soon after appears round the mouth, eyes, temples, and neck, and in a short time diffuses itself all over the body. But this yellowness is so far from being always an encouraging prognostic, as some would have it, that it most commonly proves a mortal symptom. Sometimes indeed, though seldom, this suffusion of bile upon the surface has proved critical; but then it did not come on till the eighth or ninth day, nor appear till the coma and all the other bad symptoms began to abate; and then in proportion as the yellowness increases, all the bad symptoms decrease. But the case is most commonly quite the reverse; especially when the yellowness comes soon on: and then it suffers in the most fatal symptoms of the disease, viz. a deep coma, a low, vermicular, and interrupting pulse, great hemorrhages from various parts of the body, a delirium with laborious and interrupted respiration, great anxiety, deep sighing, restlessness, a subfultus tendinum, coldness of the extreme parts first, and then all over the body, a faltering of the speech, tremors, and convulsions, which are soon after followed by death. So that from the first appearance of the yellowness we may say the patient is in the last stage of the disease, whether it terminates in death or recovery.

It has been observed, that, in some strong sanguine constitutions, when the patients have not been bled to a sufficient quantity in the beginning of the disease, the pulse has continued full, strong, and rapid, but never hard; the face flushed, eyes inflamed; the tongue dry, with great thirst and heat, till the second or last stage of the fever is come on, when the pulse has suddenly Febres. suddenly funk, and death soon after ensued. Yet in others, who seemed to be of a plethoric habit, the tongue has been moist all along, though they have been delirious most of the time, and the heat of their skin and the strength and quickness of their pulse have continued, after the first stage of the disease was over, pretty near to that of their natural state in health, till within a few hours of death; and when they have had a coma on them, one who is not well acquainted with the nature of this disease would, from the pulse, heat, breathing, and other symptoms, have taken them to be in a natural sleep. Others, when the pulse has begun to sink, and the fatal period seemed to be just approaching, to the great surprise of all present have recovered their senses, sat up and talked pretty cheerfully for an hour or two, and in the midst of this seeming security have been suddenly seized with convulsions which carried them off immediately.

In the latter stage of this fever, the blood is so attenuated and dissolved, that we frequently see it flowing not only out of the nose and mouth, but from the eyes, and even through the pores of the skin; great quantities also of black, half-baked, or half-mortified blood, are frequently voided both by vomiting and by stool, with great quantities of yellow and blackish putrid bile by the fame passages; and the urine, which was before of a high terebrant colour, is now almost black, and is frequently mixed with a considerable quantity of half-diluted blood. The pulse, which was much funk before, now becomes very low, unequal, and intermittent; the breathing difficult and laborious; and the anxiety inexprefible; an oppression with a burning heat about the precordia comes on, though the extremities are cold, and often covered with cold clammy sweats; a constant delirium follows; and then a total losf of the outward senses as well as the judgment, with livid spots in many parts of the body, especially about the precordia; and sometimes gangrenes in other parts of the body, which are very soon succeeded by death.

In a short time after death, the body appears much more full of livid, large, mortified spots, particularly about the precordia and hypochondres, especially the right; which parts seem, even from the first seizure, to be the principal seat of this terrible disease; and, upon opening the bodies of those who die of it, we generally find the gall-bladder and biliary ducts turgid, and filled with a putrid blackish bile; and the liver, stomack, and adjoining parts, full of livid or blackish mortified spots; and the whole corpse soon putrefies after death, and can be kept but a few hours above ground.

Dr Lind is of opinion, that the remarkable dissolution of the blood, the violent haemorrhages, black vomit, and the other symptoms which characterize the yellow fever, are only accidental appearances in the common fever of the West Indies; that they are to be esteemed merely as adventitious, in the same manner as purple spots and bloody urine are in the smallpox, or as an hiccough in the dyfentery: like these they only appear when the disease is attended with a high degree of malignity, and therefore always indicate great danger. This opinion, he thinks, is confirmed by an observation of Dr Wind's, that in 1750 the crew of a Dutch ship of war were distressed by the yellow fever, accompanied with the black vomit; but when the ship left the harbour, and changed the noxious land air for one more healthy, the fever continued, but was not accompanied with the black vomit.

Diseases similar to this fever, Dr Lind informs us, may arise in any part of the world where the air is intensely hot and unwholesome; and therefore he treats as chimerical the notion of its being imported from one part of the world to another. An example of this happened at Cadiz in Spain, in the months of September and October 1764, when excessive heat, and want of rain for some months, gave rise to violent, epidemic, bilious disorders, resembling those of the West Indies, of which 100 persons often died in a day. At this time the winds blew principally from the south, and after sunset there fell an unusual and very heavy dew. But his opinion on this subject is liable to strong objections. And however the disease may originate, yet the late introduction of it from Spain into the forts of Gibraltar, from which, by proper attention, it had been excluded in former epidemics, demonstrates the contagious nature of this fever beyond all possibility of doubt.

It has been a matter of much dilpute, whether the yellow fever is of an infectious nature or not. Some time ago it became an object of consideration before the Right Hon. the Lords Commissioners of Trade and Plantations, where it was urged among other reasons, for not removing the seat of government and justice in the island of Jamaica from Spanish Town to Kingston, that there was danger from Greenwich hospital, situated near Kingston, of an infection from the yellow fever being frequently communicated to that town. On this affair a physician was consulted, who had long practised in that island, and who gave it as his opinion, that from the yellow fever in that island there was no infection. This was the opinion not only of that gentleman, but of many others who had an opportunity of being well acquainted with this fever in Jamaica. But this opinion probably only arose from these practitioners having confounded the ordinary remittent fever of the West Indies, which is often accompanied with bilious symptoms, and is from thence often denominated the yellow fever, with the typhus icteroides, a disease essentially different from the bilious remittent which often prevails both in the West and East Indies. Dr Lind gives a remarkable instance of its being of an infectious nature.—A gentleman dying at Barbados of a yellow fever, his wearing apparel and linen, packed up in a chest, were sent to his friends at Philadelphia; where, upon opening the chest, the family was taken ill; and the clothes being unluckily hung abroad to be aired, they presently diffused the contagion of the yellow fever over the whole town, by which 200 persons died.

In the description of the same fever by Dr Lining, as it appeared in South Carolina, there are several particulars considerably different from that by Dr Hillary. According to the former, people complained for a day or two before the attack, of a headache, pain in the loins and extremities, especially in the knees and calves of the legs, loss of appetite, debility, and a spontaneous laflitude. Some, however, were seized suddenly, without any such previous symptoms. After a chilliness and horror, with which this disease generally invades, a fever succeeded. The pulse was very frequent, till near the termination of the fever, and was generally full, Febres full, hard, and consequently strong: in some, it was small and hard; in others, soft and small; but in all those cases, it frequently varied in its fulness and hardness. Towards the termination of the fever, the pulse became smaller, harder, and less frequent. In some there was a remarkable throbbing in the carotids and in the hypochondria; in the latter of which it was sometimes so great, that it caused a constant tremulous motion of the abdomen. The heat generally did not exceed 102 degrees of Fahrenheit's thermometer; in some it was less; it varied frequently, and was commonly nearly equal in all parts, the heat about the precordia being seldom more intense than in the extremities when these were kept covered. On the first day of the disease, some had frequent returns of a sense of chilliness, though there was not any abatement of the heat. In a few, there happened so great a remission of the heat for some hours, when at the same time the pulse was soft and less frequent, and the skin so moist, that one from these circumstances might reasonably have hoped that the fever would only prove a remittent or intermittent. About the end of the second day, the heat began to abate. The skin was sometimes (though rarely) dry; but oftener, and indeed generally, it was moist, and disposed to sweat. On the first day, the sweating was commonly profuse and general; on the second day, it was more moderate: but on both these, there happened frequent and short remissions of the sweatings; at which times the febrile heat increased, and the patient became more uneasy. On the third day, the disposition to sweat was so much abated, that the skin was generally dry; only the forehead and backs of the hands continued moist. The respiration was by no means frequent or difficult; but was soon accelerated by motion, or the fatigue of drinking a cup of any liquid. The tongue was moist, rough, and white, even to its tip and edges. On the second day, its middle in some was brown. On the third day, the whiteness and roughness of the tongue began to abate. The thirst in very few was great. A nausea, vomiting, or frequent retchings to vomit, especially after the exhibition of either medicines or food, came on generally the third day, as the fever began to lessen; or rather as the fulness of the pulse, heat, and disposition to sweat, began to abate. Some indeed, but very few, on the first day, had a vomiting, either bilious or phlegmatic. Very few complained of anxiety or oppression about the precordia or hypochondria, nor was there any tenion or hardnes about the latter. On the first day they generally dozed much, but were afterwards very watchful. Restlessness and almost continual jactations came on the second day. A great despondency attended the sick, and the strength was much prostrated from the first attack. The pain in the head, loins, &c. of which they had complained before the attack, was much increased, and in some the pain in the forehead was very acute and darting; but those pains went generally off the second day. The face was flushed; and the eyes were hot, inflamed, and unable to bear much light. On the first day, many of them at times were a little delirious, but afterwards not until the recess of the fever. The blood drawn by venefaction had not any inflammatory crust; in warm weather, it was florid like arterial blood, and continued in one soft homogeneous-like mass, without any separation of the serum after it was cold. When Typhus, there was any separation, the crassamentum was of a very lax texture. The stools, after the first day, were fetid, inclined to a black colour, and were very rarely bilious, soft, or liquid, excepting when forced by art; for an obstinate costiveness attended the febrile state. The urine was discharged in a large quantity, was pale, sometimes limpid, and rarely of a higher than a straw colour, except when the weather was very warm, and then it was more saturated, of a deep colour, and discharged in smaller quantities. It had a large cloud, except when it was very pale or limpid; but more generally it had a copious white sediment, even on the first day of the fever. On the second day, the urine continued to be discharged very copiously; in some it was then turbid, and deposited a more copious sediment than on the first day; this sediment was sometimes of a brownish colour; in which case it was generally followed by bloody urine, either about the end of the second or beginning of the third day.—The colour and quantity of the urine, discharged in equal times, were remarkably variable, being now limpid, then of a deeper colour; now discharged in a larger, then in a smaller quantity; which could not be ascribed to any change made either in the quantity or quality of the drink.

The fever accompanied with those symptoms terminated on the third day, or generally in less than 72 hours from the first attack, not by any assimilation or coction and excretion of the morbid matter: for if by the latter, there would have been some critical discharge by sweat, urine, stool, or otherwise, none of which happened; and if by the former, nothing then would have remained but great debility. This fever, however, did not terminate in either of these salutary ways, excepting in some, who were happy enough to have the disease conquered in the beginning by proper evacuations, and by keeping up a plentiful sweat, till the total solution of the fever, by proper mild diaphoretics and diluents. But in those who had not that good fortune, however tranquil things might appear, yet the face of affairs was quickly changed: for this period was soon succeeded by the second stadium; a state, though without any fever, much more terrible than the first: the symptoms in which were the following. The pulse, immediately after the recess of the fever, was very little more frequent than in health, but hard and small. However, though it continued small, it became, soon afterwards, slower and very soft; and this softness of the pulse remained as long as the pulse could be felt. In many, in this stage of the disease, the pulse gradually subsided, until it became scarcely perceptible; and this, notwithstanding all the means used to support and fill it; and when this was the case, the icteritious-like suffusion, the vomiting, delirium, restlessness, &c. increased to a great degree. In some, the pulse, after being exceedingly small and scarcely perceptible, recovered considerably its fulness; but that favourable appearance was generally of but short continuance. The heat did not exceed the natural animal heat; and when the pulse subsided, the skin became cold, and the face, breast, and extremities acquired somewhat of a livid colour. The skin was dry when the weather was cold, but was moist and clammy when the weather was hot. The respiration was natural, or rather slow. The tongue was moist, and much cleaner than in the former stage; its tip and edges, as also the gums and lips, were of a more florid red colour than usual. Very few complained of thirst, though they had a great desire for cold liquors. The vomiting or retching to vomit increased, and in some was so constant that neither medicines nor aliment of any kind were retained. Some vomited blood; others only what was last exhibited mixed with phlegm; and others again had what is called the black vomit. The retching to vomit continued a longer or shorter time according to the state of the pulse; for as that became fuller, and the heat greater, the retching to vomit abated, and e contra. The inquietude was very obstinate; and when they dozed their flumbers were but short and unremitting. There were some who were drowsy; but these always awaked, after the shortest flumbers, with a great dejection of spirits and strength. The jaclations or restlessness were surprising: it was frequently scarce possible to keep the patients in bed; though, at the same time, they did not complain of any anxiety or uneasiness; but if asked how they did? the reply was, Very well. The debility was so great, that, if the patient was raised erect in the bed, or, in some, if the head was only raised from the pillow, while a cup of drink was given, the pulse sunk immediately, and became sometimes so small, that it could scarce be felt; at this time, they became cold, as in a horripilatio, but without the aniline-like skin: their lips and skin, especially about the neck, face, and extremities, together with their nails, acquired a livid colour. The delirium returned and increased; it was generally constant in those whose pulse was small and subfiding. The inflammation of the tunic conjunctiva or white of the eyes increased much, but without pain. A yellowness in the white of the eyes, if it did not appear before in the febrile state, became now very observable, and that ietitious tint was soon diffused over the whole surface of the body, and was continually acquiring a deeper saffron-like colour. In some, indeed, no yellowness was observable, excepting in the white of the eyes, until a little before death, when it increased very quickly, especially about the breast and neck. There were many small specks, not raised above the skin, which appeared very thick in the breast and neck, but less so in the extremities, and were of a scarlet, purple, or livid colour. In women the menstrua flowed, and sometimes excessively, though not at their regular period.

There was such a putrid diffusion of the blood in this stadium of the disease, that there were hemorrhages from the nose, mouth, ears, eyes, and from the parts which were blistered with cathartics. Nay, in the years 1739 and 1745, there were one or two instances of an hemorrhage from the skin, without any apparent puncture or loss of any part of the scarlet skin.

An obstinate colliciveness continued in some; in others, the stools were frequent and loose: in some they were black, liquid, large, and greatly fatiguing; in others, when the stools were moderate, even though they were black, they gave great relief; in others, again, the stools nearly resembled tar in smoothness, tenacity, colour, and consistence.

The urine was discharged in a large quantity, in proportion to the drink retained by the patient: it was pale if the patient was not yellow; but if yellow, then it was of a deep saffron-colour: in either case, it had a sediment, or at least a large cloud, which remained at the bottom of the glass; in some, it was very turbid; in others it was bloody: and the quantity of blood discharged with the urine bore always some proportion to the state of the pulse; when that became fuller, the quantity of blood in the urine was diminished; when the pulse subsided, the bloody urine increased, and even returned after it had ceased some days, soon after the pulse became smaller. This stage of the disease continued sometimes seven or eight days before the patient died.

When this stadium of the disease terminated in health, it was by a recess or abatement of the vomiting, hemorrhages, delirium, inquietude, jaclations, and ietitious-like suffusion of the skin and white of the eyes; while, at the same time, the pulse became fuller, and the patient gained strength, but very slowly. But when it terminated in death, those symptoms not only continued, but sooner or later increased in violence, and were succeeded with the following, which may be termed the third stadium of the disease, which quickly ended in death. The pulse, though soft, became exceedingly small and unequal; the extremities grew cold, clammy, and livid; the face and lips, in some, were flushed; in others, they were of a livid colour; the livid specks increased so fast, that in some the whole breast and neck appeared livid; the heart palpitated strongly; the heat about the precordia increased much; the respiration became difficult, with frequent sighing; the patient now became anxious, and extremely restless; the sweat flowed from the face, neck, and breast; blood flowed from the mouth, or nose, or ears, and in some from all those parts at once; the deglutition became difficult; the hiccoughs and subulatus tendinum came on, and were frequent; the patients trifled with their fingers, and picked the naps of the bedclothes; they grew comatose, or were constantly delirious. In this terrible state, some continued eight, ten, or twelve hours before they died, even after they had been so long speechless, and without any perceptible pulsation of the arteries at the wrists; whereas, in all other acute diseases, after the pulse in the wrists ceases, death follows almost immediately. When the disease was very acute, violent convulsions seized the unhappy patient, and quickly brought this stadium to its fatal end. After death, the livid blotches increased fast, especially about the face, breast, and neck, and the putrefaction began very early, or rather increased very quickly.

Such was the progress of this terrible disease through its several stadia. But in hot weather, and when the symptoms in the first stage were very violent, it passed through those stages with such precipitation that there was but little opportunity of distinguishing its different stadia, the whole tragedy having been finished in less than 48 hours. It was remarkable, that, 1. The infection was increased by warm and lessened by cold weather. 2. The symptoms in the several stadia were more or less violent, according to the heat or coolness of the weather. In hot days, the symptoms were not only more violent, but in those who seemed in moderate weather to be on the recovery, or at least in no danger, the symptoms were all so greatly heightened, Febres, when the weather grew considerably warmer, as frequently to become fatal. In cool days, the symptoms were not only milder, but many who were apparently in great danger in hot days were saved from the very jaws of death by the weather becoming happily cooler.

3. The disease was generally more fatal to those who lay in small chambers not conveniently situated for the admission of fresh air, to those of an athletic and full habit, to strangers who were natives of a cold climate, to those who had the greatest dread of it, and to those who before the attack of the disease had overheated themselves by exercise in the sun, or by excessive drinking of strong liquors; either of which indeed seemed to render the body more susceptible of the infection. Lastly, The disease proved most certainly fatal to valentudinarians, or to those who had been weakened by any previous disease.

Causes of, and persons subject to, this disease. The yellow fever attacks principally Europeans, especially those who have but lately arrived in the hot climates. Negroes are entirely exempt from it, though the mulattoes and tawnyes are as liable to be seized with it as the whites themselves. The cause of the disease seems to be a particular kind of contagion; but Dr Lind seems to be of opinion, that the immediate cause of the symptoms is a disposition in the glutinous part of the blood to separate from the others, and to become putrefied. In some persons who have been bled in the yellow fever, the blood has been observed very viscid; the coagulum covered with a yellow gluten half an inch in thickness, and impenetrable to the finger unless cut by the nail; the serum being at the same time of the consistence of a thin syrup, and of a deep yellow tinct. This serum tasted bitter, and resembled a composition of foot. The appearances on dissection, with his conclusions from them, we shall give in his own words: "In a man who died on the eleventh day of a yellow fever, whose body emitted no bad smell 36 hours after death, and was still yellow, I found all the bowels of the abdomen found; the liver and spleen were remarkably so; as also the stomach and intestines. There was no suffusion of the bile either in the intestines or stomach. The gall-bladder, of the natural size, contained the usual quantity of bile, somewhat thicker than common, and grumous (b).

"Upon examining further, this disease was found to have lain wholly on the left side, where, within the breast, was found near a quart of yellowish water, in which were many large flakes of yellowish gluten, appearing, by comparison, precisely the same with the thick pellicle which had covered the blood taken from his arm. These flakes bore in several places a resemblance to a membranous substance beginning to be converted into a purulent jelly. The pleura, both on its inside and outside, as also its continuation, the investing membrane of the lungs, were covered with cakes of this gluten, hanging in some places loosely, in others adhering more strongly: and all in different flakes of yellow or purulent corruption. The right cavity of the breast, and all the other parts of his body, were found entirely free from disease.

"His complaints had been chiefly in his breast; and a small quantity of blood taken from him two days before his death, was covered with an impenetrable, yellow, thick gluten; the red portion below it being quite loose.

"In those fevers, I have also seen (says Dr Lind) the disease entirely confined to the heart and pericardium. In one who died on the tenth day of the fever, without having been yellow, a quantity of pus and purulent crusts were found mixed with the water of the pericardium. The heart in different places was excoriated; and, together with the inside of the pericardium, was lined with a thick membranous cake, similar to that already mentioned on the lungs and pleura. In some places this cake had a purulent, in others a gelatinous appearance, exactly resembling the coagulum of the blood. His complaints had been, a great oppression on the breast, and an extreme difficulty of breathing. In a third person, who died on the thirteenth day of the fever, above two quarts of pus and purulent jelly were found in the cavity of the belly. The source of such an extraordinary quantity of matter was not from any preceding inflammation, nor any imposthume, that we could discover; but from innumerable ulcerations on the surface of the intestines, omentum, mesentery, and peritoneum. Neither did those ulcerations (or excoriations, as they rather appeared in several places) seem to be the primary fountains of the matter, but to have been occasioned by its acrimony.

"This purulent appearance seems to arise merely from an extravasation of one of the component parts of the blood, the gluten or fibrine as it is now called. Blood taken from persons in a fever, and frequently even from persons in perfect health, after standing in a clean vessel for a short time, commonly separates into three distinct portions; viz. the serum, or water of the blood, the red concreted mass, and a viscid pellicle termed the fixe, which spreads itself on the top of the red concretion. Some time ago, when making experiments with the blood taken from persons in the fever, I was surprised to find it often covered with that viscid crust. This induced me to extend my experiments to large quantities of blood from different subjects, which I had opportunities of inspecting at once in so large an hospital. For this purpose I one morning ordered ten patients in the fever to be bled, taking two ounces from each. A larger quantity was taken, for its inspection, from two men in health. That day I had occasion to prescribe bleeding to a woman in labour, two hours before her delivery; to a girl of fifteen years of age afflicted with a lunacy proceeding from the chlorosis; to three patients in the rheumatism; and to a person labouring under an obstruction of the liver.

"From a nice comparison, and an examination of the blood in these cases, I found in general, that the more

(b) In others who died in this yellow state, the bile in the gall-bladder was found of a thick ropy consistence like pitch, but the liver never appeared in the least affected. Dr Lind at first in several bodies opened the head only; but afterwards judged that all the cavities ought to be inspected. more size there was on the top, and the thicker and more viscid this white pellicle showed itself, the concretion below it was of a more loose coherence. This was not so observable when only some slight white streaks appeared on the top. But when much size had separated itself, the red mass became very soft at the bottom of the vesicle, and less compact in its different parts, in proportion to their distance from the surface, towards which this whitish portion had ascended.

"From this and from other experiments it appears, that this crust or pellicle is the natural gluten which becomes strongly diffused, in certain circumstances and diseases, to separate itself. And whereas the serum and red concretion are easily incorporated together, it will be found, that this glue, after its separation, becomes immiscible with either. We have, by gentle drying, converted it into a perfectly tough elastic membrane; and, by the means of a small portion of the red mass being left adhering to it, into a substance resembling muscular flesh; and it is capable of undergoing various changes into corruption, in the same manner as either of these.

"Now, I can see no reason why this gluten, in its morbid state, may not separate itself from the circulating blood, and be deposited in the cavities of the body, as readily as the serum does in droppings; the former having always a less disposition than the latter to incorporate with the mass.

"In dissecting persons who died of fevers in London and Minorca, and where no infection was suspected, appearances similar to these have also fallen under the inspection of those accurate anatomists Drs Hunter and Cleghorn. Hence it may be prefixed very difficult to distinguish fevers that are produced by infection, from some others. I cannot, however, be induced to think, as those gentlemen seem to do, that these preternatural substances which were found in the cavities of the body are the consequence, but rather that they are the cause, of the inflammation and excoriations. I believe these substances to be at first diseased extravasated gluten, and conjecture their different states greatly to depend upon the different times at which they were deposited.

"I have remarked, in a variety of dead bodies, three different kinds of extravasation; these occurred in such as had died of the fever, of consumption, and of fevers. In the former of those diseases, red coagulated blood is found extravasated in almost all parts of the body, not only into the tela celluloa, but into the bellies of the muscles, particularly of the legs and thighs, which often become quite stuffed and even distorted with large grumous masses. The intestines and mesentery are often spotted also with extravasated blood; and I have seen large ecchymoses on the stomach. Those appearances at first sight resembled so many distinct mortifications; and by this appearance some anatomists have been deceived; but, upon a nice examination, the texture of the parts is found to be sound and firm. There is likewise, in that disease, sometimes, an extravasation of water, chiefly collected in the tela celluloa.

"But as, in the limbs of scorbutic persons, it is extremely difficult to make a good dissection by reason of such quantities of extravasated blood that everywhere obstruct the operator; so, on the contrary, the lower extremities of those who have died consumptive, with swelled legs, are, of all subjects, in the best state to afford a satisfactory view of the muscles. The water enclosed in their legs having inflamed itself, by passing the tela celluloa, into the spaces between the muscles, the muscles are easily separated from each other; and their several origins and insertions may be distinctly traced by means of their having been cleaned and washed by the water in the investing cellular membrane. Thus there are extravasations of three sorts; viz. First, The grumous mass in the scurvy; and this I have often remarked where no serum was observed. Secondly, The serum alone in anaerobic swellings. The third and last is what was taken notice of in those who died of fevers, being the gluten of the blood, accompanied for the most part with some serum; both of them altogether confined to the large cavities of the body.

"I conjecture, that in those fevers there is always an ulcerous or purulent disposition in the blood; and that the gluten is greatly diseased. I have frequently seen it have a true purulent appearance soon after it was drawn off, when the patient seemed not very ill.

"And I further conjecture, that the mischief often lies within the breast; as also that the great benefit derived from the very early application of blisters, in a great measure flows from so many ulcerations and vents being timely provided for the free discharge of those purulent and tainted particles from the body.

"If an infection depends, as many have imagined, on the admission of certain foreign particles into the blood, this gluten seems to be primarily affected by it; and a discharge of this, by washing those particles out of the body, tends in a great measure to remove that disease.

"It is an observation of the best practical writers, that ulcers and fetors are most excellent preservatives against receiving an infection, even that of the plague itself. And indeed a suppuration and plentiful discharge from a proper ulcer, whether produced by nature or by art, seems to open a channel the best appropriated for an exit out of the body to some of the most malignant poisons. Thus the most favourable crisis in the plague, and in most pestilential fevers, happens when nature excites tumors kindly suppurring in the groin or armpits, by whose beneficial and plentiful discharge the deadly poison is expelled from the constitution.

"I have observed it to be amongst the most certain characteristics of the worst fevers, that the blisters either do not rise and fill, or discharge such yellow, greenish, fetid, and highly offensive stuff, that even experienced nurses could give a pretty certain conjecture from the blisters of the different degrees of malignity in the fever. We have more than once endeavoured to conceal the bad state of some patients in the hospital; but a discovery was always made of their condition in the washhouse, from the linen sent there stained with the discharges from the blistered parts. And indeed a careful inspection of the state and discharge from the blisters, together with their effects, furnishes us, in those diseases, with some of the most certain diagnostics of their nature, and prognostics of their event."

Prognosis. This distemper, where it attacks with violence, violence, is generally fatal; the prognosis therefore must be commonly unfavourable, and always uncertain; neither can any thing more be said on this subject, than that an abatement of the symptoms already enumerated affords a favourable prognostic, and an increase of them the contrary.

Cure. The cure of this terrible disease, according to Dr Hilary, is very easy and simple. His indications are, 1. To moderate the too great and rapid motion of the fluids, and abate the too great heat and violence of the fever in the two first days of the disease, as much and as safely as we can. 2. To evacuate and carry out of the body as much of the putrid bile and other humours, and as expeditiously and safely as possible. 3. To put a stop to the putrefaction disposition of the fluids, and to prevent the gangrenes from coming on, by suitable antifeptics.

The first indication is answered by bleeding, which, in the first stage of this fever, is sometimes absolutely necessary in some degree; the quantity to be taken away must be determined by the age and strength of the patients, the degree of plethora, fulness of the pulse, &c. When called at the beginning, he orders 12, 14, 16, 18, or 20 ounces of blood to be taken away on the first or second day; and if the patient's pulse rise after the first bleeding, or if the fever still continue high and the pulse full, he repeats the bleeding once on the days above mentioned. But bleeding a third time is seldom or never required; neither is bleeding on the third day almost ever necessary; and when it is performed on that day, it ought to be done with the greatest caution and judgment: neither should a vein be opened after the third day in this fever, unless some very extraordinary symptoms and circumstances require it; which seldom or never happen. On that day, indeed, the pulse generally sinks, and the blood is in such a diffused state, that bleeding must be accounted highly pernicious. Nevertheless, it is indispensably necessary in the beginning of the distemper; and if omitted at that time, the violent heat and motion of the blood increase the putrefaction of the humours to such a degree as to bring on the fatal consequences much sooner than would otherwise have happened. If blood-letting be thus advised by Dr Hilary, it has been still more strongly recommended by Dr Rush, who, in his first publication on the subject of the dreadful yellow fever which proved so fatal at Philadelphia, represented it as an almost infallible remedy for the disease. But the observations and experience of others have by no means confirmed the practice which he recommended.

After bleeding, we come to the second indication of cure, namely, to evacuate as much of the bilious and putrid humours as soon and as safely as we can. The great irritation of the stomach, by the putrid bilious humours constantly attending this fever, with almost continual retchings and violent vomitings, seem to indicate the giving of an emetic: but the stomach is always observed to be so violently stimulated and irritated, and most commonly inflamed, by the acrimony of the putrefient bile, that any emetic, even the most mild and gentle, given in the smallest dose, brings on an incessant vomiting, which continues, in spite of all remedies, till a mortification and death ensue. Instead of this, it is proper to give large draughts of warm water, which, without any additional stimulus to the stomach, evacuates its acid and putrid contents, commonly with great relief to the patient: the warm water also acts as an emollient foment to the inflamed coats of the stomach; and thus abates the inflammation, and prevents gangrene and mortification from coming on.

After the patient has by this means vomited seven or eight times, or oftener, and discharged a great quantity of yellow and blackish bilious matter, a grain or a grain and a half of the thebaic extract is given, in order to procure some respite from the violent retching, vomiting, and anxiety. The person is desired to take nothing into his stomach for two hours after this, by which means it is seldom or never rejected; and thus all the symptoms are considerably abated, the retching and vomiting either totally cease or are very much lessened, so that medicines may now be exhibited which the stomach would not have retained before. These are cooling acid juleps, or other antifeptic remedies; but neither nitre nor any of its preparations will commonly be found to flay on the stomach, nor, according to Dr Hilary, are the nitrous medicines, or even the common antiemetic draughts, proper to be given in this disease, even though they should agree with the stomach, on account of their attenuating property.

If the patient has not a stool or two after drinking the warm water and vomiting, it is necessary to give a gentle purging clyster; and when fix or eight hours rest have been obtained, a gentle antiphlogistic and antifeptic purge, in order to evacuate by stool as much of the bilious matter as we possibly can. Or if the patient has a purging before, which sometimes though very rarely happens, a dose of toasted rhubarb is given, and an antifeptic anodyne after it has operated, to abate and check the too great purging, but not to stop it, as this evacuation has been always observed to be of service, provided it be not very violent.

After this indication is completely answered, the next is to exhibit such proper antifeptic medicines as may stop the putrefactive disposition of the fluids. Here the cinchona would seem to be the most proper remedy; but unluckily the stomachs of the patients in this disease are so much irritated, and fo apt to reject every thing, that it cannot be retained in any form whatever. In this case Dr Percival recommends columbo root, the infusion of which is found to be a powerful antiemetic and antiputrefective medicine, and might perhaps go far alter the state of the stomach as to make it bear the bark. Dr Hilary, however, who was ignorant of the virtues of columbo, substituted the radix serpentinæ Virginianæ with succus. A slight infusion of this root not only fat easily on the stomach of the patients, but moderately raised the pulse and fever, both of which are now too low. The following receipt was found the most agreeable and efficacious:

R. Rad. serpentin. Virginian. 5ij. Croc. Ang. 3 fs. M. et infunde vafe claufo in aq. bul. q. per horam unam ut col. 3vj. Adde aq. menth. simp. 3ij. Vin. Maderienf. 3iv. Syr. croc. vel syr. è mecon. 3i. Elix. vitriol. acid. q. f. ad grat. acid. sap. Exhibe cochlearia duo vel tria singulis horis vel bhoris, vel fieprio pro re nata.

By the use of this medicine, and soft light nourishment taken in small quantities, the pulse is usually kept up and the distemper goes off. But if, after taking this a little while, we find that the pulse does not rise, but on the contrary that a coldness of the extreme parts comes on, the medicines must be made more warming, by increasing the quantity of the snakeroot and saffron, or by adding vinum croceum, confectio carduca, or the like, but not by the use of volatile spirits and salts, which hurt by their stimulating and dissolving qualities. Blisters Dr Hilary reprobates in the strongest terms, and affirms that he has seen the place where a blister was applied turned perfectly black and sphacelated; so that if the spine and end of the ribs had not hindered, a large square passage would have been opened into the cavity of the thorax, had the patient lived a few hours after it.

At the same time that the strength of the patient is kept up by the medicines above mentioned, or by others similar, he gave repeated gentle purgatives every second or third day, and sometimes, when the symptoms were very urgent, every day, for four or five days successively. But if proper methods be taken in the beginning of the disease, it is seldom that such a repetition of purging is necessary.

Dr Hilary's plan of treating the yellow fever is, in our opinion, as judicious as any that has yet been proposed. But, among the late writers, some have recommended mercury, particularly under the form of calomel, as the most efficacious remedy which can be employed. In some cases it has certainly been given to an almost incredible extent, in a very short time, without exciting either purging or salivation. And it cannot be denied, that patients have not unfrequently recovered under the use of it. But calomel can no more be reckoned an infallible remedy for this disease than blood-letting.

Since the introduction of cold affusion, in the cure of typhus fevers, by Dr Currie, it has been imagined by some, that this practice would afford a very efficacious remedy in the typhus idiocides, as well as in the typhus mitior. But experience has not yet confirmed the utility of this practice.

Some have suggested the internal use of the oxygenated muriatic acid, properly diluted, as an article from which great benefit may be expected in the yellow fever. This practice deserves, we think, a fair trial: but the utility of it still remains to be determined by experience.

To the genus of typhus also belong all those fevers attended with very profuse and debilitating sweats, and which have sometimes, not without good reason, been accounted plagues; such as the English sweating-sickness, Miliaris sudatoria, Sauv. sp. 5. Ephemeris sudatoria, Sauv. sp. 7. Ephemeris Britannica, Caius de ephem. Britan.

GENUS VI. SYNOCCHUS.

Synochus, Sauv. gen. 81. Lin. 13. Lenta, Lin. 14. Phrenitis, Vog. 18. Febris continua putrida, Boerh. 730.

This is a contagious distemper, being a complication of a synocha and typhus; for the description and cure of which, we must of consequence refer to what hath been already said concerning these diseases.

The Heptic Fever.

Heistica, Sauv. gen. 83. Lin. 24. Vog. 80. Sag. 684.

This disease is reckoned by Dr Cullen to be merely symptomatic; as indeed seems very probable, since it generally accompanies absorption of pus into the blood from internal suppurations, or indeed from such as are external, provided they be very large or of a bad kind.

Description. The best, perhaps the only proper, description of this disorder we have is that by Dr Heberden. According to him, the appearance of the hectic fever is not unlike that of the genuine intermittent; from which, however, the disease is very different in its nature, while at the same time it is much more dangerous. In the true intermittent, the three stages of cold, heat, and sweat, are far more distinctly marked, the whole fit is much longer, the period which it observes is more confluent and regular, and the intermissions are more perfect, than in the hectic fever. For in the latter, even during the clearest remission, there is usually a feverish quickness perceptible in the pulse, which seldom fails to exceed the utmost limit of a healthy one by at least 10 strokes in a minute.

The chills of the hectic fever is sometimes succeeded by heat, and sometimes immediately by a sweat without any intermediate state of heat. The heat will sometimes come on without any remarkable chills preceding; and the chills has been observed to go off without being followed either by heat or sweat. The duration of these stages is seldom the same for three fits together; and as it is not uncommon for one of them to be wanting, the length of the whole fit must vary much more than in the true intermittent; but in general it is much shorter.

A patient subjected to hectic fever is little or nothing relieved by the occurrence of the sweat; but is often as anxious and restless under it as during the chills or heat. When the sweat is over, the fever will sometimes continue; and in the middle of the fever the chills will return; which is a most certain mark of this disease.

The hectic fever will return with great exactness, like an intermittent, for two or perhaps three fits; but Dr Heberden informs us, that he does not remember ever to have known it keep the same period for four fits successively. The paroxysm will now and then keep off for 10 or 12 days; and at other times, especially when the patient is very ill, it will return so frequently on the same day, that the chills of a new fit will follow immediately the sweat of the former. It is not unuseful to have many threatenings of a shivering in the same day; and some degree of drowsiness is apt to attend the cessation of a fit.

The urine in a true intermittent is clear during the fits and turbid during the intervals; but in the hectic fever it is liable to all kinds of irregularity. It will be equally clear or turbid in both stages; or turbid in the fits and clear in the intervals; and sometimes it will be, as in a true intermittent, clear during the fever, and thick at the going off.

Hectic patients often complain of pains like those of the rheumatism, which either affect by turns almost every part of the body, or else return constantly to the same part; which is often at a great distance from the seat of the principal disorder, and, as far as is known, without any peculiar connection with it. Those pains are so violent in some patients, as to require a large quantity of opium. As far as Dr Heberden has observed, they are most common where the hectic arises from some ulcer open to the external air, as in cancers of the face, breast, &c. Joined with this fever, and arising probably from one common cause, he has been surprised to see swellings of the limbs, neck, or trunk of the body, rise up almost in an instant, as if the part was all at once grown fatter. These swellings are not painful, hard, or discoloured, and they continue for several hours.

Dr Heberden has seen this fever attack those who seemed in tolerable health, in a sudden and violent manner, like a common inflammatory one; and like that, also, in a very short time bring them into imminent danger of their lives; after which it has begun to abate, and to afford hopes of a perfect recovery. But though the danger might be over for the present, and but little of a fever remain; yet that little has soon demonstrated, that it was kept up by some great mischief within, and, proving unconquerable by any remedies, has gradually undermined the health of the patient, and never ceased except with his life. This manner of its beginning, however, is a rare occurrence. It much oftener diffembles its strength at first; and creeps on so slowly, that the subjects of it, though they be not perfectly well, yet for some months hardly think themselves ill; complaining only of being sooner tired with exercise than usual, of want of appetite, and of falling away. But gentle as the symptoms may seem, if the pulse be quicker than ordinary, so as to have the artery to beat 90 times and perhaps 120 times in a minute, there is the greatest reason to be apprehensive of the event. In no disorder, perhaps, is the pulse of more use to guide our judgment than in the hectic fever; yet even here we must be upon our guard, and not trust entirely to this criterion; for one in about twenty patients, with all the worst signs of decay from some incurable cause, which irresistibly goes on to destroy his life, will show not the smallest degree of quickness, nor any other irregularity of the pulse, to the day of his death.

Causes, &c. This fever will supervene whenever there is a great collection of matter formed in any part of the body; but it more particularly attends upon the inflammation of a scirrhou gland, and even upon one that is slight and only just beginning; the fever growing worse in proportion as the gland becomes more inflamed, ulcerated, or gangrenous. And such is the lingering nature of those glandular disorders, that the first of those stages will continue for many months, and the second for some years.

If this scirrhou inflammation be external, or in the lungs, or some of the abdominal viscera, where the disturbance of their functions plainly points out the seat of the disorder, no doubt can be entertained concerning the cause of the fever. But if the part affected be not obvious to the senses, and its precise functions be not known, the hectic, which is there only part of the train of another disease, may be mistaken for the primary or only affection.

Lying-in-women, on account of the violence sustained in delivery, generally die when affected with this fever. Women of the age of near 50 and upwards are particularly liable to it. For, upon the cessation of their natural discharge, the glands of the breasts, ovaries, or womb, too commonly begin to grow scirrhous, and proceed to be cancerous. Not only these, but the glandular parts of all the abdominal viscera, are disposed to be affected at this particular time, and to become the seats of incurable disorders.

The injuries done to the stomach and liver by hard drinking are attended with similar symptoms, and terminate in the same manner.

Dr Heberden observes, that the slightest wound by a fine-pointed instrument is known upon some occasions to bring on the greatest disturbances, and the most alarming symptoms, nay even death itself. For not only the wounded part will swell and be painful, but by turns almost every part of the body; and very distant parts have been known to come even to suppuration. These symptoms are constantly accompanied with this irregular intermittent, which lasts as long as any of them remain.

Prognosis. This anomalous fever is never less dangerous than when it originates from a kindly suppuration, into which all the diseased parts are melted down, and for which there is a proper outlet.

The symptoms and danger from some small punctures, with their concomitant fever, most frequently give way in a few days; though in some persons they have continued for two or three months, and in others have proved fatal.

The inflammation of internal scirrhou glands, or of those in the breasts, sometimes goes off, and the fever, which depended upon it, ceases; but it much oftener happens, that it proceeds to cancerous and gangrenous ulcers, and terminates only in death. Death is also, almost universally, the consequence of hectic fever from tubercles of the lungs, which have in general at least been considered as glandular bodies in a scirrhou state.

Cure. It is not to be expected that the same remedies will in every case be adapted to a fever which, arising from very different causes, is attended with such a variety of symptoms. A mixture of affectifida and opium has in some persons seemed singularly serviceable in this fever, when brought on by a small wound; but in most other cases the principal if not the sole attention of the physician must be employed in relieving the symptoms, by tempering the heat, by preventing both coliciveness and purging, by procuring sleep, and by checking the sweats. If, at the same time, continues Dr Heberden, he put the body into as good general health as may be, by air, exercise, and a proper course of mild diet, he can perhaps do nothing better than to leave all the rest to nature. In some few fortunate patients, nature appears to have such resources, as may afford reason for entertaining hopes of cure, even in very bad cases. For some have recovered from this fever attended with every symptom of an abdominal viscera incurably diseased, after all probable methods of relief from art had been tried in vain, and after the flesh and strength were so exhausted as to leave scarce any hopes from nature. In those deplora- ble circumstances, there has arisen a swelling not far from the probable seat of the disorder, and yet without any discoverable communication with it. This swelling has come to an abscess; in consequence of which the pulse has soon returned to its natural state, as have also the appetite, flesh, and strength. What nature has performed in those rare cases, Dr Heberden acquaints us, he has often endeavoured to imitate, by making blisters or applying blisters near the seat of the disease; but he cannot say with the same success.

It seems at present, Dr Heberden observes, to be the opinion of many practitioners, that gangrenes will be stopped, and suppuration become more kindly, by the use of Peruvian bark; and therefore this remedy is always either advised or permitted in the irregular fever joined with suppurations and gangrenes. But he affirms he does not remember ever to have seen any good effect from cinchona in this fever unattended with an apparent ulcer; and even in gangrenes it often fails, that in successful cases, where it has been administered, there must be room for suspicion that the success was owing to another cause. Dr Heberden acknowledges, at the same time, that he never saw any harm from cinchona, in these, or indeed in any other cases, except a slight temporary purging or sickness, where it has happened to disagree with the stomach, or where the latter has been loaded by taking the medicine too fast, especially in dry boluses wrapped in wafer-paper.

In hectic illnesses, where all other means have proved ineffectual, a journey to Bath is usually proposed by the friends, and wished for by the sick; but Dr Heberden justly observes, that, besides the fatigue and many inconveniences of a journey to a dying person, the Bath waters are peculiarly hurtful in this fever, which they never fail to increase, and thereby aggravate the sufferings and hasten the death of the patient.

ORDER II. PHLEGMASIAE.

Phlegmasiae membranofae et parenchymatofae, Sauv. Clas III. Ord. I. II. Sog. 65. Morbi febriiles phlogitici, Lin. Clas III. Febres continue compositae inflammatoriae, Vog. Morbi acuti febriiles, Boerh. 770. Febres inflammatoriae, Hoffm. II. 105. Junck. 61.

The phlegmasiae, or topical inflammations, are a very numerous assemblage of diseases. Their great characteristics are, the general symptoms of fever, and a topical inflammation, attended with the lesion of some important function. In most instances, when blood is drawn, it is found upon coagulation to be covered with a buffy coat. Under this order, many important genera are comprehended, each requiring a separate consideration.

GENUS VII. PHLOGOSIS.

Sp. I. PHLOGOSIS PHLEGMONE.

Phlegmone austorum, Sauv. gen. 15. Lin. 39. Vog. 351. Inflammatio, Lin. 231. Boerh. 370. Junck. 20.

This disease is a synoche fever, accompanied with an inflammation of some particular part either external or internal, and consequently it varies very much in its form and the degree of danger attending it, according to the situation and functions of the part affected with topical inflammation. To this species, therefore, belong the following diseases:

Furunculus, Sauv. gen. 18. Vog. 352. Tereminthus, Vog. 381. Pupula, Lin. 275. Sauv. p. 6. Varus, Vog. 436. Lin. 269. Sauv. p. 7. Bacchia, Lin. 270. Gutta rosea, Sauv. gen. 4. Gutta rofacea, Vog. 437. Hordolum, Sauv. gen. 27. Lin. 276. Vog. 434. Otalgia, Sauv. gen. 197. Lin. 44. Vog. 148. Dolor otalgicus, Hoffm. II. 336. Parulis, Vog. 362. Maftodynia, Sauv. gen. 210. Vog. 153. Paronychia, Sauv. gen. 21. Lin. 258. Vog. 343. Arthrocae, Sauv. gen. 78. Lin. 256. Pedarthrocae, Vog. 419. Spina ventosa, Beerh. 526. Phimosis, Sauv. gen. 22. Lin. 297. Vog. 348. Paraphimosis, Vog. 349.

For the cure of inflammations, Dr Cullen lays down the following indications. 1. To remove the remote causes when they are evident and continue to operate. 2. To take off the phlogistic diathesis affecting the whole system, or the particular part. 3. To take off the spasm of the particular part, by remedies applied to the whole system, or to the part itself.

The means of removing the remote causes will readily occur, from considering the particular nature and circumstances of the different kinds. Acid matters must be removed, or their action must be prevented, by the application of demulcents. Compressing and overstretching powers must be taken away; and from their several circumstances, the means of doing so will be obvious.

The means of taking off the phlogistic diathesis of the system are the same with those already mentioned under the cure for synoche. The means of taking off the spasm also from the particular part, are much the same with those already mentioned. Only it is to be remembered, that topical bleedings, such as cupping with scarifications, applying leeches, &c. are in this case much more indicated; and that some of the other remedies are to be directed more particularly to the part affected, as shall be more fully considered when we treat of those diseases attended with particular inflammations.

When a tendency to suppuration is perceived, the proper indication is to promote the production of perfect pus as much as possible. For this purpose various remedies, supposed to possess a specific power, have been proposed: but it does not appear that any of them are possessed of a virtue of this kind; and, in Dr Cullen's opinion, all that can be done is to favour the suppuration by such applications as may support a moderate heat in the part, by some tenacity confine the periphraxis, and by an emollient quality may weaken the cohesion of the teguments, and favour their erosion. As all abscesses are occasioned by the effusion of fluids, and as in the case of certain effusions a suppuration be- comes not only unavoidable but desirable, it may be supposed that most of the means of procuring a resolution, by diminishing the force of circulation, &c. ought to be avoided. But as we observe on the one hand, that a certain degree of increased impetus, or of the original symptoms of inflammation, is necessary to produce a proper suppuration; so it is then especially necessary to avoid those means of resolution which may diminish too much the force of circulation. And on the other hand, as the impetus of the blood, when violent, is found to prevent the proper suppuration; so, in such cases, though a tendency to suppuration may have begun, it may be proper to continue those means of resolution which moderate the force of the circulation. With respect to the opening of abscesses when completely formed, see the article SURGERY.

When an inflammation has taken a tendency to gangrene, that event is to be prevented by every possible means; and these must be different according to the nature of the several causes: but after a gangrene has in some degree taken place, it can be cured only by the separation of the dead from the living parts. This in certain circumstances can be performed, and most properly, by the knife. In other cases it can be done by exciting a suppuratory inflammation on the verge of the living part, whereby its cohesion with the dead part may be everywhere broken off, so that the latter may fall off by itself. While this is doing, it is proper to prevent the further putrefaction of the part, and its spreading wider. For this purpose various antiseptic applications have been proposed: but Dr Cullen is of opinion, that while the teguments are entire, these applications can hardly have any effect; and therefore that the fundamental procedure must be to scarify the part so as to reach the living substance, and, by the wounds made there, to excite the suppuration required. By the same incisions also we give access to antiseptics, which may both prevent the progress of the putrefaction in the dead, and excite the inflammation necessary on the verge of the living parts.

When the gangrene proceeds from loss of tone, and when this, communicated to the neighbouring parts, prevents that inflammation which, as we have said, is requisite to the separation of the dead parts from the living, it will be necessary to obviate this loss of tone by tonic medicines given internally; and for this purpose cinchona has been found to be most effectual. But when the gangrene arises from the violence of inflammation, the bark may not only fail of proving a remedy, but may do harm: for its power as a tonic is especially suited to those cases of gangrene which proceed from an original loss of tone, as in the case of palsy and edema; or in those cases where a loss of tone takes place after the original inflammatory symptoms are removed.

On the other hand, Mr Bell is of opinion, that incisions made with a view to admit the operation of antiseptic remedies in gangrenes, as well as the remedies themselves, must be pernicious from the irritation they occasion, and from the danger of wounding blood-vessels, nerves, or tendons, and also by allowing a free passage for the putrefied fluids into the parts not yet affected. And unless they be carried so deep as to reach the sound parts, applications of the antiseptic kind can never have any effect in answering the purpose for which they were intended. The same author Phlogos. also remarks, that all the advantages commonly observed from the great number of applications recommended for gangrene, are obtained with more ease, and generally too with more certainty, from the use of some gentle stimulating embrocation; which, by exciting a slight irritation upon the surface, especially when assisted by a free use of cinchona, produces for the most part such a degree of inflammation as is wished for. With this view he has frequently known a weak solution of sal ammoniac, a dram of the salt to two ounces of vinegar and fix of water, form a mixture of very proper strength for every purpose of this kind. But the degree of stimulus can easily be either increased or diminished according to circumstances, by using a larger or smaller proportion of the salt.

Whenever, either by the means recommended, or by a natural exertion of the system, a slight inflammation appears between the diseased and sound parts, we may in general, with tolerable certainty, expect, that in due time the parts will be separated; and when a full suppuration is once fairly established, there can be little doubt that the mortified parts will be soon and easily removed.

A complete separation being effected, the sore is to be treated in the manner described under the article SURGERY; with a proper attention, at the same time, to the support of the general system by the continuance of nourishing diet, and cinchona with such quantities of wine as may seem necessary.

With regard to the bark, however, it is proper to take notice of another case of mortification in which it is likewise unsuccessful, as well as in that attended with a high degree of inflammation; and that is, in those mortifications of the toes and feet, common in old people, or which arise from any cause increasing the rigidity of the vessels to such a degree as to prevent the motion of the fluids through them. In this case Mr Pott has discovered, that all kinds of warm applications are very unsuccessful; but by the free use of opium, together with sedatives and relaxants externally applied, he has frequently seen the tumefaction of the feet and ankles subside, the skin recover its natural colour, and all the mortified parts separate in a very short time, leaving a clean sore. But as to scarifications, or any other attempt to separate artificially the mortified from the sound parts, he thinks them very prejudicial, by giving pain; which is generally of itself violent in this disease, and which seems to have a great share in producing the other evils.

The other terminations of inflammation either do not admit of any treatment except that of preventing them by resolution, or properly belong to the article SURGERY.

Sp. II. PHLOGOSIS ERYTHEMA.

Erythema, Sauv. gen. 11. Eryfielas auctorum, Vog. 343. Hieropyr. Vog. 344. Anthrax, Sauv. gen. 19. Lin. 272. Vog. 353. Carbo et carbunculus auctorum. Erythema gangrenosum, Sauv. sp. 7. Erythema à frigore. Erythema pernio, Sauv. sp. 4. Pernio, Lin. 259. Vog. 350. Erythema ambusio, Sauv. sp. 2. Eryfipelas ambusio, Sauv. sp. 4. Combustura, Lin. 245. Combustio, Boerh. 476. Encaufis, Vog. 347. Erythema ab acri alieno applicato. Eryfipelas Sinene, Sauv. sp. 7. Erythema ab acri inquilino. Erythema intertrigo, Sauv. sp. 5. Intertrigo, Lan. 247. Vog. 502. Erythema a compresione. Erythema paratrima, Sauv. sp. 6. Erythema à punctura, Sauv. sp. 9. Eryfipelas à vefpis, Sauv. sp. 19. Pfydracia à vefpis, Sauv. sp. 2. Erythema cum phlegmone. Eryfipelas phlegmonodes auctorum. Erythema cum oedemate. Eryfipelas symptomaticum, Sauv. sp. 6.

The word erythema does not apply to any primary disease, but to a great number of those cutaneous inflammations denominated by another general term, viz. the eryfipelas, or "St Anthony's fire;" and which being commonly symptomatic of some other inflammation or disorder, are to be removed only by removing the primary disease; the erythema is found scarcely to bear any kind of warm application to itself; and is very apt, if treated as a primary disease, to terminate in a gangrene of the part affected, or some other disorder still more dangerous. The difference between the phlegmone or preceding species, and erythema, according to Dr Cullen, is, that, in the former, the inflammation seems particularly to affect the vessels on the internal surface of the skin, communicating with the lax adjacent cellular texture; whence a more copious effusion, and that too of serum convertible into pus, takes place. In the erythema the affection is of the vessels on the external surface of the skin communicating with the rete mucosum. This affection does not admit of any effusion but what separates the cuticle, and gives occasion to the formation of a blister, while the smaller size of the vessels admits only of the effusion of a thin fluid very seldom convertible into pus. For the cure of the fever attended with erythema or eryfipelas, see below; and for the external treatment of erythema, see SURGERY.

GENUS VIII. OPHTALMIA.

Inflammation of the EYES.

Ophthalmia, Sauv. gen. 196. Lin. 43. Vog. 341. Sag. 231. Junck. 24. Chemosis, Vog. 46. Ophthalmites, Vog. 47. Inflammatio oculorum, Hoffm. II. 165. Ophthalmia taraxis, Sauv. sp. 1. Ophthalmia humida, Sauv. sp. 8. Ophthalmia chemofis, Sauv. sp. 12. Ophthalmia cryfipelata, Sauv. sp. 7. Ophthalmia tuberculosa, Sauv. sp. 6. Ophthalmia phlyctenodes, Sauv. sp. 21. Ophthalmia choreoidea, Sauv. sp. 13. Ophthalmia tenebricosa, Sauv. sp. 10. Ophthalmia trachoma, Sauv. sp. 4. Ophthalmia ficca, Sauv. sp. 5. Ophthalmia angularis, Sauv. sp. 14. Ophthalmia tuberculosa, Sauv. sp. 3. Ophthalmia trichiasis, Sauv. sp. 2. Ophthalmia cancrofa, Sauv. sp. 15. Ophthalmia à fyncehia, Sauv. sp. 16. Ophthalmia à lagophthalmo, Sauv. sp. 17. Ophthalmia ab elcomate, Sauv. sp. 18. Ophthalmia ab ungue, Sauv. sp. 19. Ophthalmia à cornee fistula, Sauv. sp. 20. Ophthalmia uveae, Sauv. sp. 22. Ophthalmia metaftatica, Sauv. sp. 24. Ophthalmia scrophulosa, Sauv. sp. 9. Ophthalmia siphilitica, Sauv. sp. 11. Ophthalmia febricosa, Sauv. sp. 23.

From reading this long list of distinctions which authors have invented in the ophthalmia, it is evident, that by far the greatest part of them are symptomatic, or merely the consequence of other disorders present in the habit; and therefore the remedies must be directed towards the removal of these primary disorders; and when they are gone the ophthalmia will be removed of course. Dr Cullen observes, that the inflammation of the eye may be considered as of two kinds; according as it is seated in the membranes of the ball of the eye, when it is named ophthalmia membranarum; or as it is seated in the sebaceous glands placed in the tarbus, or edges of the eyelids, in which case it may be termed ophthalmia tarbi. These two kinds are very frequently connected together, as the one may excite the other; but they are still to be distinguished according as the one or the other may happen to be the primary affection.

1. The inflammation of the membranes of the eye affects especially, and most frequently, the adnata, and appears in a turgescence of its vessels; so that the red vessels which are naturally there, become not only increased in size, but many more appear than in a natural state. This turgescence of the vessels is attended with pain, especially upon the motion of the ball of the eye; and this irritation, like every other, applied to the surface of the eye, produces an effusion of tears from the lachrymal gland.

The inflammation commonly, and chiefly, affects the adnata spread on the anterior part of the bulb of the eye; but usually spreads also along the continuation of the adnata on the inside of the palpebrae; and as that is extended on the tarbus palpebrarium, the excretories of the sebaceous glands opening there are also frequently affected. When the affection of the adnata is considerable, it may be communicated to the subjacent membranes of the eye, and even to the retina itself; which thereby acquires so great sensibility, that every impression of light becomes painful. The inflammation of the membranes of the eye is in different degrees, according as the adnata is more or less affected, or according as the inflammation is either of the adnata alone, or of the subjacent membranes also; and upon these differences, different species have been established; but they seem all to differ only in degree, and are to be cured by the same remedies more or less employed.

The proximate cause of ophthalmia is not different from that of inflammation in general; and the different circumstances of ophthalmia may be explained by Practice.

by the difference of its remote causes, and by the different parts of the eye which it happens to affect; as may be understood from what has been already said. We shall therefore proceed to give an account of the method of cure.

The great objects to be aimed at in the treatment of ophthalmia, are, in the first place, the resolution of the inflammation which has already taken place; and, secondly, the removal of those consequences which frequently arise from the inflammation, especially if it have been of long standing. But besides these, while it has appeared from former observation, that there is a peculiar disposition to the disease, practices may often be successfully employed to combat this disposition, and thus prevent the return of the affection.

The ophthalmia membranarum requires the remedies proper for inflammation in general; and when the deeper-located membranes are affected, and especially when a pyrexia is present, large general bleedings may be necessary. But this last is seldom requisite, and, for the most part, the ophthalmia is an affection merely local, accompanied with little or no pyrexia. General bleedings therefore have little effect upon it, and the cure is chiefly to be obtained by topical bleeding, that is, blood drawn from the vessels near the inflamed part; and opening the jugular vein, or the temporal artery, may be considered as in some measure of this kind. It is commonly sufficient to apply a number of leeches round the eye; but it is perhaps still better to draw blood by cupping and scarifying from the temples. In many cases, the most effectual remedy is to scarify the internal surface of the inferior eyelid, and to cut the turgid vessels upon the adnata itself.

Besides bloodletting, purging, as a remedy suited to inflammation in general, has been considered as peculiarly adapted to inflammation in any part of the head, and therefore to ophthalmia; and it is sometimes useful: but, for the reasons given before with respect to general bleeding, purging in the case of ophthalmia does not prove useful in any proportion to the evacuation excited.—For relaxing the spasm in the part, and taking off the determination of the fluids to it, blistering near the part has commonly been found useful. When the inflammation does not yield to the application of blisters after topical bleeding, great benefit is often obtained by supporting a discharge from the blistered part, under the form of an iuflis, by which means a more permanent determination of blood from the part is obtained.

It is probably also on the same principle that the good effects obtained from the use of erthine medicines in obstinate cases of ophthalmia are to be accounted for. By these erthines, in particular, which occasion and support for some time a great discharge from the nose, great benefit has often been obtained. The powder of afarabacca, or the infusion of hippocastanum, sniffed up the nose at bedtime in proper doses, are often productive of the best effects, when many other remedies have been tried in vain.

Ophthalmia, as an external inflammation, admits of topical applications. All those, however, which increase the heat and relax the vessels of the part, prove hurtful; and the admixture of cool air to the eye, and the application of cooling and astringent medicines, which at the same time do not produce irritation, prove useful. Of all these the solution of acetite of lead, assiduously applied, is perhaps the best. In the cure of this distemper, indeed, all irritation must carefully be avoided, particularly that of light; and the only certain means of doing this is by keeping the patient in a very dark chamber.

2. In the ophthalmia tarfi, the same medicines may be necessary, as have been already recommended for the ophthalmia membranarum. However, as the ophthalmia tarfi may often depend upon an acrimony deposited in the sebaceous glands of the part, so it may require various internal remedies according to the variety of the acrimony in fault; for which we must refer to the consideration of scrophula, phthisis, or other diseases with which this ophthalmia may be connected; and where these shall not be evident, certain remedies more generally adapted to the evacuation of acrimony, such as mercury, may be employed. In the ophthalmia tarfi, it almost constantly happens that some ulcerations are formed on the tarlus. These require the application of mercury and copper, which alone may sometimes cure the whole affection; and they may be useful even when the disease depends upon a fault of the whole system.

Both in the ophthalmia membranarum, and in the ophthalmia tarfi, it is necessary to obviate that gluing together of the eyelids which commonly happens in sleep; and which may be done by infusing a little of any mild unctuous medicine between the eyelids before the patient shall go to sleep.

The lighter kinds of inflammations from the dust or the fun, may be removed by fomenting with warm milk and water, adding a small portion of brandy; and by anointing the borders of the eyelids with unguentum tinctae, or the like, at night, especially when those parts are excoriated and sore. But in bad cases, after the inflammation has yielded a little to evacuations, the catapla/ma aluminis of the London Pharmacopeia spread on lint, and applied at bedtime, has been found the best external remedy. Before the use of the latter, the solution of sulphate of zinc is preferred with advantage; and in violent pains it is of service to foment frequently with a decoction of white poppy-heads. One of the most common and most disagreeable consequences of ophthalmia, is an effusion of the cornea, so far obstructing the passage of light as to diminish or prevent vision. This is sometimes so considerable as to admit of removal by operation: but in lighter cases it may often be removed by the application of different gentle echarotics; and in this way, without the least danger of any inconvenience, good effects are often obtained, from gently introducing into the eye at bedtime a powder consisting of equal parts of supertartarite of potas and sugar, reduced together to a fine powder.

Where there is a disposition to frequent returns of this affection, cinchona is often employed with success in combating it: But nothing in general answers better than frequent and regular cold bathing of the eyes.

Besides the various species of ophthalmia which were before known in Britain, another has lately been introduced, that contagious ophthalmia, viz. with which the British troops were affected in Egypt, and which they have imported into this island on their return from thence.

Of this affection many interesting accounts have been published. Perhaps the best is an elaborate treatise by Mr Edmonston, who has had many opportunities of witnessing the affection, and extensive practice in the treatment of the disease, both in Egypt and in Britain. To his work therefore we may refer those who wish for the most full information respecting it. We shall only observe, that now, no doubt can be entertained respecting the contagious nature of the disease; and that therefore the first great object necessary in the treatment is the complete separation of the diseased from the found.

GENUS IX. PHRENITIS.

PHRENSY, or Inflammation of the BRAIN.

Phrenitis, Sauv. gen. 101. Lin. 25. Sag. gen. 301. Boerh. 771. Hoffm. II. 131. Junck. 63. Phrenismus, Vog. 45. Cephalitis, Sauv. gen. 109. Sag. gen. 310. Sphacelilimus, Lin. 32. Phrenitis vera, Sauv. fp. 1. Boerh. 771. Phrenitis idiopathica, Junck. 63. Cephalalgia inflammatoria, Sauv. fp. 9. Cephalitis spontanea, Sauv. fp. 3. Cephalitis fibralis, Sauv. fp. 4. Siriasis, Vog. 34; Cephalitis Litturana, Sauv. fp. 5.

Dr Cullen observes, that the true phrenitis, or inflammation of the membranes or substance of the brain, is very rare as an original disease: but, as a symptom of others, much more frequent; of which the following kinds are enumerated by different authors:

Phrenitis synochi pleuritica, Sauv. fp. 2. Phrenitis synochi tanguinea, Sauv. fp. 4. Phrenitis calentura, Sauv. fp. 11. Phrenitis Indica, Sauv. fp. 12. Cephalitis Ægyptiaca, Sauv. fp. 1. Cephalitis epidemica anno 1510, Sauv. fp. 6. Cephalitis vermallosa, Sauv. fp. 7. Cephalitis cerebella, Sauv. fp. 8. Phrenitis miliaris, Sauv. fp. 3. Phrenitis variolosa, Sauv. fp. 5. Phrenitis morbillosa, Sauv. fp. 6. Phrenitis à plicá, Sauv. fp. 8. Phrenitis aphrophilica, Sauv. fp. 9. Phrenitis à tarantismo, Sauv. fp. 14. Phrenitis hydrophobia, Sauv. fp. 15. Phrenitis à dolore, Sauv. fp. 13. Cephalitis traumatica, Sauv. fp. 2.

Description. The signs of an impending phrenitis are, immoderate and continual watchings; or if any sleep be obtained, it is disturbed with dreams, and gives no refreshment; acute and lasting pains, especially in the hind part of the head and neck; little thirst; a great and flow repiration, as if proceeding from the bottom of the breast; the pulse sometimes small and flow, sometimes quick and frequent; a suppression of urine; and forgetfulness. The distemper when present may be know by the following signs:

The veins of the head swell, and the temporal arteries Phrenitis, throb much; the eyes are fixed, sparkle, and have a fierce aspect; the speech is incoherent, and the patient behaves very roughly to the bystanders, with furious attempts to get out of bed, not indeed continually, but returning as it were by paroxysms; the tongue is dry, rough, yellow, or black; there is a coldness of the external parts; a proneness to anger; chattering of the teeth; a trembling of the hands, with which the sick seem to be gathering something, and actually do gather the naps off the bed-clothes.

Causes of, and persons subject to, this disorder. People of a hot and biliary habit of body, and such as are of a paffionate disposition, are apt to be affected with phrenitis. In the same danger are those who make much use of spices, or are given to hot and spirituous liquors; who have been exposed more than usual to the sun, or obliged to undergo inmoderate studies or watchings; who are subject to headaches, or in whom some cutaneous hemorrhages have been stopped; or the disease may arise from some injury offered to the head externally. Sir John Pringle observes, that the phrenitis, when considered as an original disease, is apt to attack soldiers in the summer season when they are exposed to the heat of the sun, and especially when asleep and in liquor. A symptomatic phrenitis is also more frequent in the army than elsewhere, on account of the violence done to all fevers when the sick are carried in waggons from the camp to the hospital, where the very noise or light alone would be sufficient, with more delicate natures, to raise a phreny. From these and similar causes, a state of active inflammation, affecting some parts within the cranium, is produced: and there can be no doubt, that from this all the symptoms of the disease arise, and particularly that peculiar delirium which characterizes it. But in what manner local diseases, even of the brain itself, produce affections of the mind, we are still totally in the dark.

Prognosis. Every kind of phrenitis, whether idiopathic or symptomatic, is attended with a high degree of danger; and, unless removed before the fourth day, a gangrene or sphacelus of the meninges readily takes place, and the patient dies delirious. The following are the most fatal symptoms: A continual and furious delirium, with watching; thin watery urine, white faeces, the urine and stools running off involuntarily, or a total suppression of these excretions; a ready disposition to become stupid, or to faint; trembling, rigor, chattering of the teeth, convulsions, hicough, coldness of the extremities, trembling of the tongue, shrill voice, a sudden cessation of pain, with apparent tranquility. The following are favourable: Sweats, apparently critical, breaking out; a freeing effort of nature to terminate the disease by a diarrhoea; a large hemorrhagy from the nose; swellings of the glands behind the ears; hemorrhoids.

Cure. From what has been said of the theory of this disease, the cure must entirely depend on obtaining a resolution of the inflammation. The objects chiefly to be aimed at with this view are, 1. The removal of such exciting causes as continue to operate. 2. The diminution of the momentum of the blood in the circulating system in general. 3. The diminution of impetus at the brain in particular: and, 4. The avoiding ing circumstances which tend either to accelerate the motion of the blood or to give determination to the head.

Different practices may be used with these intentions; but the most powerful remedies are to be immediately employed. Large and repeated bleedings are especially necessary; and these too taken from veffels as near as possible to the part affected. The opening the temporal artery has been recommended, and with some reason; but as the practice is attended with inconveniences, perhaps the opening of the jugular veins may in general prove more effectual; with which, however, may be joined the drawing of blood from the temples by cupping and fearifying. It is also probable, that purging may be of more use in this than in some other inflammatory affections, as it may operate by revulsion. For the same purpose of revulsion, warm pediluvia are a remedy, but rather ambiguous. The taking off the force of the blood in the veffels of the head by an erect posture is generally useful. Blistering is also useful, but chiefly when applied near to the part affected. In short, every part of the antiphlogistic regimen is here necessary, and particularly the admission of cold air. Even cold substances applied to the head have been found useful; and the application of such refrigerants as vinegar is certainly proper. Opiates are thought to be hurtful in every inflammatory state of the brain. On the whole, however, it must be remarked, that practitioners are very uncertain with regard to the means proper to be used in this disease; and the more so, that the symptoms by which the disease is commonly judged to be present, appear sometimes without any internal inflammation; and on the other hand, dissections have shown that the brain has been inflamed, where few of the peculiar symptoms of inflammation had appeared before death.

GENUS X. CYNANCHE.

Cynanche, Sauv. gen. 110. Lin. 33. Sag. gen. 300. Angina, Vog. 49. Hoffm. II. 125. Junck. 30. Angina inflammatoria, Boerh. 798.

Sp. I. CYNANCHE TONSILLARIS. The Inflammatory QUINSY.

Cynanche tonsillaris, Sauv. sp. 1. Angina inflammatoria, sp. 5. Boerh. 805.

Description. This is an inflammation of the mucous membrane of the fauces, affecting principally that congeries of mucous follicles which forms the tonsils; and from thence spreading along the velum and uvula, so as frequently to affect every part of the mucous membrane. The disease appears by some tumour and redness of the parts; is attended with a painful and difficult deglutition; a troublesome clamminess of the mouth and throat; a frequent but difficult excretion of mucus; and the whole is accompanied with pyrexia. The inflammation and tumour are commonly at first most considerable in one tonsil; and afterwards, abating in that, increase in the other. This disease is not contagious.

Causes of, and persons subject to, this disorder. This disease is commonly occasioned by cold externally applied, particularly about the neck. It affects especially the young and languid; and a disposition to it is often acquired by habit. It occurs especially in the spring and autumn, when vicissitudes of heat and cold frequently take place.

Prognosis. This species of cynanche terminates frequently by resolution, sometimes by suppuration, but hardly ever by gangrene; though in some cases sloughy spots appear on the fauces: the prognosis therefore is generally favourable.

Cure. As the principal morbid affection in this disease, on which all its characterising symptoms immediately depend, is the active inflammation in the tonsils and neighbouring parts, the object first and principally to be aimed at in the cure is to obtain a resolution of this inflammation. Sometimes, however, it is necessary to have recourse to practices, with the view of obviating urgent symptoms before a resolution can be effected: and in other cases, where a resolution cannot be obtained, it must be the aim of the practitioner to promote a speedy and favourable suppuration. After suppuration has taken place, the proper means of promoting a discharge of the purulent matter will conclude the cure. Here some bleeding may be necessary; but large and general evacuations are seldom beneficial. The opening of the ranular veins is an insignificant remedy, according to Dr Cullen, but is recommended as efficacious by Sir John Pringle: more benefit, however, may in general be derived from leeches to the external fauces. The inflammation may be often relieved by moderate astringents, and particularly by acids applied to the parts affected. In many cases, nothing has been found to give more relief than the vapour of warm water received into the fauces.

Besides these, blistering, and still more frequently rubefacient medicines, are applied with success, as well as antiphlogistic purgatives; and every part of the antiphlogistic regimen is to be observed, except the application of cold. Sir John Pringle recommends a thick piece of flannel moistened with two parts of common sweet oil, and one of spirit of hartshorn (or in a larger proportion, if the skin will bear it), to be applied to the throat, and renewed once every four or five hours. By this means the neck, and sometimes the whole body, is put into a sweat, which after bleeding either carries off or lessens the inflammation. When the disease has a tendency to suppuration, nothing will be more useful than receiving into the fauces the steams of warm water. Benefit is also obtained from poultices applied to the external fauces. When the abscess is attended with much swelling, if it break not spontaneously, it ought to be opened by a lancet; and this does not require much caution, as even the inflammatory state may be relieved by some scarification of the tonsils. When this disease runs very rapidly to such a height as to threaten suffocation, it is sometimes necessary to have recourse to bronchotomy as the only means of saving the life of the patient. But there is reason to believe that this operation has sometimes been employed where it was not necessary; and we may safely venture to say, that it is but seldom requisite; inasmuch that Dr Cullen tells us, he has never in his practice seen any case requiring bronchotomy.

Sp. II. CYNANCHE MALIGNA. The malignant, putrid, or ulcerous SORE THROAT.

Cynanche maligna, Sauv. sp. 3. Cynanche ulcerosa, Sauv. var. a. Journ. de Med. 1758. Cynanche gangraenosa, Sauv. var. b. Journ. de Med. 1756. Ulcera faucium et gutturis anginosa et lethalia, Hif- panis Garrotillo, Lud. Mercat. consult. 24. Angina ulcerosa, Fothergill's Account of the ulcerous sore throat, edit. 1751. Huxham on the malignant ulcerous sore throat, from 1751 to 1753. Febris epidemica cum angina ulcuculofa, Douglas's Practical History, Bolton, 1736. Angina epidemicca, Raffel, Oceon. Natur. p. 105. Angina gangraenosa, Withering's Differt. Inaug. Edinb. 1766. Angina suffocativa, Bard's Inquiry, New York, 1771. Angina maligna, Johnstone on the malignant Angina, Worcester, 1779.

History and Description. This distemper is not particularly described by the ancient physicians; though perhaps the Syrian and Egyptian ulcers mentioned by Arcteus Cappadox, and the pestilential ulcerated tonsils we read of in Aetius Amideus, were of this nature. Some of the scarlet fevers mentioned by Morton seem also to have approached near to it. In the beginning of the last century, a disease exactly similar to this is described by the physicians of that time, as raging with great violence and mortality in Spain and some parts of Italy; but no account of it was published in this country till the year 1748, when a very accurate one was drawn up by Dr Fothergill, and in 1752 by Dr Huxham. The latter observes, that this disease was preceded by long, cold, and wet seasons; by which probably the bodies of people were debilitated, and more apt to receive contagion, which possibly also might be produced by the stagnant and putrid waters.

The attack of this disease was very different in different persons. Sometimes a rigor, with fulness and soreness of the throat, and painful stiffness of the neck, were the first symptoms complained of. Sometimes alternate chills and heats, with some degree of giddiness, drowsiness, or headache, ushered in the distemper. It seized others with more severe feverish symptoms; great pain of the head, back, and limbs; a vast oppression of the precordia, and continual sighing. Some grown persons went about for days in a drooping state, with much uneasiness and anxiety, till at last they were obliged to take to their beds.—Thus various was the disease, says Dr Huxham, at the onset. But it commonly began with chills and heats, load and pain of the head, soreness of throat, and hoarseness; some cough, sickness at stomach, frequent vomiting and purging, in children especially, which were sometimes very severe; though a contrary state was more common to the adult. There was in all a very great depression of spirits, very sudden weakness, great heaviness on the breast, and faintness, from the very beginning. The pulse in general was quick, small, and fluttering, though sometimes heavy and undulating. The urine was commonly pale, thin, and crude; however, in many grown persons, it was passed in small quantities and high-coloured, or like turbid whey. The eyes were heavy, reddish, and as it were weeping; the countenance very often full, flushed, and bloated, though sometimes pale and funk.

How flight ever the disorder might appear in the day-time, at night the symptoms became greatly aggravated, and the feverish habit very much increased, nay, sometimes a delirium occurred on the very first night; and this exacerbation constantly returned through the whole course of the disease. Indeed, when it was considerably on the decline, our author says he has been often pretty much surprised to find his patient had passed the whole night in a phrensy, whom he had left tolerably cool and sedate in the day.

Some few hours after the seizure, and sometimes contemporary with it, a swelling and soreness of the throat was perceived, and the tonsils became very tumid and inflamed, and many times the parotid and maxillary glands swelled very much, and very suddenly, even at the very beginning; sometimes so much as even to threaten strangulation. The fauces also very soon appeared of a high florid red, or rather of a bright crimson, colour, very shining and glossy; and most commonly on the uvula, tonsils, velum palatinum, and back part of the pharynx, several whitish or ash-coloured spots appeared scattered up and down, which oftentimes increased very fast, and soon covered one or both the tonsils, uvula, &c.: those in the event proved floughs of superficial ulcers (which sometimes, however, ate very deep into the parts). The tongue at this time, though only white and moist at the tip, was very foul at the root, and covered with a thick, yellowish or brown coat. The breath also now began to be very nauseous; which offensive smell increased hourly, and in some became at length intolerable, and that too sometimes even to the patients themselves.

The second or third day every symptom became much more aggravated, and the fever much more considerable; and those that had struggled with it tolerably well for 30 or 40 hours, were forced to submit. The restlessness and anxiety greatly increased, as well as the difficulty in swallowing. The head was very giddy, pained, and loaded; there was generally more or less of a delirium; sometimes a pervigilium and perpetual phrenzy, though others lay very stupid, but often starting and muttering to themselves. The skin was very hot, dry, and rough; there was very rarely any disposition to sweat. The urine was pale, thin, crude; often yellowish and turbid. Sometimes vomiting was urgent, and sometimes a very great looseness, in children particularly. The floughs were now much enlarged, and of a darker colour, and the surrounding parts tended much more to a livid hue. The breathing became much more difficult; with a kind of a rattling stertor, as if the patient was actually strangling, the voice being exceeding hoarse and hollow, exactly resembling that from venereal ulcers in the fauces: this noise in speaking and breathing was so peculiar, that any person in the least conversant with the disease might easily know it by this odd noise; from whence indeed the Spanish physicians gave it the name of garrotillo, expressing the noise made by persons when they are strangled with a rope. Dr Fothergill never observed in one of them the shrill barking noise that we frequently hear in inflammatory cynanche. The breath breath of all the diseased was very nauseous; of some insufferably fetid, especially in the advance of the disease to a crisis; and many about the fourth or fifth day spit off a vast quantity of stinking purulent mucus tinged sometimes with blood: and sometimes the matter was quite livid, and of an abominable smell. The nostrils-likewife in many were greatly inflamed and excoriated, continually dripping down a very sharp ichor or fainous matter, so excessively acrid, that it not only corroded the lips, cheeks, and hands of the children that laboured under the disease, but even the fingers and arms of the very nurses that attended them: as this ulceration of the nostrils came on, it commonly caused an almost ineffectual sneezing in the children; but few adults were affected with it, at least to any considerable degree. It was surprising what quantities of matter some children discharged this way, which they would often rub on their face, hands, and arms, and blister them all over. A sudden stoppage of this rheum from the mouth and nostrils actually choked several children; and some swallowed such quantities of it, as occasioned excoriations of the intestines, violent gripings, dysentery, &c. nay, even excoriations of the anus and buttocks. Not only the nostrils, fauces, &c. were greatly affected by this extremely sharp matter, but the wind-pipe itself was sometimes much corroded by it, and pieces of its internal membrane were spit up, with much blood and corruption; and the patients lingered on for a considerable time, and at length died tabid; though there were more frequent instances of its falling suddenly and violently on the lungs, and killing in a peripneumonic manner.

Dr Huxham was affrighted sometimes to see several swallow with tolerable ease, though the tumour of the tonsils and throat, the quantity of thick mucus, and the rattling noise in breathing, were very terrible; which he thinks pretty clearly shows, that this malignant angina was more from the acrimony and abundance of the humours than the violence of the inflammation.

Most commonly the angina came on before the exanthemata; but many times the cuticular eruption appeared before the sore-throat, and was sometimes very considerable, though there was little or no pain in the fauces: on the contrary, a very severe angina seized some patients that had no manner of eruption; and yet, even in these cases, a very great itching and desquamation of the skin sometimes ensued; but this was chiefly in grown persons, very rarely in children. In general, however, a very considerable efflorescence broke out on the surface of the body, particularly in children; and it most commonly happened the second, third, or fourth day: sometimes it was partial, sometimes it covered almost the whole body, though very seldom the face: sometimes it was of an erysipelatous kind; sometimes more pustular: the pustules frequently eminent, and of a deep fiery red colour, particularly on the breast and arms; but sometimes they were very small, and might be better felt than seen, and gave a very odd kind of roughness to the skin. The colour of the efflorescence was commonly of a crimson hue, or as if the skin had been smeared over with juice of raspberries, and this even to the fingers ends; and the skin appeared inflamed and swollen, as it were; the arms, hands, and fingers, were often evidently so, and very stiff, and somewhat painful. This crimson colour of the skin seemed indeed Cynanche, peculiar to this disease. Though the eruption seldom failed of giving some manifest relief to the patient, as to anxiety, sickness at stomach, vomiting, purging, &c. yet there was observed an universal fiery eruption on some persons, without the least abatement of the symptoms, nay almost every symptom seemed more aggravated, particularly the fever, load at breast, anxiety, and delirium; Dr Huxham knew more than one or two patients die in the most raging phrensy, covered with the most universal fiery rash he ever saw: so that, as in the highly confluent smallpox, it seemed only to denote the quantity of the disease, as he terms it.

He had under his care a young gentleman, about 12 years of age, whose tongue, fauces, and tonsils, were as black as ink, and he swallowed with extreme difficulty; he continually spit off immense quantities of a black, fainous, and very fetid matter, for at least eight or ten days:—about the seventh day, his fever being somewhat abated, he fell into a bloody dyfentery, though the bloody, fainous, fetid expectoration still continued, with a most violent cough. He at length indeed got over it, to the very great surpise of every one that saw him. Now, in this patient, a fever and universal rash broke out upon the second and third day; and the itching of his skin was so intolerable, that he tore it all over his body in a most shocking manner: yet this very great and timely eruption very little relieved his fever and phrensy, or prevented the other dreadful symptoms mentioned.

An early and kindly eruption, however, was most commonly a very good omen; and, when succeeded by a very copious desquamation of the cuticle, one of the most favourable symptoms that occurred: but when the eruption turned of a dusky or livid colour, or prematurely or suddenly receded, every symptom grew worse, and the utmost danger impended, especially if purple or black spots appeared up and down, as sometimes happened; the urine grew limpid, and convulsions came on, or a fatal suffocation soon closed the tragedy.

The disease was generally at the height about the fifth or sixth day in young persons, in the elder not so soon; and the crisis many times was not till the 11th or 12th, and then very imperfect; some adults, however, were carried off in two or three days; the distemper either falling on the lungs, and killing in a peripneumonic manner; or on the brain, in which case the patient either died raving or comatose. In some, the disease brought on a very troublesome cough, purulent expectoration, haemoptoe, and hectic fever; in which they lingered on for several weeks, and then died tabid.

If a gentle easy sweat took place on the third or fourth day; if the pulse became more flow, firm, and equal; if the floughs of the fauces call off in a kindly manner, and appeared at the bottom tolerably clean and florid; if the breathing was more soft and free, and some degree of vigour and quickness returned in the eyes; all was well, and a salutary crisis followed soon by a continuance of the sweat, and a turbid, subduing, farinaceous urine, a plentiful expectoration, and a very large desquamation of the cuticle. But if a rigor came on, and the exanthemata suddenly disappeared or turned Phlegmatic. livid; if the pulse grew very small and quick, and the skin remained hot and parched as it were, the breathing more difficult, the eyes dead and glaity, the urine pale and limpid, a phreny or coma succeeded, with a coldth clammy sweat on the face or extremities; life was despaired of, especially if a languish and choking or gulping in the throat attended, with madden, liquid, involuntary, livid stools, intolerably fetid. In some few patients, Dr Huxham observed, some time before the fatal period, not only the face bloated, fallow, thinning and greasy as it were, but the whole neck very much swollen, and of a cadaverous look; and even the whole body became in some degree oedematous; and the impression of a finger would remain fixed in a part, the skin not rising again as usual; an indication that the blood stagnated in the capillaries, and that the elasticity of the fibres was quite lost.

Medical writers are still much divided in opinion, whether the cynanche maligna is to be considered as the same disease with the scarlatina anginosa, afterwards to be treated of, or not. This question will afterwards come to be more fully discussed. At present we may only observe, that although ulcerous sore throats of a malignant nature often appear sporadically, yet that the disease above described appears only as an epidemic, and is always the consequence of contagion.

We have, therefore, no doubt that the cynanche maligna of Huxham, Fothergill, and Cullen, is precisely the same disease with the scarlatina anginosa of Sauvage, Withering, and other late writers. This is abundantly demonstrated by the diversities which take place in the appearance of the disease among children of the same family during the same epidemic.

Prognosis. This may be easily gathered from the above description. The malignant and putrid tendency of the disease is evident, and an increase of the symptoms which arise from that putrefient disposition of the body must give an unfavourable prognostic. On the contrary, a decrease of these, and an apparent increase of the vis vitae, are favourable: in general, what is observed to be favourable in the nervous and putrid malignant fevers, is also favourable in this, and vice versa.

Causes. Since the accurate accounts given by Dr Fothergill and Huxham of the epidemics which prevailed about 50 years ago, this disease has frequently been observed at times epidemic in almost every different part of Britain. Like smallpox, measles, and chincough, it seems in every case to be the effect of a peculiar and specific contagion. It has been observed to prevail, equally generally in every situation, and at every season; and on exposure to the contagion, no age, sex, or condition, is exempted from it. But the having once had the disease, seems in this affection to afford the same security against future contagion as in the small-pox: at least instances, where it can be said that the same individual has been twice affected with it, are both very rare and very doubtful, as well as in small-pox.

Cure. Like other febrile contagions, the malignant ulcerous sore throat is terminated only by a natural course; and the chief business of the practitioner is to combat unfavourable occurrences. In this the septic tendency of the disease is chiefly to be kept in view. The debility with which it is attended renders all evacuations by bleeding and purging improper, except in a few instances where the debility is less, and the inflammatory symptoms more considerable. The fauces are to be preserved from the effects of the acrid matter poured out upon them, and are therefore to be frequently washed out by antiseptic gargles or injections; and the putrefient state of the whole system should be guarded against and corrected by internal antiseptics, especially by the Peruvian bark given in the beginning and continued through the course of the disease. Great benefit is also often derived from the liberal use of the mineral acids. Both the sulphuric and muriatic, in a state of proper dilution, have been highly extolled by different medical writers, and are productive of the best effects in actual practice, when they can be introduced to a sufficient extent. In particular, the oxygenated muriatic acid, as recommended by Mr Brathwaite, has been found productive of the greatest advantages. Emetics, both by vomiting and nasaueting, prove useful. When any considerable tumor occurs, blisters applied externally will be of service, and in any case may be proper to moderate the inflammation.

Very lately, the internal use of the capsicum annum, or Cayenne pepper, as it is commonly called, has been highly celebrated in this affection; and it is particularly said to have been employed with singular success in the West Indies.

But of all the remedies lately proposed, none has been more highly extolled than the external use of cold water. It has even been contended by some that by dashing cold water on the surface of the body, an immediate artificial cure of this disease may be obtained. We are, however, fully persuaded, that cold water will no more destroy the contagion of this disease than of small-pox; and we cannot help thinking that the practice is seldom necessary, and sometimes hurtful.

Sp. III. CYNANCHE TRACHEALIS.

The Croup.

Cynanche trachealis, Sauv. sp. 5. Cynanche laryngea auctorum, Eller de cogn. et curand. morb. fect. 7. Angina inflammatoriae, sp. 1. Boehr. 801. Angina latens et difficilis, Dodon. obf. 18. Angina interna, Tulp. 1. 1. obf. 51. Angina perniciosa, Greg. Horst. Obf. 1. iii. obf. 1. Suffocatio stridula, Home on the Croup. Asthma infantum, Millar on the Asthma and Chincough. Asthma infantum spasmodicum, Ryb, Dissertation, Lond. 1770. Cynanche stridula, Crawford Differt. Inaug. Edin. 1771. Angina epidemica anno 1743. Molloy apud Rutty's History of the weather. Morbus strangulatorius, Starr, Phil. Trans. No 495. Morbus truculentus infantum, Francaf. ad Viadrum et in vicinia graffian ann. 1758. C. a Bergen. A nova. N. C. tom. ii. p. 157. Catarrhus suffocativus Barbadenis ann. 1758. Hilary's Diseases of Barbadoes. Angina inflammatoria infantum, Ruffel, Oecon. nat. p. 72. Angina polyposa five membranacea Michealis. Argentorati 1773, et auctores ab eo allegati.

The best description of this disease we have in Dr Cullen's Practice of Physic. He informs us, that it consists in an inflammation of the glottis, larynx, or upper part of the trachea, whether it affect the membranes of these parts or the muscles adjoining. It may arise first in these parts, and continue to subside in them alone; or it may come to affect these parts from the clyanche tonsillaris, or maligna, spreading into them.

In either way it has been a rare occurrence, and few instances of it have been marked and recorded by physicians. It is to be known by a peculiar roaring sound of the voice, by difficult respiration, with a sense of straitening about the larynx, and by a pyrexia attending it.

From the nature of these symptoms, and from the direction of the bodies of persons who died of this disease, there is no doubt of its being of an inflammatory kind. It does not, however, always run the course of inflammatory affections; but frequently produces such an obstruction of the passage of the air, as suffocates, and thereby proves suddenly fatal.

It particularly proves fatal, in consequence of the trachea being obstructed by a membranous substance lining the inside of it, and very nearly approaching in appearance to the inflammatory exudation often discovered on the intestinal canal in those dying of enteritis.

If we judge rightly of the nature of this disease, it will be obvious, that the cure of it requires the most powerful remedies of inflammation to be employed upon the very first appearance of the symptoms. When a suffocation is threatened, whether any remedies can be employed to prevent it, is not yet determined by sufficient experience: but it is evident, that in certain cases the life of the patient can be preserved only by the removal of that matter which obstructs the passage of air through the trachea.

The accounts which books have hitherto given us of inflammations of the larynx, and the parts connected with it, amount to what we have now said; and many instances are recorded of the disease happening in adult persons: but there is a peculiar affection of this kind happening to infants, which has been little taken notice of till lately. Dr Francis Home is the first who has given any distinct account of this disease; but, since he wrote, several other authors have taken notice of it, and have given different opinions concerning it.

This disease seldom attacks infants till after they have been weaned. After this period, the younger they are, the more they are liable to the disease. The frequency of it becomes less as children become more advanced; and there are few instances of children above 12 years of age being affected with it. It attacks children of the midland countries, as well as those who live near the sea; but it occurs much more frequently at certain places than at others. It does not appear to be contagious; and its attacks are frequently repeated in the same child. It is often manifestly the effect of cold applied to the body; and Cynanche, therefore appears most frequently in the winter and spring seasons. It very commonly comes on with the ordinary symptoms of a catarrh; but sometimes the peculiar symptoms of the disease show themselves at the very first.

These peculiar symptoms are the following: A hoarseness, with some shrillness and ringing sound, both in speaking and coughing, as if the noise came from a brazen tube. At the same time, there is a sense of pain about the larynx, some difficulty of respiration, with a whizzing sound in inspiration, as if the passage of the air were straitened. The cough which attends it, is commonly dry; and if anything be spit up, it is matter of a purulent appearance, and sometimes films resembling portions of a membrane. With all these symptoms, there is a frequency of pulse, a restless sleep, and an uneasy sense of heat. When the internal fauces are viewed, they are sometimes without any appearance of inflammation; but frequently a redness, and even swelling, appears; and sometimes there is an appearance of matter like to that rejected by coughing, together with the symptoms now described, and particularly with great difficulty of breathing, and a sense of strangling in the fauces, by which the patient is sometimes suddenly taken off.

Many dissections have been made of infants who had died of this disease, and almost constantly there has appeared a preternatural substance, apparently membranous, lining the whole internal surface of the upper part of the trachea, and extending in the same manner downwards into some of its ramifications. This preternatural membrane may be easily separated, and sometimes has been found separated in part from the subjacent proper membrane of the trachea. This last is commonly found entire, that is, without any appearance of erosion or ulceration; but it frequently shows the vestiges of inflammation, and is covered by a matter resembling pus, like to that rejected by coughing; and very often a matter of the same kind is found in the bronchiae, sometimes in considerable quantity.

From the remote causes of this disease; from the catarrhal symptoms commonly attending it; from the pyrexia constantly present with it; from the same kind of preternatural membrane being found in the trachea when the clyanche maligna is communicated to it; and from the vestiges of inflammation on the trachea discovered upon dissection; we must conclude, that this disease consists in an inflammatory affection of the mucous membrane of the larynx and trachea, producing an exudation analogous to that found on the surface of inflamed visceræ, and appearing partly in a membranous crust, and partly in a fluid form resembling pus.

Though this disease consists in an inflammatory affection, it does not commonly end either in suppuration or gangrene. The most troublesome circumstance of it seems to consist in a spasm of the muscles of the glottis, threatening suffocation.

When this disease terminates in health, it is by resolution of the inflammation, by ceasing of the spasm of the glottis, by an expectoration of the matter exuding from the trachea, and of the crusts formed there, there, and frequently it ends without any expectoration, or at least with such only as attends an ordinary catarrh. But in some instances, a fatal termination has very speedily taken place, in consequence of the discharge of the membranous substance from the trachea, even under its proper tubular form.

When the disease ends fatally, it is by a suffocation seemingly depending upon a spasm affecting the glottis; but sometimes, probably, depending upon a quantity of matter filling the bronchiae, or obstructing the trachea.

As we suppose the disease to be an inflammatory affection, so we attempt the cure of it by the usual remedies of inflammation. Bleeding, both general and topical, has often given immediate relief, and, by being repeated, has entirely cured the disease. Blistering also, near to the part affected, has been found useful. Upon the first attack of the disease, vomiting, immediately after bleeding, seems to be of considerable use, and sometimes suddenly removes the disease. But emetics are still more useful in advanced periods. By the employment of these, the matter obstructing the trachea, and inducing spasmodic affections, has often been successfully removed, when the situation of the patient seemed to be almost desperate. And as in the progress of the disease fresh effusions of this matter are very apt to take place, the frequent repetition of emetics becomes necessary. It is often necessary to have recourse to those operating the most expeditiously, such as sulphate of zinc even in large doses. In every stage of the disease, the antiphlogistic regimen is necessary, and particularly the frequent use of laxative glysters. Some practitioners consider mercury, particularly under the form of calomel, as an almost infallible remedy in this disease. It has particularly been extolled by Mr James Anderson, an eminent surgeon in Edinburgh. But we are sorry to say that in some cases at least, after the fairest trial, it has been found to fail. Though we suppose that a spasm affecting the glottis is often fatal in this disease, antispasmodic medicines have not in general been found of great service. Some, however, have strongly recommended the use of asepticia under the form of injection; others place great confidence in oil or oily mixtures, taken by the mouth: but more immediate benefit is derived from tepid bathing, and the employment of sulphuric ether, both externally and internally.

By these, when the disease is spasmodic, it is often successfully removed. But by much the most dangerous form of the disease is the inflammatory state giving the exudation. And when this inflammatory exudation has even been removed from the upper part of the trachea, yet it has sometimes proved fatal from the inflammation and exudation extending to the branches of the apera arteria. By such an occurrence the writer of the present article had the misfortune to lose a favourite son; an amiable youth; in the fourteenth year of his age, who was highly admired and sincerely regretted by all to whom he was known.

Sp. IV. CYNANCHE PHARYNGEA. Cynanche pharyngea, Sauv. sp. 6. Eller de cogn. et cur. lect. 7. Angina inflammatoriae, sp. 4. Boerh. 804. This is not materially different from the cynanche tonsillaris; only that the inflammation is said to begin in the pharynx, though Dr Cullen says he never knew an instance of it. The symptoms are almost the same, and the cure is precisely so, with that of the cynanche tonsillaris.

Sp. V. CYNANCHE PAROTIDÆA. Cynanche parotidea, Sauv. sp. 14. Gallis Orellions et Ouries, Tiffet Avis au peuple, No 116. Encyclopédie, au mot Oreillons. Angina externa, Angitis the MUMPS, Ruffel oceon. natur. p. 114. Scottis the BRANKS. Catarhbus Bellinfusans, Sauv. sp. 4. Osservazioni di Girol. Gaspuri, Venez. 1731. Osservazioni di Targ. Tozetti, Racolta 1ma, p. 176.

This is a disease well known to the vulgar, but little taken notice of by medical writers. It is often epidemic, and manifestly contagious. It comes on with the usual symptoms of pyrexia, which is soon after attended with a considerable tumor of the external fauces and neck. The swelling appears first as a glandular moveable tumor at the corner of the lower jaw; but it soon becomes uniformly diffused over a great part of the neck, sometimes on one side only, but more commonly on both. The swelling continues to increase till the fourth day; but from that period it declines, and in a few days more goes off entirely. As the swelling of the fauces recedes, it not unfrequently happens that some tumor affects the testicles in the male sex, or the breasts in the female. These tumors are sometimes large, hard, and somewhat painful; but are seldom either very painful or of long continuance. The pyrexia attending this disease is commonly slight, and goes off with the swelling of the fauces; but sometimes, when the swelling of the testicles does not succeed to that of the fauces, or when the one or the other has been suddenly repressed, the pyrexia becomes more considerable, is often attended with delirium, and has sometimes proved fatal.

As this disease commonly runs its course without either dangerous or troublesome symptoms, so it hardly requires any remedies. An antiphlogistic regimen, and avoiding cold, are all that will be commonly necessary. But when, upon the receding of the swellings, the pyrexia comes to be considerable, and threatens an affection of the brain, it will be proper, by warm fomentations, to bring back the swelling; and by vomiting, bleeding, or blistering, to obviate the consequences of its absence.

GENUS XI. PNEUMONIA. Febris pneumonia, Hoffm. II. 136.

Sp. I. PERIPNEUMONIA. Peripneumony, or Inflammation of the Lungs. Peripneumonia, Sauv. gen. 112. Lin. 34. Vog. 51. Sag. gen. 311. Boerh. 829. Juncker 67. Peripneumonia pura five vera Auctorum, Sauv. sp. 1. Peripneumonia gastrica, Sauv. sp. 11. Morgagni de cau. et fed. Epist. xx. art. 30, 31. Peripneumonia catarrhalis, Sauv. sp. 6. Peripneumonia Peripneumonia mothra, Sydenh. feet. 6. cap. 4. Boerh. 867. Morgagni de cauf. et fed. Epift. xxi. ii.—15. Peripneumonia putrida, Sauv. fp. 2. Peripneumonia ardens, Sauv. fp. 3. Peripneumonia maligna, Sauv. fp. 4. Peripneumonia typhodes, Sauv. fp. 5. Amphimerina peripneumonica, Sauv. fp. 15.

Sp. II. Pleuritis.

The Pleurify, or Inflammation of the Pleura.

Pleuritis, Sauv. gen. 103. Lin. 27. Vog. 56. Sag. gen. 303. Boerh. 875. Junck. 67. Paraphrenesis, Sauv. gen. 102. Lin. 26. Paraphrenitis, Vog. 55. Boerh. 907. Diaphragmitis, Sag. gen. 304. Pleuritis vera, Sauv. fp. 1. Boerh. 875. Verna princeps morb. acut. pleuritis, l. i. cap. 2. 3. Zeviani della parapleuritide, cap. 3. Morgagni de fed. et cauf. morb. Epift. xx. art. 56. xxi. 45. Wendt de pleuritis, apud Sandfort, thel. ii. Pleuritis pulmonis, Sauv. fp. 2. Zevian. dell. para- pleur. iii. 28, &c. Pleuropneumonia, pleuro-peripneumonia, peripneumo-pleuritis Aurorum. Baronius de pleuri-pneumonia. Ill. Halleri opulicul. patholog. obf. 13. Morgagni de fed. et cauf. Epift. xx and xxi. paf- fim. Cleghorn, Minora, p. 247. Triller de pleuriti- tude, aph. 1, 2, 3. cap. i. 8. Huham, Dif. on pleuritis, &c. chap. i. Ill. Pringle, Dif. of the army. Pleuritis convulsiva, Sauv. fp. 13. Bianch. Hift. hep. vol. i. p. 234. Pleuritis hydrothoracica, Sauv. fp. 15. Morgagni de cauf. et fed. xx. 34. Pleuritis dorsalis, Sauv. fp. 3. Verna, p. 3. cap. 8. Pleuritis mediastini, Sauv. fp. 3. P. Sal. Dif. de affec. part. cap. 6. Friend, Hift. Med. de Aven- zoare. Mediastinia, Vog. 52. Pleuritis pericardii, Sauv. fp. 5. Verna, p. iii. cap. 9. Parapleuritis, Zeviani della parapleuritide. Pleurodyne parapleuritis, Sauv. fp. 19. Paraphrenes diaphragmatica, Sauv. fp. 1. De Haen. Rat. med. i. 7. iii. p. 31. Paraphrenes pleuritica, Sauv. fp. 2. Paraphrenes hepatica, Sauv. fp. 3.

Under the general head of Pneumonia, Dr Cullen comprehends all inflammations of the thoracic vis- cera, or membrane lining the inside of that cavity; as the symptoms do not always sufficiently distinguish the seat of the affection, nor does a difference in the situation of the affected place make any difference in the cure.

Description. Pneumonic inflammation, however various in the seat, always discovers itself by pyrexia, difficult breathing, cough, and pain in some part of the thorax. It almost always comes on with a cold stage, and is accompanied with the other symptoms of pyrexia; though in some few instances the pulse may not be more frequent, nor the heat of the body increased beyond what is natural. Sometimes the pyrexia is from the beginning accompanied with the other symptoms; but frequently it is formed some hours before them, and particularly before the pain be felt. The pulse for the most part is frequent, full, strong, hard, and quick; but, in a few instances, especially in the advanced state of the disease, it is weak, soft, and at the same time irregular. The difficulty of breathing is most considerable in inspiration, both because the lungs do not easily admit of a full dilatation, and because the dilatation increases the pain attending the disease. The difficulty of breathing is also greater when the patient is in one posture of the body rather than another. It is generally greater when he lies on the side affected; though sometimes the contrary happens. Very often the patient cannot lie upon either side, and can find ease only when lying on the back; and sometimes he cannot breathe readily, except when in somewhat of an erect posture. The cough, in different cases, is more or less urgent or painful. It is sometimes dry, or without any expectoration, especially in the beginning of the disease; but more commonly it is, even from the beginning, moist, and the matter spit up various both in consistence and colour, and frequently it is streaked with blood. The pain is also different in different cases, and felt in different parts of the thorax, but most frequently in one side. It has been said to affect the right side more frequently than the left; but this is uncertain, and we are sure that the left side has been very often affected. Sometimes it is felt as if it was under the sternum; sometimes in the back between the shoulders; and when in the sides, its place has been higher or lower, more forward or backward; but the place of all most frequently affected is about the fifth or seventh rib, near the middle of its length, or a little more forward. The pain is often severe and pungent; but sometimes more dull and obtuse, with a sense of weight rather than of pain. It is most especially severe and pungent when occupying the place last mentioned. For the most part it continues fixed in one part, but sometimes shoots from the side to the scapula on one hand, or to the sternum and clavicle on the other.

Dr Cullen supposes that the disease is always seated, or at least begins, in some part of the pleura, taking that membrane in its greatest extent, as now commonly understood; that is, as covering not only the internal surface of the cavity of the thorax, but also as forming the mediastinum, and as extended over the pericardium, and over the whole surface of the lungs. But as the symptoms never clearly indicate where the seat of the disease is, there is but little foundation for the different names by which it has been distinguished. The term pleurify is improperly limited to that inflammation which begins in and chiefly affects the pleura coftalis. This Dr Cullen thinks is a rare occurrence; and that the pneumonia much more frequently begins in the pleura investing the lungs, producing all the symptoms which belong to what hath been called the pleuritis vera. The word peripneumonia has been applied to an inflammation beginning in the parenchyma, or cellular texture of the lungs, and having its seat chiefly there. But to Dr Cullen it seems very doubtful if any acute inflammation of the lungs, or any disease which has been called peripneumony, be of that kind. It seems probable, that every acute inflammation begins in membranous parts; and in every direction of persons who have died of peripneumony, the external membrane of the lungs, or some part of the pleura, has appeared to have been considerably affected. An inflammation of the pleura covering the upper surface of the diaphragm, has been distinguished by the appellation of paraphrenitis, as supposed to be attended with the peculiar symptoms of delirium, risus fardonicus, and other convulsive motions: but it is certain, that an inflammation of that portion of the pleura, and affecting also even the muscular substance of the diaphragm, has often taken place without any of the symptoms above mentioned; and neither the directions which have fallen under Dr Cullen's observation, nor any accounts of directions, support the opinion that an inflammation of the pleura covering the diaphragm is attended with delirium more commonly than any other pneumatic inflammation.—It is to be observed, however, that though the inflammation may begin in one particular part of the pleura, the morbid affection is commonly communicated to the whole extent of the membrane.

The pneumatic inflammation, like others, may terminate by resolution, suppuration, or gangrene: but it has also a termination peculiar to itself; namely, when it is attended with an effusion of blood into the cellular texture of the lungs, which, soon interrupting the circulation of the blood through the viscous, produces a fatal suffocation. This indeed appears to be the most common termination of pneumatic inflammation when it ends fatally; for upon the dissection of almost every person who has died of this disease, it appears that such an effusion had happened. From the same directions we learn, that pneumatic inflammation commonly produces an exudation from the internal surface of the pleura, which appears partly as a soft viscid crust, often of a compact membranous form, covering every where the surface of the pleura, and particularly those parts where the lungs adhere to the pleura costalis, or mediastinum; and this crust seems always to be the cement of such adhesion. The same exudation shows itself also by a quantity of a ferous fluid commonly found in the cavity of the thorax; and some exudation or effusion is usually found to have been made into the cavity of the pericardium. It seems likewise probable, that an effusion of this kind is sometimes made into the cavity of the bronchiae; for in some persons who have died after labouring under a pneumatic inflammation for a few days only, the bronchiae have been found filled with a considerable quantity of ferous and thickish fluid, which must be considered rather as the effusion above mentioned, having had its thinner parts taken off by respiration, than as a pus so suddenly formed in the inflamed part. It is, however, not improbable, that this effusion, as well as that made into the cavities of the thorax and pericardium, may be a matter of the same kind with that which in other inflammations is poured into the cellular texture of the parts inflamed, and there converted into pus; but in the thorax and pericardium it does not always put on this appearance, because the crust covering the surface prevents the abstraction of the thinner part. This abstraction, however, may be compensated in the bronchiae, by the drying power of the air; and therefore the effusion into them may assume a more purulent appearance. In many cases of pneumonic inflammation, when the expectoration is very copious, it is difficult to suppose that the whole proceeds from the mucous follicles of the bronchiae; and it seems probable that a great part of it may come from the effused ferous fluid just mentioned; and this too will account for the appearance of the expectoration being so often purulent. Perhaps the same thing will account for that purulent matter found in the bronchiae, which Mr de Haen says he had often observed when there was no ulceration in the lungs, and which he accounts for in a very strange manner, namely, by supposing a pus formed in the circulating blood.

Dr Cullen is of opinion, that the effusion into the bronchiae above mentioned often concurs with the effusion of red blood into the cellular substance of the lungs to occasion the fatal suffocation which frequently terminates peripneumony: that the effusion of serum alone may have this effect: and that the serum poured out in a certain quantity, rather than any debility in the powers of expectoration, is the cause of that cessation of spitting which precedes the fatal event; for in many cases the expectoration has ceased, when no other symptoms of debility have appeared, and when, upon dissection, the bronchiae have been full of liquid matter. Nay, it is even probable, that in some cases such an effusion may take place without any symptoms of violent inflammation; and in other cases the effusion taking place may seem to remove the symptoms of inflammation which had appeared before, and thus account for those unexpected fatal terminations which have sometimes happened.

Pneumonic inflammation seldom terminates by resolution, without being attended with some evident evacuation. An hemorrhage from the nose happening on some of the first days of the disease has sometimes put an end to it; and it is said, that an evacuation from the hemorrhoidal veins, a bilious evacuation by stool, and an evacuation of urine with a copious sediment, have feverally had the same effect; but such occurrences have been rare. The evacuation most frequently attending, and seeming to have the greatest effect in promoting resolution, is an expectoration of a thick, white, or yellowish matter, a little streaked with blood, copious, and brought up without much or violent coughing. Very frequently the resolution of this disease is attended with, and perhaps produced by, a sweat, if it be warm, fluid, copious, over the whole body, and attended with an abatement of the frequency of the pulse, heat of the body, and other febrile symptoms. Although, from the history now given, it appears that pleurisy and peripneumony cannot with propriety be considered as different diseases, yet it is certain that in different cases this affection occurs with an assemblage of symptoms separate and distinct. Thus even Dr Cullen himself, in his Nosology, has defined pleuritis to consist in pyrexia, attended with pungent pain of the side, painful respiration, difficulty of lying down, particularly on the affected side, and distressing cough, in the beginning dry, but afterwards humid, and often with bloody expectoration. While again he has defined peripneumony to consist in pyrexia, attended with a dull pain under the sternum and between the shoulders, anxiety, difficulty of breathing, hu- Pneumonia.

Flegmatic cough, expectoration generally bloody, a soft pulse, and a tumid livid appearance of the countenance. It is highly probable, that the first of these sets of symptoms chiefly arises from a state of active inflammation, and the second from effusion. Thus, in certain cases, the symptoms may appear perfectly separate and distinct; but more frequently both inflammation and effusion are united; and thus the symptoms in both definitions are in general combined in the same patient. But still pleuritis, strictly so called, may be considered as characterized by the acute pungent pain at a particular spot of the chest, and that pain much aggravated on a full inspiration; while proper peripneumonia is distinguished by the dull gravitative pain extended over the whole chest, and by the laborious respiration.

Causes of, and persons subject to, this disorder. The remote cause of pneumatic inflammation is commonly cold applied to the body, obstructing perspiration, and determining to the lungs, while at the same time the lungs themselves are exposed to the action of cold. These circumstances operate chiefly when an inflammatory diathesis prevails in the system; and therefore those principally affected with this disease are persons of the greatest vigour, in cold climates, often in the winter season, but particularly in the spring, when vicissitudes of heat and cold are frequent. This disease, however, may arise in any season when such varieties take place. Other remote causes also may have a share in producing this distemper; such as every means of obstructing, straining, or otherwise injuring, the pulmonary organs. The pneumatic inflammation has sometimes been so much an epidemic, that it hath been suspected of depending on a specific contagion; but Dr Cullen never met with an instance of its being contagious.

Prognosis. In pneumatic inflammations, a violent pyrexia is always dangerous. The danger, however, is chiefly denoted by the difficulty of breathing. When the patient can lie on one side only; when he can lie on neither side, but only on his back; when he cannot breathe with tolerable ease, except when the trunk of his body is erect; when even in this posture the breathing is very difficult, and attended with a turgescence and flushing of the face, with partial sweats about the head and neck, and an irregular pulse; these circumstances mark the difficulty of breathing in different degrees; and consequently, in proportion, the danger of the disease. A frequent violent cough, aggravating the pain, is always the symptom of an obstinate disease; and as the disease is seldom or never resolved without some expectoration, so a dry cough must always be an unfavourable symptom.

The proper characteristics of the expectoration have been already laid down; and though an expectoration which has not these marks must indicate a doubtful state of the disease, yet the colour alone can give no certain prognostic. An acute pain, very much interrupting inspiration, is always the mark of a violent disease; but not of a more dangerous disease than an obtuse pain, attended with very difficult respiration, demonstrating effusion into the cells.

When the pains, which had at first affected one side only, shall afterwards spread into the other; or when, leaving the side first affected, they pass entirely into the other; these are always marks of a dangerous disease.

A delirium coming on during a pneumatic inflammation is always a symptom denoting much danger.

When pneumatic disorders terminate fatally, it is on one or other of the days of the first week, from the third to the seventh. This is the most common case; but, in a few instances, death has happened at a later period. When the disease is violent, but admitting of resolution, this also happens frequently in the course of the first week; but in a more moderate disease the resolution is often put off to the second week. The disease generally suffers a remission on some of the days; from the third to the seventh: which, however, may be often fallacious, as it sometimes returns again with as much violence as before; and in such a case with great danger. Sometimes it disappears on the third day, while an erysipelas makes its appearance on some external part; and if this continue fixed, the pneumatic inflammation does not recur. If the disease continue beyond the 14th day, it will terminate in a suppuration, or PHTHISIS. The termination by gangrene is much more rare than has been imagined: and when it does occur, it is usually joined with the termination by effusion; the symptoms of the one being hardly distinguishable from those of the other.

Cure. This must proceed upon the general plan mentioned under SYNCHIA; but, on account of the importance of the part affected, the remedies must be employed early, and as fully as possible: and these are chiefly directed with one of three views, viz. for obtaining a resolution of the inflammation in the thorax, for mitigating the urgent symptoms before a resolution can be effected, and for counteracting or obviating the consequences of the disease. Venection is the remedy chiefly to be depended on; and may be performed in either arm, as the surgeon finds most convenient; and the quantity taken away ought in general to be as large as the patient's strength will allow. The remission of pain, and the relief of respiration, during the flowing of the blood, may limit the quantity to be then drawn; but if these symptoms of relief do not appear, the bleeding should be continued to a considerable extent, unless symptoms of a beginning syncope come on. It is seldom that one bleeding, however large, will cure this disease; and though the pain and difficulty of breathing may be much relieved by the first bleeding, these symptoms commonly recur after no long interval recur, often with as much violence as before. In this case the bleeding is to be repeated even on the same day, and perhaps to the same quantity as before. Sometimes the second bleeding may be larger than the first. There are persons, who, by their constitution, are ready to faint even upon a small bleeding; and in such persons this may prevent the drawing so much blood at first as a pneumatic inflammation may require: but as the same persons are found to bear after-bleedings better than the first, this allows the second and subsequent bleedings to be larger, and to such a quantity as the symptoms of the disease may seem to require.

Bleedings are to be repeated according to the state of the symptoms, and they will be more effectual when practised in the course of the first three days than afterwards; but they are not to be omitted though four days of the disease may already have elapsed. If the physician has not been called in time, or the first bleed- Phlegmatic affections have not been sufficiently large, or even though they should have procured some remission, yet upon the return of the urgent symptoms, bleeding may be repeated at any time within the first fortnight, or even after that period, if a suppuration be not evident, or if after a seeming solution the disease shall have returned.

With respect to the quantity of blood which may be taken away with safety, no general rules can be given; as it must be very different according to the state of the disease, and the constitution of the patient. In an adult male of tolerable strength, a pound of blood is a full bleeding. Any quantity above 20 ounces is a large, and any quantity below 12 is a small, bleeding. An evacuation of four or five pounds, in the course of two or three days, is generally as much as most patients will bear; but if the intervals between the bleedings, and the whole of the time during which the bleedings have been employed, have been long, the quantity taken upon the whole may be greater.

When a large quantity of blood has been taken from the arm, and it is doubtful if more can be taken in that manner with safety, some blood may still be taken by cupping and scarifying. This will especially be proper, when the recurrence of the pain, rather than the difficulty of breathing, becomes the urgent symptom; and then the cupping and scarification should be made as near as possible to the pained part.

An expectoration sometimes takes place very early in this disease; but if the symptoms continue urgent, the bleedings must be repeated notwithstanding the expectoration: but in a more advanced state, and when the symptoms have suffered a considerable remission, we may then trust the cure to the expectoration alone. It is not observed that bleeding, during the first days of the disease, stops expectoration; on the contrary, it has been often found to promote it; and it is only in a more advanced state of the disease, when the patient has been already exhausted by large evacuations and a continuance of his illness, that bleeding seems to put a stop to expectoration; and even then, this stoppage seems not to take place so much from the powers of expectoration being weakened by bleeding, as by its favouring the serous effusion in the bronchiae, already taken notice of.

Besides bleeding, every part of the antiphlogistic regimen ought here to be carefully employed; the patient must keep out of bed as much as he can bear; must have plenty of warm diluting drinks, impregnated with vegetable acids, accompanied with nitre or some other cooling neutral salt; and the belly also ought to be kept open by emollient clysters or cooling laxative medicines. Vomiting in the beginning is dangerous; but in a somewhat advanced state of the disease emetics have been found the best means of promoting expectoration. Fomentations and poultices to the pained part have been found useful; but blistering is found to be much more effectual. A blister, however, ought not to be applied till at least one bleeding has been premised, as venefication is less effectual when the irritation of a blister is present. If the disease be moderate, a blister may be applied immediately after the first bleeding; but in violent cases, where it may be presumed that a second bleeding may soon be necessary after the first, it will be proper to delay the blister till after the second bleeding, when it may be supposed that the irritation occasioned by the blister fever will be over before another bleeding becomes necessary. It may frequently be of use in this disease to repeat the blistering; and in that case the plasters should always be applied somewhene on the thorax, for when applied to more distant parts they have less effect. The keeping the blistered parts open, and making what is called a perpetual blisser, has much less effect than a repeated blistering.

Many methods have been proposed for promoting expectoration, but none appear to be sufficiently effectual; and some of the expectorants, being acid stimulant substances, are not very safe. The gums usually employed seem to be too heating; the squills less so; but they are not very powerful, and sometimes inconvenient, by the constant nausea they occasion. The volatile alkali may be of service as an expectorant, but it ought to be reserved for an advanced state of the disease. Mucilaginous and oily demulcents appear to be useful, by allaying that acrimony of the mucus which occasions too frequent coughing; and which coughing prevents the stagnation and thickening of the mucus, and thereby its becoming mild. The receiving into the lungs the steams of warm water, impregnated with vinegar, has often proved useful in promoting expectoration; and, for this purpose, the machine called the INHALER, lately invented by Dr Mudge of Plymouth, promises to be of great service. But of all others, the antimonial emetics, given in nauseating doses, are perhaps the most powerful for promoting expectoration. The kermes mineral has been greatly recommended; but does not seem to be more efficacious than tartrite of antimony or antimonial wine; and the dose of the kermes is much more uncertain than that of the others.

Though this disease often terminates by a spontaneous sweating, this evacuation ought not to be excited by art, unless with much caution. When, after some remission of the symptoms, spontaneous sweats arise, they may be encouraged; but it ought to be without much heat, and without stimulant medicines. If, however, the sweats be partial and clammy only, and a great difficulty of breathing still remain, it will be very dangerous to encourage them.

Physicians have differed much with regard to the use of opiates in pneumonic affections. It appears, however, that in the beginning of the disease, and before bleeding and blistering have produced some remission of the pain, and of the difficulty of breathing, opiates have had a bad tendency, by their increasing the difficulty of breathing and other inflammatory symptoms. But in a more advanced state of the disease, when the difficulty of breathing has abated, and when the urgent symptom is a cough, proving the chief cause of the continuance of pain and want of rest, opiates may be employed with great advantage and safety. The interruption of the expectoration which they seem to occasion, is for a short time only; and they seem often to promote it, as they occasion a stagnation of what was by frequent coughing dissipated insensibly: and therefore give the appearance of what physicians have called concealed matter.

Opium combined with calomel has of late been highly extolled in this and other inflammatory diseases by Dr Hamilton of Lynn Regis; who has given a full account count of the success attending his practice with this remedy for the space of 16 years, in the 9th volume of the Edinburgh Medical Commentaries. And since his recommendation, the same remedy has often been employed by others with great benefit.

VOMICA, or Abscess of the Lungs.

Vomica, Boerh. 835. Junck. 35. Pleurodyne vomica, Sauv. fp. 21.

Phthisis sometimes follows pneumonia, though the case is not frequent. The symptoms of it so much resemble ordinary phthisis, that it can most properly be treated of under that head.

EMPYEMA.

This is another consequence of a pneumonia terminating unfavourably, and is occasioned by the effusion of a quantity of purulent matter into the cavity of the thorax, producing a lingering and painful disorder, very often incurable.

Description. The first sign of an empyema is a cessation of the pain in the breast, which before was continual: this is followed by a sensation of weight on the diaphragm; and a fluctuation of matter, sometimes making a noise that may be heard by the bystanders: the acute fever is changed into a hectic, with an exacerbation at night: a continual and troublesome dry cough remains. The respiration is exceedingly difficult, because the lungs are prevented by the matter from fully expanding themselves. The patient can lie easily on that side where the matter is effused, but not on the other, because then the weight of the matter on the mediastinum produces uneasiness. The more the hectic heat is augmented, the more is the body emaciated, and its strength decayed. In some there is danger of suffocation when they stoop down, which goes off when they alter that posture of the body; and in some there is a purulent spitting.—These symptoms are accompanied with great anxiety, palpitations of the heart, and faintings. Sometimes the patients have a sensation like a hot vapour ascending from the cavity of the thorax to their mouth. Others, in a more advanced state of the disease, have a putrid taste in the mouth. At the same time, profuse night sweats waste the body, and greatly weaken the patient. The face at first grows red on that side where the matter lies, at last the Hippocratic face comes on, and the eyes become hollow. The pulse is quick, but more frequently intermittent. Sometimes the nails are crooked, and pustules appear on the thorax; and frequently, according to the testimony of Hippocrates, the feet swell, and, on the affected side of the breast, there is an inflation and swelling of the skin.

Causes, &c. An empyema may arise either from the bursting of a vomica of the lungs, or from a suppuration taking place after the inflammatory stage of pneumonia; or sometimes from a suppuration in the case of a quinsy, when the inflammation had extended to the alpura arteria, from whence arises a kind of bloody sputtle, and the patients are afflicted with an empyema, unless they die on the 7th day of the disease, according to the observation of Hippocrates. It may arise also from external violence, as wounds of the thorax, &c. blood extravasated, corrupted, or changed into pus.

Like the vomica, it is a rare distemper, but may attack Peritonitis. all those subject to pneumonia.

Prognosis. Very few recover after an empyema has been once formed, especially if the operation of paracentesis be neglected. After this operation is performed, if a great quantity of bloody fetid pus be discharged, if the fever continue, and if the patient spit up a purulent, pale, frothy, livid, or green matter, with a decay of strength, there is no hope: But when a small quantity of pus, of a white colour, not very fetid, is discharged; when the fever and thirst presently cease, the appetite returns, and faeces of a good consistence are discharged, the strength also returning in some degree; there is then hope of a perfect recovery. If the matter be not dried up in seven weeks time, the disease readily changes to a fistulous ulcer, which is very difficult to cure. An empyema affecting both sides of the thorax is more dangerous than that which affects only one.

Cure. This consists in evacuating the purulent matter contained in the cavity of the thorax, which is best done by the operation of paracentesis of the thorax. See Surgery. Afterwards the ulcer is to be treated with ablergent and consolidating medicines, and the same internal ones are to be given as in a Phthisis.

GENUS XIII. CARDITIS.

Inflammation of the HEART.

Carditis, Sauv. gen. 111. Vog. 54. Pericarditis, Vog. 53. Carditis spontanea, Sauv. fp. 1. Senac. Traité de Cœur, l. iv. c. 7. Meckel, Mem. de Berlin, 1756. Erytphelas pulmonis, Lomm. Obser. lib. ii.

Description. This disease is attended with all the symptoms of pneumonia; but in a higher degree; it is besides said to be accompanied with hydrophobic symptoms, fainting, palpitation of the heart, a feeming madness, a sunk and irregular pulse, watery eyes, and a dejected countenance, with a dry and black tongue. On dissection, the heart and pericardium are found very much inflamed, and even ulcerated, with many polypous concretions.

Causes, &c. The same as in the pneumonia.

Prognosis. In the carditis the prognosis is more unfavourable than in the pneumonia; and indeed, unless the disease very quickly terminates, it must prove fatal, on account of the constant and violent motion of the heart, which exasperates the inflammation, and increases all the symptoms.

Cure. Here bleeding is necessary in as great a degree as the patient can possibly bear, together with blistering, and the antiphlogistic regimen likewise carried to a greater height than in the pneumonia; but the general method is the same as in other inflammatory diseases.

GENUS XIV. PERITONITIS.

Inflammation of the PERITONÆUM.

Sp. I. Inflammation of the PERITONÆUM properly so called.

Peritonitis, Vog. 62. Lieutad. Hist. anat. med. lib. i. obf. 3. Raygerus apud eund. lib. i. obf. 341. Morgagni. de sed. LVII. 20.

Sp. II. Inflammation of the PERITONÆUM extended over the Omentum.

Epiploitis, Sauv. gen. 106. Sag. gen. 308. Omentitis, Vog. 61. Omenti inflammatio, Boerh. 985, et Ill. Van Swieten, Comm. Stork. An. Med. I. 132. Hulme on the puerperal fever.

Sp. III. Inflammation of the PERITONÆUM stretched over the Mesentery.

Mefenteritis, Vog. 6c. Enteritis mefenterica, Sauv. fp. 4.

GENUS XV. GASTRITIS.

Inflammation of the STOMACH.

A. GASTRITIS PHLEGMONODÆA, or the genuine Gastritis.

Gastritis legitima, Sauv. fp. 1. Eller. de cogn. et cur. morbi febr. xii. Haller. obf. 14. hift. 3. Lieut. Hist. Anat. Med. lib. i. 74. Gastritis cryphleptola, Sauv. fp. 4. Cardialgia inflammatoria, Sauv. fp. 13. Tralles, de opio febr. ii. p. 231.

These diseases Dr Cullen has thought proper to consider all under the general head of Gastritis, as there are no certain signs by which they can be distinguished from each other, and the method of cure must be the same in all.

Description. The inflammation of the stomach is attended with great heat and pain in the epigastric region, extreme anxiety, an almost continual and painful hiccup, with a most painful vomiting of everything taken into the stomach. Sometimes a temporary madness ensues; and there is an inflance in the Edinburgh Medical Essays of the disorder being attended with an hydrophobia. The pulse is generally more sunk than in other inflammations, and the fever inclines to the nature of a typhus. The disorder is commonly of the remitting kind, and during the remissions the pulse frequently intermits. During the height of the disease, a mortal phreny frequently supervenes. The disease terminates on the fourth, seventh, or ninth day, or from the eleventh to the fifteenth; and is more apt to end in a gangrene than pneumatic inflammations, and more frequently in a firrhus than in an abscess.

Causes, &c. The inflammation of the stomach may arise from any acid substance taken into it; from a vehement passion, too large draughts of cold liquor, especially when the person is very hot; from a surfeit; a stoppage of perspiration; repulsion of the gout; inflammations of the neighbouring viscera; or from external injuries, such as wounds, contusions, &c.—It affects chiefly those of a plethoric habit and hot bilious constitution.

Prognosis. This disease is always very dangerous, and the prognosis doubtful, which also must always be in proportion to the severity of the symptoms. A cessation of pain, coldness about the precordia, great debility, with a languid and intermitting pulse, with Gastritis, an abatement of the hiccup, denote a gangrene and speedy death. From the sensibility of the stomach also, and its great connexion with the rest of the system, it must be obvious, that an inflammation of it, by whatever causes produced, may be attended with fatal consequences; particularly, by the great debility it produces, it may prove suddenly fatal, without running through the usual course of inflammations.—Its tendency to admit of resolution may be known by its having arisen from no violent cause, by the moderate state of the symptoms, and by a gradual remission of these symptoms in the course of the first or at most of the second week of the disease. The tendency to gangrene may be suspected from the symptoms continuing with unremitting violence, notwithstanding the use of proper remedies; and a gangrene already begun may be known by the symptoms above mentioned, particularly great debility and sudden cessation of pain. The tendency to suppuration may be known by the symptoms continuing but in a moderate degree for more than one or two weeks, and by a considerable remission of the pain, while a sense of weight and anxiety still remain. When an abscess has been formed, the frequency of the pulse is first abated: but soon after it increases, with frequent cold shivering, and an exacerbation in the afternoon and evening; followed by night sweats, and other symptoms of hectic fever. These at length prove fatal, unless the abscess open into the cavity of the stomach, the pus be evacuated by vomiting, and the ulcer soon healed.

Cure. It appears from dissections, that the stomach may very often be inflamed when the characteristic marks of it have not appeared; and therefore we are often exposed to much uncertainty in the cure. But when we have sufficient evidence that a state of active inflammation has taken place in the stomach, the principal object to be aimed at is to obtain a resolution. Before, however, this can be accomplished, it will often be necessary to employ measures with the view of obviating urgent symptoms. When the symptoms appear in the manner above described, the cure is to be attempted by large and repeated bleedings employed early in the disease; and from these we are not to be deterred by the weakness of the pulse, for it will commonly become fuller and softer after the operation. A blifter ought also to be applied to the region of the stomach; and the cure will be assisted by fomentations of the whole abdomen, and by frequent emollient and laxative clysters. The irritability of the stomach in this disease will admit of no medicines being thrown into it; and if any can be supposed necessary, they must be exhibited in clysters. Diluting drinks may be tried; but they must be of the very mildest kind, and given in very small quantities at a time. Opiates, in whatever manner exhibited, cannot be retained in the stomach during the first days of the disease; but when the violence of the disease shall have abated, and when the pain and vomiting recur at intervals only, opiates given in clysters are frequently employed with advantage; and after bleeding and blisters no remedy is more effectual either in allaying the pain or vomiting. As soon as the stomach will retain any laxative, gentle refrigerant cathartics, taken by the mouth, such as the soda phosphorata, soda tartarifata, or the like, Phlegma-are productive of great benefit. A tendency to gangrene in this disease is to be obviated only by the means just now mentioned; but when it does actually supervene, it admits of no remedy. A tendency to suppuration is to be obviated by the same means employed early in the disease. After a certain period it cannot be prevented by any means whatever; and, when actually begun, must be left to nature; the only thing that can be done by art being to avoid all irritation.

B. GASTRITIS ERYSIPELATOSA, or the Erysipelatous Gastritis.

Description. This species of inflammation takes place in the stomach much more frequently than the former. From dissections it appears that the stomach has been often affected with inflammation, when neither pain nor fever had given any notice of it; and such is justly looked upon to have been of the erysipelatous kind. This kind of inflammation also is especially to be expected from acrimony of any kind applied to the stomach; and would certainly occur much more frequently, were not the interior surface of this organ commonly defended by mucus exuding in large quantity from the numerous follicles placed immediately under the villous coat. On many occasions, however, the exudation of mucus is prevented, or the liquid poured out is of a less virulent kind, so as to be less fitted to defend the subjacent nerves; and it is in such cases that acrid matters may readily produce an erysipelatous affection of the stomach.

In many cases this kind of inflammation cannot be discovered, as it takes place without pain, pyrexia, or vomiting: but in some it may; namely, when it spreads into the oesophagus, and appears on the pharynx and on the whole internal surface of the mouth. When therefore an erysipelatous inflammation affects the mouth and fauces, and there shall be at the same time in the stomach an unusual sensibility to all acids, and also a frequent vomiting, there can be little doubt of the stomach's being affected in the same manner. Even when no inflammation appears in the fauces, if some degree of pain be felt in the stomach, if there be a want of appetite, an anxiety and frequent vomiting, an unusual sensibility with regard to acids, some thirst, and frequency of pulse, there will then be room to suspect an inflammation in the stomach; and such symptoms, after some time, have been known to discover their cause by the inflammation rising to the fauces or mouth. Inflammation of this kind is often disputed to pass from one place to another on the same surface, and, in doing so, to leave the place it had at first occupied. Such an inflammation has been known to spread successively along the whole tract of the alimentary canal; occasioning, when in the intestines, diarrhoea, and in the stomach vomitings; the diarrhoea ceasing when the vomitings came on, and the vomitings on the coming on of the diarrhoea.

Causes, &c. An erysipelatous inflammation may arise from acrid matters taken into the stomach; or from some internal causes not yet well known. It frequently occurs in putrid diseases, and in those recovering from fevers.

Cure. When the disease is occasioned by acrid matters taken internally, and these may be supposed still present in the stomach, they are to be wafhed out by drinking a large quantity of warm and mild medicines, and exciting gentle vomiting. At the same time, if the nature of the acrimony and its proper corrector be known, this should be thrown in; or if a specific corrector be not known, some general demulcents should be employed.

These measures, however, are more suited to prevent than to cure inflammation after it has taken place. When this last may be supposed to have happened, if it be attended with a sense of heat, with pain and pyrexia, according to the degree of these symptoms, the measures proposed for the cure of the other kind are to be more or less employed. When an erysipelatous inflammation of the stomach has arisen from internal causes, if pain and pyrexia occur, bleeding may be employed in persons not otherwise weakened; but in case of its occurring in putrid diseases, or where the patients are already debilitated, bleeding is inadmissible; all that can be done being to avoid irritation, and only throwing into the stomach what quantity of acids and asecental aliment it shall be found able to bear. In some conditions of the body in which this disease is apt to occur, cinchona and bitters may seem to be indicated; but an erysipelatous state of the stomach will seldom allow them to be used.

Genus XVI. ENTERITIS.

Inflammation of the Intestines.

Enteritis, Sauv. gen. 105. Lin. 29. Vog. 57. Sag. gen. 397. Intestinorum inflammatio, Boerh. 959. Febris intestinorum inflammatoria ex mesenterio, Hoffm. ii. 170.

Sp. I. ENTERITIS PHLEGMONODÆA, or the Acute Enteritis.

Enteritis iliaca, Sauv. sp. 1. Enteritis colica, Sauv. sp. 2. Boerh. 963.

Description. This disease shows itself by a fixed pain in the abdomen, attended with fever, vomiting, and coarsiveness. The pain is often felt in different parts of the abdomen, but more frequently spreads over the whole, and is particularly violent about the navel.

Causes, &c. Inflammations of the intestines may arise from the same causes as those of the stomach; though commonly the former will more readily occur from cold applied to the lower extremities, or to the belly itself. It is also found supervening on the spasmodic colic, incarcerated hernia, and volvulus.

Prognosis. Inflammations of the intestines have the same terminations with those of the stomach, and the prognosis in both cases is much the same.

Cure. The cure of enteritis is in general the same with that of gastritis; but in this disease there is commonly more opportunity for the introduction of liquids, of acid, asecent, and other cooling remedies, and even of laxatives; but as a vomiting frequently attends the enteritis, care must be taken not to excite that vomiting by the quantity or quality of any thing thrown into the stomach. With regard to the suppura- ration and gangrene of the intestines following the enteritis, the observations made respecting these terminations of gastritis are equally applicable in this disease.

Sp. II. ENTERITIS ERYSIPELATOSA, or Erysipelatous Enteritis.

Concerning this nothing farther can be said, than what hath been already delivered concerning the gastritis.

GENUS XVII. HEPATITIS.

Inflammation of the LIVER.

Hepatitis, Sawv. gen. 113. Lin. 35. Vog. 58. Sag. gen. 312. Boerh. 914. Huffin. ii. 14. Junk. 66.

Description. The inflammation of the liver is thought to be of two kinds, acute and chronic; but the latter very often does not discover itself except by an abscess found in the liver after death, and which is supposed to have been occasioned by some degree of inflammation; for this reason the chronic inflammation often escapes observation, and we shall here only treat of the acute hepatitis.

The acute hepatitis is attended with considerable fever; a frequent, strong, and hard pulse; high-coloured urine; an acute pain in the right hypochondrium, increased by pressing upon the part. The pain is very often in such a part of the side as to make it appear like a pleurisy; and frequently, like that, is increased on inspiration. The disease is also commonly attended with a cough, which is generally dry, though sometimes moist; and when the pain thus resembles a pleurisy, the patient cannot lie easily except upon the side affected. The pain is frequently extended to the clavicle, and to the top of the shoulder; and is attended sometimes with hiccough, and sometimes with vomiting. Some have added jaundice, or a yellowness of the eyes, to the symptoms of this distemper; but experience shows that it has often occurred without any such symptom.

When hepatitis is of the chronic kind, depending more on an accumulation and effusion in the liver, than on an increased action of its small vessels, the patient complains rather of a sense of weight than of pain; and the fever is by no means either acute or confluent; but it often returns in paroxysms somewhat resembling the attacks of an intermittent. This disease is very slow in its progress, frequently continuing for many months, and at last terminating in a very considerable suppuration. In most cases, however, it may be discovered by careful examination of the region of the liver externally. By this means, a considerable enlargement of that viscus may in general be detected.

Cause, &c. The remote causes of hepatitis are not always to be discerned, and many have been assigned on a very uncertain foundation. It is principally a disease of warm climates. It has been supposed that the disease may be an affection either of the extremities of the hepatic artery, or those of the vena portarum; and the supposition is by no means improbable. The opinion, however, most commonly adopted is, that the acute hepatitis is an affection of the external membrane of the liver, and the chronic kind an affection of the parenchyma of that viscus. The acute Hepatitis disease may be feated either on the convex or concave surface of the liver; and in the former case a more pungent pain and hiccough may be produced, and the respiration is more considerably affected. In the latter there occurs less pain; and a vomiting is produced, commonly by some inflammation communicated to the stomach. The inflammation on the concave surface of the liver may be readily communicated to the gall-bladder and biliary ducts: and this, perhaps, is the only case of idiopathic hepatitis attended with jaundice.

Prognosis. The inflammation of the liver, like others, may end by resolution, suppuration, or gangrene; and the tendency to the one or to the other of these events may be known from what has been already mentioned concerning the prognosis in gastritis. The resolution of hepatitis is often the consequence of, or is attended with, evacuations of different kinds. A haemorrhage sometimes from the nose, and sometimes from the haemorrhoidal vessels, gives a solution of the disease. Sometimes the same thing is accomplished by a bilious diarrhoea; and sometimes the resolution is attended with sweating, and an evacuation of urine depositing a copious sediment. Sometimes it may be cured by an erysipelas appearing in some external part. When the disease has ended in suppuration, the pus collected may be discharged by the biliary ducts; or, if the suppurred part does not adhere anywhere closely to the neighbouring parts, it may be discharged into the cavity of the abdomen: but if, during the first state of inflammation, the affected part of the liver shall have formed a close adhesion to some of the neighbouring parts, the discharge after suppuration may be various, according to the different seat of the abscess. When seated on the convex part of the liver, if the adhesion be to the peritoneum lining the common teguments, the pus may make its way through these, and be discharged outwardly: or if the adhesion shall have been to the diaphragm, the pus may penetrate through this, and into the cells of the lungs; from whence it may be discharged by coughing. When the abscess is seated on the concave part of the liver, in consequence of adhesions, the pus may be discharged into the stomach or intestines; and into these last, either directly, or by the intervention of the biliary ducts. Upon a consideration of all these different circumstances, therefore, together with the general principles of inflammation, must the prognosis of this disease be established.

Cure. For the cure of hepatitis, we must have recourse to the general means of resolving other inflammatory disorders. Bleeding is to be used according to the degree of fever and pain. Blisters are to be applied: fomentations of the external parts, emollient clysters, gentle laxatives, diluents and refrigerants, are also useful. The cure, however, particularly in warm climates, where the disease is much more common than it is in Britain, is chiefly trusted to mercury. Not only in cases of the chronic kind, but in acute hepatitis also, after an attempt has been made to alleviate the urgent symptoms by bleeding and blistering, recourse is immediately had to this powerful mineral. It is employed by different practitioners, and Phlegma in different cases, under various forms. Some are very fond of the use of calomel. But the preference is in general given, and perhaps with judice, to friction with mercurial ointment over the region of the liver. But under whatever form it may be employed, it is necessary that it should be introduced to such an extent as to keep the patient on the verge of salivation for some length of time; the duration being regulated by the circumstances of the case.

From the liberal use of mercury, there can be no doubt that a successful resolution has been obtained in many cases, which would otherwise have infallibly terminated in suppuration. But notwithstanding the most careful employment of it in some cases, suppuration will ensue; and then it is very doubtful whether any benefit will be derived from the continuance of it. But when a suppuration has been formed, and the abscess points outwardly, the part must be opened, the pus evacuated, and the ulcer healed according to the ordinary methods in use for healing abscesses and ulcers in other parts.

Chronic hepatitis often terminates in scirrhous. Against this, after mercury has failed, nitric acid taken internally has sometimes been employed with success.

GENUS XVIII. SPLENITIS.

Inflammation of the SPLEEN.

Splenitis, Sauv. gen. 114. Lin. 36. Vog. 59. Junck. 67. Sag. gen. 313. Lienis inflammatio, Boerh. 958. et Van Swieten, Comm. Splenicis phlegmonodaeas, Sauv. sp. 1. Forest, l. xx. obi. 5, 6. De Haen, apud Van Swieten, p. 958. Pleuritis splenica, Sauv. sp. 19. Splenalgia suppuratoria, Sauv. sp. 3.

Description. This disease, according to Juncker, comes on with a remarkable shivering, succeeded by a most intense heat and very great thirst; a pain and tumour are perceived in the left hypochondrium, and the paroxysms for the most part assume a quartan form. When the patients expose themselves for a little to the free air, their extremities immediately grow very cold. If a hemorrhage happens, the blood flows out of the left nostril. The other symptoms are the same with those of the hepatitis. Like the liver, the spleen is also subject to a chronic inflammation, which often happens after agues; and the tumour which succeeds the inflammation is in many cases very considerable, and is called the ogre cake, though that name is also frequently given to a scirrhous tumour of the liver succeeding intermittents.

Causes, &c. The causes of this distemper are in general the same with those of other inflammatory disorders; but those which determine the inflammation to that particular part more than another, are very much unknown. It attacks persons of a very plethoric and sanguine habit of body rather than others.

Prognosis. What has been said of the inflammation of the liver applies also to that of the spleen, though the latter is less dangerous than the former. Here also a vomiting of black matter, which in other acute diseases is such a fatal symptom, sometimes proves critical, according to the testimony of Juncker. Sometimes the hemorrhoids prove critical; but very often the inflammation terminates by scirrhous.

Cure. This is not at all different from what has been already laid down concerning the hepatitis.

GENUS XIX. NEPHRITIS.

Inflammation of the KIDNEYS.

Nephritis, Sauv. gen. 115. Lin. 37. Vog. 65. Sag. gen. 314. Nephritis vera, Sauv. sp. 1.

Description. The nephritis has the same symptoms which take place in other inflammations; but its distinguishing mark is the pain in the region of the kidney, which is sometimes obtuse, but more frequently pungent. The pain is not increased by the motion of the trunk of the body so much as a pain of the rheumatic kind affecting the same region. It may also frequently be distinguished by the pain shooting along the course of the ureter, and it is often attended with a drawing up of the testicle, and a numbness of the limb on the side affected; though indeed these symptoms most commonly attend the inflammation arising from a calculus in the kidney or ureter. The disease is also attended with frequent vomiting, and often with coliciveness and colic pains. The urine is most commonly of a deep red colour, and is voided frequently and in a small quantity at a time. In more violent cases the urine is commonly colourless.

Causes, &c. The remote causes of this disease may be various; as external contusion, violent or long-continued riding; strains of the muscles of the back incumbent on the kidneys; various acids in the course of circulation conveyed to the kidneys; and perhaps some other internal cause not yet well known: the most frequent is that of calculous matter obstructing the tubuli uriniferi, or calculi formed in the pelvis of the kidneys, and either sticking there or falling into the ureter.

Prognosis. This is not different from that of other inflammatory diseases.

Cure. When any of those causes operating as inducing the inflammation still continue to act, the first object in the cure must be the removal of these; but the principal intention to be had in view, is the resolution of the inflammation which has already taken place. But when, notwithstanding efforts for this purpose, the disease terminates in suppuration, it must be the endeavour of the practitioner to promote the discharge of purulent matter, and the healing of the ulceration in the kidney.

These different objects are principally accomplished by bleeding, external fomentation, frequent emollient clysters, antiphlogistic purgatives, and by the free use of mild and demulcent liquids. The use of blisters is scarcely admissible, or at least will require great care to avoid any considerable absorption of the cantharides.

The other species of nephritis enumerated by authors are only symptomatic. GENUS XX. CYSTITIS.

Inflammation of the BLADDER.

Cystitis, Sauv. gen. 108. Lin. 31. Vog. 66. Sag. gen. 399. Inflammatio vesicæ, Hoffm. ii. 157.

The CYSTITIS from Internal Causes.

Cystitis spontanea, Sauv. sp. 1.

The CYSTITIS from External Causes.

Cystitis à cantharidibus, Sauv. sp. 2. Cystitis traumatica, Sauv. sp. 3.

The inflammation of the bladder from internal causes is a very rare distemper; and when it does at any time occur, is to be cured in the same manner with other inflammations, avoiding only the use of blisters. When the disease arises from the internal use of these flies, camphor is recommended, besides other cooling medicines, and particularly cooling and emollient clysters.

GENUS XXI. HYSTERITIS.

Inflammation of the UTERUS.

Hysteritis, Lin. 38. Vog. 63. Metritis, Sauv. gen. 107. Sag. gen. 315. Inflammatio et febris uterina, Hoffm. II. 156.

Description. This disease is often confounded with that called the puerperal or child-bed fever; but is essentially distinct from it, as will be shewn in its proper place. The inflammation of the uterus is often apt to terminate by gangrene: there is a pain in the head, with delirium; and the uterine region is so exceedingly tender, that it cannot bear the most gentle pressure without intolerable pain. When the fundus uteri is inflamed, there is great heat, throbbing, and pain, above the pubes; if its posterior part, the pain is more confined to the loins and rectum, with a tenesmus; if its anterior part, it floats from thence towards the neck of the bladder, and is attended with a frequent irritation to make water, which is voided with difficulty; and if its sides or the ovaria are affected, the pains will then dart into the inside of the thighs.

Causes, &c. Inflammations of the uterus, and indeed of the rest of the abdominal viscera, are very apt to take place in child-bed women; the reason of which seems to be the sudden change produced in the habit, and an alteration in the course of the circulating blood by the contraction of the uterus after delivery. The pressure of the gravid uterus being suddenly taken off from the aorta descendens after delivery, the resistance to the impulse of the blood passing through all the vessels derived from it, and distributed to the contiguous viscera, will be considerably lessened: it will therefore rush into those vessels with a force superior to their resistance; and, by putting them violently on the stretch, may occasion pain, inflammation, and fever. This contraction of the uterus also renders its vessels impervious to the blood which had freely passed through them for the service of the child during pregnancy; and consequently a much larger quantity will be thrown upon the contiguous parts, which will still add to their distention, and increase their tendency to inflammation.

Prognosis. An inflammation of the uterus may in general be expected to produce an obstruction of the lochia; but the fever produced seldom proves fatal, unless the inflammation be violent, and end in a gangrene.

Cure. This is to be attempted by the same general means already recommended, and the management of this disorder entirely coincides with that of the puerperal fever.

GENUS II. RHEUMATISMUS.

The RHEUMATISM.

Rheumatismus, Sauv. gen. 185. Lin. 62. Vog. 138. Boerh. 1400. Junck. 19. Dolores rheumatici et arthritici, Hoffm. II. 317. Myofitis, Sag. gen. 301.

The Acute RHEUMATISM.

Rheumatismus acutus, Sauv. sp. 1. Rheumatismus vulgaris, Sauv. sp. 2.

A. The LUMBAGO, or Rheumatism in the Muscles of the Loins.

Lumbago rheumatica, Sauv. gen. 212. Sag. p. 1. Nephralgia rheumatica, Sauv. sp. 4.

B. The SCIATICA, ICHIAS, or Hip-Gout.

Ichias rheumaticum, Sauv. 213. sp. 10.

C. The Bastard PLEURISTY, or Rheumatism in the Muscles of the Thorax.

Pleurodyne rheumatica, Sauv. gen. 148. sp. 3. Pleuritis spuria, Boerh. 878.

The other species, which are very numerous, are all symptomatic; as, Lumbago plethorica, Sauv. sp. 3. Ichias fanguinea, Sauv. sp. 2. Pleurodyne plethorica, Sauv. sp. 1. Rheumatismus hystericus, Sauv. sp. 7. Ichias hystericum, Sauv. sp. 3. Pleurodyne hysteric, Sauv. sp. 6. Rheumatismus saltatorius, Sauv. sp. 8. Pleurodyne flatulenta, Sauv. sp. 4. Pleurodyne à spafmate, Sauv. sp. 9. Rheumatismus scorbuticus, Sauv. sp. 4. Lumbago scorbutica, Sauv. sp. 5. Pleurodyne scorbutica, Sauv. sp. 11. Ichias typhiliticum, Sauv. sp. 7. Pleurodyne venerea, Sauv. sp. 5. Lumbago sympathica, Sauv. sp. 13. Lumbago à saburrà, Sauv. sp. 8. Pleurodyne à cocochylia, Sauv. sp. 7. Rheumatismus saltatorius verminosus, Sauv. sp. 8. Ichias verminosum, Sauv. sp. 8. Pleurodyne verminosa, Sauv. sp. 2. Rheumatismus metallicus, Sauv. sp. 10. Lumbago à hydrothorace, Sauv. sp. 14. Lumbago pseudoischuria, Sauv. sp. 16. Pleurodyne à rupto celophago, Sauv. sp. 20. Pleurodyne rachitica, Sauv. sp. 13. Ichias à sparganosi, Sauv. sp. 5. Pleurodyne catarrhalis, Sauv. sp. 14. Rheumatismus necrocos, Sauv. sp. I4. Rheumatismus dorfalis, Sauv. sp. II. Lumbago à fatyriafi, Sauv. sp. I5. Rheumatismus febricofus, Sauv. sp. 9. Lumbago febrilis, Sauv. sp. 4. &c. &c.

Description. The rheumatism is particularly distinguished by pains affecting the joints, and for the most part the joints alone; but sometimes also the muscular parts. Very often they flow along the course of the muscles from one joint to another, and are always much increased by the action of the muscles belonging to the joint or joints affected. The larger joints are those most frequently affected, such as the hip-joint and knees, of the lower extremities, and the shoulders and elbows of the upper ones. The ankles and wrists are also frequently affected; but the smaller joints, such as those of the toes or fingers, seldom suffer. Sometimes the disease is confined to one part of the body, yet very frequently it affects many parts; and then it begins with a cold fitage, which is immediately succeeded by the other symptoms of pyrexia, and particularly by a frequent, full, and hard pulse. Sometimes the pyrexia is formed before any pains are perceived; but more commonly pains are felt in particular parts before any symptoms of fever occur. When no pyrexia is present, the pain may be confined to one joint only; but when any considerable pyrexia takes place, though the pain may chiefly be felt in one joint, yet it seldom happens that it does not affect several joints, often at the very same time, but for the most part shifting their place, and having abated in one joint they become more violent in another. They do not commonly remain long in the same joint, but frequently shift from one to another, and sometimes return to joints formerly affected; and in this manner the disease often continues for a long time. The fever attending these pains has an exacerbation every evening, and is most considerable during the night, when the pains also become more violent; and it is at the same time that the pains shift their place from one joint to another. These seem to be also increased during the night by the body being covered more closely, and kept warmer.

A joint, after having been for some time affected with pain, commonly becomes also affected with some swelling and redness, which is painful to the touch. It seldom happens that a swelling coming on does not take off the pain entirely, but it rarely secures the joint against a return of it. This disease is commonly attended with more or less sweating, which occurs early, but is seldom free or copious, and seldom proves critical, though it may give temporary relief of the pain. The urine is high-coloured, and in the beginning without sediment. This, however, does not prove entirely critical, for the disease often continues long after such a sediment has appeared in the urine. The blood is always fizzy. The acute rheumatism differs from all other inflammatory diseases, in not being liable to terminate in suppuration: this almost never happens; but the disease sometimes produces effusions of a transparent gelatinous fluid into the sheaths of the tendons: but if these effusions be frequent, it is certain that the liquor must often be absorbed; for it very seldom happens, that considerable or permanent tumours have been produced, or such as required to be opened and to have the Rheumatism contained fluid evacuated. Such tumours, however, have sometimes occurred, and the opening made in them has produced ulcers very difficult to heal.

Sometimes rheumatism will continue for several weeks; but it seldom proves fatal, and it is rare that the pyrexia continues to be considerable for more than two or three weeks. While the pyrexia abates in its violence, if the pains of the joints continue, they are less violent; more limited in their place, being confined commonly to one or a few joints only; and are less ready to change their place.

It is often a very difficult matter to distinguish rheumatism from gout: but in rheumatism there in general occurs much less affection of the stomach; it affects chiefly the larger joints, and several of these are often affected with severe pain at the same time: it occurs at an earlier period of life than gout; it is not observed to be hereditary; and it can in general be traced to some obvious exciting cause, particularly to the action of cold.

Causes, &c. This disease is frequent in cold, and more uncommon in warm climates. It appears most frequently in autumn and spring; less frequently in winter, while the frost is constant; and very seldom during the heat of summer. It may, however, occur at any season, if vicissitudes of heat and cold be for the time frequent. For the most part, the acute rheumatism arises from the application of cold to the body when unusually warm; or when the cold is applied to one part of the body, whilst the other parts are kept warm; or lastly, when the application of the cold is long continued, as when moist or wet clothes are applied to any part of the body.—These causes may affect persons of all ages; but the rheumatism seldom appears either in very young or in elderly persons, and most commonly occurs from the age of puberty to that of 35. These causes may also affect persons of any constitution, but they most commonly affect those of a sanguine temperament.

With respect to the proximate cause of rheumatism, there have been various opinions. It has been imputed to a peculiar acrimony; of which, however, there is no evidence; and the consideration of the remote causes, the symptoms, and cure, render it very improbable. A disease of a rheumatic nature, however, may be occasioned by an acrid matter applied to the nerves, as is evident from the toothache, a rheumatic affection generally arising from a carious tooth. Pains arising from deep-seated suppurations may also resemble the rheumatism; and many cases have occurred in which such suppurations occasioned pains resembling the lumbago and scilias; but from what has been already said, it seems improbable that ever any pure rheumatic case should end in suppuration.

The proximate cause of rheumatism has by many been supposed to be a lentor in the fluids obstructing the vessels of the part; but in the observations formerly made, sufficient reasons have been already laid down for rejecting the doctrine of lentor. While we cannot therefore find either evidence or reason for supposing that the rheumatism depends on any change in the state of the fluids, we must conclude that the proximate cause of it is the same with that of other inflammations not depending upon a direct stimulus. In the case of rheumatism, it is supposed that the most common remote cause of it, that is, cold applied, operates especially on the vessels of the joints, these being less covered by a cellular texture than those of the intermediate parts of the limbs. It is farther supposed, that the application of cold produces a contraction of the extreme vessels, and at the same time an increase of tone or phlogistic diathesis in the course of them, from which arises an increased impetus of the blood, and at the same time a resistance to the free passage of it, and consequently inflammation and pain. It is also supposed, that the resistance formed excites the vis medicatrix to a further increase of the impetus of the blood; and to support this, a cold stage arises, a spasm is formed, and a pyrexia and phlogistic diathesis are produced in the whole system.

Hence the cause of rheumatism appears to be exactly analogous to that of inflammations depending on an increased influx of blood to a part while it is exposed to the action of cold. But there seems to be further in this disease some peculiar affection of the muscular fibres. These seem to be under some degree of rigidity; and therefore less easily admit of motion, and are pained upon the exertions of it. This also seems to be the affection which gives opportunity to the propagation of pains from one joint to another, and which are most severely felt in the extremities terminating in the joints, because beyond these the oscillations are not propagated. This affection of the muscular fibres explains the manner in which strains and spasms produce rheumatic affections; and, on the whole, shows, that with an inflammatory affection of the languiferous system, there is also in rheumatism a peculiar affection of the muscular fibres, which has a considerable share in producing the phenomena of the disease. And it would even appear, that in what has commonly been called acute rheumatism, in contradistinction to the chronic, of which we are next to treat, there exists not only a state of active inflammation in the affected parts, but also of peculiar irritability; and that this often remains after the inflammation is very much diminished or has even entirely ceased. Hence a renewal of the inflammation and recurrence of the pain take place from very slight causes; and in the treatment of the disease both the state of inflammation and irritability must be had in view.

Cure. For counteracting the state of active inflammation, the chief aim of the practitioner must be to diminish the general impetus of the circulation, and the impetus at the part particularly affected. For counteracting the state of irritability, he must endeavour to remove the disposition to increased action in the vessels; to prevent the action of causes exciting painful sensations; and to obviate their influence on the part. The cure therefore requires, in the first place, an antiphlogistic regimen, and particularly a total abstinence from animal food, and from all fermented or spirituous liquors; substituting a mild vegetable or milk diet, and the plentiful use of soft diluting liquors. On this principle also, blood-letting is the chief remedy of acute rheumatism. The blood is to be drawn in large quantity; and the bleeding is to be repeated in proportion to the frequency, fulness, and hardness of the pulse, and the violence of the pain. For the most part, large and repeated bleedings during the first days of the disease seem to be necessary, and accordingly have been very much employed; but to this some bounds are to be set; for very profuse bleedings occasion a flow recovery, and are ready to produce a chronic rheumatism.

To avoid that debility of the system which general bleedings are apt to occasion, the urgent symptom of pain may be often relieved by topical bleedings; and when any swelling or redness has come upon a joint, the pain may very certainly be relieved by this evacuation: but as the pain and continuance of the disease seem to depend more upon the phlogistic diathesis of the whole system than upon the affection of particular parts, so topical bleedings will not supply the place of the general bleedings proposed above in most instances.

To take off the phlogistic diathesis prevailing in this disease, purging may be useful, if procured by medicines which do not stimulate the whole system, as neutral salts, and other medicines which have a refrigerant power. Purging, however, is not so useful as bleeding in removing the phlogistic diathesis; and when the disease has become general and violent, frequent stools are inconvenient, and even hurtful, by the motion and pain which they occasion.

Next to blood-letting, nothing is of so much service, both in alleviating the pains in this disease and in removing the phlogistic diathesis, as the use of fudorifics: and of all the medicines belonging to this class, what has commonly been known by the name of Dover's powder, a combination of powder of ipecacuan and opium, is the most convenient and the most effectual. Copious sweating, excited by this medicine, and supported for 10 or 12 hours by tepid diluents, such as decoction of the woods, or the like, will in most instances produce a complete remission of the pain: and by this practice, combined with blood-letting and proper regimen, the disease may often be entirely removed.

If, however, after complete intermissions from pain for some length of time have been obtained by these means, it be found that there is a great tendency to a return of the pains without any obvious cause, recourse may be had with very great benefit to the use of the Peruvian bark. By the early use of this, where a complete intermission from pain is obtained, the necessity of repeated blood-letting and sweating is often superceded; but where a complete remission cannot be obtained, it has been supposed by some to be hurtful: and in these cases, when blood-letting and fudorifics have been pushed as far as may be thought prudent, without being productive of the desired effect, very great benefit is often derived from the use of calomel combined with opium, as recommended in the Edinburgh Medical Commentaries, by Dr Hamilton of Lynn Regis.

In this disease, external applications are of little service. Fomentations in the beginning of the disease rather aggravate than relieve the pains. The rubefacients and camphire are more effectual: but they commonly only move them from one part to another, and do not prove any cure of the general affection. Blistering may also be very effectual in removing the pain from a particular part; but will be of little use, except where the pains are much confined to one place.

ARTHRODYNAIA, or Chronic RHEUMATISM.

Rheumatismus chronicus Auditorum.

Description. When the pyrexia attending the acute rheumatism has ceased; when the swelling and redness of the joints are entirely gone, but pains still continue to affect certain joints, which remain stiff, feel uneasy upon motion, changes of weather, or in the night time only, the disease is then called the chronic rheumatism, as it often continues for a very long time.

The limits between the acute and chronic rheumatism are not always exactly marked. When the pains are still ready to shift their place; when they are especially severe in the night time; when, at the same time, they are attended with some degree of pyrexia, and with some swelling, and especially some redness of the joints; the disease is to be considered as partaking of the nature of the acute rheumatism. But when there is no longer any degree of pyrexia remaining; when the painful joints are without redness; when they are cold and stiff; when they cannot easily be made to sweat; or when, while a free and warm sweat is brought out on the rest of the body, it is only clammy and cold on the painful joints; and when, further, the pains of these are increased by cold, and relieved by heat, applied to them; the case is to be considered as that of a purely chronic rheumatism: or, perhaps more properly, the first of the conditions now described may be termed the state of irritability, and the second the state of atony.

The chronic rheumatism, or rather the atonic, may affect different joints; but is especially apt to affect those which are surrounded with many muscles, and those of which the muscles are employed in the most constant and vigorous exertions. Such is the case of the vertebræ of the loins, the affection of which is named lumbago; or of the hip joint, when the disease is named ichias or sciatica.

Violent strains and sprains occurring on sudden and somewhat violent exertions, bring on rheumatic affections, which at first partake of the acute, but very soon change into the nature of the chronic, rheumatism.—Such are frequently the lumbago, and other affections, which seem to be more feated in the muscles than in the joints. The distinction of the rheumatic pains from those resembling them which occur in the phthisis and feverly must be obvious, either from the seat of the pains, or from the concomitant symptoms peculiar to those diseases. The distinction of the rheumatism from the gout will be more fully understood from what is laid down under the genus Podagra.

Causes, &c. The phenomena of the purely chronic rheumatism lead us to conclude, that its proximate cause is an atony both of the blood-vessels and of the muscular fibres of the part affected, together with such a degree of rigidity and contraction in the latter as frequently attend them in a state of atony: and indeed this atony, carried to a certain extent, gives rise to a state of paralytic, with an almost total loss of motion in the affected limbs. The paralytic state of rheumatism therefore may be pointed out as a fourth condition of the disease, often claiming the attention of rheumatism the practitioner.

Cure. From the view just now given of the proximate cause of chronic rheumatism, the chief indication of cure must be, to restore the activity and vigour of the part, which is principally to be done by increasing the tone of the moving fibres, but which may sometimes also be aided by giving condensation to the simple fluid. When, however, the disease has degenerated into the state of paralysis, the objects to be aimed at are, the restoration of a due condition to the nervous energy in the part affected; the obtaining free circulation of blood through the vessels of the part; and the removal of rigidity in membranes and ligaments.

For answering these purposes, a great variety of remedies, both external and internal, are had recourse to. The chief of the external are, the supporting the heat of the part, by keeping it constantly covered with flannel; the increasing the heat of the part by external heat, applied either in a dry or humid form; the diligent use of the flesh-brush, or other means of friction; the application of electricity in sparks or shocks; the application of cold water by affusion or immersion; the application of essential oils of the most warm and penetrating kind; the application of salt brine; the employment of the warm bath or of the vapour baths, either to the body in general or to particular parts; and, lastly, the employment either of exercise of the part itself as far as it can easily bear, or by riding or other modes of gestation.

The internal remedies are, large doses of essential oils drawn from resinous substances, such as turpentine; substances containing such oils, as guaiac; volatile alkaline salts, &c. These or other medicines are directed to procure sweat; and calomel, or some other preparation of mercury, in small doses, may be continued for some time. But of all the remedies which have been found useful in atonic rheumatism, perhaps the best is cinchona. It is particularly serviceable in the earlier periods of the disease. It has often been highly efficacious in preventing the degeneracy of the inflammatory into the atonic state of the disease; and by some practitioners, particularly Dr Haygarth of Bath, it has been highly extolled in acute rheumatism. Besides these, there are several other remedies recommended. The cicuta, aconitum, and hyoscyamus, have in particular been highly extolled; and an infusion of the rhododendron chrysanthum is said to be employed by the Siberians with very great success. An account of the Siberian mode of practice is given by Dr Matthew Guthrie of Peterburgh, in the fifth volume of the Edinburgh Medical Commentaries, and has been followed with success at other places. Among other internal remedies for rheumatism, the use of arsenic has of late been recommended by Dr Bardley of Liverpool. It is advised to be given under the form of the mineral solution proposed by Dr Fowler as a remedy in intermittent fever and in periodic headaches. Under this form, it is now ascertained by extensive experience that arsenic may be taken internally with as much safety as any other active medicine; and in some cases of rheumatism in which it has been employed at Edinburgh, there is reason to believe that it has been productive of benefit. GENUS XXIII. ODONTALGIA, the Toothach.

Odontalgia, Sauv. gen. 198. Lin. 45. Vog. 145. Sag. gen. 159. Junck. 25. Odontalgia sive rheumatismus odontalgicus, Hoffm. II. 330. Odontalgia cariosa, Sauv. sp. 1. Odontalgia scorbutica, Sauv. sp. 4. Odontalgia catarrhalis, Sauv. sp. 3. Odontalgia arthritica, Sauv. sp. 6. Odontalgia gravidarum, Sauv. sp. 2. Odontalgia hysterica, Sauv. sp. 8. Odontalgia itomachica, Sauv. sp. 9.

Description. This well-known disease makes its attack by a most violent pain in the teeth, most frequently in the molares, more rarely in the incisores, reaching sometimes up to the eyes, and sometimes backward into the cavity of the ear. At the same time there is a manifest determination to the head; and a remarkable tension and inflation of the veins takes place, not only in the parts next to that where the pain is located, but over the whole head.

Causes, &c. The toothach is sometimes merely a rheumatic affection, arising from cold, but more frequently from a carious tooth. It is also a symptom of pregnancy, and takes place in some nervous disorders; it may attack persons at any time of life, though it is most frequent in the young and plethoric.

Cure. Many empirical remedies have been proposed for the cure of the toothach, but none have in any degree answered the purpose. When the affection is purely rheumatic, blisters behind the ear will almost always remove it; but when it proceeds from a carious tooth, the pain is much more obstinate. In this case it has been recommended to touch the pained part with a hot iron, or with sulphuric acid, in order to destroy the aching nerve; to hold strong spirits in the mouth; to put a drop of oil of cloves into the hollow of the tooth, or a pill of equal parts of opium and camphor; but one of the most useful applications of this kind is strong nitrous acid, diluted with three or four times its weight of spirit of wine, and introduced into the hollow of a tooth from which great pain arises, either by means of a hair pencil or a little cotton. Cinchona has also been recommended, and perhaps with more justice, on account of its tonic and antiseptic powers; but very often all these remedies will fail, and the only infallible cure is the extraction of the tooth. See Surgery.

GENUS XXIV. PODAGRA, the Gout.

Podagra, Vog. 175. Boerh. 1254. Febris podagrica, Vog. 69. Arthritis, Sauv. gen. 183. Lin. 60. Vog. 139. Sag. gen. 142. Dolor podagricus et arthriticus versus, Hoffm. II. 339. Dolores arthritici, Hoffm. II. 317. Afectus spatifico-arthritici, Junck. 46.

Sp. I. The Regular Gout. Arthritis podagrica, Sauv. sp. 1.

Arthritis rachialgica, Sauv. sp. 17. Arthritis reflexiva, Sauv. sp. 4.

Sp. II. The Atomic Gout. Arthritis melancholica, Sauv. sp. 6. Arthritis hiemalis, Sauv. sp. 2. Arthritis chlorotica, Sauv. sp. 5. Arthritis athmatica, Sauv. sp. 9.

Sp. III. The Retrocedent Gout.

Sp. IV. The Misplaced Gout.

Description. What we call a paroxysm of the gout is principally constituted by an inflammatory affection of some of the joints. This sometimes comes on suddenly, without any warning, but is generally preceded by several symptoms; such as the ceasing of a sweating which the feet had been commonly before affected with; an unusual coldness of the feet and legs; a frequent numbness, alternating with a sense of prickling along the whole of the lower extremities; frequent cramps of the muscles of the legs; and an unusual turgescence of the veins.

While these symptoms take place in the lower extremities, the body is affected with some degree of torpor and languor, and the functions of the stomach in particular are more or less disturbed. The appetite is diminished; and flatulency, or other symptoms of indigestion, are felt. These symptoms take place for several days, sometimes for a week or two, before a paroxysm comes on; but commonly, upon the day immediately preceding it, the appetite becomes keener than usual.

The circumstances of paroxysms are chiefly the following. They come on most commonly in the spring, and sooner or later according as the vernal heat succeeds sooner or latter to the winter's cold, and, perhaps, sooner or later also, according as the body may happen to be more or less exposed to vicissitudes of heat and cold.

The attacks are sometimes felt first in the evening, but more commonly about two or three o'clock in the morning. The paroxysm begins with a pain affecting one foot, most frequently in the ball or first joint of the great toe, but sometimes in other parts of the foot. With the attack of this pain, there is commonly more or less of a cold shivering; which, as the pain increases, gradually ceases; and is succeeded by a hot stage of pyrexia, which continues for the same time with the pain itself. From the first attack, the pain becomes, by degrees, more violent, and continues in this state with great reliefs of the whole body till next midnight, after which it gradually remits; and, after it has continued for twenty-four hours from the commencement of the first attack, it commonly ceases almost entirely; and, with the coming on of a gentle sweat, allows the patient to fall asleep. The patient, upon coming out of this sleep in the morning, finds the pained part affected with some redness and swelling, which, after having continued for some days, gradually abates.

When a paroxysm has thus come on, although the violent pain after 24 hours be considerably abated, the patient is not entirely relieved from it. For some days days he has every evening a return of more considerable pain and pyrexia, and these continue with more or less violence till morning. After going on, in this manner, for several days, the disease sometimes goes entirely off, not to return till after a long interval.

When the disease, after having thus remained for some time in a joint, ceases entirely, it generally leaves the person in very perfect health, enjoying greater ease and alacrity in the functions of both body and mind than he had for a long time before experienced.

At the beginning of the disease, the returns of it are sometimes only once in three or four years: but as it advances, the intervals become shorter, and at length the attacks are annual; afterwards they come twice each year; and at length recur several times during the course of autumn, winter, and spring; and as, when the fits are frequent, the paroxysms become also longer, fo, in the advanced state of the disease, the patient is hardly ever tolerably free from it, except perhaps for two or three months in summer.

The progress of the disease is also marked by the parts which it affects. At first, it commonly affects one foot only; afterwards every paroxysm affects both feet, the one after the other; and as the disease proceeds, it not only affects both feet at once, but, after having ceased in the foot which was last attacked, returns again into the first, and perhaps a second time also into the other. Its changes of places are not only from one foot to another, but from the feet into other joints, especially those of the upper extremities; so that there is hardly a joint of the body which, on one occasion or another, is not affected. It sometimes affects two different joints at the very same time; but more commonly it is at any one time severe in a single joint only, and passes in succession from one joint to another; so that the patient's affliction is often protracted for a long time.

When the disease has often returned, and the paroxysms have become very frequent, the pains are commonly less violent than they were at first; but the patient is more affected with sickness, and the other symptoms of the atonic gout, which shall be hereafter mentioned.

After the first paroxysm of the disease, the joints which have been affected are entirely restored to their former suppleness and strength: but after the disease has recurred very often, the joints affected do neither fo suddenly nor entirely recover their former state, but continue weak and stiff; and these effects at length proceed to such a degree, that the joints lose their motion entirely.

In many persons, but not in all, after the disease has frequently recurred, concretions of a chalky nature are formed upon the outside of the joints, and for the most part immediately under the skin. The matter seems to be deposited at first in a fluid form, afterwards becoming dry and firm. In their firm state, these concretions are a hard earthy substance, very entirely soluble in acids. After they have been formed, they contribute, with other circumstances, to destroy the motion of the joints.

In most persons who have laboured under the gout for many years, a nephritic affection comes on, and discovers itself by all the symptoms which usually attend calculous concretions in the kidneys, and which we shall have occasion to describe in another place.

All that is necessary to be observed here is, that the nephritic affection alternates with paroxysms of the gout; and that the two affections, the nephritic and the gouty, are hardly ever present at the same time. This also may be observed, that children of gouty or nephritic parents commonly inherit one or other of these diseases; but whether the principal disease of the parent may have been either gout or nephritis alone, some of the children have the one and some the other. In some of them the nephritic affection occurs alone, without any gout supervening; and this happens to be frequently the case with the female children of gouty parents.

In the whole of the history already given, we have described the most common form of the disease, and which therefore, however diversified in the progress of it, may be still called the regular state of the gout.—Upon some occasions, however, the disease assumes different appearances: but as we suppose the disease to depend always upon a certain diathesis, or disposition of the system; fo every appearance which we can perceive to depend upon that fame disposition, we still consider as symptomatic, and view the disease to be a case of the gout. The principal circumstance, in what we term the regular gout, is the inflammatory affection of the joints; and whatever symptoms we can perceive to be connected with, or to depend upon, the disposition which produces that inflammatory affection, but without its taking place or being present at the same time, we name the irregular gout.

Of such irregular gout there are three different states, which may be named the atonic, the retrocedent, and the misplaced gout.

The first is, when the gouty diathesis prevails in the system; but, from certain causes, does not produce the inflammatory affection of the joints. In this case, the morbid symptoms which appear, are chiefly affections of the stomach, such as loss of appetite, indigestion, and its various attendants of fickness, nausea, vomiting, flatulence, acid eructations, and pains in the region of the stomach. These symptoms are frequently accompanied with pains and cramps in several parts of the trunk and the upper extremities of the body, which are relieved by the discharge of wind from the stomach. Together with these affections of the stomach, there commonly occurs a coughiness; but sometimes a loofenes, with colic pains. These affections of the alimentary canal are often attended with all the symptoms of hypochondriasis, such as dejection of mind, a constant and anxious attention to the slightest feelings, an imaginary aggravation of these, and an apprehension of danger from them.

In the same atonic gout, the viscera of the thorax also are sometimes affected, and palpitations, faintings, and asthma occur.

In the head also occur headaches, giddiness, apoplectic and paralytic affections.

When the several symptoms now mentioned occur in habits having the marks of a gouty disposition, this may be suspected to have laid the foundation for them; and especially when either, in such habits, a manifest tendency to the inflammatory affection has formerly appeared, or when the symptoms mentioned are are intermixed with, and are relieved by some degree of the inflammatory gout. In such cases there can be no doubt of considering the whole as a state of the gout.

Another state of the disease we name the retrocedent gout. This occurs when an inflammatory state of the joints has, in the usual manner, come on, but without arising to the ordinary degree of pain and inflammation; or at least without these continuing for the usual time, or without their receding gradually in the usual manner; these affections of the joints suddenly and entirely cease, while some internal part becomes affected. The internal part most commonly attacked is the stomach; which then is affected with anxiety, sickness, vomiting, or violent pain; but sometimes the internal part is the heart, which gives occasion to a syncope; sometimes it is the lungs, which are affected with asthma; and sometimes it is the head, giving occasion to apoplexy or palsy. In all these cases there can be no doubt that the symptoms are all a part of the same disease, however different the affection may seem to be in the parts which it attacks.

The third state of irregular gout, which we name the misplaced, is when the gouty diathesis, instead of producing the inflammatory affection of the joints, produces an inflammatory affection of some internal part, and which appears from the same symptoms that attend the inflammations of those parts arising from other causes.

Whether the gouty diathesis does ever produce such inflammation of the internal parts without having first produced it in the joints, or whether the inflammation of the internal part be always a translation from the joints previously affected, we dare not determine; but, even supposing the latter to be always the case, we think the difference of the affection of the internal part must still distinguish the misplaced from what we have named the retrocedent gout.

With regard to the misplaced gout, Dr Cullen, whom we here follow, tells us, that he never met with any cases of it in his practice, nor does he find any distinctly marked by practical writers, except that of a pneumonic inflammation.

There are two cases of a translated gout; the one of which is an affection of the neck of the bladder, producing pain, strangury, and a catarrhus vesicae: the other is an affection of the rectum, sometimes indicated by pain alone in that part, and sometimes by hemorrhoidal symptoms. In gouty persons such affections have been known to alternate with inflammatory affections of the joints; but whether these belong to the retrocedent or to the misplaced gout, Dr Cullen pretends not to determine.

It is commonly supposed, that there are some cases of rheumatism which are scarcely to be distinguished from the gout; but these, Dr Cullen thinks, are but few; and that the two diseases may be for the most part distinguished with great certainty, by observing the predisposition, the antecedent circumstances, the parts affected, the recurrences of the disease, and its connection with the system; which circumstances, for the most part, appear very differently in the two diseases.

Causer, &c. The gout is generally an hereditary disease; but some persons, without any hereditary disposition, seem to acquire it; and in some an hereditary disposition may be counteracted from various causes. It attacks the male sex especially; but it sometimes, though more rarely, attacks also the female. The females liable to it are those of the more robust and full habits; and it very often happens to those before the menstrual evacuation has ceased. Dr Cullen hath also found it occurring in several females whose menstrual evacuations were more abundant than usual.

The gout seldom attacks eunuchs; and when it does, seems to fall upon those who happen to be of a robust habit, to lead an indolent life, and to live very full. It attacks especially men of robust and large bodies, who have large heads, are of full and corpulent habits, and whose skins are covered with a thick rete mucosum, which gives a coarse surface. To speak in the style of the ancient physicians, the gout will seldom be found to attack those of a sanguine, or such as are of a purely melancholic temperament; but very readily those of a cholerico-sanguine temperament. It is, however, very difficult to treat this matter with precision. The gout seldom attacks persons employed in constant bodily labour, or those who live much upon vegetable aliment. It does not commonly attack men till after the age of 35; and generally not till a still later period. There are indeed instances of the gout appearing more early; but these are few in comparison of the others. When the disease does appear early in life, it seems to be in those who have the hereditary disposition very strong, and to whom the remote causes hereafter mentioned have been applied in a very considerable degree.

As the gout is an hereditary disease, and affects men particularly of a certain habit, its remote causes may be considered as predisposing and occasional. The predisposing cause, as far as expressed by external appearances, has been already marked; and physicians have been very confident in assigning the occasional causes: but in a disease depending so much upon a predisposition, the assigning occasional causes must be uncertain; as in the predisposed the occasional causes may not always appear, and in persons not predisposed they may appear without effect; and this uncertainty must particularly affect the case of the gout.

The occasional causes of the disease seem to be of two kinds. First, Those which induce a plethoric state of the body. Secondly, Those which in plethoric habits, induce a state of debility. Of the first kind are a sedentary, indolent manner of life, and a full diet of animal food. Of the second kind of occasional causes which induce debility are excess in venery; intemperance in the use of intoxicating liquors; indigestion, produced either by the quantity or quality of the aliment; much application to study or business, night watching, excessive evacuations; the ceasing of usual labour; a sudden change from a very full to a very spare diet; the large use of acids and aecents; and, lastly, cold applied to the lower extremities. The former seem to act by increasing the predisposition; the latter are commonly the exciting causes, both of the first attacks, and of the repetitions of the disease.

With respect to the proximate cause of the gout, it has generally been thought that it depends on a certain tain morbid matter always present in the body; and that this matter, by certain causes, thrown upon the joints or other parts, produces the several phenomena of the disease.

This doctrine, however ancient and generally received, appears to Dr Cullen to be very doubtful. For,

First, There is no direct evidence of any morbid matter being present in persons disposed to the gout. There are no experiments or observations which show that the blood or other humours of gouty persons are in any respect different from those of the sound. Previous to attacks of the gout, there appear no marks of any morbid state of the fluids; for the disease generally attacks those persons who have enjoyed the most perfect health, and appear to be in that state when the disease comes on. At a certain period of the disease, a peculiar matter indeed appears in gouty persons; but this, which does not appear in every instance, and which appears only after the disease has subsisted for a long time, seems manifestly to be the effect, not the cause, of the disease. Further, Though there be certain acids which, taken into the body, seem to excite the gout, it is probable that these acids operate otherwise in exciting the disease, than by affording the material cause of it. In general, therefore, Dr Cullen thinks there is no proof of any morbid matter being the cause of the gout.

Secondly, The suppositions concerning the particular nature of the matter producing the gout, have been so various, and so contradictory, as to allow us to conclude, that there is truly no proof of the existence of any of them. With respect to many of these suppositions, they are so inconsistent with chemical philosophy, and with the laws of the animal economy, that they must be entirely rejected.

Thirdly, The supposition of a morbid matter as the cause, is not consistent with the phenomena of the disease, particularly with its frequent and sudden translations from one part to another.

Fourthly, The supposition is further rendered improbable by this, that if a morbid matter did exist, its operation should be similar in the several parts which it attacks: whereas it seems to be very different, being stimulant, and exciting inflammation, in the joints; but sedative and destroying tone in the stomach; which, upon the supposition of the same particular matter acting in both cases, is not to be explained by any difference in the part affected.

Fifthly, Some facts alleged in proof of a morbid matter, are not confirmed; such as those which would prove the disease to be contagious. There is, however, no proper evidence of this, the facts given being not only few, but exceptionable, and the negative observations innumerable.

Sixthly, Some arguments brought in favour of a morbid matter are founded upon a mistaken explanation. The disease has been supposed to depend upon a morbid matter, because it is hereditary. But the inference is not just: for most hereditary diseases do not depend upon any morbid matter, but upon a particular conformation of the structure of the body transmitted from the parent to the offspring; and this last appears to be particularly the case in the gout. It may be also observed, that hereditary diseases depending upon a morbid matter, appear always much more early in life than the gout commonly does.

Seventhly, The supposition of a morbid matter being the cause of the gout, has been hitherto useless, as it has not suggested any successful method of cure. Particular theories of gout have often corrupted the practice, and have frequently led from those views which might have been useful, and from that practice which experience had approved. Further, Though the supposition of a morbid matter has been generally received, it has been as generally neglected in practice. When the gout has affected the stomach, nobody thinks of correcting the matter supposed to be present there, but merely of restoring the tone of the moving fibres.

Eighthly, The supposition of a morbid matter is quite superfluous: for it explains nothing, without supposing that matter to produce a change in the state of the moving powers; and a change in the state of the moving powers, produced by other causes, explains every circumstance without the supposition of a morbid matter; and it may be observed, that many of the causes exciting the gout, do not operate upon the state of the fluid, but directly and solely upon that of the moving powers.

Lastly, Dr Cullen contends that the supposition of a morbid matter is superfluous; because, without that, the disease can be explained, he thinks, in a manner more consistent with its phenomena, with the laws of the animal economy, and with the method of cure which experience has approved. We now proceed to give this explanation; but, before entering upon it, we must premise some general observations which Dr Cullen states.

The first observation is, That the gout is a disease of the whole system, or depends upon a certain general conformation and state of the body, which manifestly appears from the facts above mentioned. But the general state of the system depends chiefly upon the state of its primary moving powers; and therefore the gout may be supposed to be an affection of these.

The second observation is, That the gout is manifestly an affection of the nervous system; in which the primary moving powers of the whole system are lodged. The occasional or exciting causes are almost all such as act directly upon the nerves and nervous system; and the greater part of the symptoms of the atonic or retrocedent gout are manifestly affections of the same system. This leads us to seek for an explanation of the whole of the disease, in the laws of the nervous system, and particularly in the changes which may happen in the balance of its several parts.

The third observation is, That the stomach, which has so universal a consent with the rest of the system, is the internal part that is the most frequently, and often very considerably, affected by the gout. The paroxysms of the disease are commonly preceded by an affection of the stomach; many of the exciting causes act first upon the stomach; and the symptoms of the atonic and retrocedent gout are most commonly and chiefly affections of the same organ. This observation leads us to remark, that there is a balance subsisting between the state of the internal and that of the external parts; and, in particular, that the state of the stomach is connected with that of the external parts, so that the state of tone in the one may be communicated to the other.

These observations being premised, Dr Cullen offers the following pathology of the gout.

In some persons there is a certain vigorous and plethoric state of the system, which at a certain period of life is liable to a loss of tone in the extremities. This is in some measure communicated to the whole system, but appears more especially in the functions of the stomach. When this loss of tone occurs while the energy of the brain still retains its vigour, the vis medicatrix nature is excited to restore the tone of the parts; and accomplishes it, by exciting an inflammatory affection in some part of the extremities. When this has subsisted for some days, the tone of the extremities and of the whole system is restored, and the patient returns to his ordinary state of health.

This is the course of things in the ordinary form of the disease, which we name the regular gout; but there are circumstances of the body, in which this course is interrupted or varied. Thus, when the atony has taken place, if the reaction do not succeed, the atony continues in the stomach, or perhaps in other internal parts; and produces that state which Dr Cullen, for reasons now obvious, named the atomic gout.

A second case of variation in the course of the gout is, when to the atony the reaction and inflammation have to a certain degree succeeded, but from causes either internal or external the tone of the extremities and perhaps of the whole system is weakened; so that the inflammatory state, before it had either proceeded to the degree, or continued for the time, requisite for restoring the tone of the system, suddenly and entirely ceases: whence the stomach, and other internal parts, relapse into the state of atony; and perhaps have that increased by the atony communicated from the extremities: all which appears in what has been termed the retrocedent state of the gout.

A third case of variation from the ordinary course of the gout, is, when to the atony, usually preceding, an inflammatory reaction fully succeeds, but has its usual determination to the joints prevented by some circumstances; and is therefore directed to some internal part, where it produces an inflammatory affection, and that state of things which we have named the misplaced gout.

Though this theory of Dr Cullen's be supported with much ingenuity, yet we may confidently venture to assert, that on this subject he has been less successful in establishing his own opinions, than in combating those of others; and this theory, as well as others formerly proposed, is liable to numerous and unanswerable objections. According to the hypothesis, a vigorous and plethoric habit should in every case exist prior to the appearance of gout; which is by no means consistent with fact: nor is it true that a vigorous and plethoric habit is liable at a certain age to a loss of tone in the extremities; which is another necessary condition in the hypothesis. Loss of tone often occurs in the extremities without exerting any peculiar influence on the stomach; and why a loss of tone in the stomach should excite the vis medicatrix nature to restore it, by exciting an inflammatory affection in some part of the extremities, is very inconceivable. Were the hypothesis true, every dyspeptic patient should infallibly be affected with gout; which however, is by no means the case. In short, every step in the theory is liable to unanswerable objections; and it by no means, any more than former hypotheses, explains the phenomena of the disease, particularly what Dr Cullen has himself so accurately pointed out, the connection of gouty with calculus complaints.

A very ingenious work has lately been published by an anonymous author, entitled "A Treatise on Gravel and upon Gout;" in which the sources of each are investigated, and effectual means of preventing or removing these diseases recommended. In this treatise an attempt is made to prove, that both diseases depend upon a peculiar concreting acid, the acid of calculi, or the lithic or uric acid, as it has been styled by some. He supposes this acid, constantly present to a certain degree in the circulating fluids, to be precipitated by the introduction of other acids; and in this manner he explains the influence of acid wines and other liquors, as claret, cyder, &c. inducing gout; for he considers the circumstance chiefly constituting the disease as being an inflammation in parts of which the functions have been interrupted by the redundant acid precipitated. Although this theory be supported with much ingenuity, yet it is also liable to many objections. The sudden attack of the affection; its sudden transition from one part of the body to another; the instant relief of one part when another comes to be affected; and the various anomalous forms which the disease puts on, having an exact resemblance to different affections; are altogether irreconcileable to the idea of its depending on any fixed obstruction at a particular part arising from concreting acid. Nor does the plan of prevention and cure which he proposes, and which consists chiefly in abstinence from acid, and in the destruction of acid, by any means correspond in every particular to the best established facts respecting the treatment of gout; to which we next proceed.

Cure. In entering upon this, we must observe, in the first place, that a cure has been commonly thought impossible; and we acknowledge it to be very probable, that the gout, as a disease of the whole habit, and very often depending upon original conformation, cannot be cured by medicines, the effects of which are always very transitory, and seldom extend to the producing any considerable change of the whole habit.

It would perhaps have been happy for gouty persons if this opinion had been implicitly received by them; as it would have prevented their having been so often the dupes of self-interested pretenders, who have either amused them with inert medicines, or have rashly employed those of the most pernicious tendency. Dr Cullen, who has treated of the cure of the disease with great judgment, as he has done the theory with much ingenuity, is much disposed to believe the impossibility of the cure of the gout by medicines; and more certainly still inclined to think, that, whatever may be the possible power of medicines, yet no medicine for curing the gout has hitherto been found. Although almost every age has presented a new remedy, all hitherto offered have, very soon after, been either neglected as useless, or condemned as pernicious.

But though unwilling to admit the power of medicines, yet he contends, that a great deal can be done towards towards the cure of the gout by a regimen; and he is firmly persuaded, that any man who, early in life, will enter upon the constant practice of bodily labour, and of abstinence from animal food, will be preserved entirely from the disease.

Whether there be any other means of radically curing the gout, the Doctor is not able to say. There are histories of cures of the gout, in which it is said, that by great emotions of mind, by wounds, and by other accidents, the symptoms have been suddenly relieved, and never again returned; but how far these accidental cures might be imitated by art, or would succeed in other cases, is at least extremely uncertain.

The practices proper and necessary in the treatment of the gout, are to be considered under two heads: First, As they are to be employed in the intervals of paroxyms; or, secondly, As during the time of these. In the intervals of paroxyms, the indications are, to prevent altogether the return of paroxyms; or at least to render them less frequent and more moderate. During the time of paroxyms, the indications are, to moderate the violence and shorten the duration of them as much as can be done with safety.

It has been already observed, that the gout may be entirely prevented by constant bodily exercise, and by a low diet; and Dr Cullen is of opinion, that this prevention may take place even in persons who have a hereditary disposition to the disease. Even when the disposition has discovered itself by several paroxyms of inflammatory gout, he is persuaded that labour and abstinence will absolutely prevent any returns of it for the rest of life. These, therefore, are the means of answering the first indication to be pursued in the intervals of paroxyms.

Exercise in persons exposed to the gout, in Dr Cullen's opinion, operates by answering two purposes: One of these is the strengthening of the tone of the extreme vessels; and the other, the guarding against a plethoric state. For the former, if exercise be employed early in life, and before intemperance has weakened the body, a very moderate degree of it will answer the purpose; and, for the latter, if abstinence be at the same time observed, less exercise will be necessary.

With respect to exercise, this in general is to be observed, that it should never be violent; for if violent, it cannot be long continued, and must always endanger the bringing on an atony in proportion to the violence of the preceding motions.

It is also to be observed, that the exercise of gestation, though considerable and constant, will not, if it be entirely without bodily exercise, answer the purpose of preventing the gout. For this end, therefore, the exercise must be in some measure that of the body; and must be moderate, but at the same time constant and continued through life.

In every case and circumstance of the gout in which the patient retains the use of his limbs, bodily exercise, in the intervals of paroxyms, will be always useful; and in the beginning of the disease, when the disposition to it is not yet strong, exercise may prevent a paroxysm which otherwise would have come on. In more advanced states of the disease, however, when there is some disposition to a paroxysm, much walking will bring it on; either as it weakens the tone of the lower extremities, or as it excites an inflammatory disposition in them; and thus it seems to be that sprains or contusions often bring on a paroxysm of the gout.

Abstinence, the other part of the regimen for preventing the gout, is of more difficult application. If an abstinence from animal food be entered upon early in life, while the vigour of the system is yet entire, Dr Cullen has no doubt of its being both safe and effectual; but if the motive for this diet shall not have occurred till the constitution has been broken by intemperance, or by the decline of life, a low diet may then endanger the induction of an atonic state.

Further, If a low diet be entered upon only in the decline of life, and be at the same time a very great change from the former manner of living, the withdrawing of an accustomed stimulus of the system may readily throw it into an atonic state.

The safety of an abstemious course will be greater or less according to the management of it. Animal food especially disposes to the plethoric and inflammatory state, and that food is to be therefore especially avoided; but on the other hand, vegetable aliment of the lowest quality is in danger of weakening the system too much by not affording sufficient nourishment, and more particularly of weakening the tone of the stomach by its acescence. It is therefore a diet of a middle nature that is to be chosen; and milk is precisely of this kind, as containing both animal and vegetable matter.

As approaching to the nature of milk, and as being a vegetable matter containing the greatest portion of nourishment, the farinaceous foods are next to be chosen, and are the food most proper to be joined with milk.

With respect to drink, fermented liquors are useful only when they are joined with animal food, and that by their acescence; and their stimulus is only necessary from custom. When, therefore, animal food is to be avoided, fermented liquors are unnecessary; and by increasing the acescence of vegetables, these liquors may be hurtful. The stimulus of fermented or spirituous liquors is not necessary to the young and vigorous, and when much employed impairs the tone of the system. These liquors, therefore, are to be avoided, excepting as custom and the declining state of the system may have rendered them necessary. For preventing or moderating the regular gout, water is the only proper drink.

With respect to an abstemious course, it has been supposed, that an abstinence from animal food and fermented liquors, or the living upon milk and farinacea alone for the space of one year, might be sufficient for a radical cure of the gout: and it is possible that, at a certain period of life, in certain circumstances of the constitution, such a measure might answer the purpose. But this is very doubtful: and it is more probable, that the abstinence must, in a great measure, be continued, and the milk diet be persisted in, for the remainder of life. It is well known, that several persons who had entered on an abstemious course, and had been thereby delivered from the gout, have, however, upon returning to their former manner of full living, had the disease return upon them with as much violence as before, or in a more irregular and more dangerous form.

It has been alleged, that, for preventing the return of the gout, blood-letting or scarifications of the feet, frequently repeated, and at stated times, may be practised with advantage; but of this Dr Cullen tells us he has had no experience; and the benefit of the practice is not, as far as we know, confirmed by the observation of any other practitioner.

Exercise and abstinence are the means of avoiding the plethoric state which gives the disposition to the gout; and are therefore the means proposed for preventing the paroxyfms, or at least for rendering them less frequent and more moderate. But many circumstances prevent the readinefs necessary in pursuing these measures; and therefore in such cases, unless great care be taken to avoid the exciting caufes, the difeafe may frequently return, and, in many cases, the preventing of paroxyfms is chiefly to be obtained by avoiding thefe exciting caufes already enumerated.

A due attention in avoiding thefe different caufes will certainly prevent fits of the gout; and the taking care that the exciting caufes be never applied in a great degree, will certainly render fits more moderate when they do come on. But, upon the whole, it will appear, that a very strict attention to the general conduct of life is in this matter neceffary; and therefore, when the predisposition has taken place, it will be extremely difficult to avoid the difeafe.

Dr Cullen is firmly persuaded, that by obviating the predisposition, and by avoiding the exciting caufes, the gout may be entirely prevented: but, as the measures neceffary for this purpofe will, in moft cafes, be purfued with difficulty, and even with reluctance, men have been very defirous to find a medicine which might anfwer the purpofe without any reftraint on their manner of living. To gratify this defire, physicians have propofed, and, to take advantage of it, empirics have feigned, many remedies. Of what nature several of thefe remedies have been, it is difficult to fay: but of thofe which are unknown, we conclude, from their having been only of temporary fame, and from their having foon fallen into neglect, that they have been either inert or pernicious. We fhall therefore make no inquiry after them; and fhall now remark only upon one or two known remedies for the gout which have been lately fashionable.

One of thefe is what has been named in England the Portland powder. This is not a new medicine, but is mentioned by Galen, and, with fome little variation in its composition, has been mentioned by the writers of almost every age fince that time. It appears to have been at times in fashion, and to have again fallen into neglect; and Dr Cullen thinks that this laft has been owing to its having been found to be, in many instances, pernicious. In every instance which he has known of its exhibition for the length of time prefcribed, the persons who had taken it were indeed afterwards free from any inflammatory affection of the joints; but they were affected with many symptoms of the atonic gout; and many, foon after finishing their course of the medicine, have been attacked with apoplexy, asthma, or dropfy, which proved fatal.

Another remedy which has had the appearance of preventing the gout, is alkali in various forms; fuch as the fixed alkali, both mild and caufic, lime water, foap, and absorbent earths; and of late the alkaline aerated water has been more fashionable than any other. Since it became common to exhibit thefe medicines in nephritic and calculous cafes, it has often happened that they were given to thoſe who were at the fame time ſubject to the gout; and it has been observed, that under the uſe of theſe medicines, gouty perſons have been longer free from the fits of their difeafe. That, however, the uſe of theſe medicines has entirely prevented the returns of gout, Dr Cullen does not know; becauſe he never pulled the uſe of them for a long time, being apprehensive that the long-continued uſe of them might produce a hurtful change in the ſtate of the fluids.

As the prevention of gout depends very much on ſupporting the tone of the ſtomach, and avoiding indigeflion; fo coſtiveness, by occasioning this, is very hurtful to gouty perſons. It is therefore neceffary for ſuch perſons to prevent or remove coſtiveness, by a laxative medicine, when needful; but it is at the fame time proper, that the medicine employed ſhould be ſuch as may keep the belly regular, without much purging. Aloetics, rhubarb, magnolia alba, oleum ricini, or flowers of ſulphur, may be employed, as the one or the other may happen to be best suited to particular perſons.

Thefe are the several meafures to be purfued in the intervals of the paroxyfms; and we are next to mention the meafures proper during the time of them.

As during the time of paroxyfms the body is in a feveril state, no irritation ſhould then be added to it; every part, therefore, of the antiphlogiftic regimen, except the application of cold, ought to be ſtrictly obſerved.

An exception to the general rule, however, may occur when the tone of the ſtomach is weak, and when the patient has been before much accuftomed to the uſe of ſtrong drink; for then it may be allowable, and even neceffary, to give ſome animal food and a little wine.

That no irritation is to be added to the ſystem during the paroxyfms of gout, except in the cafes mentioned, is agreed upon among physicians: but it is a more difficult matter to determine, whether, during the time of paroxyfms any meafures may be purfued to moderate the violence of reaction and of inflammation. Dr Sydenham has given it as his opinion, that the more violent the inflammation and pain, the paroxyfm will be the ſhorter, as well as the interval between the preſent and the next paroxyfm longer; and, if this opinion be admitted as juft, it will forbid the uſe of any remedies which might moderate the inflammation; which is, to a certain degree, undoubtedly neceffary for the health of the body. On the other hand, acute pain preſses for relief; and although a certain degree of inflammation may feem absolutely neceffary, there is reaſon to believe, a moderate degree of it may anfwer the purpofe; and it is even probable, that in many cafes the violence of inflammation may weaken the tone of the parts, and thereby invite a return of paroxyfms. It feems to be in this way, that, as the difeafe advances, the paroxyfms become more frequent. From these last considerations, it seems probable, that, during the time of paroxyms some measures may be taken to moderate the violence of the inflammation and pain, and particularly, that in first paroxyms, and in the young and vigorous, blood-letting at the arm may be practised with advantage; but this practice cannot be repeated often with safety; because blood-letting not only weakens the tone of the system, but also contributes to produce plethora. However, bleeding by leeches on the foot, and upon the inflamed part, may be practised and repeated with greater safety; and instances have been known of its having been employed with safety to moderate and shorten paroxyms; but how far it may be carried, we have not had experience enough to determine.

Besides blood-letting and the antiphlogistic regimen, it has been proposed to employ remedies for moderating the inflammatory spasm of the part affected, such as warm bathing and emollient poultices. These have sometimes been employed with advantage and safety; but, at other times, have been found to give occasion to a retrocession of the gout.

Blistering is a very effectual means of relieving and diffusing a paroxysm of the gout; but has also frequently had the effect of rendering it retrocedent. The flogging with nettles is analogous to blistering; and probably would be attended with the same danger. The burning with moxa, or other substances, is a remedy of the same kind; but though not found hurtful, there is no sufficient evidence of its proving a radical cure.

Camphor, and some aromatic oils, have the power of allaying the pain, and of removing the inflammation from the part affected; but these remedies commonly make the inflammation only shift from one part to another, and therefore with the hazard of its falling upon a part where it may be more dangerous; and they have sometimes rendered the gout retrocedent.

Among other remedies which have of late been highly extolled during a paroxysm of gout, some have recommended the use of strong purgatives frequently repeated; others have highly extolled the affluvius application of cold water to the affected foot. But we may safely venture to assert that both practices are very doubtful, if not very dangerous.

From these reflections it will appear, that some danger must attend every external application to the parts affected during a paroxysm; and that therefore the common practice of committing the person to patience and flannel alone, is established upon the best foundation. Opiates give the most certain relief from pain; but, when given in the beginning of gouty paroxyms, it has by some been thought that they occasion these to return with greater violence. When, however, the paroxyms shall have abated in their violence, but still continue to return, so as to occasion painful and restless nights, opiates may be given with safety and advantage; especially in the case of persons advanced in life, and who have been often affected with the disease. When, after paroxyms have ceased, some swelling and stiffness still remain in the joints, these symptoms are to be diffused by the diligent use of the flesh-brush. Purging immediately after a paroxysm will be always employed with the hazard of bringing it on again; but keeping the belly gently open even during the continuance of the paroxysm is highly proper.

Thus far of the regular gout. We now proceed to consider the management of the disease when it has become irregular.

In the atonic gout, the cure is to be accomplished by carefully avoiding all debilitating causes; and by employing, at the same time, the means of strengthening the system in general, and the stomach in particular.

For strengthening the system in general, Dr Cullen recommends frequent exercise on horseback, and moderate walking. Cold bathing also may answer the purpose; and may be safely employed, if it appear to be powerful in stimulating the system, and be not applied when the extremities are threatened with any pain.

For supporting the tone of the system in general, when threatened with atonic gout, some animal food ought to be employed, and the more acescent vegetables ought to be avoided. In the same cafe, some wine also may be necessary; but it should be in moderate quantity, and of the least acescent kinds, and if every kind of wine shall be found to increase the acidity of the stomach, ardent spirits and water must be employed.

For strengthening the stomach, bitters and the Peruvian bark may be used; but care must be taken that they be not constantly employed for any great length of time.

The most effectual medicine for strengthening the stomach is iron, which may be employed under various preparations; but the best appears to be the rust in fine powder, which may be given in large doses.

For supporting the tone of the stomach, aromatics may be exhibited; but should be used with caution, as the frequent and copious use of them has an opposite effect; and they should therefore be given only in compliance with former habits, or for palliating present symptoms.

When the stomach happens to be liable to indigestion, gentle vomits may be frequently given, and proper laxatives should be always employed to obviate or to remove coarseness.

In the atonic gout, or in persons liable to it, to guard against cold is especially necessary; and the most certain means of doing this, is by repairing to a warm climate during the winter season. In the more violent cases, blistering the lower extremities may be useful; but that remedy should be avoided when any pain threatens the extremities. In persons liable to the atonic gout, infuses may be established in the extremities as in some measure a supplement to the disease.

A second case of the irregular gout, is the retrocedent.

When this affects the stomach and intestines, relief is to be instantly attempted by the free use of strong wines, joined with aromatics, and given warm; or, if these shall not prove powerful enough, ardent spirits must be employed, and are to be given in a large dose. In moderate attacks, ardent spirits, impregnated with garlic or with asafoetida, may be used; or, even without the ardent spirits, a solution of asafoetida with the volatile alkali, may answer the purpose. Opiates are often an effectual remedy; and may be joined with aromatics, as in the electuarium opiatum; or they may be usefully joined with volatile alkali and camphor. Musk has likewise proved useful in this disease.

When the affection of the stomach is accompanied with vomiting, this may be encouraged, by taking draughts of warm water, at first with wine, and afterwards without it; having at length recourse, if necessary, to some of the remedies above mentioned, and particularly the opiates.

In like manner, if the intestines be affected with diarrhoea, this is to be at first encouraged by taking plentifully of weak broth; and when this shall have been done sufficiently, the tumult is to be quieted by opiates.

When the retrocedent gout shall affect the lungs, and produce asthma, this is to be cured by opiates, by antispasmodics, and perhaps by blistering on the back or breast.

When the gout, leaving the extremities, shall affect the head, and produce pain, vertigo, apoplexy, or palsy, our resources are very precarious. The most probable means of relief is, blistering the head; and, if the gout shall have receded very entirely from the extremities, blisters may be applied to these also. Together with these blisterings, aromatics, and the volatile alkali, may be thrown into the stomach.

The third case of the irregular gout is the misplaced; that is, when the inflammatory affection of the gout, instead of falling upon the extremities, falls upon some internal part. In this case, the disease is to be treated by blood-letting, and by such other remedies as would be proper in an idiopathic inflammation of the same parts.

Whether the translation fo frequently made from the extremities to the kidneys, is to be considered as an instance of the misplaced gout, seems uncertain: but Dr Cullen is disposed to think it something different; and therefore is of opinion, that, in the nephralgia calculosa produced upon this occasion, the remedies of inflammation are to be employed no farther than they may be sometimes necessary in that disease, arising from other causes than the gout.

Besides what have been mentioned, a variety of other practices may be necessary and proper against the various anomalous symptoms, which are at times produced by irregular gout. But of these we cannot propose to treat. And we may conclude with observing, that in every form of gout, the cure principally depends on avoiding occasional causes, particularly luxury and laziness.

GENUS XXV. ARTHROPUOSIS.

Lumbago ploadic, Sauv. sp. 6. Fordyce, Practice of Phyfic, part ii. p. 70. Lumbago apoptematola, Sauv. sp. 12. Lumbago ab arthrocace, Sauv. p. 17. Icthias ex abscessu, Sauv. sp. 6. Morbus coxarius, De Haen, Rat. Med. Vol. I. c. xxxii.

This is a disease very much resembling the rheumatism; but differing both from it and the gout, in that it occasions suppurations, which they seldom or never do. It frequently, according to Sauvages, attacks the psoas muscle; and occasions excruciating pains, and erysipelas, then collections of purulent matter.

The only cure, if suppuration cannot be prevented, is to lay open the part where the matter is contained, which would otherwise be absorbed, and occasion a fatal hectic.

ORDER III. EXANTHEMATA.

Exanthemata, Sag. Clas X. Phlegmatis exanthematicae, Sauv. Clas III. Ord. I. Morbi exanthematici, Lin. Clas I. Ord. II. Febres exanthematicae, Vog. Clas I. Ord. II.

GENUS XXVI. ERYSIPELAS.

St Anthony's Fire.

Erysipelas, Sauv. gen. 97. Lin. 10. Sag. gen. 296. Febris erysipelacea, Vog. 68. Hoffman. II. 98.

Sp. I. ERYSIPELAS with Blisters.

Erysipelas roseum, Sauv. sp. 1. Sennert. de febr. lib. ii. c. 15. Febris erysipelatosa, Sydenham, sect. vi. cap. 5. Erysipelas typhodes, Sauv. sp. 2. Erysipelas peffilens, Sauv. sp. 5. Erysipelas contagiosum, Sauv. sp. 9.

Description. The erysipelas of the face, where this affection very frequently appears, comes on with a cold shivering, and other symptoms of pyrexia. The hot stage of this is frequently attended with a confusion of the head, and some degree of delirium; and almost always with drowsiness, and perhaps coma. The pulse is always frequent, and commonly full and hard.—When these symptoms have continued for one, two, or at most three days, an erythema appears on some part of the face. This at first is of no great extent; but gradually spreads from the part it first occupied to the other parts of the face, till it has affected the whole; and frequently from the face it spreads over the hairy scalp, or descends on some part of the cheek. As the redness spreads, it commonly leaves, or at least is abated in the parts it had before occupied. All the parts which the redness affects are also affected with some swelling, which continues for some time after the redness has abated. The whole face becomes considerably turgid; and the eyelids are often so much swelled as entirely to shut up the eyes. When the redness and swelling have continued for some time, there commonly arise, sooner or later, blisters of a larger or smaller size on several parts of the face. These contain a thin colourless liquor, which sooner or later runs out. The surface of the skin, in the blistered places, sometimes becomes livid and blackish; but this seldom goes deeper, or discovers any degree of gangrene affecting the cutis vera. On the parts of the face not affected with blisters, the cuticle suffers, towards the end of the disease, a considerable desquamation. Sometimes the tumor of the eyelids ends in a suppuration.

The inflammation coming upon the face does not produce any remission of the fever which had before prevailed; and sometimes the fever increases with the spreading and increasing inflammation. The inflamma- Exanthematious commonly continues for eight or ten days; and for the same time, the fever and symptoms attending it also continue. In the progress of the disease, the delirium and coma attending it sometimes go on increasing, and the patient dies apoplectic on the seventh, ninth, or eleventh day of the disease. In such cases it has been commonly supposed, that the disease is translated from the external to the internal parts. But Dr Cullen thinks that the affection of the brain is merely a communication from the external affection, as this continues increasing at the same time with the internal. When a fatal event does not take place, the inflammation, after having affected the whole face, and perhaps the other external parts of the head, ceases, and with that the fever also; and, without any other crisis, the patient returns to his ordinary health. This disease is not commonly contagious; but as it may arise from an acrid matter externally applied, so it is possible that the disease may sometimes be communicated from one person to another; and certainly there are several well authenticated instances of its prevailing in such a manner, even in particular wards of hospitals, as to leave no doubt respecting its contagious nature. Persons who have once laboured under this disease are liable to returns of it.

Prognosis. The event of this disease may be foreseen from the state of the symptoms which denote more or less the affection of the brain. If neither delirium nor coma come on, the disease is seldom attended with any danger; but when these symptoms appear early in the disease, and are in a considerable degree, the utmost danger is to be apprehended.

Cure. The erysipelas of the face is to be cured, according to the opinion of most practitioners, much in the same manner as phlegmonic inflammations; by blood-letting, cooling purgatives, and by employing every part of the antiphlogistic regimen. Many observations, however, would lead us to conclude, that in not a few cases the concomitant fever has here a tendency to the typhoid type; and therefore evacuations, apparently serviceable in the first instance, have afterwards a bad effect. The evacuations of blood-letting and purging are to be employed more or less according to the urgency of symptoms; particularly those which mark an affection of the brain. As the pyrexia continues, and often increases with the inflammation of the face, so the evacuations above mentioned are to be employed at any time of the disease. When, however, the fever, in place of marks of the phlogistic diathesis, particularly a full, hard, and strong pulse, is attended with symptoms of great debility, and with a small pulse easily compressible; evacuations, particularly under the form of blood-letting, must be used with very great caution. Even in such cases, however, the use of refrigerant cathartics may still be persisted in with more safety and greater advantage. But whether evacuants have been employed or not, when symptoms of debility run to a great height, and marks of a putrefactive tendency appear, recourse must be had to wine and the cinchona. In cases which at the commencement require evacuation, these are often in the after periods employed with very great benefit.

In this, as in other diseases of the head, when that part happens to be the seat of erysipelas, it is proper to put the patient, as often as he can easily bear it, into somewhat of an erect posture; and as there is always an external affection, to various external applications have been proposed to be made to the part affected; but almost all of them are of doubtful effect.

An erysipelas frequently appears on other parts of the body besides the face, and such other erysipelatous inflammations frequently end in suppuration; but these cases are seldom dangerous. At coming on they are sometimes attended with drowsiness, and even with some delirium; but this seldom happens, and these symptoms do not continue after the inflammation is formed; and Dr Cullen does not remember to have seen an instance of the translation of an inflammation from the limbs to an internal part; and though these inflammations of the limbs be attended with pyrexia, they seldom require the same evacuations as the erysipelas of the face.

Sp. II. Erysipelas with Phlyctenæ.

Erysipelas zoster, Sauv. sp. 8. Zona; Anglis, The Shingles, Ruffel de tab. gland. p. 124. Hist. 35. Herpes zoster, Sauv. sp. 9.

This differs from the former in no other way than in being attended with an eruption of phlyctenæ or small watery bladders on several parts of the body.—The method of cure is the same.

GENUS XXVII. PESTIS, the PLAGUE.

Pestis, Sauv. gen. 91. Lin. 2. Junck. 78. Febris pestilentialis, Vog. 33. Hoffm. 11. 93. Pestis benigna, Sauv. sp. 2. Pestis Maffilensis, Clas III. Traité de la peste, p. 41. Ejusdem pestis, Cl. 5ta, Traité, p. 228. Pestis remittens, Sauv. sp. 9. Pestis vulgaris, Sauv. sp. 1. Pestis Maffil. Cl. II. Traité, p. 38. Ejusd. Cl. III. et IV. Traité, p. 225, &c. Waldschmidt, de peste Hollatica, apud Halleri, Diff. Pract. Tom. V. Chenot. de peste Tranylvanica, 1755, 1759, De Haen, Rat. Med. pars xiv. Pestis Egyptiaca, Sauv. sp. 11. Alpin. de Med. Egypt. Pestis interna, Sauv. sp. 3. Pest. Maffil. Cl. I. Traité, p. 37—224.

History. Of this distemper Dr Cullen declines giving any particular history, because he never saw it; from the accounts of other authors, however, he is of opinion, that the circumstances peculiarly characteristic of it, especially of its more violent and dangerous states, are, 1. The great loss of strength in the animal functions, which often appears early in the disease. 2. The stupor, giddiness, and consequent flagging, which resembles drunkenness, or the headache and various delirium, all of them denoting a great disorder in the functions of the brain. 3. Anxiety, palpitation, syncope, and especially the weakness and irregularity of the pulse, denoting a considerable disturbance in the action of the heart. 4. Nausea and vomiting, particularly the vomiting of bile, which shows an accumulation of vitiated bile in the gall-bladder and biliary ducts, and from thence derived into the intestines and stomach; and which denote a considerable spasm, and loss of tone in the extreme vessels on the surface of the body. 5. The buboes and carbuncles, which denote an acrimony prevailing in the fluids; and, lastly, The pectechie, haemorrhages, and colliquative diarrhoea, which denote a putrefactive tendency prevailing in a great degree in the mass of blood.

To these characteristics of the plague enumerated by Dr Cullen, we shall add one mentioned by Sir John Pringle, which, though perhaps less frequent than the others, yet seems worthy of notice. It is this, That in the plague there is an extraordinary enlargement of the heart and liver. In nine dissections of bodies dead of the plague at Marseilles, this extraordinary enlargement of the heart is taken notice of in all of them, and of the liver in seven of them. The account was sent to the Royal Society by M. Didier, one of the physicians to the king of France, and has been published in the Philosophical Transactions. In the first case, the author takes notice, that "the heart was of an extraordinary bigness; and the liver was of double the natural size."—Case 2. The heart was of a prodigious bigness, and the liver much enlarged.—Case 3. The heart double the natural bigness.—Case 4. The heart was very large, and the liver was bigger and harder than ordinary.—Case 5. The heart was of a prodigious bigness.—Case 6. The heart was larger than in its natural state; the liver also was very large.—Case 7. The heart was of a prodigious size, and the liver was very large.—Case 8. The heart was much larger than natural, and the liver of a prodigious size.—Case 9. The heart was double the natural bigness, and the liver was larger than ordinary."—This preternatural enlargement, Sir J. Pringle thinks, is owing to the relaxation of the solid parts, by which means they become unable to resist the impetus of blood, and therefore are easily extended; as in the case of infancy, where the growth is remarkably quick. And a similar enlargement he takes notice of in the feverly, and other putrid diseases.

A very elaborate work has lately been published on the subject of the plague by Dr Patrick Ruffel, formerly physician to the British factory at Aleppo. In this work, a very full history is given of the various forms and varieties of the disease. He makes particular observations on the following symptoms, which, in addition to the pestilential eruptions, he considers as the most important concomitants of plague, viz. fever, delirium, coma, impediment or loss of speech, deafness, muddiness of the eyes, white tongue, state of the pulse, respiration, anxiety, pain at the heart, inquietude, debility, fainting, convulsion, appearances of the urine, perspiration, vomiting, loofenes, and haemorrhage; and he concludes these remarks with some observations on the occurrence of the plague with pregnant women. To point out more distinctly the stable varieties of the disease, he arranges the pestilential cases which fell under his observation at Aleppo under fix classes: and he concludes his description with a very minute and particular account of the pestilential eruptions, appearing under the form either of buboes, carbuncles, or other exanthemata. The presence of the two first, he observes, either separately or conjunctly, leaves the nature of the distemper unequivocal. But fatal has been the error of rashly pronouncing a distemper not to be a plague from their absence. Buboes affected the inguinal, axillary, parotid, maxillary, and cervical glands. But the first were the most commonly affected, and the two latter seldom observed to swell, without either the parotid swelling at the time, or soon after. Of the carbuncles, Dr Ruffel describes five different varieties. The other exanthemata, which he observed sometimes, though less frequently, attending the plague, were pectechie, a marbled appearance of the skin, an erythematous redness, streaks of a reddish purple or livid colour, vices or weals, and large blue or purple spots, the maculae magna of authors. In some cases, an extraordinary concurrence of eruptions took place, which was chiefly observed among children under 10 years of age.

Caufet, &c. From a consideration of the symptoms above mentioned, Dr Cullen concludes, that the plague is owing to a specific contagion, often suddenly producing the most considerable debility in the nervous system, or moving powers, and a general putrefaction in the fluids. Dr Ruffel also considers the disease as being universally the consequence of what may be called pestilential contagion; and has judiciously repelled the objections which have been brought against this doctrine.

Prevention. Here we must refer to all those methods of preventing and removing the incipient contagion of putrid fevers, which have been fully enumerated. Dr Cullen is persuaded that the disease never arises in the northern parts of Europe, but in consequence of being imported from some other country. The magistrate's first care, therefore, ought to be, to prevent the importation; and this may generally be done by a due attention to bills of health, and to the proper performance of quarantines.—With respect to the latter, he is of opinion, that the quarantines of persons may with safety be much less than 40 days; and if this were allowed, the execution of the quarantine would be more exact and certain, as the temptation to break it would be in a great measure avoided. With respect to the quarantine of goods, it cannot be perfect unless the suspected goods be unpacked, duly ventilated, and other means be employed for correcting the infection they may carry; and if all this be properly done, it is probable that the time commonly prescribed for quarantine may also be shortened.

A second measure in the way of prevention is required, when an infection has reached and prevailed in any place, to prevent that infection from spreading into others. This can only be done by preventing the inhabitants or the goods of any infected place from going out of it till they have undergone a proper quarantine.

The third measure, and which ought to be employed with great care, is, to prevent the infection from spreading among the inhabitants of a place in which it has arisen. And in this case, a great deal may be done by the magistrate: 1. By allowing as many of the inhabitants as are free from infection, and are not necessary to the service of the place, to go out of it. 2. By discharging all assemblies, or unnecessary intercourse of the people. 3. By ordering some necessary communications to be performed without contact. contact. 4. By making such arrangements and provisions as may render it easy for the families remaining to shut themselves up in their own houses. 5. By allowing persons to quit houses where an infection appears, upon condition that they go into lazarettos. 6. By ventilating and purifying, or destroying, at the public expence, all infected goods. 7. By avoiding hospitals, and providing separate apartments for infected persons.

The fourth and last part of the business of prevention reflects the conduct of persons necessarily remaining in infected places, especially those obliged to have some communication with persons infected. Those obliged to remain in places infected, but not to have any near communication with the sick, must avoid all near communication with other persons or their goods; and it is probable, that a small distance will serve, if, at the same time, there be no stream of air to carry the effluvia of persons or goods to some distance. Those who are obliged to have a near communication with the sick ought to avoid any of the debilitating causes which render the body susceptible of infection, as a spare diet, intemperance in drinking, excess in venery, cold, fear, or other depressing passions of the mind. A full diet of animal food is also to be avoided, because it increases the irritability of the body, and favours the operation of contagion; and indigestion, whether from the quantity or quality of the food, contributes very much to the same end.

Besides these, it is probable that the moderate use of wine and spirituous liquors, moderate exercise, and the cold bath, may be of use; tonic medicines also, of which cinchona is deservedly accounted the chief, may be used with some probability of success. If any thing is to be expected from antiseptics, Dr Cullen thinks camphor preferable to every other. In general, however, every one is to be indulged in the medicine of which he has the best opinion, provided it is not evidently hurtful. Whether infusés be useful in preserving from the effects of contagion, is a matter of doubt. Dr Russel in his treatise enters very fully into the consideration of the means of prevention, both with respect to quarantines, lazarettos, and bills of health. He is of opinion, that the present laws on these subjects are in many respects defective: and he thinks, that a set of new regulations would have the best chance of a deliberate and impartial discussion in the senate, if the inquiry were taken at a time free from all apprehension of immediate danger.

Cure. According to Dr Cullen, the indications are the same as in fever in general, but are not all equally important. The measures for moderating the violence of reaction, which operate by diminishing the action of the heart and arteries, have seldom, he thinks, any place here, excepting that the antiphlogistic regimen is generally proper. Some physicians have recommended bleeding, and Sydenham even seems to think it an effectual cure; but Dr Cullen supposes, that for the most part it is unnecessary, and in many cases might do much hurt. Dr Russel, however, who on this subject speaks from experience and actual observation, is of a different opinion. With most of his patients, a single bleeding was employed with advantage; and even where the sick under his inspection were bled oftener than once, he did not find that the low state was thereby hurried on. Purging has also been recommended; and in some degree it may be useful in drawing off the putrefied matter frequently present in the intestines; but a large evacuation in this way may certainly be hurtful.

The moderating the violence of reaction, as far as it can be done, by taking off the spasm of the extreme vessels, is a measure, in Dr Cullen's opinion, of the utmost necessity in the cure of the plague; and the whole of the means formerly mentioned, as suited to this indication, are extremely proper. The giving an emetic, at the first approach of the disease, would probably be of great service; and it is probable, that at some other periods of the disease, emetics might be useful, both by evacuating bile abounding in the alimentary canal, and by taking off the spasm of the extreme vessels. Indeed Baron Ath, and some other of the Russian practitioners, represent the early and repeated use of emetics as the only effectual mode of cure.

According to the observations of Dr de Mertens, who wrote a very interesting treatise on the fatal plague which raged at Moscow in 1771, and which carried off upwards of 20,000 inhabitants in the space of one month, emetics were often of the greatest service.

From some principles with respect to fever in general, and with respect to the plague in particular, Dr Cullen is of opinion, that after the exhibition of the first vomit, the body should be disposed to sweat; but this sweat should be raised only to a moderate degree, though it must be continued for 24 hours or more if the patient bears it easily. The sweating is to be excited and conducted according to the rules laid down under SYNCHIA; and must be promoted by the plentiful use of diluents rendered more grateful by vegetable acids, or more powerful by being impregnated with some portion of neutral salts. To support the patient under the continuance of the sweat, a little weak broth, acidulated with the juice of lemons, may be given frequently, and sometimes a little wine if the heat of the body be not considerable. If sudorific medicines be judged necessary, opiates will be found more effectual and safe; but they should not be combined with aromatics, and probably may be more effectual if joined with a portion of emetics and of neutral salts. But if, notwithstanding the use of emetics and sudorifics in the beginning, the disease should still continue, the cure must turn upon the use of means for obviating debility and putrefaction; and for this purpose tonic medicines, especially cinchona and cold drink, are the most proper.

GENUS XXVIII. VARIOLA.

The SMALLPOX.

Variola, Sauv. gen. 92. Lin. 3. Sag. gen. 290. Febris variolosa, Vog. 35. Hoffm. II. 49. Variolae, Boerh. 1371. Junck. 76.

Sp. I. Dijinct SMALIPOX.

Variola discreta benigna, Sauv. sp. 2. Variolae regulares discretae, Sydenh. sect. iii. cap. 2. Variolae discretae simplices, Helvet. Obf. sp. 1. Variola discreta complicata, Sauv. sp. 2. Helvet. sp. 2. Variolae anomala, Sydenh. sect. iv. cap. 6. Variola discreta dyfenterioides, Sauv. sp. 4. Sydenh. sect. iv. cap. 1. Variola discreta vesicularis, Sauv. sp. 5. Variola discreta crystallina, Mead. de variol. cap. 2. Variola discreta verrucosa, Sauv. sp. 6. Mead. ibid. Variola discreta filiquosa, Sauv. sp. 7. Freind Oper. p. 358. Variola discreta miliaris, Sauv. sp. 8. Helvet. Obf. sp. 3.

Sp. II. The Confluent SMALLPOX.

Variola confluen, Sauv. sp. 9. Variola regulares confluentes, ann. 1667. Sydenham, sect. iii. cap. 2. Variolae confluentes simplices, Helvet. Obf. sp. 1. Variola confluen crystallina, Sauv. sp. 10. Variola japonica, Kempfer. Vesiculae divae Barbarae, C. Pits. Obf. 149. Variola confluen maligna, Helvet. Obf. sp. 1. Variola confluen cohaerens, Sauv. sp. 11. Variola confluen maligna, Helvet. sp. 2. Variola confluen nigra, Sauv. sp. 12. Sydenham, sect. v. cap. 4 Variola confluen maligna, Helvet. sp. 3. Variola sanguinea, Mead de variolis. cap. 2. Variola confluen corymbosa, Sauv. sp. 13. Variola confluen maligna, Helvet. sp. 4.

Description. In the distinct smallpox, the disease begins with a synoche or inflammatory fever. This fever generally comes on about mid-day, with some symptoms of a cold stage, and commonly with a considerable languor and drowsiness. A hot stage is soon formed, and becomes more considerable on the second and third day. During this course children are liable to frequent startings from their flumbers; and adults, if they are kept in bed, are disposed to much sweating. On the third day, children are sometimes affected with one or two epileptic fits. Towards the end of the third day the eruption commonly appears, and gradually increases during the fourth; appearing first on the face, and successively on the inferior parts, so as to be completed over the whole body on the fifth day. From the third day the fever abates, and by the fifth it entirely ceases. The eruption appears first in small red spots hardly eminent, but by degrees rising into pimples. There are generally but few on the face; but, even when more numerous, they are separate and distinct from one another. On the fifth or sixth day, a small vesicle, containing an almost colourless fluid, appears on the top of each pimple. For two days these vesicles increase in breadth only, and there is a small hollow pit in their middle, so that they are not raised into spheroidal pustules till the eighth day. These pustules from their first formation continue to be surrounded with an exactly circular inflamed margin, which, when they are numerous, diffuses some inflammation over the neighbouring skin, so as to give somewhat of a damask-rose colour to the spaces between the pustules. As the pustules increase in size, the face swells considerably if they are numerous on it; and the eye lids particularly are so much swelled, that the eyes are entirely shut. As the disease proceeds, the matter in the pustules becomes by degrees more opaque and white, and at length assumes a yellowish colour. On the 11th day the swelling of the face is abated, and the pustules seem quite full. On the top of each a darker spot appears; and at this place the pustule, on the 11th day, or soon after, is spontaneously broken, and a portion of the matter oozes out; in consequence of which the pustule is shrivelled, and subides; while the matter oozing out dries, and forms a crust upon its surface. Sometimes only a little of the matter oozes out, and what remains in the pustule becomes thick and even hard. After some days, both the crusts and the hardened pustules fall off, leaving the skin which they covered of a brownish red colour; nor doth it resume its natural colour till many days after. In some cases, where the matter of the pustules has been more liquid, the crusts formed from it are later in falling off, and the part they covered suffers some desquamation, which occasions a small hollow or pit.

On the legs and hands the matter is frequently absorbed; so that at the height of the disease, these pustules appear as empty as vehicles. On the 10th and 11th days, as the swelling of the face subides, a swelling arises in the hands and feet; but which again subides as the pustules come to maturity.—When the pustules on the face are numerous, some degree of pyrexia appears on the 10th and 11th days; but disappears again after the pustules are fully ripened, or perhaps remains in a very flight degree till the pustules on the feet have finished their course; and it is seldom that any fever continues longer in the distinct smallpox. When the pustules are numerous on the face, upon the sixth or seventh day some uneasiness of the throat, with a hoarseness of the voice, comes on, and a thin liquid is poured out from the mouth. These symptoms increase with the swelling of the face; and the liquids of the mouth and throat becoming thicker are with difficulty thrown out; and there is at the same time some difficulty in swallowing, so that liquids taken in to be swallowed are frequently rejected or thrown out by the nose. But all these affections of the fauces are abated as the swelling of the face subides.

In the confluent smallpox all the symptoms above mentioned are much more severe. The eruptive fever particularly is more violent; the pulse is more frequent and more contracted, approaching to that state of pulse which is observed in typhus. The coma is more considerable, and there is frequently a delirium. Vomiting also frequently attends, especially at the beginning of the disease. In very young infants epileptic fits are sometimes frequent on the first days of the disease, and sometimes prove fatal before any eruption appears, or they usher in a very confluent and putrid smallpox. But at the same time, it has been justly remarked by Dr Sydenham, and other accurate observers, that epileptic attacks more frequently precede distinct and mild than malignant and confluent smallpox. The eruption appears in the confluent more early on the third day, and it is frequently preceded or accompanied with an erysipelatous efflorescence. Sometimes times the eruption appears in clusters like the meales. When the eruption is completed, the pimples are always more numerous upon the face, and at the same time smaller and less eminent. Upon the eruption the fever suffers some remission, but never goes off entirely; and after the fifth or sixth day it increases again, and continues to be considerable throughout the remaining part of the disease. The vesicles formed on the top of the pimples appear sooner; and while they increase in breadth, they do not retain a circular, but are every way of an irregular figure. Many of them run into one another, insomuch that very often the face is covered with one vesicle rather than with a number of pustules. The vesicles, as far as they are any way separated, do not arise to a spheroidal form, but remain flat, and sometimes the whole of the face appears an even surface. When the pustules are in any measure separated, they are not bounded by an inflamed margin, but the part of the skin that is free from pustules is commonly pale and flaccid. The liquor that is in the pustules changes from a clear to an opaque appearance, and becomes whitish or brownish, but never acquires the yellow colour and thick consistence that appears in the distinct smallpox. The swelling of the face, which only sometimes attends the distinct smallpox, always attends the confluent kind; it also comes on more early, and rises to a greater height, but abates considerably on the tenth or eleventh day. At this time the pustules or vesicles break and shrivel; pouring out at the same time a liquor, which is formed into brown or black crusts, which do not fall off for a long time after. Those of the face, in falling off, leave the skin subject to a desquamation, which pretty certainly produces pittings. On the other parts of the body the pustules of the confluent smallpox are more difficult than on the face; but never acquire the same maturity and consistence of pus as in the properly distinct kind.—The salivation, which sometimes only attends the distinct smallpox, very constantly attends the confluent; and both the salivation and the affection of the fauces above mentioned occur, especially in adults, in a higher degree. In infants a diarrhoea comes frequently in place of a salivation.

In this kind of smallpox there is often a very considerable putrefaction of the fluids, as appears from petechiae, from feros vesicles, under which the skin shows a disposition to gangrene, and from bloody urine or other hemorrhages; all of which symptoms frequently attend this disease. In the confluent smallpox also, the fever, which had only suffered a remission from the eruption to the maturation, at or immediately after, this period is frequently renewed again with considerable violence. This is what has been called the secondary fever, and is of various duration and event.

Cauter, &c. It is evident that the smallpox is originally produced by a contagion; and that this contagion is a ferment with respect to the fluids of the human body, which assimilates a considerable portion of them to its own nature: or, at least, we have every reason to believe that a small quantity of contagious matter introduced, is somehow multiplied and increased in the circulating fluids of the animal body. This quantity passes again out of the body, partly by insensible perspiration, and partly by being deposited in pustules: Variola. The causes which determine more of the variolous matter to pass by perspiration, or to form pustules, are probably certain circumstances of the skin, which determine more or less of the variolous matter to stick in it, or to pass freely through it. The circumstance of the skin, which seems to determine the variolous matter to stick in it, is a certain state of inflammation depending much on the heat of it: thus we have many instances of parts of the body, from being more heated, having a greater number of pustules than other parts. Thus parts covered with plasters, especially those of the stimulant kind, have more pustules than others.

—Certain circumstances also, such as adult age, and full living, determining to a phlogistic diathesis, seem to produce a greater number of pustules, and vice versa. It is therefore probable, that an inflammatory state of the whole system, and more particularly of the skin, gives occasion to a greater number of pustules; and the causes of this may produce most of the other circumstances of the confluent smallpox, such as the time of eruption, the continuance of the fever, the effusion of a more putrefient matter, and less fit to be converted into pus, together with the form and other circumstances of the pustules.

Prognosis. The more exactly the disease retains the form of the distinct kind, it is the safer; and the more completely the disease takes the form of the confluent kind, it is the more dangerous. It is only when the distinct kind shows a great number of pustules on the face, or otherwise by fever or putrefaction, approaching to the circumstances of the confluent, that the distinct kind is attended with any danger.

In the confluent kind the danger is always very considerable; and the more violent and permanent the fever is, the greater the danger; and especially in proportion to the increase of the symptoms of putrefaction. When the putrid disposition is very great, the disease sometimes proves fatal before the eighth day; but in most cases death happens on the eleventh, and sometimes not till the fourteenth or seventeenth day.

Though the smallpox may not prove immediately fatal, the more violent kinds are often followed by a morbid state of the body, sometimes of very dangerous event. These consequences, according to Dr. Cullen, may be imputed sometimes to an acid matter produced by the preceding disease, and deposited in different parts; and sometimes to an inflammatory diathesis produced and determined to particular parts of the body.

Since the introduction of smallpox into Europe, there is perhaps no disease which has produced a greater number of deaths. But, fortunately, a discovery is now made, by which there is reason to hope that this loathsome disease may be altogether exterminated; its prevention, viz. by the inoculation of the vaccine or cowpox.

This most important discovery we owe to the successful exertions of Dr. Edward Jenner; to whom, for these exertions, repeated rewards have been voted by the British legislature, but who unquestionably enjoys a much higher reward in the satisfaction of having conferred an inestimable blessing on the human species. For an account of the progress of this discovery, we must refer our readers to Dr Jenner's publication. Here we shall only observe, that it had long been remarked in some parts of England, particularly in the neighbourhood of Berkley, where Dr Jenner resided, that cows were liable to a putrid disease on their udders, somewhat resembling smallpox; that this disease was communicated by contact to the fingers of those employed in milking the cows; and, finally, that those thus infected with cowpox, were completely protected against the contagion of smallpox.

Founding on these observations, Dr Jenner ascertained by experiment, that the inoculation of vaccine matter was an infallible preventive of smallpox; and that this vaccine matter had equal power in preventing variola when transferred from one human subject to another, as when obtained immediately from the cow. It is not therefore wonderful that this practice of vaccine inoculation should soon have become general, both in Britain and in every quarter of the world. Nor is it perhaps surprising, that it should have been violently opposed by ignorant and obstinate men. Hence numerous publications have of late appeared both for and against this practice. Many mistakes have undoubtedly been committed by ignorance and inattention; and thus the preventive has been supposed to fail. For the best account both of the method of performing the operation, of conveying the vaccine matter from one place to another, and of the tests of constitutional affection in those cases in which the inflammation is slight, and in which no fever is perceptible, we may refer our readers to a treatise published at Edinburgh in 1822, by Mr James Bryce, entitled Practical Observations on the Inoculation of Cowpox.

Of the efficacy of vaccine inoculation as a preventive of smallpox, few candid men will entertain any doubt, after the following report on vaccination, from the Royal College of Physicians in London, ordered to be printed on the 8th of July 1807, by the British parliament.

REPORT, &c.

The Royal College of Physicians of London, having received his majesty's commands, in compliance with an address from the house of commons, "to inquire into the state of vaccine inoculation in the united kingdom, to report their opinion and observations upon that practice, upon the evidence which has been adduced in its support, and upon the causes which have hitherto retarded its general adoption;"—have applied themselves diligently to the business referred to them.

Deeply impressed with the importance of an inquiry which equally involves the lives of individuals, and the public prosperity, they have made every exertion to investigate the subject fully and impartially. In aid of the knowledge and experience of the members of their own body, they have applied separately to each of the licentiates of the college; they have corresponded with the colleges of physicians of Dublin and Edinburgh; with the colleges of surgeons of London, Edinburgh, and Dublin; they have called upon the societies established for vaccination, for an account of their practice, to what extent it has been carried on, and what has been the result of their experience; and they have, by public notice, invited individuals to contribute whatever information they had feverally collected. They have in consequence been furnished with a mass of evidence communicated with the greatest readiness and candour, which enables them to speak with confidence upon all the principal points referred to them.

I. During eight years which have elapsed since Dr Jenner made his discovery public, the progress of vaccination has been rapid, not only in all parts of the united kingdom, but in every quarter of the civilized world. In the British islands some hundred thousands have been vaccinated, in our possessions in the East Indies upwards of 800,000, and among the nations of Europe the practice has become general. Professional men have submitted it to the fairest trials, and the public have, for the most part, received it without prejudice. A few indeed have flood forth the adversaries of vaccination, on the same grounds as their predecessors who opposed the inoculation for the smallpox, falselly led by hypothetical reasoning in the investigation of a subject which must be supported, or rejected, upon facts and observation only. With these few exceptions, the testimony in favour of vaccination has been most strong and satisfactory, and the practice of it, though it has received a check in some quarters, appears still to be upon the increase in most parts of the united kingdom.

II. The college of physicians, in giving their observations and opinions on the practice of vaccination, think it right to premise, that they advance nothing but what is supported by the multiplied and unequivocal evidence which has been brought before them, and they have not considered any facts as proved but what have been stated from actual observation.

Vaccination appears to be in general perfectly safe: the instances to the contrary being extremely rare. The disease excited by it is slight, and seldom prevents those under it from following their ordinary occupations. It has been communicated with safety to pregnant women, to children during dentition, and in their earliest infancy; in all which respects it possesses material advantages over inoculation for the smallpox; which though productive of a disease generally mild, yet sometimes occasions alarming symptoms, and is in a few cases fatal.

The security derived from vaccination against the smallpox, if not absolutely perfect, is as nearly so as can perhaps be expected from any human discovery; for amongst several hundred thousand cases, with the results of which the college have been made acquainted, the number of alleged failures has been surprisingly small, so much so, as to form certainly no reasonable objection to the general adoption of vaccination; for it appears that there are not nearly so many failures, in a given number of vaccinated persons, as there are deaths in an equal number of persons inoculated for the smallpox. Nothing can more clearly demonstrate the superiority of vaccination over the inoculation of the smallpox, than this consideration; and it is a most important fact, which has been confirmed in the course of this inquiry, that in almost every case, where the smallpox has succeeded vaccination, whether by inoculation or by casual infection, the disease has varied much from its ordinary course; it has neither been the same in the violence, nor in the duration of its symptoms, but has, with very few exceptions, been remarkably mild, as if the smallpox had been deprived, by the previous vaccine disease, of all its usual malignity.

The testimonies before the college of physicians are very decided in declaring, that vaccination does less mischief to the constitution, and less frequently gives rise to other diseases, than the smallpox, either natural or inoculated.

The college feel themselves called upon to state this strongly, because it has been objected to vaccination, that it produces new, unheard-of, and monstrous diseases. Of such assertions no proofs have been produced, and, after diligent inquiry, the college believe them to have been either the inventions of designing, or the mistakes of ignorant men. In these respects then, in its mildness, its safety, and its consequences, the individual may look for the peculiar advantages of vaccination. The benefits which flow from it to society are infinitely more considerable, it spreads no infection, and can be communicated only by inoculation. It is from a consideration of the pernicious effects of the smallpox, that the real value of vaccination is to be estimated. The natural smallpox has been supposed to destroy a sixth part of all whom it attacks; and that even by inoculation, where that has been general in parishes and towns, about one in 350 has usually died. It is not sufficiently known, or not adverted to, that nearly one-tenth, some years more than one-tenth of the whole mortality in London, is occasioned by the smallpox; and however beneficial the inoculation of the smallpox may have been to individuals, it appears to have kept up a constant source of contagion, which has been the means of increasing the number of deaths by what is called the natural disease. It cannot be doubted that this mischief has been extended by the inconsiderate manner in which great numbers of persons, even since the introduction of vaccination, are still every year inoculated with the smallpox, and afterwards required to attend two or three times a-week at the places of inoculation, through every stage of their illness.

From this, then, the public are to expect the great and uncontroverted superiority of vaccination, that it communicates no casual infection, and, while it is a protection to the individual, it is not prejudicial to the public.

III. The college of physicians, in reporting their observations and opinions on the evidence adduced in support of vaccination, feel themselves authorized to state that a body of evidence so large, so temperate, and so confident, was perhaps never before collected upon any medical question. A discovery so novel, and to which there was nothing analogous known in nature, though resting on the experimental observations of the inventor, was at first received with diffidence: it was not, however, difficult for others to repeat his experiments, by which the truth of his observations was confirmed, and the doubts of the cautious were gradually dispelled by extensive experience. At the commencement of the practice, almost all that were vaccinated were afterwards submitted to the inoculation of the smallpox; many underwent this operation a second, and even a third time, and the uniform success of these trials quickly bred confidence in the new discovery. But the evidence of the security derived from vaccination against the smallpox does not rest alone upon those who afterwards underwent various inoculation, although amounting to many thousands; for it appears, from numerous observations communicated to the college, that those who have been vaccinated are equally secure against the contagion of epidemic smallpox. Towns, indeed, and districts of the country in which vaccination had been general, have afterwards had the smallpox prevalent on all sides of them without suffering from the contagion. There are also in the evidence a few examples of epidemic smallpox having been subdued by a general vaccination. It will not, therefore, appear extraordinary that many who have communicated their observations should state, that though at first they thought unfavourably of the practice, experience had now removed all their doubts.

It has been already mentioned, that the evidence is not universally favourable, although it is in truth nearly so, for there are a few who entertain sentiments differing widely from those of the great majority of their brethren. The college, therefore, deemed it their duty, in a particular manner, to inquire upon what grounds and evidence the opposers of vaccination rested their opinions. From personal examination, as well as from their writings, they endeavoured to learn the full extent and weight of their objections. They found them without experience in vaccination, supporting their opinions by hearsay information and hypothetical reasoning; and, upon investigating the facts which they advanced, they found them to be either misapprehended or misapplied; or that they fell under the description of cases of imperfect smallpox, before noticed, and which the college have endeavoured fairly to appreciate.

The practice of vaccination is but of eight years standing, and its promoters, as well as opponents, must keep in mind, that a period so short is too limited to ascertain every point, or to bring the art to that perfection of which it may be capable. The truth of this will readily be admitted by those acquainted with the history of inoculation for the smallpox. Vaccination is now, however, well understood, and its character accurately described. Some deviations from the usual course have occasionally occurred, which the author of the practice has called furious cowpox, by which the public have been misled, as if there were a true and a false cowpox; but it appears, that nothing more was meant, than to express irregularity or difference from that common form and progress of the vaccine pustule from which its efficacy is inferred. Those who perform vaccination ought therefore to be well instructed, and should have watched with the greatest care the regular progress of the pustule, and learnt the most proper time for taking the matter. There is little doubt that some of the failures are to be imputed to the inexperience of the early vaccinators, and it is not unreasonable to expect that farther observation will yet suggest many improvements that will reduce the number of anomalous cases, and furnish the means of determining, with greater precision, when the vaccine disease has been effectually received.

Though the college of physicians have confined themselves in estimating the evidence to such facts as have occurred in their own country, because the accuracy of them could best be ascertained, they cannot be insensi- to the confirmation these receive from the reports of the successful introduction of vaccination, not only into every part of Europe, but throughout the vast continents of Asia and America.

IV. Several causes have had a partial operation in retarding the general adoption of vaccination; some writers have greatly undervalued the security it affords, while others have considered it to be of a temporary nature only; but if any reliance is to be placed on the statements which have been laid before the college, its power of protecting the human body from the smallpox, though not perfect indeed, is abundantly sufficient to recommend it to the prudent and dispassionate, especially as the smallpox, in the few instances where it has subsequently occurred, has been generally mild and transient. The opinion that vaccination affords but a temporary security is supported by no analogy in nature, nor by the facts which have hitherto occurred. Although the experience of vaccine inoculation be only of a few years, yet the same disease, contracted by the milkers of cows in some districts, has been long enough known, to ascertain that, in them at least, the unlikenessibility of the smallpox contagion does not wear out by time.

Another cause, is the charge against vaccination of producing various new diseases of frightful and monstros appearance. Representations of some of these have been exhibited in print in a way to alarm the feelings of parents, and to infuse dread and apprehension into the minds of the uninformed. Publications with such representations have been widely circulated, and though they originate either in gross ignorance, or wilful misrepresentation, yet they have lessened the confidence of many, particularly of the lower classes, in vaccination; no permanent effects, however, in retarding the progress of vaccination, need be apprehended from such causes, for, as soon as the public shall view them coolly and without surprize, they will excite contempt, and not fear.

Though the college of physicians are of opinion that the progress of vaccination has been retarded in a few places by the above causes, yet they conceive that its general adoption has been prevented by causes far more powerful, and of a nature wholly different. The lower orders of society can hardly be induced to adopt precautions against evils which may be at a distance; nor can it be expected from them, if these precautions are attended with expense. Unless therefore, from the immediate dread of epidemic smallpox, neither vaccination nor inoculation appear at any time to have been general, and when the cause of terror has passed by, the public have relapsed again into a state of indifference and apathy, and the fatal practice has come to a stand. It is not easy to suggest a remedy for an evil so deeply imprinted in human nature. To inform and instruct the public mind may do much, and it will probably be found that the progress of vaccination in different parts of the united kingdom will be in proportion to that instruction. Were encouragement given to vaccination, by offering it to the poorer classes without expense, there is little doubt but it would in time supersede the inoculation for the smallpox, and thereby various sources of various infection would be cut off; but till vaccination becomes general, it will be impossible to prevent the constant recurrence of the natural smallpox by means of those who are inoculated, except it should appear proper to the legislature to adopt, in its wisdom, some measure by which those who still, from terror or prejudice, prefer the smallpox to the vaccine disease, may, in thus conflicting the gratification of their own feelings, be prevented from doing mischief to their neighbours.

From the whole of the above considerations, the college of physicians feel it their duty strongly to recommend the practice of vaccination. They have been led to this conclusion by no preconceived opinion, but by the most unbiased judgment, formed from an irresistible weight of evidence which has been laid before them. For when the number, the respectability, the disinterestedness, and the extensive experience of its advocates, is compared with the feeble and imperfect testimonies of its few opposers; and when it is considered that many, who were once adverse to vaccination, have been convinced by further trials, and are now to be ranked among its warmest supporters, the truth seems to be established as firmly as the nature of such a question admits; so that the college of physicians conceive that the public may reasonably look forward with some degree of hope to the time when all opposition shall cease, and the general concurrence of mankind shall at length be able to put an end to the ravages at least, if not to the existence, of the smallpox.

LUCAS PEPYS, President. Royal College of Physicians, 10th of April, 1807.

J.A. HERVEY, Register.

APPENDIX.

No. 1. To the Royal College of Physicians of London.

GENTLEMEN,

I am ordered by the King and Queen's College of Physicians, in Ireland, to thank the Royal College of Physicians of London for the communication they have had the honour to receive from them, of certain propositions relative to vaccination, whereon his majesty has been pleased to direct an inquiry to be instituted, and in the prosecution of which, the co-operation of the college in Ireland is requested.

And I am directed to acquaint you, that the said college having referred the investigations of these propositions to a committee, have received from them a report, of which the inclosed is a copy; and that they desire the same may be considered as containing their opinion upon the subject.

I have the honour to be, Gentlemen, Your most obedient humble servant, By order of the King and Queen's College of Physicians in Ireland. HUGH FERGUSON, Regtler. Dublin, 11th Nov. 1806.

"The practice of vaccination was introduced into this this city about the beginning of the year 1801, and appears to have made inconsiderable progress at first. A variety of causes operated to retard its general adoption, amongst which the novelty of the practice, and the extraordinary effects attributed to vaccination, would naturally take the lead.

"Variolous inoculation had been long, almost exclusively, in the hands of a particular branch of the profession, whose prejudices and interests were strongly opposed to the new practice; and by their being the usual medical attendants in families, and especially employed in the diseases of children, their opinions had greater effect upon the minds of parents. The smallpox is rendered a much less formidable disease in this country by the frequency of inoculation for it, than it is in other parts of his majesty's dominions, where prejudices against inoculation have prevailed; hence parents, not unnaturally, objected to the introduction of a new disease, rather than not recur to that, with the mildness and safety of which they were well acquainted.

"In the beginning of the year 1804, the cowpox institution was established under the patronage of the earl of Hardwicke, and it is from this period that we may date the general introduction of vaccination into this city, and throughout all parts of Ireland.

"The success of the institution, in forwarding the new practice, is to be attributed in a great measure to the respectable ability of the gentlemen who superintended it, and to the diligence, zeal, and attention of Dr. La-batt, their secretary and inoculator. In order to shew the progress which has been made in extending vaccination, your committee refer to the reports of the Cowpox Institution for the last two years, and to extracts from their register for the present year.

<table> <tr> <th></th> <th>Patients Inoculated.</th> <th>Packets issued to Practitioners in general.</th> <th>Packets to Army Surgeons.</th> </tr> <tr> <td>1804</td> <td>578</td> <td>776</td> <td>236</td> </tr> <tr> <td>1805</td> <td>1032</td> <td>1124</td> <td>178</td> </tr> <tr> <td>1806</td> <td>1356</td> <td>1340</td> <td>220</td> </tr> <tr> <td>Total</td> <td>2966</td> <td>3240</td> <td>634</td> </tr> </table>

"In the above statement, the numbers are averaged to the end of the present year, on the supposition of patients referring to the institution as usual. The correspondence of the institution appears to be very general throughout every part of Ireland, and by the accounts received, as well from medical practitioners as others, the success of vaccination seems to be uniform and effectual. At the present period, in the opinion of your committee, there are few individuals in any branch of the profession, who oppose the practice of vaccination in this part of his majesty's dominions.

"It is the opinion of your committee, that the practice of cowpox inoculation is safe, and that it fully answers all the purposes that have been intended by its introduction. At the same time, your committee is willing to allow that doubtful cases have been reported to them as having occurred, of persons suffering from smallpox, who had been previously vaccinated. Upon minute investigation, however, it has been found, that these supposed instances originated generally in error, misrepresentation, or the difficulty of discriminating between smallpox and other eruptions, no case having come to the knowledge of your committee, duly authenticated by respectable and competent judges, of genuine smallpox succeeding the regular vaccine disease.

"The practice of vaccination becomes every day more extended; and, when it is considered that the period at which it came into general use in Ireland is to be reckoned from so late a date, your committee is of opinion, that it has made already as rapid a progress as could be expected.

(Signed) "JAMES CLEGHORN. "DANIEL MILLS. "HUGH FERGUSON."

No II.

Physicians Hall, Edinburgh 26th Nov. 1806.

GENTLEMEN,

THE Royal College of Physicians of Edinburgh have but little opportunity themselves of making observations on vaccination, as that practice is entirely conducted by surgeon apothecaries, and other medical practitioners not of their college, and as the effects produced by it are so inconsiderable and slight, that the aid of a physician is never required.

The College know that in Edinburgh it is universally approved of by the profession, and by the higher and middle ranks of the community; and that it has been much more generally adopted by the lower orders of the people than ever the inoculation for smallpox was, and they believe the same to obtain all over Scotland.

With regard to any causes which have hitherto prevented its general adoption, they are acquainted with none except the negligence or ignorance of parents among the common people, or their mistaken ideas of the impropriety or criminality of being accessory to the production of any disease among their children, or the difficulty or impossibility, in some of our country districts, of procuring vaccine matter, or a proper person to inoculate.

The evidence in favour of vaccination appeared to the Royal College of Physicians of Edinburgh so strong and decisive, that in May last, they spontaneously and unanimously elected Dr Jenner an honorary fellow of their college—a mark of distinction which they very rarely confer, and which they confine almost exclusively to foreign physicians of the first eminence.

They did this with a view to publish their opinion with regard to vaccination, and in testimony of their conviction of the immense benefits which have been, and which will in future be derived to the world, from inoculation for the cowpox, and as a mark of their sense of Dr Jenner's very great merits and ability in introducing and promoting this invaluable practice.

I have the honour to be, Gentlemen, Your most obedient humble servant, TH. SPENS, C. R. M. Ed. Pr. To the Royal College of Physicians of London.

No III.

No III.

At a special court of assistants of the Royal College of Surgeons, convened by order of the Master, and holden at the College on Tuesday the 17th day of March 1807;

Mr Governor Lucas in the chair:

Mr Long, as chairman of the board of curators, reported, that the board are now ready to deliver their report on the subject of vaccination.

It was then moved, seconded, and resolved, that a report from the board of curators, on the subject of vaccination, which was referred to their consideration by the court of assistants, on the 21st day of November last, be now received.

Mr Long then delivered to Mr Governor Lucas (prefiding in the absence of the master) a report from the board of curators.

It was then moved, seconded, and resolved, that the report, delivered by Mr Long, be now read; and it was read accordingly, and is as follows.

To the Court of Assistants of the Royal College of Surgeons in London.

THE report of the Board of Curators, on the subject of vaccination, referred to them by the court, on the 21st day of November 1806; made to the court on the 17th of March 1807.

The court of assistants having received a letter from the Royal College of Physicians of London, addressed to this college, stating, that his majesty had been graciously pleased, in compliance with an address from the honourable House of Commons, to direct his Royal College of Physicians of London to enquire into the state of vaccination in the united kingdom, to report their observations and opinion upon that practice, upon the evidence adduced in its support, and upon the causes which have hitherto retarded its general adoption; that the college were then engaged in the investigation of the several propositions thus referred to them, and requesting this college to co-operate and communicate with them, in order that the report thereupon might be made as complete as possible.

And having, on the 21st day of November last, referred such letter to the consideration of the board of curators, with authority to take such steps respecting the contents thereof as they should judge proper, and report their proceedings thereon, from time to time, to the court: the board proceeded with all possible dispatch to the consideration of the subject.

The board being of opinion, that it would be proper to address circular letters to the members of this college, with a view of collecting evidence, they submitted to the consideration of the court, holden on the 15th day of December last, the drafts of such letter as appeared to them best calculated to answer that end; and the same having been approved by the court, they caused copies thereof to be sent to all the members of the college in the united kingdom, whose residence could be ascertained, in the following form; viz.

"Sir, "The Royal College of Surgeons being desirous to co-operate with the Royal College of Physicians of London, in obtaining information respecting vaccination, submit to you the following questions, to which the favour of your answer is requested.

"By order of the Court of Assistants, "Okey Belfour, Secretary." Lincoln's-Inn-Fields, Dec. 15. 1806.

"1st, How many persons have you vaccinated? "2d, Have any of your patients had the smallpox after vaccination? In the case of every such occurrence, at what period was the vaccine matter taken from the vehicle? How was it preferred? How long before it was inserted? What was the appearance of the inflammation? And what the interval between vaccination and the variolous eruption? "3d, Have any bad effects occurred in your experience in consequence of vaccination? And if so, what were they? "4th, Is the practice of vaccination increasing or decreasing in your neighbourhood? If decreasing, to what cause do you impute it?"

To such letters the board have received 426 answers: and the following are the results of their investigation:

The number of persons, stated in such letters to have been vaccinated, is 164,381.

The number of cases in which smallpox had followed vaccination is 56.

The board think it proper to remark under this head, that, in the enumeration of cases in which smallpox has succeeded vaccination, they have included none but those in which the subject was vaccinated by the surgeon reporting the facts.

The bad consequences which have arisen from vaccination are, eruptions of the skin in 66 cases, and inflammation of the arm in 24 instances, of which three proved fatal.

Vaccination, in the greater number of counties from which reports have been received, appears to be increasing; it may be proper, however, to remark, that, in the metropolis, it is on the decrease.

The principal reasons assigned for the decrease are,

Imperfect vaccination. Inflames of smallpox after vaccination. Supposed bad consequences. Publications against the practice. Popular prejudices.

And such report having been considered, it was moved, seconded, and

Resolved, That the report now read be adopted by this court, as the answer of the court to the letter of the Royal College of Physicians, of the 23d day of October last, on the subject of vaccination.

Resolved, That a copy of these minutes and resolutions, signed by Mr Governor Lucas (prefiding at this court in the presence of the master) be transmitted by the secretary to the register of the Royal College of Physicians.

(Signed) Wm. Lucas.

No IV. MEDICINE.

NO IV.

Sir, Edinburgh, March 3, 1807. I mentioned in my former letter, that I would take the earliest opportunity of laying before the Royal College of Surgeons of Edinburgh, the communication with which the Royal College of Physicians of London had honoured them, on the 23d of October last:

I am now directed by the Royal College to send the following answer on that important subject.

The practice of vaccine inoculation, both in private, and at the vaccine institution established here in 1801, is increasing so rapidly, that for two or three years past, the smallpox has been reckoned rather a rare occurrence, even among the lower orders of the inhabitants of this city, unless in some particular quarters about twelve months ago; and, among the higher ranks of the inhabitants, the disease is unknown.

The members of the Royal College of Surgeons have much pleasure in reporting, that, as far as their experience goes, they have no doubt of the permanent security against the smallpox which is produced by the constitutional affection of the cowpox; and that such has hitherto been their success in vaccination, as also to gain for it the confidence of the public, inasmuch that they have not been required, for some years past, to inoculate any person with smallpox who had not previously undergone the inoculation with the cowpox.

The members of the Royal College have met with no occurrence in their practice of cowpox inoculation, which could operate in their minds to its disadvantage; and they beg leave particularly to notice, that they have seen no instance of obstinate eruptions, or of new and dangerous diseases, which they could attribute to the introduction among mankind of this mild preventive of smallpox. The Royal College of Surgeons know of no causes which have hitherto retarded the adoption of vaccine inoculation here; on the contrary, the practice has become general within this city; and from many thousand packets of vaccine matter having been sent by the members of the Royal College, and the vaccine institution here, to all parts of the country, the Royal College have reason to believe that the practice has been as generally adopted throughout this part of the united kingdom as could have been expected from the distance of some parts of the country from proper medical assistance, and other circumstances of that nature.

I have the honour to be, Sir, Your most obedient servant, WM FARQUHARSON, 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 Variola, 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, holden 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 1800 to the 25th of November 1806, 11,594 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 lazaretto, 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 diffused 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 gargarismus 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 cardinals, but to wine, cinchona, and the mineral acids.

GENUS XXIX. VARICELLA.

CHICKENPOX.

Varicella, Vog. 42. Variola lymphatica, Sauv. fn. 1. Anglis, The CHICKENPOX, Edin. Med. Essays, vol. ii. art. 2. near the end. Heberden, Med. Tranfach. art. 17. The WATERY-POX.

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

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

On the fifth day of the eruption they are reddish. On the second day there is at the top of most of them a very small bladder, about the size of a millet seed. This is sometimes full of a watery and colourless, sometimes of a yellowish liquor, contained between the cuticle and skin. On the second, or, at the farthest, on the third day from the beginning of the eruption, as many of these 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 abate 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 vehicle at the top of them, grows yellow and thick, and dries into a scab. On the fifth day of the eruption they are almost all dried and covered with a slight crust. The inflammation of these pocks is very small, and the contents of them do not seem to be owing to suppuration, as in the smallpox, but rather to what is extravasated under the cuticle by the serous vessels of the skin, as in a common blister. It is not wonderful, therefore, that this liquor appears so soon as on the second day; and that, upon the cuticle being broken, it is presently succeeded by a slight scab: hence too, as the true skin is so little affected, no mark or scar is likely to be left, unless in one or two pocks, where, either by being accidentally much fretted or by some extraordinary sharpness of the contents a little ulcer is formed in the skin.

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

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

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

1. The appearance, on the second or third day from the eruption, of that vehicle 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 anything more of it than its name. Morton speaks of it as if he supposed it to be a very mild genuine smallpox. But these two distempers are certainly totally different from one another, not only on account of their different appearances above mentioned, but because those who have had the smallpox are capable of being infected with the chickenpox; but those who have once had the chickenpox are not capable of having it again, though to such as have never had this distemper, it seems as infectious as the smallpox. Dr Heberden wetted a thread in the most concocted pus-like liquor of the chickenpox which he could find; and after making a slight incision, fion, it was confined upon the arm of one who had formerly had it; the little wound healed up immediately, and showed no signs of any infection.

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

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

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

GENUS XXX. RUBEOLA.

MEASLES.

Rubeola, Sauv. gen. 94. Lin. 4. Sag. 293. Febris morbillolia, 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 confluent drowsiness attends the beginning of this disease. The eruption, as we have said, commonly appears upon the fourth day, first on the face, and successively on the lower parts of the body. It appears first in small red points; but soon after, a number of these appear in clusters, which do not arise in visible pimples, but, by the touch, are found to be a little prominent. This is the case on the face; but, in other parts of the body, the prominence, or roughness, is hardly to be perceived. On the face, the eruption retains its redness, or has it increased, for two days; but on the third, the vivid redness is changed to a brownish red; and in a day or two more the eruption disappears, while a mealy desquamation takes place. During the whole time of the eruption, the face is somewhat turgid, but seldom considerably swelled. Sometimes, after the eruption has appeared, the fever ceases entirely: but this is seldom the case; and more commonly the fever continues or is increased after the eruption, and does not cease till after the desquamation. Even then the fever does not always cease, but continues with various duration and effect. Though the fever happen to cease upon the eruption's taking place, it is common for the cough to continue till after the desquamation, and sometimes much longer. In all cases, while the fever continues, the cough also continues, generally with an increase of the difficulty of breathing; and both of these symptoms sometimes arise to a degree which denotes a pneumatic 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 diarrhea 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 caudamentum, as in inflammatory diseases. For the most part, the measles, even when violent, are without any putrid tendency; but in some cases, such a tendency appears both in the course of the disease, and especially after the ordinary course of it is finished.

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

Prognosis. From the description of this distemper already given, it appears that the measles are attended with a catarrhal affection, and with an inflammatory diathesis to a considerable degree; and therefore the danger of them is to be apprehended chiefly from the coming on of a pneumatic 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 dyspnoea; and generally may be employed very freely. But as the symptoms of pneumonic inflammation seldom come on during the eruptive fever, and as this is sometimes violent immediately before the eruption, though a sufficiently mild disease be to follow; bleeding is seldom very necessary during the eruptive fever, and may often be deferred for the times of greater danger which are perhaps to follow.

In all cases of measles, where there are no marks of putrefaction, and where there is no reason, from the known nature of the epidemic, to apprehend putrefaction, bleeding is the remedy most to be depended upon: but affluence 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 mafs 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 dyspnoea, 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 retiring the heat of the body, and thereby again bringing out the eruption.

Upwards of 20 years ago, inoculation for the measles was proposed, and practised in several instances with success, by Dr Home of Edinburgh. His method of communicating the infection was, by applying to an incision in each arm cotton moistened with the blood of a patient labouring under the measles; but with others who have made similar trials, the attempt has not yet succeeded. Attempts have been made to inoculate this disease by means of the fluid discharged under the form of tears, the 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 forenses 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, Lin. 7. Miliaris, Sauv. gen. 95. Sag. gen. 295. Febris miliaris, Vog. 37. Febris purpurata rubra et alba miliaris, Hoffm. II. 68. Febris purpurea seu miliaris, Junck. 75. Germanis der Frichel. Ged. Welsch. Hift. Med de novo puerparum morbo, qui der Frichel dicitur, Lips. 1655. Hamilton, de febr. miliar. 1710. Fontanus, de febr. mil. 1747. Allioni de miliar. 1758. Fordyce, de febr. mil. 1748. Fisher, de febr. mil. 1767. De Haen, de divit. febr. 1760, et in Ration. med. pat. sim. Matt. Collin ad Baldinger de miliar. 1764. Miliaris Miliaris benigna, Sauv. sp. i. Miliaris maligna, Sauv. sp. 2. Miliaris recidivans, Sauv. sp. 3. Miliaris Germanica, Sauv. sp. 5. Miliaris Boia, Sauv. sp. a. Miliaris Britannica, Sauv. sp. i. Miliaris nova febris, Sydenh. Sched. monit. Sauv. sp. d. Miliaris fudatoria, Sauv. sp. e. Miliaris nautica, Sauv. sp. g. Miliaris purpurata, Sauv. sp. h. Miliaris lactea, Sauv. sp. c. Miliaris puerperarum, Sauv. sp. k. Miliaris corbutica, Sauv. sp. l. Miliaris critica, Sauv. sp. b.

History and Description. This disease is said to have been unknown to the ancients, and that it appeared for the first time in Saxony about the middle of the last century. It is said to have since spread from thence into all the other countries of Europe; and since the period mentioned, to have appeared in many countries in which it had never appeared before.

From the time of its having been first taken notice of, it has been described and treated of by many different writers; and by all of them, till very lately, has been considered as a peculiar idiopathic disease. It is said to have been constantly attended with peculiar symptoms. It comes on with a cold stage, which is often considerable. The hot stage, which follows, is attended with great anxiety, and frequent sighing. The heat of the body becomes great, and soon produces profuse sweating, preceded, however, with a sense of pricking, as of pin points in the skin; and the sweat is of a peculiar rank and disagreeable odour. The eruption appears sooner or later in different persons, but at no determined period of the disease. It seldom or never appears upon the face; but appears first upon the neck and breast, and from thence often spreads over the whole body.

The eruption named military, is said to be of two kinds; the one named the red, the other the white miliary. The former, which in English is strictly named a 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 miliary eruption, appears at first like the red, in very small red pimples, for the most part distinct, but sometimes clustered together. Their little prominence is better distinguished by the finger than by the eye. Soon after the appearance of this eruption, and, at least, on the second day, a small vesicle is visible upon the top of the pimples. At first the vesicle is whey-coloured; but soon becomes white, and stands out like a little globe. 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 concourse of symptoms, are steadily the same in different persons, so as to give any specific character to the disease. When the disease is violent, the most common symptoms are phrenetic, catatonic, 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 mass of blood, but generated under particular circumstances in the skin itself. That it depends upon particular circumstances of the skin, is also probable from its being observed that the eruption seldom or never appears upon the face, although it affects the whole of the body besides; and that it comes upon those places especially which are more closely covered; and that it can be brought out upon particular places by external applications.

It is to be observed, that this eruptive disease differs from the other exanthemata in many circumstances, especially the following; that it is not contagious, and therefore never epidemic; that the eruption appears at no determined period of the disease; that the eruption has no determined duration; that successive eruptions frequently appear in the course of the same Exanthematous fever, and that such eruptions frequently recur in the course of the same person's life. All this renders it very probable, that, in the miliary fever, the morbid matter is not a subsisting contagion communicated to the blood, and thence, in consequence of fever and affination, 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 fluor albus. He has also observed it to have happened to men in fevers, after wounds from which they had suffered a great loss of blood.

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

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

It appears so clearly that this eruption is always a Miliaria, symptomatic and facultious 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 loofhens 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 hardnels 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 unfavourable sickness at stomach which frequently occurs, and which is often observed to precede fresh eruptions taking place during the Exanthematous course of the disease. With the view of counter-acting and alleviating this symptom, recourse is had to wine and other cordial medicines. But with many patients nothing is found to have so much influence as the use of camphor, particularly when introduced gradually in small doses, under the form of the mistura camphorata of the London Pharmacopoeia, or of the emulfo camphorata of that of Edinburgh.

GENUS XXXII. SCARLATINA.

SCARLET FEVER.

Scarlatina, Sauv. gen. 98. Vog. 39. Sag. 294. Junck. 73.

Sp. I. The Mild SCARLET FEVER.

Scarlatina febris, Sauv. sp. 1. 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 disorder has been published by Dr Withering in the year 1778. This disease made its appearance, we are told, at Birmingham and the neighbouring villages, about the middle of May 1778. It continued in all its force and frequency to the end of October; varying, however, in some of its symptoms, as the air grew colder. In the beginning of November it was rarely met with; but towards the middle of that month, when the air became warmer, it increased again, and in some measure resumed those appearances it possessed in the summer months, but which it had lost during the cold winds in October.

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

Description. With various general symptoms of fever, the patient at first complains of a dejection of spirits, a flight forenses or rather stiffness in the neck, with a sense of straitness in the muscles of the neck and shoulders, as if they were bound with cords. The second day of the fever this straitness in the throat increases, and the patients find a difficulty in swallowing: but the difficulty seems less occasioned by the pain excited in the attempt, or by the straitness of the passage, than by an inability to throw the necessary muscles into action. The skin feels hot and dry, but not hard; and the patients experience frequent, small, pungent pains, as if touched with the point of a needle. The breath is hot and burning to the lips, and thirst makes them wish to drink; but the tendency to sickness, and the exertions necessary in deglutition, are so unpleasant, that they seldom care to drink much at a time. They have much uneasiness scarlatina, 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 these are easily washed off; and real ulcerations of those parts were never observed.

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

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

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

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

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

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

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

The 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.

<table> <tr> <th>Scarlatina Anginosa.</th> <th>Angina Gangrenosa.</th> </tr> <tr> <td>Season. . Summer . . Autumn.</td> <td>Season. . Spring . . Winter.</td> </tr> </table>

<table> <tr> <th>Scarlatina Anginosa.</th> <th>Angina Gangrenosa.</th> </tr> <tr> <td>Air. Hot . . Dry.</td> <td>Air. . Warm . . Moist.</td> </tr> <tr> <td>Places. High . . Dry . . Gravelly.</td> <td>Places. Clef. . Low . . Damp. . Marthy.</td> </tr> <tr> <td>Subjects. Vigorous. Both sexes alike. Robust in most danger.</td> <td>Subjects. Delicate. Women and female children. Robust adults not in danger.</td> </tr> <tr> <td>Skin. Full scarlet . . smooth . . If pimply, the pimples white at the top.. Always dry and hot.</td> <td>Skin. Red tinct . . pimply. The pimples redder than the interstices .. bedewed with sweat towards morning.</td> </tr> <tr> <td>Eyes. Shining, equable, intense redness, rarely watery.</td> <td>Eyes. Inflamed and watery, or sunk and dead.</td> </tr> <tr> <td>Throat. In summer, tonsils, &c. little tumefied; no slough .. In autumn, more swelled. Integuments separating .. Sloughs white.</td> <td>Throat. Tonfils, &c. considerably swelled and ulcerated .. Sloughs dark brown.</td> </tr> <tr> <td>Breath. Very hot, but not fetid.</td> <td>Breath. Offensive to the patients and assistants.</td> </tr> <tr> <td>Voice. In summer, natural.</td> <td>Voice. Flat and rattling.</td> </tr> <tr> <td>Bowels. Regular at the accession.</td> <td>Bowels. . Purging at the accession.</td> </tr> <tr> <td>Blood. Buffy. . Firm.</td> <td>Blood. . Florid . . Tender.</td> </tr> <tr> <td>Termination. The 3d, 5th, 8th, or 11th day.</td> <td>Termination. No stated period.</td> </tr> <tr> <td>Nature. Inflammatory.</td> <td>Nature. Putrid.</td> </tr> </table>

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 till there occurs such a similarity as clearly marks the features 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 to the infection, in one the disease would have been attended with almost all the symptoms mentioned in the column of scarlatinæ angina, 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 shewn evident marks of an inflammatory, and at its termination of a putrid tendency. And there cannot be a doubt, that both the scarlatina angina 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. 1. 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 stomæh, &c. and at length acts upon the system at large.

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

5. That in consequence of certain laws of the nervous system, when the debilitating effects operate upon the senium 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 drophical.

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 sink so amazingly fast, that it is not within the reach of art to support them. When, however, a considerable quantity of acrid matter passing from the fauces into the stomach, makes its way to the rectum, a considerable degree of loofenel 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 Exanthemata.

monly found to be producive 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 latter is considerable.

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

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

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

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

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

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

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

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

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

Dr Withering concludes his essay with an 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 acid. This has been particularly extolled by Mr John Ayrce 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, Junck. 75. Scarlatina urticata, Sauv. fp. 2. Erythepalitis species altera, Sydenham, sect. vi. cap. 6. Febris scarlatina, et febris urticata, Meyserey, 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 exempt from them; and where many of them rise together, and continue an hour or two, the parts are often considerably swelled; which particularly happens in the face, arms, and hands. These eruptions will continue to infest 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, nottles, it is sometimes accompanied with long weals, as if the part had been struck with a whip. Whatever be the shape of these eminences, they always appear solid, without having any cavity or head containing either water or any other liquor; and this affords an easy mark whereby this disease may be distinguished from the itch. For it often happens, that the insufferable itching with which this eruption is attended, provokes the patient to scratch the parts so violently, that a small part of the cuticle on the top of these little tumors is rubbed off; a little scab succeeds; and, when the swelling is gone down, there is left an appearance hardly to be distinguished from the itch, but by the circumstance just now mentioned. The nettle-rash also further differs from the itch, in not being infectious.

Causes, &c. Dr Heberden is inclined to attribute this differenter 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 phalacolus, 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 sort of hairs almost invisible to the naked eye, which are easily detached, and frequently float in the air round their nest, though it have not been at all disturbed. The touch of these hairs has a similar effect with the cow-itch; that is, they occasion intolerable 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 cauca.

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 blisters, yet it might be supposed 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; mussels, shrimps, and even honey, and the kernels of fruits, will also sometimes produce symptoms of a similar kind. But whatever be its cause, Dr Heberden never saw any reason to suppose that the nettle-rash had in any way vitiated the humours to such a degree as to require the use of internal remedies; and if the itching could be certainly and expeditiously allayed, there would be no occasion for any farther cure. He concludes this history of the disorder with a case communicated to him by Dr Moncey, 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 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 Monfey, 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 Monfey 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 flight salivation ensued; however, that went off soon, and in about fix 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. 1. Febris bullosa, Vog. 41. Pemphigus major, Sauv. sp. 1. Exanthemata serosa, C. Pifon. Obf. 150. Febris pemphygodes, Ephem. Germ. D. I. A. viii. Obf. 6. Pemphigus castrensis, Sauv. sp. 2. Fébres fyneches, cum vesiculis per pectus et column sparhis, Morton. App. ad Exerc. II. Pemphigus Helveticus, Sauv. sp. 3. Langhans in Act. Helvet. vol. ii. p. 260. et in Befchreibung des Siementhals, Zurich 1753.

This is a very rare disease, insomuch 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 soldier of the 73d regiment, aged eighteen years, formerly a pedlar, and naturally of a healthy constitution, was received into the hospital at Aberdeen on the 25th of April. About twenty days before that, he had been seized with the measles when in the country; and, in marching to town, on the second day of their eruption, he was exposed to cold; upon which they suddenly disappeared.

Having arrived at Aberdeen, he was quartered in a Pemphigus damp, ill-aired, under-ground apartment. He then complained of sickness at stomach, great oppression about the precordia, headache, languor, 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 hot and feverish; pulse from 110 to 120, rather depressed; belly colitive; eyes dull and languid, but without delirium. The whole surface of his skin was interpered with vesicles, or phylecence, of the size of an ordinary walnut; many of them were larger, especially on the arms and breast. In the interfaces, 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 distended with a thin, yellowish, semi-pellucid serum, formed this appearance. Nor was the surface of the cutis ulcerated or livid; but of a red florid colour, as when the cuticle is separated by a blister, or superficial burning. No other person 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, e lap. calamarii. 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:

R. Decoct. Cort. Peruvian. 3vj. Vini rubr. Lufstan. 3ijj. M. Hujus mixturæ capiat 3fl. tertia qua-que 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 bason 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 fat easily on his stomach, the following prescription was ordered:

Rp. Pulv. subtiliss. Cort. Peruv. 5G. Vini rubri Lusitan. Aquae fontan. aa 3is. M. ft. Hautt. 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 Chrifite. From a case which Mr Chrifite describes, he is disposed to agree with Dr Dickson in thinking that sometimes at least pemphigus is not contagious. He remarks, however, that the pemphigus described by some foreign writers was extremely infectious; which he thinks may lead to a division of the disease into two species, the pemphigus simplex and complicatus: both of which, but especially the last, seem to vary much with respect to mildness and malignity.

GENUS XXXV. APHTHA.

The THRUSH.

Aphtha, Sauv. gen. 100. Lin. 9. Sag. 298. Boerh. 978. Hoffman. 11. 478. Junck. 137. Febris aphthosa, Vog. 44.

The only idiopathic species is the thrush to which infants are subject; (Aphtha lactucimen, Sauv. sp. 1.)

The aphthae 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, fending 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 exchar 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 aphthe evacuated by stool and vomiting, such as the mouth could not be thought capable of containing.

Causes, &c. The aphthous fever seems to be produced by cold and moisture, as it is found only in the northern countries, and especially in marshy places; and in them the aphthae often appear without any fever at all.

Prognosis. There is no symptom by which the coming out of aphthe 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 aphthae. The dark-coloured aphthae 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 aphthae are seldom a primary disease, we must generally endeavour to remove the disorder upon which they depend, after which they will all ORDER IV. HÆMORRHAGIÆ.

HÆMORRHAGES.

Hæmorrhagie, Vog. Clasf II. Ord. I. Hoffm. II. 194. Junck. 5. Sanguifluxus, Sauv. Clasf IX. Ord. I. Sag., Clasf V. Ord. 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 plethora, Sauv. [p. 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 fides of the head: there is a redness of the cheeks; an inflation of the face, and of the vessels of the neck and temples; a tinnitus aurium; a heavy pain of the eyes, with a prominence, dryness, and sparks; there is a vertiginous affection of the head, with an itching of the nostrils, and a sense of weight, especially about the root of the nose. In some the sleep is disturbed with dreams about blood, fire, &c. Frequently the belly is coltive, there is a diminution of the quantity of urine, a suppression of sweat, coldness of the lower extremities, and tension of the hypochondria, especially the right one.

Causes, &c. This hemorrhage 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 æqua and during the state of manhood, at which time it is to be imputed to a plethoric state of the system; to a determination of the blood, by habit, to the vessels of the nose; or to the particular weakness of these vessels.

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

Prognosis. In young people, the bleeding at the nose may be considered as a slight disease, and scarce worth notice. But, even in young persons, when it recurs very frequently and in great quantity, it is alarming; and is to be considered as a mark of an arterial plethora, which in the decline of life may give the blood a determination to parts from which the hæmorrhage would be more dangerous; and this will require more particular attention, as the marks of plethora and congestion preceding the hæmorrhage are more considerable, and as the flowing of the blood is attended with a more considerable degree of febrile disorder. These consequences are more especially to be dreaded, when the epistaxis happens to persons after their æqua, 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 fatalatory; 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 fatalatory; but if these exanthemata be accompanied with any putrid disposition, this hæmorrhage, as well as artificial bloodlettings, may have a very bad tendency.

Cure. The treatment in cases of epistaxis may be referred to two heads. 1st, The treatment during the time of the discharge; and, 2dly, The treatment after the discharge is stopped, with the view of preventing the return of it. During the former of these periods, it is necessary in the first place to consider whether the discharge should be left to its natural course or stopped by artificial means. In determining this question, regard must be paid to the quantity of the discharge; the appearance of the blood; the constitution with which epistaxis occurs; the former habit of the patient; and the consequences which result from the discharge. When, from due consideration of these circumstances, there is reason to fear that further evacuation would be attended with bad consequences, though this disease has been generally thought very slight, it should seldom be left to the conduct of nature; and in all cases it should be moderated by keeping the patient in cool air, by giving cold drink, by keeping the body and head erect, by avoiding any blowing of the nose, speaking, or other irritation; and if the blood has flowed for some time without showing any tendency to stop, we are to attempt the suppression of the hæmorrhage, by pressing the nostril from which the blood flows, washing the face with cold water, or applying this to some other parts of the body. These measures Dr Cullen judges to be proper even on the first attacks, and even in young persons where the disease is in the least hazardous: but they will till be more requisite if the disease frequently recurs without any external violence; if the returns happen to persons not 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 haemorrhages except those of the alimentary canal. The fossil astringents are more active, but differ considerably in strength from one another.—The chalybeates appear to have little strength: the preparations of lead are more powerful; but cannot be employed, on account of their pernicious qualities, unless in cases of the utmost danger. The tinctura saturina, or antiphthisica, 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 haemorrhages, 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 haemorrhages; and when the fulness and inflammatory diathesis of the system have been previously taken off by bleeding, they may, in Dr Cullen's opinion, be used with safety and advantage. Ligatures have been applied upon the limbs, for retarding the return of the venous blood from the extremities; but their use seems to be ambiguous. In the case of profuse haemorrhages, 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. Junc. 8. Hæmoptoe, Böhr. 1193. Sanguinis fluxus ex pulmonibus, Hoffm. II. 202.

Sp. I. HÆMOPTYSIS from Plethora.

Sp. II. HÆMOPTYSIS from External Violence.

Hæmoptysis accidentalis, Sauv. sp. 1. Hæmoptysis habitualis, 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 haemorrhage 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 furrow of the mouth itself, from the fauces or adjoining cavities of the nose, from the stomach, or from the lungs. It is, however, very necessary to distinguish these different cases; and for this Dr Cullen offers the following considerations.

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

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

3. When blood proceeds from the lungs, the manner in which it is brought up will commonly show from whence it comes; but, independent of that, it may also be known from the causes of hæmoptysis from the lungs, to be afterwards mentioned, having preceded.

4. When vomiting accompanies the throwing out of blood from the mouth, we may generally know the source from whence it proceeds, by considering that blood does not proceed so frequently from the stomach as from the lungs: that blood proceeding from the stomach commonly appears in greater quantity than from the lungs. The pulmonary blood also is usually of a florid colour, and mixed with a little frothy mucus 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 rarefies the blood more than it relaxes the solids, which had before been contracted by the cold of winter. Another exciting cause is a sudden diminution of the weight of the atmosphere, especially when concurring with any effort in bodily exercise. The effort alone, may often be the exciting cause in those who are already predisposed; and more particularly any violent exercise of respiration. In the predisposed, also, the disease may be occasioned by any degree of external violence.

Prognosis. 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, dyspnoea, 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 bronchiae, 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 prescribe 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. e 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 infirmate that the former is totally destitute of efficacy.

When this hemorrhage has rectified 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.

Phthitis, Savi. gen. 276. Lin. 208. Vog. 319. Sag. 101. Junct. 33. Phthitis pulmonis, Boerh. 1196. Afectio phthisica, five tabes pulmonalis, Haffn. II. 284.

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

Phthitis incipiens, Morton Physiolog. L. II. cap. 3. Phthitis fieca, Savo. fp. 1.

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

Phthitis confirmata autorum. Phthitis humida, Savo. fp. 2.

Sometimes, notwithstanding all the care that can be taken, the haemoptysis will degenerate into a phthitis 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 phthitis, 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 a 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 phthitis, 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 phthitis 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 bronchiae, become acid, 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 subsisted; while with this the cough, and especially the dyspnoea, continue, and are rather increased. At the same time the frequency of the pulse is rather increased, the feverish state suffers considerable exacerbations every evening, and by degrees a hectic fever in all its circumstances comes to be formed.

In this state of symptoms, we conclude very confidently, that an abscess, or, as it is called, a vomica, is formed in some part of the pleura, and most frequently in that portion of it investing the lungs. Here purulent matter frequently remains for some time, as if enclosed in a cyst; but commonly not long before it comes to be either absorbed and transferred to some other part of the body, or breaks through into the cavity of the lungs, or into that of the thorax. In the latter case it produces the disease called empyema; but it is when the matter is poured into the cavity of the bronchiae that it properly constitutes the phthitis pulmonalis. In the case of empyema, the chief circumstances of a phthitis 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 phthitis: for sometimes a hectic fever is not formed; the matter poured into the bronchiae is a proper and benign pus, which frequently is coughed up very readily, and spit out; and though this purulent expectoration should continue for some time, if it be without hectic fever, the ulcer soon heals, and every morbid symptom disappears. This has so frequently happened, that we may conclude, that neither the access of the air, nor the constant motion of the lungs, will prevent an ulcer of these parts from healing, if the matter of it be well-conditioned. An abscess of the lungs, therefore, does not necessarily produce phthitis 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 empyema, had been so corrupted as to become unfit for the purpose of pus in the healing of the ulcer. These seem to be possible causes of the corruption of matter in abscesses, so as to make it the occasion of a phthisis in persons otherwise sound; but it is probable that a pneumatic abscess especially produces phthisis when it happens to persons previously disposed to that disease, and therefore only as concurring with some other causes of it.

3. The third cause supposed to produce a phthisis is a catarrh; which, in many cases, seems in length of time to have the expectoration of mucus proper to it gradually changed to an expectoration of pus; and at the same time, by the addition of a hectic fever, the disease, which was at first a pure catarrh, is changed into a phthisis. But this supposition is, 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 to 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 subfusing 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 chronic state after subsisting 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 subsisting 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 abent. 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 scythe-grinders are subject to a disease of the lungs, from particles of sand mixing with iron dust, which among themselves they call the grinders rot. Tubercles, 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 feropula. 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 found 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 flight, 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 becomes alarming by its obstinacy and its effects. This may be considered as the beginning, or first period, of the disease. During this stage, the cough is sometimes dry from the first: and sometimes when it 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 falsith 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 steam 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 flannels 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 fumes, 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 antispasmodic.

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 bracing 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 tussis flamachica. 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 pukes, 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 has failed, both of which circumstances but too frequently happen, the patient begins to complain of a forenefs, and of flight lancinating pains shooting through the breast, sometimes in the direction of the mediastinum, and sometimes confined chiefly to one fide. The forenefs is pretty constant, and much increased by the cough. The pain in the fide often prevents the patient from lying on the fide affected; and this inability of lying except on one fide, frequently occurs even when no fuch pain is felt. In this stage of the difeafe, flufhing heats are felt on the palms of the hands and foles 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 firt in small quantities, coughed up with difficulty, and fome pain of the breast, and now and then fleaked with blood: this may be considered as the inflammatory period of the difeafe, to which fucceeds the supplicative fage. In the latter, the expectoration becomes more copious and purulent, the breath proportionably offensive, and the exacerbations of the hectic fever more confiderable: an increafed quickness of the pulse comes on about the middle of the day; but the moft confiderable paroxysm of the fever is at night, and at firt 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 difeafe advances, these sweats become more profufe, 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 obferve a circumfcribed rednefs of the cheeks, while the reft of the face is pale, and appears as if it were not clean wafhed. The coftivefeats that commonly accompanies the beginning of the difeafe is usually fucceeded by a diarrhcea; the fputting leffens, and all the purulent matter seems to be carried downwards. The wasting of the fat and the lofs of nourishment occasion the nails to curve inwards, the hair to fall off, and the eyes to fink in their fockets. In the mean time, the legs commonly fwell; till at length death closes a fcene which is melancholy to all but the patient himfelf, who in general continues fensible to the laft moment, and even then indulges a vain hope of prolonging a miferable exifence. In fome cafes, and that not unfrequently, a delirium comes on towards the clofe of the difeafe.

The hectic fever that attends this and fome other chronic diseases, is evidently the effect of acrimony, and moft commonly of pus abforbed 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 obferve in fevers of this denomination; a variety which is doubtlefs much greater than we are aware of. Thus we find that the matter of the smallpox excites a fever of this kind; but this fecondary fever, as it is called, differs from the hectic attendant on consumptions; nor does the latter correspond with that which fometimes accompanies the fuppuration of a cancerous ulcer. In the pulmonary consumption, or at leaft in the third stage of it, the fever induced often appears to be of the putrid kind, and has been denominated febrit heftica putrida by the judicious Phisits, Morton, who considers it as being combined with a peripneumonic or inflammatory fever, which recurs as often as fresh tubercles begin to inflame. For although we have named one period of the difeafe the inflammatory, and another the fupplicative period, yet we are not to fuppoft that the latter is exempt from inflammation. While matter is poured into the bronchiae, or abforbed and carried into the fyftem from one part of the lungs, other parts are in a crude flate of inflammation, or advancing towards fuppuration; fo that, on examining the lungs of perfons who die confumptive, we find fome tubercles that are fmall and juft formed, fome that are large and full of matter, and others that are in a flate of ulceration. This eafily accounts for the occasional combination of inflammatory symptoms with thole of the putrid hectic. When the matter abforbed is a laudable pus, as in the cafe of the ploas abfcelis, we find the form of the hectic fever differing from either of thole we have mentioned.

Cure. In thofe different periods of the difeafe, the curative indications are fufficiently obvious. To prevent the formation of fresh tubercles; to obviate the inflammation of thole already formed; to promote their refolution; to allay morbid irritability, the cough, and other troublefome symptoms; and, above all, to check the tendency to the hectic state, are the views that every rational phyfician propofes to himfelf in the treatment of the genuine confumption. We know of no medicines that can exert their specific effects upon the lungs by difolving tuberculous concretions; nor is it probable, from what we know of the animal economy, that any fuch will ever be discovered. Yet medicines that operate in a general manner upon the fyftem, may, by promoting abforption, and diminishing the determination to the lungs, tend to difperfe tubercles, or to prevent their formation. There are not wanting inftances of wonderful recoveries, in cafes where the evil was fuppofted to be beyond the power of phyfic; and in fome, where nature was left to herfelf; fo that a phyfician who has obferved the various and powerful resources nature has within herfelf, will be very cautious how he afferts that a difeafe is incurable.

The moft formidable effects of ulcerated lungs are the abforption and confequent hectic. It feems evident, that, in many cafes, death is brought on by this, rather than by the lungs themfelves being rendered unfit for the purpofes of relpiration. So that if we can obviate the effects of the abforption, diminish the preternatural determination to the lungs, and fulfil the other general indications juft now mentioned, we may very often enable nature to recover herfelf. It may be alleged indeed, that the phyficians art has hitherto proved very unfeefuful in thole cafes; but may not this be owing to the remedies that are employed being very often fuch as are inimical to the cure?

The cinchona is, perhaps, the moft commonly employed of any, and often confided in as an ultimate refource in thole cafes. But befides this, the fulphuric acid, the balsams, and frequent bleedings, have each had their partizans. The ufe of blifters and iffues, opiates, a milk and vegetable diet, exercife, and change of air, are pretty generally recommended by all. Concerning cinchona, Desault long ago obferved, 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 distempered 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 exasperate 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 admissible.

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 perseverance 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 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 propriety 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 refining the effect; it restrains the colligative sweats; and if the lungs be not injured past repair, it is allowed to be a very useful auxiliary.

Various are the opinions concerning the efficacy of Bristol water in this disease. The experienced author last mentioned informs us, that he has seen many persons recover from pulmonary diseases after drinking these waters, whose cure seemed to be doubtful from any other process; and he thinks this circumstance, added to the general reputation of Bristol waters in phthisical cases, affords sufficient inducement to recommend the trial of them in the early 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 flytcity, 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 Dickton 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 traveling 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. Deffault, who practiced 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 Simons 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 Carmichael 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 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 falutary nutriment seems to disagree. A propensity to generate bile, or too strong a disposition to acæcy 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 venefication 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 menes, if they have made their appearance, most generally cease. This alarms their female friends, and they call upon the physician to use his utmost endeavours for restoring the discharge; believing the cessation of it to be the immediate cause of the phthisical complaint. Induced by their solicitations, medicines have sometimes been administered, which, without obtaining this end, have tended to aggravate the distemper. This deficiency is often of no real disadvantage in those cases; and in many the evacuation would prove injurious, by diminishing the strength, which is already too much impaired. Even small bleedings at the regular periods have often done more harm than good. A sudden suppression may require bleeding; but when the evacuation fails through want of strength, and from poverty of blood, the renewal of it increases the disease.

Besides these remedies, Dr Simmons strongly recommends a frequent repetition of vomits. Many physicians have supposed, that where there is any increased determination to the lungs, vomits do mischief; but 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 useful in every period of the disease, or in every patient. In general, it will be found that the earlier in the disease emetics are had recourse to, the more likely they will be to do good, and the less likely to do harm. The cases in which 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 catarrhal evacuations.

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 flood, 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 astringency 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 diffused 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-myrhr. 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, dropt 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 day time. Formerly he made use of a fumigating machine, described in the Gentleman's Magazine for 1748, in which the air, inspired by the patient, is made to pass through hot water by means of a tube that communicates with the external air, and with the bottom of the vessel: but we have now a more elegant, and, on account of the valve and mouth-piece, a more useful instrument of this kind, 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 Beehrhaave, tells us, from the information of a person of credit, that in some parts of Spain they have a method of curing the phthisis pulmonalis by the use of this remedy; and he quotes the celebrated Solano de Luque in confirmation of this practice. Solano speaks of the baños 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 solanum nigrum and hog's lard. He observes, that a new pit must be made every time the operation is repeated; and advises the use of these baths only from the end of May to the end of October. Dr Fouquet, an ingenious French physician, has tried this remedy in two cases. In one, a confirmed phthisis, he was unsuccessful; but the remedy had not a fair trial. The patient, a man 30 years of age, had been for several months afflicted with cough, hectic fever, and profuse catarrhal 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 sea-fever. Dr Priestley observes, that the Indians, he has been told, have a custom of burying their patients labouring under putrid diseases up to the chin in fresh mould, which is also known to take off the fetor from flesh meat beginning to putrefy. The rancidity of a ham, for example, may be corrected by burying it for a few hours in the earth. The efficacy of this remedy in the sea scurvy has, it is said, frequently been experienced by the crews of our East India ships.

Solano, who is fond of philosophizing in his writings, is of opinion, that the earth applied in this way absorbs the morbid taint from the system; but does it not seem more probable, that the effluvia of the earth, by being absorbed and carried into the circulation, correct the morbid state of the fluids, and thus are equally useful in the sea scurvy and in the pulmonary hectic? That the earth when moistened does emit a grateful odour is a fact generally known; and Baglivi long ago gave his testimony in favour of the grateful effects of the effluvia of fresh earth. He ascribes these good effects to the nitre it contains.

The earth bath, both in consumptive cases and likewise in a variety of other affections, has of late been extensively employed in Britain by a celebrated empiric. But, as far as we can learn, in most cases it produced to the patient a very distressing sensation of cold; in some, it seemed to be productive of bad effects, probably in consequence of this cold; and we have not heard of any consumptive cases in which good effects were decidedly obtained from it.

With regard to the drains, such as blisters, issues, and fetons, which are so frequently recommended in pulmonary complaints, there is less danger of abuse from them than from the practice of venesection. The discharge they excite is not calculated to weaken the patient much; and the relief they have so often been found to afford, is a sufficient reason for giving them a trial. Blisters, as is well known, act in a twofold manner; by obviating spasm, and producing revulsion: Issues and fetons act chiefly in the latter of these two ways; and in this respect their effects, though less sudden and less powerful at first, are more durable from the continuance of the discharge they occasion. It is perhaps hardly necessary to remark, that, if much service is to be expected from either of these remedies, they should be applied early in the disease. The ingenious Dr Mudge, who experienced the good effects of a large febrilepary issue on his own person, very properly observes, that the discharge in these cases ought to be considerable enough to be felt. But it is seldom possible for us to prevail on the delicate persons, who are most frequently the victims of this disease, to submit to the application of a caustic between the shoulders. The discharge produced by a feton is by no means inconsiderable; and as in these cases there is generally some part of the breast that is more painful or more affected by a deep inspiration than the rest, a feton in the side, as near as can be to the seat of the pain, will be an useful auxiliary. Dr Simmons has seen it evidently of great use in several cases.

GENUS XXXVIII. HÆMORRHOIS.

HÆMORRHOIDS, or PILES.

Hæmorrhoidis, Sauv. gen. 217. Lin. 192. Sag. gen. 182.

Hæmorrhoidalis fluxus, Hoffm. 219. Hæmorrhoides, Junck. 11. et 12. Leucorrhoidis, Vog. 112.

Sp. I. External PILES.

Var. A. Bloody PILES.

Hæmorrhoidis moderata, Sauv. sp. I. Hæmorrhoides ordinatae, Junck. 11. Hæmorrhoides nimiae, Junck. 11. Hæmorrhoidis immodica, Sauv. sp. 2. Hæmorrhoides excedentes, Alberti de hæmorrhoid. p. 179. Hæmorrhoidis polyposa, Sauv. sp. 3.

Var. B. Mucous PILES.

Hæmorrhoides decoloratae, albae, et mucidae, Junck. 13. Alberti, p. 248.

Sp. II. The PILES from a Procidentia Ani.

Hæmorrhoidis ab exania, Sauv. sp. 4.

Sp. III. The Running PILES.

Sp. IV. The Blind PILES.

Hæmorrhoides cæcae, Junck. 12. Alberti, p. 274.

Description. The discharge of blood from small tumors on the verge of the anus constitutes what is called the hæmorrhoids or piles. They are distinguished into the external and internal, according to the situation of the tumors, either without or within the anus. Sometimes, however, these tumors appear without discharging any blood; and in this case they are called the hæmorrhoides cæcae, 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 ferous discharge from the anus; and sometimes this ferous 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 ferous discharge hath therefore been named the hæmorrhoidis 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 leucophlegmatia 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 haemorrhoidal flux, formerly frequent, ceases to flow; and in that case it generally happens that the persons are affected with apoplexy or palsy. Sometimes haemorrhoidal tumors are affected with inflammation, which ends in suppuration, and gives occasion to the formation of fistulous ulcers in those parts.

The haemorrhoidal tumors have often been considered as varices or dilatations of the veins; and in some cases various dilatations have appeared upon dissection. These, however, do not appear 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 haemorrhoidal 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 haemorrhoids, and of its effects upon the system, might arise from the difference of the hemorrhoidal vessels from whence the blood issued. But Dr Cullen is of opinion, that we can scarce ever distinguish the vessels from which the blood flows, and that the frequent inoculations of both arteries and veins belonging to the lower extremity of the rectum, will render the effects of the hemorrhage much the same, from whatever source it proceeds.

With regard to the haemorrhoids, 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 haemorrhoidal 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 constive. From the same causes, the disease happens frequently to those who are subject to a prolapsus ani. In voiding the faeces, it almost always happens that the internal coat of the rectum is more or less protruded; and, during this protrusion, it sometimes happens that the sphincter ani is contracted: in consequence of this, a strong constriction is made, which preventing the protruded gut from being replaced, and at the same time preventing the return of blood from it, occasions a considerable swelling, and the formation of a tumid ring round the anus.

Upon the sphincter's being a little relaxed, as it is immediately after its strong contraction, the portion of the gut which had fallen out is commonly taken into the body again; but by the frequent repetition of the accident, the size and fulness of the ring formed by the prolapsed intestine is much increased. It is therefore more slowly and difficultly replaced; and in this consists the chief uneasiness of haemorrhoidal 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 protraded 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 prelude of the uterus upon the rectum, and partly from the captive 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 acrid kind, and particularly aloetics, 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 falutary 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 excels, 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 superceded.

Cure. The general intentions of cure in cases of hemorrhoids are much varied, according to the circumstances of the affection at the time. When hemorrhoid exists 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 relieve 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 coarseness; 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 discharge, and to observe it exactly. Another cause of the hemorrhoids 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 intestines 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 faeces, it is to be removed by obviating the coarseness which occasions it. But in some persons it is owing to a laxity of the rectum; and in those it is often most confiderable 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 actite 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 contraction 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 case of excessive bleeding, we are on all occasions to endeavour to moderate the flux, even where the disease has occurred as a critical discharge; for if the primary disease shall be entirely and radically cured, the preventing any return of the haemorrhoid 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, left, 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 leucoplegmatica: but Dr Cullen 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 suppressed. 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 hemorrhage, 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. III. 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 sanguinis, Boerh. 1303. Convulso uteri, five abortus, Hoffm. III. 176.

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

Menorrhagia rubra, Cul. Menorrhagia immodica, Sauv. sp. 3. Menorrhagia fillatitia, 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 fitage; 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 oedematous 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 surpise. 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 leucorrhea.

Causes, &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 costive 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 refraining 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, whenever that can be done; and by such attention the disease may be often entirely cured. When the remote causes cannot be avoided, or when the avoiding them has been neglected, and a copious menstruation has come on, it should be moderated as much as possible, by abstaining from all exercise at the coming on or during the continuance of the menstruation; by avoiding even an erect posture as much as possible; by shunning external heat, and of course warm chambers and soft beds; by using a light and cool diet; by taking cold drink, at least as far as former habits will allow; by avoiding venery; by obviating coitiveness, 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 leucorrhea: 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, astringents both external and internal may be employed. In such cases, Dr Cullen asks, May small doses of emetics be of service?

When the menorrhagia depends on the laxity of the uterine vessels, it will be proper, in the intervals of menstruation, to employ tonic remedies; as cold bathing and chalybeates. The exercises of gestation also may be very useful, both for strengthening the whole system, and for taking off the determination of the blood to the internal parts.

These remedies may be employed in all cases of menorrhagia, from whatever cause it may have proceeded, if it shall have already induced a considerable degree of debility in the body.

Sp. II. ABORTION.

Menorrhagia abortus, Cul. Menorrhagia gravidarum, Sauv. sp. 6. Abortus effluxio, Sauv. sp. 1. a, Abortus subtrimestris. b, Abortus subfemestris. c, Abortus octimetrus. 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 hysteroptosi, Sauv. sp. 5. Menorrhagia ulcerosa, Sauv. sp. 9.

Sp. V. The Leucorrhea, Fluor Albus, or WHITES.

Menorrhagia alba, Cul. Leucorrhea, Sauv. gen. 267. Menorrhagia decolor, Sauv. sp. 7. Leucorrhea Americana, Sauv. sp. 5. Leucorrhea Indica, Sauv. sp. 6. Leucorrhea Nabothi, Sauv. sp. 9. Leucorrhea gravidarum, Sauv. sp. 8.

Description. The fluor albus, female weakness, or whiter, 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 uncontrasted, the fluor albus sometimes immediately follows the menses, and goes off by degrees as they gradually close. It also comes from the mucous glands of the womb, as is particularly evident in very young females of eight and ten years old; in whom, though very rarely, it has been observed, and where it must then necessarily have escaped from those parts, as the uterine vesicles are not sufficiently enlarged for its passage at so early a period.

Sometimes, as in women with child, it proceeds from the passage to the womb, and not from the womb itself; which, during pregnancy, is closely sealed up, so that nothing can pass from thence till the time of labour. The application of those instruments called pessaries, from the pain and irritation they occasion, 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 vesicles at the part, by which the fluids are vitiated and changed from their natural qualities.

The fluor albus has been supposed to supply the want of the menses; because where the first prevails, the last is generally either irregular or totally wanting: but it might more properly be said, that the presence of the fluor albus, which is a preternatural evacuation, occasions the absence of that which is natural; as is evident from the return of the menses after the fluor albus has been cured. Indeed, when this discharge appears about the age of 13 or 14, and returns once a month, with symptoms like those of the menses, then it may be deemed strictly natural, and therefore ought not to be stopped.

Prognosis. The fluor albus may be distinguished into two kinds. The first arises from a simple weakness, or the relaxation of the solids; which may either be general, where the whole bodily system is enervated and unfriended; or partial, where the womb only is thus affected, in consequence of hard labour, frequent miscarriages, a suppression or immoderate quantity of the menses, or a sprain of the back or loins.

In the first case, the discharge being generally mild, may be safely taken away. In the second, it may proceed from a vitiated or impure blood, where the body, from thence, is loaded with 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 disposes the patient to barrenness, a bearing down, dropy, 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 fluor albus follows the menses, as already observed.

The Tunbridge or Spa waters may be drank at the same time; and, if necessary, an infusion of green tea, or pure linth's forge water, may be used with a wom-byringe 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 alterative pill night and morning. After this course has been continued a fortnight or three weeks, she may begin with the strengthening bitter infusion, or 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 she begins to take the bitter infusion, it will be proper to use the Tunbridge or Pyrmont water for common drink; but if these cannot conveniently be had, the alkaline aerated water, impregnated with iron, will make an excellent substitute. If it should render her coughive, and occasion headach, she may defit, 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 dropy, or consumption; it were to be wished that women, on such occasions, would be more attentive to their own safety, by using all possible means, in due time, to prevent those disorders.

Dr Leake says he has attended more patients labouring under the fluor albus in the autumn than at any other season 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 used 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 melvies vesicatorii of the Edinburgh Pharmacopoeia. This medicine he employed in much larger doses than is commonly prescribed. Thus a mixture containing an ounce of the tincture of cantharides, diffused in fix 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 fix 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, and the patient is affected with a frequent irritation to make water. In the fluor albus, pains in the loins, and loss of strength, attend the discharge; and if any inflammation or heat of urine follow, they happen in a less degree, and only after a long continuance of the discharge, which, becoming sharp and acrimonious, excoriates the surrounding parts.

In the gonorrhoea, the discharge suddenly appears without any evident cause; but in the fluor albus, it comes on more slowly, and is often produced by irregularities of the menses, frequent abortion, sprains, or long-continued illness.

In the gonorrhoea, the discharge is greenish or yellow, less in quantity, and not attended with the same symptoms of weakness. In the fluor albus, 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 hemorrhage 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.

HÆMATEMESIS, Sauv. gen. 242. Lin. 184. Vog. 89. Sag. gen. 177.

Species: Plethorica, Catamenialis, Scorbutica, &c.

HÆMATURIA, 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. 30. Tuffis catarrhalis et rheumatica, Hoffm. III. 109.

Sp. I. Catarrh from COLD.

Catarrhus à figore, Cul. Catarrhus benignus, Sauv. sp. 1. Catarrhus pectorosus, Sauv. sp. 6. Coryza catarrhalis, Sauv. sp. 1. Coryza phlegmatorrhaea, Sauv. sp. 2. Salmuh. Obl. cent. 1, 37. Junck. 28. Morgagn. de fed. xiv. 21. Coryza febricofa, Sauv. sp. 6. Tuffis catarrhalis, Sauv. sp. 1. N. Rosen. Diff. apud Haller, Difput. Pracl. tom. ii. Rheuma catarrhale, 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 Rubellolus; Tufis Variolosa, Vermifera, Calculosa, Phthisica, Hysterica, à dentitione, Gravidarium, Metallicolarm, &c.

Description. The catarrh is an increased excretion of mucus from the mucous membrane of the nose, fauces and bronchia; 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 tussis or cough; and a cough, indeed, always attend 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 gravedo 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 found persons not far advanced in life, is always a slight and safe disease: but, in persons of a phthisical disposition, a catarrh may readily produce a hemoptysis, or perhaps form tubercles, in the lungs; and 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 phlegmatace. 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 Profusiva, 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 looses by insensible 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 influx 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 influx 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 catarrh.

The phenomena of contagious catarrhs have been much the same with those of the others; and the disease has always been particularly remarkable for this, that it has been the most widely and generally spreading epidemic known. It has seldom appeared in any one country of Europe, without appearing successively in 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 not only sooner show febrile symptoms, but to a more considerable degree. Accordingly, it more speedily runs its course, which is commonly finished in a few days. It sometimes ends by a spontaneous sweat; and this, in some persons, produces a miliary 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 Catarrhus 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 pneumatic inflammation. In the phthisical 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 diluted drink, a little warmed, to promote a very gentle sweat; and after this to take care to return very gradually only to the use of the free air. When the disease is more violent, not only the antiphlogistic regimen, exactly observed, but various remedies also, become necessary. To take off the phlogistic diathesis which always attends this disease, blood-letting, more or less, according as the symptoms shall require, is the proper remedy. After blood-letting, for restoring the determination of the fluids to the surface of the body, and at the same time for expediting the secretion of mucus in the lungs, which may take off the inflammation of its membrane, vomiting is the most effectual means. For the last-mentioned purpose, it has been supposed that squills, gum-ammoniac, the volatile alkali, and some other medicines, might be useful; but their efficacy has never been found considerable: and if squills have ever been very useful, it seems to have been rather by their emetic than by their expectorant powers. When the inflammatory affections of the lungs seem to be considerable, it is proper, besides blood-letting, to apply blisters to the back or sides.

As a cough is often the most troublesome circumstance of this disease, so demulcents may be employed to alleviate it. But after the inflammatory symptoms are much abated, if the cough still remains, opiates afford the most effectual means of relieving it; and, in the circumstances just now mentioned, they may be very safely employed. 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 glycyrrhizae cum opio of the Edinburgh Pharmacopoeia, maconreia, where purified opium is combined with extract of liquorice, gum arabic, and other demulcents, to the extent of about a grain in a dram of the composition. After the inflammatory and febrile states of this disease are very much gone, the most effectual means of discharging all remains of the catarrhal affection is by some exercise of gestation diligently employed.

Besides the remedies above mentioned, Dr Mudge, in a treatise on this disease, recommends the steam of warm water as a most efficacious and safe remedy for a catarrh, and which indeed he seems to consider as little less than infallible. The method of breathing in these steams is described under the word Inhaler; but he gives a caution to people in health, who may accidentally see his machine, not to make the experiment of breathing through cold water with it, or they will be almost certain of catching a severe cold. His directions for those troubled with the catarrh are as follow:

"In the evening, a little before bedtime, the patient, if of adult age, is to take three drams, or as many tea-spoonfuls, of elixir paregoricum, in a glass of water: if the subject be younger, for instance under five years old, one tea-spoonful; or between that and ten years, two. About three quarters of an hour after, the patient should go to bed, and, being covered warm, the inhaler three parts filled with water nearly boiling (which, from the coldness of the metal, and the time it ordinarily takes before it is to be used by the patient, will be of a proper degree of warmth), and being wrapped up in a napkin, but so that the valve in the cover is not obstructed by it, is to be placed at the arm-pit, and the bedclothes being drawn up and over it close to the throat, the tube is to be applied to the mouth, and the patient should inspire and expire through it for about twenty minutes or half an hour.

"It is very evident, as the whole act of respiration is performed through the machine, that in inspiration the lungs will be filled with air which will be hot, and loaded with vapour, by passing through the body of water; and in expiration, all that was contained in the lungs will, by mixing with the steam on the surface of the water, be forced through the valve in the cover, and settle on the surface of the body under the bedclothes.

"The great use of this particular construction of the inhaler is this: First, As there is no necessity, at the end of every inspiration, to remove the tube from the mouth, in order to expire from the lungs the vapour which had been received into them, this machine may therefore be used with as much ease by children as older people. And, secondly, As a feverish habit frequently accompanies the disorder, the valve in that respect also is of the utmost importance: for a sweat, or at least a free perspiration, not only relieves the patient from the restless anxiety of a hot, dry, and sometimes parched skin, but is also, of all evacuations, the most eligible for removing the fever; and it will be generally found, that, after the inhaler so constructed has been used a few minutes, the warm vapour under the clothes will, by settling upon the trunk, produce a sweat, which will gradually extend itself to the legs and feet.

"In a catarrhous fever, or any feverish habit attending this cough, it would be proper to take a draught of warm thin whey a few minutes before the inhaler 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 so 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 further molestation from it than once or twice in the morning to throw off the trifling leakage which, unperceived, had dripped into the bronchies and 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 forenses 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 putting 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 ineffectual cough, occasioned by a matter which, dripping in the early state of the disease into the bronchies 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, 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, incrating the general perspiration by the falutary 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 pelutant 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 5s or 9ij of bals. fulph. anisat. taken twice a-day, in a little powdered sugar or any other vehicle, a very efficacious one. I have also, many times, known a falutary revulsion 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 perishable 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 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 forenelf, 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 changes of air and occasional bleedings, the patient will find his greatest security in a drain from a large scapular ilium, assisted by a diet of ashes milk and vegetables."

GENUS XLI. DYSENTERIA.

The Dysentery.

Dysenteria, Save. 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 tares 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 seybula. 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 captive, with an unusual flatulence in the bowels. Sometimes, though more rarely, some degree of diarrhea is the first appearance.—In most cases, the disease begins with griping, and a frequent inclination to go to stool. In indulging this, little is voided, but some tenesmus attends it. By degrees the stools become more frequent, the griping more severe, and the tenesmus more considerable.—With these symptoms there is a loss of appetite, and frequently sickness, nausea, and vomiting, also affecting the patient. At the same time there is always more or less of pyrexia present. It is sometimes of the remittent kind, and observes a tertian period.—Sometimes the pyrexia is manifestly inflammatory, and very often of a putrid kind. These febrile states continue to accompany the disease during its whole course, especially when it terminates soon in a fatal manner. In other cases, the febrile state almost entirely disappears, while the proper dysenteric symptoms remain for a long time after. In the course of the disease, whether for a shorter or a longer time, the matter voided by stool is very various. Sometimes it is merely a mucous matter, without any blood, exhibiting that disease which is named by some the morbus mucosus, and by others the dysenteria alba. For the most part, however, the mucus discharged is more or less mixed with blood. This sometimes appears only in streaks among the mucus; but at other times is more copious, giving a tinct 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 fancies, proceeding from gangrenous parts. There are very often mixed with the liquid matter some films of a membranous appearance, and frequently some small masses of a seemingly sebaceous matter. While the stools voiding these various matters, are, in many instances, exceedingly fre- 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 anything 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 constriction: for, as we have said above, the natural feces are seldom voided; and when they are, it is in a form which gives reason to suppose they have been long retained in the cells of the colon, and consequently that the colon had been affected with a preternatural constriction. This is confirmed by almost all the dissections which have been made of the bodies of dysenteric patients; in which, when gangrene had not entirely destroyed the texture and form of the parts, large portions of the great guts have been found affected with a very considerable constriction.

The proximate cause of dysentery, or at least the chief part of the proximate cause, seems to consist in a preternatural contraction 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 feces, retained in the colon, are the cause of the griping, frequent stools, and tenesmus: for the evacuation of these feces, whether by nature or by art, gives relief from the symptoms mentioned; and it will be more fully and usefully confirmed by this, that the most immediate and successful cure of dysentery is obtained by an early and constant attention to the preventing the constriction, and the frequent evacuation of feces 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

Prophylaxis of greatest experience in this disease, seem to be of opinion, that it is to be cured most effectually by purging, assiduously employed. The means may be various; but the most gentle laxatives are usually sufficient; and, as the medicine must be frequently repeated, these are the most safe, more especially as an inflammatory state so frequently accompanies the disease. Whatever laxatives produce an evacuation of natural feces, 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 tartrite 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 fohil alkali, such as the soda vitriolata tartariflata or phlorphorata. 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 mercurial 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 flood.

For relieving the constriction of the colon, and evacuating the retained feces, cathars may sometimes be useful; but they are seldom so effectual as laxatives given by the mouth; and acrid cathars, 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 constriction of the colon, and thereby aggravate the disease; and if, at the same time, the use of them supersede 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 semicuprum, or by fermentation 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 queafia, radix indica lopeziana, verbascum, 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 acid. 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 febrile 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. Soporofii, Lin. Clas VI. Ord. II. Adynamiae, Vog. Clas VI. Nervorum resolutiones, Hoffm. III. 194. Affectus soporosi, Hoffm. III. 209. Motuum vitalium defectus, Junck. 114.

GENUS XLII. APOPLEXIA.

The APOPLEXY.

Apoplexia, Sauv. gen. 182. Lin. 101. Vog. 229. Boerh. 1007. Junck. 117. Sag. gen. 288. Wepser. Hift. 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. Haemorrhagia cerebri, Hoffm. II. 240.

To this genus also Dr Cullen reckons the following diseases to belong:

Catalepsis, Sauv. gen. 176. Lin. 129. Vog. 230. Sag. gen. 281. Boerh. 1036. Junck. 44. Affectus cerebri (paediatrico-ecstaticus), Hoffm. III. 44. Ectasis, 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, coruscations before the eyes, and redness of the face, usually precede. The distinguishing symptom of the disease is a deep sleep, attended with violent snorting; if any thing be put into the mouth, it is returned through the nose; nor can any thing be swallowed without fluttering 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, Apoplexia, a drawing of the tongue the same way, and flammering of the speech. Difictions sometimes show a rupture of some vessels of the meninges, or even vellus of the brain itself; though sometimes, if we may believe Dr Willis, no defect is to be observed either in the cerebrum or cerebellum.

Causes, &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 subsisted 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 ferous apoplexy, aftermentioned. 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. fp. 7. Apoplexia serosa, Preysinger, fp. 4. Morg. de causis, &c. IV. LX. Carus à hydrocephalo, Sauv. fp. 16. Cataphora hydrocephalia, Sauv. fp. 6. Cataphora somnolenta, Sauv. fp. 1. Lethargus literatorum, Sauv. 7. Van Swieten in Aphor. 1010. 27 and 32.

Description. In this species the pulse is weak, the face pale, and there is a diminution of the natural heat. On dissection, the ventricles of the brain are found to contain a larger quantity of fluid than they ought; the other symptoms are the same as in the former.

Causes, &c. This may arise from any thing which induces a debilitated state of the body, such as depressing passions of the mind, much study, watching, &c. It may also be brought on by a too plentiful use of diluting, acidulated drinks. It doth not, how-ever, ever follow, that the extravasated serum 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 prognostics of the sanguineous, may also be said of that of the serous apoplexy.

Cure. In this species vesciculation can scarcely be admitted: acid purgatives, emetics, and stimulating clysters, are recommended to carry off the superabundant serum; but in bodies already debilitated, they may perhaps be liable to the same exceptions with vesciculation 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 purgans, 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 Dropy of the Brain.

Hydrocephalus interior, Sauv. fp. 1. Hydrocephalus internus, Whytt's works, page 725. London Med. Obf. vol. iv. art. 3, 6, and 25. Gaudelius de hydrocephalo, apud Sandifort Theaur. vol. ii. Hydrocephalus acutus, Quin. Diff. de hydrocephalo, 1779. Asthenia à hydrocephalo, Sauv. fp. 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 suspects that those who imagine they have been more successful, had mistaken another distemper for this. It is by all supposed to consist in a dropy 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 Huek, and from some 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 flight 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-peated pain in the head, extending across the forehead from temple to temple; of which, and a sickness, they alternately complain in short and affecting exclamations; doing a little in the intervals, breathing irregularly, and sighing much while awake. Sometimes their sighs, for the space of a few minutes, are incessant.

As the disease advances, the pulse becomes slower and irregular, the strokes being made both with unequal force and in unequal times, till within a day or two of the fatal termination of the disorder, when it becomes exceeding quick; the breathing being at the same time deep, irregular, and laborious. After the first 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 precordia 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 with a very great degree of Crabismus. 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 overpreads the whole body, respiration is rendered totally suspensive, 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 fickle and incendant headaches; 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 captive, but it is likewise with the greatest difficulty that stools can be procured. These are generally of a very dark greenish colour with an oiliness or a glazy 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 feasted 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 disposition, 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 crabismus, 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 compulsion producing a state of infidelity; 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 obfinate drapies, 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 atrabilaris, Sauv. sp. 12. Preyssinger. 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 semulenta, Sauv. sp. 3. Carus a narcoticis, Sauv. sp. 14. Lethargus a narcoticis, Sauv. sp. 3. Carus a plumbagine, Sauv. sp. 10. Apoplexia mephitica, Sauv. sp. 14. Asphyxia a mephite, Sauv. sp. 9. Asphyxia a multo, Sauv. sp. 3. Catalepsis a tumo, Sauv. sp. 3. Asphyxia a umis, Sauv. sp. 2. Asphyxia a carbone, Sauv. sp. 16. Asphyxia foricariorum, Sauv. sp. 11. Asphyxia federatorum, Sauv. sp. 10. Carus ab infolatione, 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 apoplectie fever. 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 bunsels 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 few 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-glares 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, hasted 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.

"Caelius 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 droplets of cotton impregnated with various matter, was immediately on the introduction, afflicted with an excruciating headache, and had a conitant 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 oppreotive to the lungs. It is a matter of importance, therefore, that the common opinion should be more agreeable to truth; for where suffocation is supposed to be the effect, there will be little apprehension of danger, so long as the breath keeps free from pain or oppression.

"It may be well to remember, that the poison itself is distinct from that gross matter which is offensive to the smell; and that this is frequently in its most active state when undiluted by the sense. Were Comata, 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 till 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 diffuse 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 roufing 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 apoplexia, 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 diffusion 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 reside 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 swallowing considerable quantities of ardent spirits may be a means of making us resist the cold, and preventing the bad effects of it from arising to such 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. Aphthixia à pathemate, Sauv. sp. 7. Ecstasie catuche, Sauv. sp. 1. Ecstasie relutata, Sauv. sp. 2. Apoplexies from violent passions may be either sanguineous or ferous, though more commonly of the former than the latter species. The treatment is the same in either case. Or they may partake of the nature of catalepsy; in which case the method of treatment is the same with that of the genuine catalepsy.

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 awaked 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. sp. 4. Asphyxia immerorum, Sauv. sp. 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 intermitting, exanthematia, hysteria, epilepsy, gout, worms, ichuria, and scurvy.

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. Paralyis, Sauv. gen. 169. Lin. 104. Vog. 226. Junck. 115. Atonia, Lin. 120.

Sp. I. The Partial Palsy.

Paralyis, Sauv. gen. 169. Lin. 104. Vog. 226. Junck. 115. Paralyis plethorica, Sauv. sp. 1. Paralyis feroa, Sauv. sp. 12. Paralyis nervica, Sauv. sp. 11. Mutitas à glofolyihi, Sauv. sp. 1. Aphonia paralytica, Sauv. sp. 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. sp. 7. Hemiplegia phalmodica, Sauv. sp. 2. Hemiplegia feroa, Sauv. sp. 10.

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

Paraplexia, Sauv. gen. 171. Sag. gen. 277. Paraplegia, Lin. 102. Vog. 227. Paraplexia sanguinea, Sauv. sp. 2. Paraplexia à lipna bifida, Sauv. sp. 3. Paraplexia rheumatica, Sauv. sp. 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 flammering, 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 found side, with the cunic 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. Palyses 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 Poïctou, 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. Palyses are also the infallible consequences of injuries to the large nerves. 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 emetics from time to time; to apply blisters, and insert ifues.

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 lourging 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 Fresnoi; and Dr Alderfon 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.

Paralytis metallariorum, Sauv. sp. 22. Hemiplegia saturnina, Sauv. sp. 14.

This kind of palsy arises most frequently from lead taken into the body, and is a consequence of the colica piertonum, 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, asthma, or convulsions; and therefore need not be treated of by itself.

ORDER II. ADYNAEMIAE.

Adynamiae, Vog. Clas VI. Defectivi, Lin. Clas VI. Order I. Leiopopychiae, 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. Alphixia, 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. sp. 5. Senac. Tr. de Coeur, p. 540. Syncope à cardiogme, Sauv. sp. 7. Senac. de Coeur, 414. Morgagn. de Sed. XXV. 2. 3. 10. Syncope à polypo, Sauv. sp. 8. Senac. p. 471. Syncope ab hydrocardia, Sauv. sp. 12. Senac. 533. Schreiber Almag. L. III. § 196. Syncope Lanzoni, Sauv. sp. 18. Lanzon. Op. II. p. 462. Alphixia Valsalviana, Sauv. sp. 13.

Sp. II. Occasional SYNCOPE.

Leiopathymia à pathemate, Sauv. sp. 1. Senac. p. 544. Syncope pathetica, Sauv. sp. 21. Alphixia à pathemate, Sauv. sp. 7. Syncope ab antipathia, Sauv. sp. 9. Senac. p. 544. Syncope à veneno, Sauv. sp. 10. Senac. p. 546. Syncope ab apostematis, Sauv. sp. 11. Senac. p. 554. Syncope à phaeolo, Sauv. sp. 14. Senac. p. 553. Syncope ab inanitione, Sauv. sp. 1. Senac. p. 536. Syncope à phlebotomia, Sauv. sp. 4. Syncope à dolore, Sauv. sp. 2. Senac. sp. 583. Alphixia. Asphyxia traumatica, Sauv. sp. 14. Asphyxia neophytorum, Sauv. sp. 17.

Description. A syncope begins with a remarkable anxiety about the heart; after which follows a sudden extinction, as it were, not only of the animal powers and actions, but also of the vital powers, so that the patients are deprived of pulse, sense, and motion, all at once. In those cases which physicians have distinguished by the name of leptomycia, 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 apoplecty, not the smallest sign of life can be perceived; the face has a death-like paleness, the extremities are cold, the eyes shut, or at least troubled; the mouth sometimes shut, and sometimes gaping wide open; the limbs flaccid, and the strength quite gone; as soon as they begin to recover, they fetch deep and heavy sighs.

Causes, &c. Fainting is occasioned most commonly by profuse evacuations, especially of blood; but it may happen also from violent passions of the mind, from surfeits, excessive pain, &c. People of delicate constitutions are very subject to it from slight causes; and sometimes it will arise from affections of the heart and large vessels not easy to be understood. Fainting is also a symptom of many disorders, especially of that fatal one called a polypus of the heart, of the plague, and many putrid diseases.

Prognosis. When fainting happens in the beginning of any acute distemper, it is by no means a good omen; but when it takes place in the increase or at the height of the disease, the danger is somewhat less; but in general, when fainting comes on without any evident cause, it is to be dreaded. In violent hemorrhagies 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 blooded 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 constrictions, 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 Dyspepsia, this way.

When a surfeit, or any species of faburra, 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 flannels; 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 hemorrhagies, 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 apoplecty, 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 faburra, Sauv. sp. 9. Anorexia exhaustorum, Sauv. sp. 8. Anorexia paralytica, Sauv. sp. 1. Nausea ex cacochylia, Sauv. sp. II. Vomitus pituitosus, Sauv. sp. 26. Vomitus ruminatio, Sauv. sp. 6. Vomitus à faburra, Sauv. sp. 2. Vomitus à crapula, Sauv. sp. 1. Vomitus lacteus, Sauv. sp. 3. Flatulentia infantilis, Sauv. sp. 5. Flatulentia acida, Sauv. sp. 1. Flatulentia nidrola, Sauv. sp. 2. Cardialgia bradypepta, Sauv. sp. 9. Cardialgia à faburra, Sauv. sp. 2. Cardialgia lactantium, Sauv. sp. II. Cardialgia flatulenta, Sauv. sp. 3. Cardialgia paralytica, Sauv. sp. 7. Gastrodynia faburrallis, Sauv. sp. 1. Gastrodynia flatulenta, Sauv. sp. 2. Gastrodynia periodynia, Sauv. sp. 7. Gastrodynia astringens, Sauv. sp. 9. Gastrodynia atterens, Sauv. sp. 10. Gastrodynia à frigore, Sauv. sp. 18.

Besides these there are a great number of symptomatic species.

Description. It is by no means easy to define exactly the disorder 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 fame is swallowed again, after the manner of ruminating animals. While matters are in this situation, the heart sometimes palpitates, and the breath is quick, and drawn with difficulty; the head aches and is giddy; and sometimes both these symptoms are continual, and very violent, insomuch that the patient is not only tormented with pain, but flaggers as if he was drunk. From the too great accretion 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 coughness, 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 trouble. Dyspepsia fome. The patient is either deprived of rest, or wakes suddenly out of his sleep, and is disturbed by frightful dreams; at the same time that the mind seems to be affected as well as the body, and he becomes peevish, fretful, and incapable of paying attention to any thing 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 anaeræa or afecies.

Causes, &c. The causes of dyspepsia may be any thing 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 dropy, 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 tannaceous powders, as being purgative while diffused 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 counter-acting this symptom, as well as of obviating coiffenfcs, flatulence, and a variety of others, is by restoring 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. 1998. Malum hypochondriacum, Hoffm. III. 65. Junck. 36.

Although some of the nosological 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, sanguinea, 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, pressing, 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 edematous 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 characteristic symptoms of the disease.

Causes, &c. The general causes of the hypochondriac affection are said to be a plethora, and preternatural 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 caules, 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 caules; 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 leucophlegmata, anaerarca, 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 peripatatory 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 caules 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, Sawv. Clas IV. Vog. Clas V. Sag. Clas VIII. Motorii, Lin. Clas VII. Morbi spasmici et convulvi, Hoffm. III. 9. Spasmi et convulsiones, Junkc. 45, 54. Epilepsia, Boerh. 1071, 1088.

GENUS XLVIII. TETANUS.

Tetanus, Sawv. gen. 122. Lin. 127. Vog. 180. Sag. gen. 228. Catochus, Sawv. gen. 123. Lin. 128. Vog. 183. Sag. gen. 229. Opifhotonus, Vog. 181. Epifhotonus, 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 opifhotonus and tetanus, either with regard to the variety of painful symptoms which almost without intermission distract the sick, or the danger of the diseases themselves, from which few recover, in comparison of the number they attack. In both, the vital actions are very imperfectly performed, most of those which are called natural being as it were suspended at once; and so far is the patient from being able to execute any voluntary motion, that the whole machine undergoes the most excruciating distortions, from the violent and unnatural contractions of the muscles. Happy it is for the inhabitants of the more temperate climates, that such diseases appear rarely among them; but in those countries which lie in the more southern and warmer latitudes, they are endemic, especially to negro slaves. In South Carolina, they show themselves at all seasons, but not so often in winter, more frequently in spring and autumn; and are most common in the summer, when people work abroad and are alternately exposed to the scorching heat of the sun and heavy showers, which often happen suddenly, and greatly alter the temperature of the air. Others are seized with the opifhotonus 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 any thing like a full description been given of them by any ancient or modern author which I have seen. Hippocrates indeed takes notice of them in many places, and seems to regard them only as consequences of other diseases, or of wounds or ulcers of the nervous or tendinous parts; of which symptomatic kind of opifhotonus he gives three remarkable cases in lib. v. § vii. de Morb. vulg. and repeats them in another place: but the few symptoms he recounts do not shew themselves with us. Galen, Coelius 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 emprofhotonos, 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 emprofhotonos. 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 emprofhotonos; 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 furious 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 lafitude. These increase, and become fo troublesome when he attempts to turn his head, or to bend it forward, as to oblige him to walk very erect; for he can by no means look downward, nor to either side, without turning his whole body. He cannot open his jaws without pain; and has some difficulty in swallowing, which discourages him from attempting to eat. At times he feels a sudden and painful traction under the cartilage eniformis, 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; 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 apishkotonor, 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 mischievous symptoms in a few hours: in which case, the danger may truly be estimated 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 left 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.

"STAD. 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 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-hyoïd and sterno-hyoïd 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 reeline, 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 flow. 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 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 so lately suffered. 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 some 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.

"STAD. III. In this last stage, the patient is reduced to the most calamitous and distressful circumstances: for he is on a continual rack, according to the most literal meaning of that word; the spasm returning oftener than once in a minute, is much more violent, and holds him longer, so that he has scarcely any remission. The anterior muscles of the whole body now suffer equal contractions with the posterior; but the last overcome the force of the others, so that the spine is strongly recurvated, and forms a hollow arch with the 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 defended 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 emotions may be plainly seen, and a palpitating sublatory 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 any thing that was put into his mouth. In this state patients are commonly delirious: and as they cannot fulfill many hours under so great a suspension of the vital and natural functions, a mortal anxiety ensues and releases. releases them; oftener a continued and severe spasm finishes the tragedy, when it was before almost at an end: but most frequently a general convulsion puts a period to their sufferings; and whichever way this happens, they for the most part relax just before death.

"In the tetanus, the general symptoms are nearly the same as in the opiphotonus, 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 opiphotonus, 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 spasmus 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 opiphotonus. 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 polyphros, or some other purging salt, mixed with oleum ricini; or if that should not be at hand, with oil of sweet almonds and a little tincture of senna. The opiates are to be given in large and frequently repeated doses; such as a grain of the extractum thebaicum, or 20 drops of the tincture, every second or third hour; and it will be safest not to trust to the thebaic tincture which is kept ready prepared in the shops, but 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 spastic 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 exasperate the disease.

This, in general, is the plan of treatment recommended by Dr Chalmers.

The same dreadful disorders frequently attack young children in the warm climates. Dr Hillary tells us, that they will there arise from the same causes which usually produce convulsions 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 acrid, or too hard to digest, which irritates their tender bowels, and so produces startings and convulsive spasms, with all the other symptoms which precede and accompany convulsions in young children in 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 acrid, and so increases the irritation of their bowels, that it first brings on startings, then convulsive spasms, and regular convulsion fits; which, if not soon removed, usually end in a perfect tetanus, 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 convolved 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 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 anodynes, and correcting the remaining acrimony of the nutritious juices in the primea vice.

To answer these intentions, the following method, with variations pro re nata et pro ratione estatis, as the cause is different, has been found to answer the desired effect the best: Bg. Ser lactis 3ij. Sapon. Venet. 3ij. Manne Calab. 3ij. vel iiij. Ol. amygd. dul. 3js. Ol. feniculi dul. gut. ij. Balf. Peruv. gut. v. Mifce. Fi enema quam primam injicendum.

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: Bg. Ag. fem. feniculi 3ijj. Magnef. albae 3js. Ocul. cancer. prep. 3j. Syr. è eichor. cum rheo. Rosar. solut. ana 3ijj. Mifce. Or. Bg. Ag. fem. feniculi 3ijj. Sapon. amygdal. 3js. Magnef. albae 3js. Syr. è eichor. cum rheo. Manne aqu. ana 3ijj. Ol. amygd. dul. 3ijj. Mifce: Exhibe cochl. parv. vel duo pro ratione estatis, omni semifhora, vel omni hora, donec respond. aluus.

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: Bg. Ag. fem. feniculi 3ijj. Magnef. albae 3js. Ocul. cancer. prep. 3j. Moschti orient. gr. iij. Spir. C. C. gut. xv. Syr. è mecon. 3js. Mifce: Exhibe cochl. parv. (a child's spoonful) ter quaterve de die, vel saepius, urgent. convuls. vel spasm.

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. Bg. Ag. feniculi. 3ijij. Moschti orient. gr. j. Tinct. thebaica. gut. iiiij. Syr. è mecon. 3ijj. Mifce pro duobus dosf. de quibus exhibe unam quam primum, et alteram si concud. spasm. redeunt.

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 feized 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 32 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 feized with the tetanus; and both died, notwithstanding all possible affluence was given. The former had his thumb amputated without effect.

In the Edinburgh Physical and Literary Essays, vol. iii. Dr Donald Munro 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 prac- 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 falcination 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 falcination. 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 fix weeks before from a joiner's chisel. At that time his mouth was so far closed, as to admit only the most liquid nourishment, which he constantly sucked through his teeth: but his legs and jaw, and the whole length of the spina dorsi, were quite immovable, being as stiff and rigid as those of a person long dead; his head was drawn backward, and he was frequently strongly convoluted. The motion indeed of both his arms was but 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 extraatum thebaicum diffusively 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 mulk, in the space of 24 hours, without any sensible effect, except the bringing on a confused flux, 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 spasmoidic kind, and that the good effects produced by the extraatum thebaicum must probably be owing to the relaxing and resolving faculty of that medicine, he directed a blifter to be applied between the shoulders, the whole length of the spine; the jaw to be anointed with the oleum lateritium; and a purge consisting of the tinctura sacra, tinctura jalapae, and the syrnum de rhamno 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 succini, the fetid gum, and the oleum amygdaeum. 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 final weakness in the parts only excepted. The jaw was relieved first, after that the spine, and last of all the legs. A pain and uneasiness in the places affected, neither of which he had felt before, were the forerunners of his approaching amendment.

From all this it seems reasonable to conclude, either that there is no certain remedy for tetanus in all cases, or that the medicines which prove effectual in one constitution will fail in another. Thus, it is possible, that in cases where opium proves ineffectual, mercury may be a remedy; and, on the contrary, where mercury fails, opium may be effectual; and even where both are ineffectual, the antispasmodics recommended by Dr Carter may be of use. It is therefore necessary for physicians to be extremely careful to observe the effects of the first doses of their remedies: for if the symptoms 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 ascribes 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 Spasmi. 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 six 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 Ruh, 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 Ruh, 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 immerging 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. Capitrum, Vog. 208.

Sp. I. TRISMUS NASCENTIUM.

Locked Jaw in children under two months old.

Trismus nascentium, Sauv. sp. 1. Heijler Comp. Med. Pract. cap. xv. § 10. Cleghorn on the Difices of Minorca, Introd. p. 33. Hoffer, in Act. Helvet. tom. i. p. 65.

This distemper is so closely connected with the tetanus, that it ought rather to be accounted a symptom of the tetanus than a primary disease. 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 spasmatica, Sauv. sp. 18. Zwingeri, Act. Helvet. tom. iii. p. 319. Convulsio à nervi punctura, Sauv. sp. 2. Trismus catarrhalis, Sauv. sp. 15. Hillary's Barba-does, 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 Teta- nus; and, indeed, trismus may be considered as being merely an incipient tetanus, or rather a slight degree of that disease.

GENUS L. CONVULSIO.

CONVULSIONS.

Convulsio, Sauv. gen. 128. Lin. 142. Vog. 191. Sag. gen. 235. Convulsio universalis, Sauv. sp. 11. Hieranofis, Lin. 144. Vog. 190. Convulsio habitualis, sp. 12. Convulsio intermittens, Sauv. sp. 16. Convulsio hemitonos, Sauv. sp. 15. Convulsio abdominis, Sauv. sp. 10. Convulsio ab inanitione, Sauv. sp. 1. Convulsio ab omanifmo, 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 convoluted and relaxed; a permanent convulsion, or unnatural contraction of particular muscles, is called a spasm or cramp. These partial convulsions may attack almost any part of the body; and are not unfrequently symptomatic, in fevers, the cholera morbus, &c. The involuntary startings of the tendons, the picking of the 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 de- 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 exciting 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 of lameness or instability of one of the legs, which the patients draw after them in a ridiculous manner: nor can they hold the arm of the same side still for a moment; for if they lay it on their breast, or any other part of their body, it is immediately forced away by a convulsive motion. If they be devious 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 antipathmatics 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 Raphania, 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-coloured 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 obstinate instance of chorea.

GENUS LII. RAPHANIA.

Raphania, Lin. 155. Vog. 143. Lin. Amoen. Acad. vol. vi. Convulfilo raphania, Sauv. sp. 7. Eclampia typhodes, Sauv. sp. 1. Sennert. de febr. l. iv. cap. 16. Gregor. Hofl. Oper. tom. ii. l. viii. obf. 22. Brunner in Ephem. Germ. d. iii. A. ii. obf. 224. Williich. ibid. cent. vii. obf. 13. Weffer. de Affect. Capitis, obf. 120. Breflauer Sammlung 1717, Julio, Septembri, et Decemb. ibid. 1723, Januar. A. N. C. vol. vii. obf. 41. Bruckmann. Comb. Norimb. 1743, p. 50.

Description. According to Sauvages, this distemper begins with a latitudine of the limbs, transient colds and shiverings, pain of the head, and anxieties of the precordia. Then come on spasmodic startings of the fingers and feet; also of the tendons and muscles, conspicuous below the skin. The disease is attended with heat, fever, delirium, stupor, contraction of the breast, suffocating dyspnoea, 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 paling 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 raddishes, 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 said 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. Hiffen. III. 9. Junck. 54. Eclampsia, Sauv. gen. 133. 185. Sag. gen. 240.

Sp. I. The CEREBRALIS, 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 STYPATHICA, 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 pedifymptomatica, 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. 13. Epilepsia rachialgica, Sauv. sp. 14. Eclampsia à doloribus, Sauv. sp. 4. a, Rachialgia. b, Ab otalgia. c, A dentitione. Eclampsia parturientium, Sauv. sp. 3. Eclampsia verminosa, Sauv. sp. 2. Eclampsia ab atrope, Sauv. sp. 11. Eclampsia ab canthe, Sauv. sp. 12. Eclampsia à cicuta, Sauv. sp. 13. Eclampsia à coriaria, Sauv. sp. 14. Epilepsia exanthematica, Sauv. sp. 11. Epilepsia cachectica, Sauv. sp. 2. Epilepsia stomachica, Sauv. sp. 3. Eclampsia à taburra, Sauv. sp. 5. Epilepsia à pathomate, 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, latitude, 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, infomuch, 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 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 latitude of all the joints.

Causes, &c. The dissection of epileptic subjects has shown a variety of morbid appearances, which may be supposed to have contributed to the disease; such as, indurations in the brain or meninges; caries of the internal surface of the cranium; projections of the 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 pallion, 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. ening 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. Numerous 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, cator, milk, opium, the feld 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 lighter, 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 Adverfaria; 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 acrid lymph. Glauber first proposed the internal use of them; and Gaubius discovered them to be the remedy of a celebrated empiric Ludemannus, 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 10 doses. A boy of about four years old, labouring under a real epilepsy, suspected to be hereditary, was cured by a grain of the flowers of zinc taken every day for some time.—A man 50 years old, thrown into convulsions from a violent passion, was cured by a grain of the calx taken every two hours. The disease had gone off upon venefication and the use of some other remedies; but returned again in two weeks, when it was finally removed by the zinc. The two last cases are related from Dr Gaubius, who affirms that he has used the flowers of zinc in cases of the chincough, hysterical hiccough, 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 cafe of hieranofos, 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. Venefication. Not to be depended on in convulsions.

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

4. Epifpaftics. 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 serpentinaria Virginiana. 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. Catfor 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. Asafetida 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. Viscus quercinus, or mistletoe, was given in the quantity of two scruples five times a-day to an epileptic patient, without success.

12. Extraclium hyoscyami was given to an epileptic patient, to one afflicted with the hemitonus, and to one who laboured under the hysterical affection, without the least good effect.

13. Folia aurantiacum were exhibited with the like bad success. Five 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 affirmed, 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 LV. 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 ossifications of that viscous, 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 convulsivum, et spasmodico-flatulentum, Asthma. 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 convulsivum, Sauv. sp. 2. Willis Pharm. rel. P. II. feêt. 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. Orthopnoea spasmodica, Sauv. sp. 3. Orthopnoea 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 flatulence, which precede the fit; but it is usually in the middle of the night that the violent difficulty of breathing comes on.

The duration of the paroxysm is uncertain, as it will sometimes terminate in three or four hours, while at other times it 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 scarcely to speak or expectorate, so great is the difficulty of breathing; and yet, notwithstanding all this apparent interruption to the free passage of the blood through the lungs, an inflammation here seldom or never furnishes 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 aafactida, 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 Spasms. 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 Mufgrave 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 so distressing and so 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 oxygum seillitium 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 dyspnoea 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 cough 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 mafs of equal parts of rhubarb, scammony, and soap.

The dry or spasmodic asthma, during the extreme violence of the fit, is best relieved by opiates; and sometimes very large doses are required. But in order to obtain permanent relief, nothing is found to answer better than 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. Iffues 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, finapilms 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 febriculofum, and invades at regular intervals, we must have recourse to the Peruvian bark. The asthma exanthematicum will require blisters or iffues, 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 alteratives, in order to correct the sharpness of the juices.

GENUS LVI. DYSPNOEA.

Habitual DIFFICULTY of BREATHING.

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

Sp. I. The Catarrhal Dyspnoea.

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 Dyspnoea.

Dyspnoea à tuberculis, à hydatibus, &c. Sauv. sp. 2, 4, 5, 20. Orthopnoea à lipomate, Sauv. sp. 18.

This is generally accompanied with a phthisis pulmonalis; but Sauvages mentions one species of phthisis to which the dry dyspnoea 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 scirrhouss enlargement of the lymphatic glands which are dispersed through the lungs, is com- Spasms. monly found in scorfulous habits, and may be distinguished by the concomitancy of those external swellings and appearances which particularly mark the scorfulous. 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. Ifuses 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 supervene.

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

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

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

Sauvages mentions this disease as much more common in brutes than in the human race: but Dr Cullen mentions his having seen some instances of it; and we have several accounts by different authors of calculous matters being coughed up by people labouring under a dyspnoea, and threatened with consumption. In three cases of this kind which fell under Dr Cullen's inspection, there was no appearance of earthy or stony concretions in any other part of the body. The calcareous matter was coughed up frequently with a little blood, sometimes with mucus only, and sometimes with pus. In one of these cases, an 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 pulmonary calculi than mankind, is, that they very seldom cough, and thus the stagnating mucus or lymph concretes into a kind of gypsic matter.

Sp. V. The Watery Dyspnoea.

Dyspnoea pituitosa, Sauv. sp. 1. Orthopnoea ab hydropeumonia, Sauv. sp. 12.

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

Sp. VI. The Dyspnoea from Corpulency.

Orthopnoea à pinguedine, Sauv. sp. 6.

There have been many instances of suffocation and death occasioned by too great corpulency. These fatal effects, however, may be almost always avoided, if the persons have resolution to persist in an active and very temperate course of life; avoiding animal food, much sleep, and using a great deal of exercise. In the third volume of the Medical Observations, however, there is an extraordinary instance of internal obesity which neither showed itself externally, nor could be removed by any medicines.

Other species of dyspnoea have been considered under Phthisis. It is frequently symptomatic of diseases of the heart and large vellols, or swellings of the abdomen, &c.

Genus LVII. Pertussis.

Chincough.

Pertussis, Sydenham, Ed. Leid. p. 200, 311, 312. Husham de aere, ad ann. 1732. Tuffis convulvia, five ferina, Hoffm. III. iii. Tuffis ferina, Sauv. sp. 10. Sag. sp. 10. Tuffis convulvia, Sauv. sp. 11. Sag. sp. 11. Amphimerina tufficulosa, 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 catarrh; and there is a remarkable affection of the eyes, as if they were swelled, 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 another inspiration of the same kind; and thus it continues for some time, very often till the patient vomits, which puts an end to the paroxysm at that time. These paroxysms are attended with a violent determination of the blood towards the head, so that the vellols become extremely turgid, and blood not unfrequently flows from the mouth and nose. The disease is tedious, and often continues for many months. It is not commonly attended with fever, unless at the commencement.

Causes, &c. The chincough is an infectious disorder, and very often epidemic: but the nature of the contagion is not understood; at least it is no farther understood than that of smallpox, measles, or similar epidemics. 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 into any town, village, or neighbourhood, it will rage epidemically 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 defence against future contagion. Every individual, however, does not seem to be equally readily affected with this contagion; like other contagious 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 unwholesome air, are most liable to its attacks, or at least suffer most from them. In general it has been concluded, that whatever weakens the follds, or tends to bring on a diffusion of the fluids, predisposes to this disease, and increases its severity.

Prognosis. The chincough 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 incrustation 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 castor 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 Butler, 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 potassa 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. Opiums 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 Succica, Sauv. sp. 4. Cardialgia Sputatoria, Sauv. sp. 5.

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

GENUS LIX. COLICA. The Colic.

Colica, Sauv. gen. 204. Lin. 50. Vog. 160. Sag. 162. Junck. 106. Colica Spasmatica 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. Paffio iliaca, Junck. 107.

Sp. I. The Spasmodic Colic.

Colica flatulenta, pituitosa, &c. Sauv. sp. 1. 2. 5. 6. 7. 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, twitting, boring, a ligature drawn very tight, &c. The belly is generally coitive, 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 coitiveness; 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 clysters will be vomited; which constitutes that disease commonly called the iliac passion.

Causes, &c. Colics may arise from any sudden check given to peristalsis, 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 contraction of the intestine occasioned by the acrimony of the bile. By this, he says, the intestine is not only contracted into an unusual narrowness, but 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 introflectio 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 hap-

pen in the human body, there is the greatest danger of a mortification; because the part which is constricted, and at any rate deprived 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 gastrootomy, 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 caecum. From this adhesion, which was close to the spine, there ran a ligamentous cord or process about two inches and a half long, unequally thick, in some places not thicker than a packthread; which by its other extremity adhered to the coats of the ileum, about two inches above the caecum. This cord formed a circle with the mesentery, large enough to admit a hen's egg, to pass through it. The cord had formed a node (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 clysters evacuated by the mouth, there is much more hope of a cure, than when the belly is obstinately coitive, 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 constriction of the intestines, and thus preventing or removing the introlufecitio. 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 every thing 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 spasmic constriction 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 prelude, would tend to fix the introlufecition 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 daffed 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 costiveness, and he had been for a week tormented with the most violent pain and vomiting, which could be flopped 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 costiveness had continued for a much longer time.

Other remedies are, the blowing air into the intestines by means of a bellows, and the injecting 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-attempted 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 peripiration, 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 afaefetida, which operate powerfully as antispasmodics, are preferable to most other modes of cure.

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

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

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 diffused in cyder, the common drink of the inhabitants of that country. This has been proved by experiment; for lead has been extracted from cyder in quantity sufficient to produce pernicious effects on the human body. The colic of Poictou, 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 griping pains to the bowels. Soon after there is a diffusion, as with wind; and frequent retchings to vomit, without bringing up any thing but small quantities of bile and phlegm. An obstinate costiveness follows, yet sometimes attended with a tenesmus, and the bowels seem to the patient as if they were drawn up towards the back; at other times they are drawn into hard lumps, or hard rolls, which are plainly perceptible to the hand on the belly. 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 syphula, and are in small quantity. There is, however, usually an obstinate coliciveness; the urine is discharged in small quantity, frequently with pain and much difficulty. The pulse is generally low, though sometimes a little quickened by the violence of the pain; but inflammatory symptoms very seldom occur. The extremities are often cold, and sometimes the violence of the pain causes cold clammy sweats and fainting. The mind is generally much affected, and the spirits are sunk. The disease is often tedious, especially if improperly treated, insomuch that the patients will continue in this miserable state for twenty or thirty days successively; nay, instances have been known of its continuing for six months. In this case the pains at last become almost intolerable: the patient's breath acquires a strong fetid smell like excrement, 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 metaetais, 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 peristaltic 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 serousinous 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 februmilhuce, 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 slighter 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 Coliciveness.

Colica stercorea, Sauv. sp. 3. Ileus à fecibus induratis, Sauv. sp. 2.

For the treatment of this species, see above.

Sp. IV. The Accidental Colic.

Colica Japonica,—accidentalis,—lactentium,—à veneno, Sauv. sp. 10. 14. 18. 20. Cholera fieca auriginofa, à fungis venenatis, ejyd. sp. 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 hepae 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 fame sometimes happens from eating a large large quantity of the shell-fish known by the name of mussels (the Mytilus). Some of the fungi, doublets, 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. fp. 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 cleansed by vomiting, and the belly is generally loofened; 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. fp. 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 six years, occasioned by calculi of this kind. The concretions were at last passed by stool; and their passage was procured by causing the patient drink a large quantity of warm water, with a view to promote the evacuation of bile, a redundancy of which was supposed to be the cause of her disorder.

GENUS LX. CHOLERA, the CHOLERA MORBUS.

Cholera, Sauv. 213. Lin. 186. Vog. 110. Sag. 188. Hoffman. II. 165. Diarrhoea choleric, Janck. 112.

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

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

Sp. II. The Accidental CHOLERA, from acid matter taken inwardly.

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

The cholera shows itself by excessive vomiting and purging of bilious matters, with violent pain, inflation 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 hiccough; and death frequently ensues in twenty-four 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 refrain 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. 105. Sag. gen. 189. Junk. 112. Hepatirrhoea, Sauv. gen. 246. Cholerica, Lin. 190. Coelica, Sauv. gen. 235. Lin. 189. Vog. 109. Sag. gen. 199. Lienteria, Sauv. gen. 256. Lin. 188. Sag. gen. 191. Vog. 108. Pituitaria, et leucorrhosis, 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 flammer in their speech, are laid to be liable to this disease. In lighter 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 antiseptic purgatives are to be made use of, after which the cure is to be completed by astringents.

Sp. II. 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, bitternels, and dryness of the mouth, yellowness of the tongue, and frequently follows an intermitting or bilious fever. When the fever is gone, the diarrhea is to be removed by acidulated and cooling drinks, with small doses of nitre.

Sp. III. The Mucous DIARRHOEA.

Diarrhoea lactentium, Sauv. sp. 19. Dyfenteria Pariflaca, Sauv. sp. 3. Diarrhoea ab hypercathartici, Sauv. sp. 16. Dyfenteria a catharticis, Sauv. sp. 12. Pituitaria, Vog. 111. Leucorrhosis, Vog. 112. Diarrhoea pituitofa, Sauv. sp. 4. Coelica mucosa, Sauv. sp. 3. Diarrhoea ferofa, 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 loofenesis 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 loofenesis are contagious; and Sir John Pringle mentions a soldier who laboured under an obstinate diarrhoea, who infected all those that used the fame privy with himself. In the loofenesis which frequently followed a dyfenterie, the fame author tells us that he began the cure with giving a vomit of ipecacuanha, after which he put the patients on a course of astringents. He used a mixture of three drachms of extract of logwood, dissolved in an ounce and a half of 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 fame medicine in obstinate diarrhoecas of all kinds. A decoction of fimarauba bark was also found effectual, when the dyfenteric symptoms had gone off. Dr Huck, who used this article in North America, also recommends it in diarrhoecas. Two or three ounces of the fimarauba 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 chylofa, Sauv. sp. 1. Coelica lactea, Sauv. sp. 4.

There are very great differences among physicians concerning the nature of this disease. Sauvages says, from Aretaeus, it is a chronic flux, in which the aliment is discharged half digested. It is attended with great pains of the stomach, resembling the prickling 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 Aretaeus, who mentions white faeces as a symptom of the distemper; from whence authors have readily fallen into the notion that they never appeared of any other colour in persons persons labouring under the coeliac passion. This error quickly produced another, which has been very generally received; namely, that the chyle was thrown out of the lacteals by reason of some obstruction there, and thus passed along with the excrements; of which he says there is not the least proof, and agrees with Aretaeus that the whiteness is only occasioned by the want of bile. He endeavours to prove at length, that the coeliac passion can neither be occasioned by an obstruction of the lacteals, nor of the mesenteric glands; though he owns that such as have died of this disease and were dissected, had obstructions in the mesenteric glands; but he denies that all those in whom such obstructions occur, are subject to the coeliac passion. He considers the distemper as arising from a cachexy of the stomachic and intestinal juices; and directs the cure to be attempted by emetics, purgatives, antiseptics, and tonics, as in other species of diarrhea.

Sp. V. The Lientery.

Lienteria spontanea, Sauv. sp. 2.

The lientery, according to Sauvages, differs from the coeliac passion only in being a lighter species of the disease. The aliment passes very quickly through the intestines, with scarce any alteration. The patients do not complain of pain, but are sometimes affected with an intolerable hunger. The cure is to be attempted by stomachics and tonics, especially the Peruvian bark. This disease is most common at the earlier periods of life; and then rhubarb in small quantities, particularly when combined with magnesia, is often productive of the best effects.

Sp. VI. The Hepatic Flux.

Hepatirrhoea intestinalis, Sauv. sp. 2.

The hepatic diarrhea is by Sauvages described as a flux of bloody serous matter like the washings of flesh, which percolates through the coats of the intestines by means of the anastomosing vessels. It is the coeliac passion of Trallianus; and which, according to Sauvages, rarely, if ever, occurs as a primary disease. It has, however, been observed to follow an inflammation of the liver, and then almost always proves fatal.

GENUS LXII. DIABETES.

A profuse Discharge of Urine.

Diabetes, Sauv. gen. 263. Lin. 197. Vog. 115. Sag. gen. 199. Junc. 99. Dobson, Med. Observat. vol. v. p. 298. Home's Clinical Experiments, sect. xvi. Diuresis, Vog. 114.

Sp. I. The Diabetes with sweet Urine.

Diabetes Anglicus, Sauv. sp. 2. Mead on Poisons, Essay I. Fjeldsm Monita Med. cap. ix, sect. 2. Dobson in Lond. Med. Observ. vol. v. art. 27. Myers Diff. inaug. de Diabete, Edinb. 1779. Diabetes febriculus, Sauv. sp. 7. Sydenh. Ep. resp. ad R. Brady.

Sp. II. Diabetes with insipid Urine.

M. Lister Exerc. Medicin. II. de Diabete. Diabetes legitimus, Sauv. sp. 1. Aretaeus de Morb. diuturn. 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 incræases. 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 divested 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 acetic one, before it became putrid and offensive. Eight ounces of blood taken from the same patient, separated into crallamentum 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 urinous smell during the evaporation; and the residuum could not be procured in a solid form, but was blackish, and much resembled very thick treacle. In Dr Home's patients, the serum of the blood had no preternatural sweetness; in one of them the crallamentum was covered with a thick inflammatory crust. In one of these patients the urine yielded an ounce and a half, and in the other an ounce, of facecarine matter from each pound. It had, however, an urinous smell, and a saline taste mixed with the sweet one; and the urine of one fermented with yeast, we are told, into "tolerable small-beer." Both these patients had a voracious appetite, and perpetual gnawing sense of hunger; as had also Dr Dobson's patient. The infipid urine of those affected with diabetes has not been examined by physicians with sufficient accuracy to enable us to speak with confidence of its contents.

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

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

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

On these grounds the principal hopes of a cure in this distemper are from astringent and strengthening medicines. Dr Dobson's patient was relieved by the following remedies; which, however, were frequently varied, as none of them produced their good effects for any length of time: Cinchona in substance, with small doses of rhubarb; decoction of the bark, with the acid elixir of vitriol; the cold infusion of the bark, of which he drank from a quart to two quarts daily; Dover's powder; alum-whey; lime-water; antimonials combined with tinctura thebaica. The warm bath was used occasionally when the skin was remarkably hot and dry, and the patient complained of restlessness and anxiety. The tincture of cantharides was likewise tried; but he could never take more than 25 drops for a dose, without exciting great uneasiness in his bowels. The body was kept constantly open, either with rhubarb or the infusion of fennel joined with rhubarb. His common drinks were rice-water, barley-water, lime-water, and milk; lime-water alone; sage, balm, or mint tea; small-beer, simple water, and water acidulated with the sulphuric acid. In seven months, these remedies, in whatever manner varied, made no further progress in removing the disease. In Dr Home's patients, all these medicines, and many others, were tried without the least good effect; inasmuch that he uses this remarkable expression: "Thus, these two patients have exhausted all that experience had ever recommended, and almost all that theory could suggest; yet in both cases, the coffee has restored all the means of cure used." It is remarkable, that though fevers were given to both, in such quantity as evidently to produce a putrefaction in the prime vices, the urine remained unaltered both in quantity and quality.

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

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

GENUS LXIII. HYSTERIA.

HYSTERICS.

Hysteria, Sauv. gen. 135. Lin. 126. Vog. 219. Sag. gen. 242. Malum hystericum, Hoffm. III. 50. Junck. 36. Affectio hysterica, Willis de Morb. Convulv. cap. 5. 10. 11. Sydenham Diff. Epit. ad G. Cole, Whytt on Nervous Diforders.

Description. The hysteric is a convulsive disease, which comes on at uncertain intervals, sometimes longer and sometimes shorter, but at no stated time. The paroxysms commonly begin with a languor and debility of the whole body; yawning, stretching, and restlessness. A sense of coldness also in the extremities, almost always precedes, and for the most part remains during the whole time of the paroxysm. To this sometimes times succeeds a sense of heat; and the two sensations alternate with each other in different parts of the body. The face is sometimes flushed and sometimes pale: and sometimes the paleness and flushing come alternately. There is a violent pain in the head; the eyes become dim, and pour out tears; there is a rumbling and inflation of the intestines; a sensation is felt like that of a globe ascending from the lower part of the abdomen or hypogastrium, which sometimes seems to roll along the whole alimentary canal. It ascends to the stomach, sometimes suddenly, sometimes slowly; and there produces a sense of inflation and weight, together with anxiety, nausea, and vomiting. At last it comes up to the throat, where it produces a sense of suffocation, and difficulty of breathing or swallowing. During this time there are the most violent pains both in the external and internal parts of the abdomen; the muscles are convoluted; the umbilicus is drawn inwards; and there are frequently such spasms of the intestines, that neither clitters can be injected, nor even flatus passes downwards. Sometimes the paroxysm remits after these symptoms have continued for a certain time, but more frequently the patients fall into fainting fits; sometimes they lie without motion, as if they were in a deep sleep; sometimes they beat their breasts violently and continually with their hands, and sometimes they are seized with general convulsions, and the disease puts on the appearance of an epilepsy. In some patients the extremities become cold and stiff, and the body has the appearance of one in a catalepsy. Sometimes a most violent beating pain takes place in some part of the head, as if a nail was driven into it, and all visible objects seem to turn round; grievous pains attack the loins, back, and bladder, and the patients discharge a surprising quantity of urine as limpid as water; which last is one of the surest signs of the disease. The mind is very much affected as well as the body. Sometimes the patients are tormented with vain fears: sometimes they will laugh, at other times cry immoderately; and sometimes their temper becomes peevish and fretful, that they cannot enjoy a moment's quiet. The appearances which take place in this affection are indeed so much varied, that they can hardly be enumerated: they may, however, with propriety, be divided into hysterical fits, which very much resemble those of epilepsy, excepting that they are not attended with an abolition of the internal senses; and hysterical symptoms, such as the globus hystericus, clonus hystericus, and the like, which are chiefly known to constitute a part of this disease from being observed to alternate with fits.

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

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

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

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

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

GENUS LXIV. HYDROPHOBIA.

The Dread of Water.

Hydrophobia, Sauv. gen. 231. Lin. 86. Vog. 3c. Sag. gen. 343. Boerk. 1138. Junck. 124. Mead on Poisons. Deffault sur la rage. Sauv. diff. sur la rage. James on canine madness. Dalby, Virtues of cinnabar and musk against the bite of a mad dog. Nugent on the hydrophobia. Choisel, Nouvelle methode pour le traitement de la rage. Journal de Medicine, passim. Medical Obs. and Inquiries, vol. iii. art. 34. vol. v. art. 20. 26. and App. Med. Tran/act. vol. ii. art. 5. 12. and 15. Heylham, Diff. inaug. de rab. canin. Edinb. 1777. Parry, Diff. inaug. de rab. contagiof. five canin. Edinb. 1778. Andry, Recherches sur la rage, 1778. Vaughan, Cafes of hydrophobia, second edit. 1778. Arnold, Cafe of hydrophobia, 1795.

Sp. I. HYDROPHOBIA Rabio/a, or Hydrophoby consequent on the Bite of a Mad Animal.

Hydrophobia vulgaris, Sauv. sp. 1.

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

Description. This disease commonly does not make its attack till a considerable time after the bite. In some few instances it has commenced in seven or eight days from the accident; but generally the patient continues in health for 20, 30, or 40 days, or even much longer. The bite, if not prevented, will in general be healed long before that time, frequently with the greatest ease; though sometimes it refits all kinds of healing applications, and forms a running ulcer which discharges a quantity of matter for many days. It has been said, that the nearer the wounded place is to the salivary glands, the sooner the symptoms of hydrophobia appear. The approach of the disease is known by the cicatrix of the wound becoming high, hard, and elevated, and by a peculiar sense of prickling at the part; pains shoot from it towards the throat: sometimes it is surrounded with livid or red streaks, and seems to be in a state of inflammation; though frequently there is nothing remarkable to be observed about it. The patient becomes melancholy, loves solitude, and has fancies at stomach. Sometimes the peculiar symptom of the disease, the dread of water, comes on all at once. We have an instance of one who, having taken a vomit of ipecacuanha for the sickness he felt at his stomach, was seized with the hydrophobia in the time he was drinking the warm water. Sometimes the disease begins like a common sore throat; and the foretells daily increasing, the hydrophobic symptoms show themselves like a convulsive scream of the muscles of the fauces. In others, the mind seems to be primarily affected, and they are subject to despondency and melancholy for some time prior to any dread of water. And when that dread commences, it is with Hydrophobia an evident mental affection. Dr James, in his Treatise on Canine Madness, mentions a boy sent out to fill two bottles with water, who was so terrified by the noise of the liquid running into them, that he fled into the house crying out that he was bewitched. He mentions also the case of a farmer, who, going to draw some ale from a cask, was terrified to such a degree at its running into the vessel, that he ran out in a great haste with the pigot in his hand. But in whatever manner this symptom comes on, it is certain that the most painful sensations accompany every attempt to swallow liquids. Nay, the bare sight of water, of a looking-glass, of any thing clear or pellucid, will give the utmost uneasiness, or even throws the patient into convulsions.

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

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

In this distemper, indeed, the symptoms are so various, that they cannot be enumerated; for we will seldom read two cases of hydrophobia which do not differ very remarkably in this respect. Some seem to have at times a furious delirium, and an inclination to spit at or bite the bystanders; while others show no such inclination, but will even suffer people to wipe the inside of their mouths with the corner of a handkerchief in order to clear away the viscid saliva which is ready to suffocate them. In some male patients there is an involuntary erection of the penis, and emission of the semen; and the urine is forced away by the frequent return of the spasms. In a letter from Dr Wolf of Warsaw to Henry Baker, F. R. S. dated Warsaw Sept. 26th, 1767, we have the following melancholy account of the cases of five persons who died of the hydrophobia: "None of them quite lost their right senses; but they were all talking without intermission, praying, lamenting, despairing, cursing, fighting, spitting a frothy saliva, screeching, sometimes belching, retching, but rarely vomiting. Every member is convolved by fits, but most violently from the navel up to the breast and oesophagus. The fit comes on every quarter of an hour; the fauces are not red, nor the tongue dry. The pulse is not at all feverish; and when the fit is over nearly like a found pulse. The face grows pale, then brown, and during the fit almost black; the lips livid; the head is drowsy, and the ears tingling; the urine limpid. At last they grow weary; the fits are less violent, and cease towards the end; the pulse becomes weak, intermittent, and not very quick; they sweat, and at last the whole body becomes cold. They compose themselves quietly as if to get sleep, and so they expire. The blood drawn a few hours before death appears good in every respect. A general observation was, that the lint and droppings of the wounds, even when dry, were always black, and that when the pus was very good in colour and appearance." In one of Dr Wolf's patients who recovered, the blood stunk intolerably as it was drawn from a vein; and one of Mr Vaughan's patients complained of an intolerable fetid smell proceeding from the wounded part, though nobody but himself could perceive it. In general, the violent convulsions cease a short time before death; and even the hydrophobia goes off, so that the patients can drink freely. But this does not always happen; for Mr Vaughan mentions the case of a patient, in whom, "when he had in appearance ceased to breathe, the spasmus cynicus was observable, with an odd convulsive motion in the muscles of the face; and the strange contortions which took place in the action of these produced the most horrid assemblage of features that can well be conceived. Of this patient also it was remarkable, that in the last hours of his life he ceased to call for drink, which had been his constant request; but was perpetually asking for something to eat."

The hydrophobia seems to be a symptom peculiar to the human race; for the mad animals which communicate the infection, do not seem to have any dread of water. Dr Wolf, in the letter above quoted, says in general, that cattle bit at the same time and by the same animal (a mad wolf) which bit the persons whose cases he related, died nearly with the same frightful raging as the men; but says nothing of their having any hydrophobia: nay, Dr James and some others assert, that the hydrophobia is not always an attendant on rabies canina in the human race; and indeed it is certain that the disease has proved mortal after this terrible symptom has been removed. With regard to the symptoms of madness in dogs, they are very equivocal; and those particularly enumerated by some authors, are only such as might be expected in dogs much heated or agitated by being violently purified and struck. One symptom indeed, if it could be Hydrophobia depended upon, would determine the matter; namely, that all other dogs avoid and run away from one that is mad; and even large dogs will not attack one of the smallest size who is infected with this disease. Upon this supposition they point out a method of discovering whether a dog who has been killed was really mad or not; namely, by rubbing a piece of meat along the inside of his mouth, and then offering it to a found dog. If the latter eats it, it is sign the dog was not mad; but if the other rejects it with a kind of howling noise, it is certain that he was. Dr James tells us, that among dogs the disease is infectious by staying in the same place; and that after a kennel has been once infected, the dogs put into it will be for a considerable time afterwards in danger of going mad also. A remedy for this, he says, is, to keep geese for some time in the kennel. He rejects as false the opinion that dogs when going mad will not bark; though he owns that there is a very considerable change in their bark, which becomes hoarse and hollow.

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

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

With regard to the immediate cause among mankind, there is not the least doubt that the hydrophobia is occasioned by the saliva of the mad animal being mixed with the blood. It does not appear that this can operate through the cuticula; but, when that is rubbed off, the smallest quantity is sufficient to com- municate the disease, and a slight scratch with the teeth of a mad animal has been found as pernicious as a large wound. It is certain also, that the infection has been communicated by the bites of dogs, cats, wolves, foxes, weasels, swine, and even cocks and hens, when in a state of madness. But it does not appear that the distemper is communicable from one hydrophobic person to another, by means of the bite, or any other way. Dr Vaughan inoculated a dog with the saliva of a hydrophobic child, but the animal continued free from disease for two months: and though the doctor promised to inform the public if it should happen to occur afterwards, nothing has hitherto appeared on that subject. A nurse also frequently killed the child during this time of his disorder, but no bad consequence ensued.

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

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

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

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

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

There is a famous East India medicine, composed of 24 grains of native and as much facitious cinnamon, made into a powder with 16 grains of mukh. This is called the Tonquin medicine, and must be taken in a tea cupful of arrack or brandy; and it is said to secure the patient for 30 days, at the expiration of which it is to be repeated; but if he has any symptoms of the disease, it must be repeated in three hours, which is said to be sufficient for a cure. The first dose is to be taken as soon after the bite as possible.

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

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

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

The following case by Dr Raymond of Marvilles shows the inefficacy of mercury even as a preventive. —On the 19th of July 1765, Mr Boyer, aged 25, of a bloated cachetic habit, was bit by a mad dog in the inferior part of the leg: the wound extended half way round, bled freely, and was like a great scratch. The patient's legs had been swelled for a considerable time before the accident; and there were also two ulcers in the other leg. Some hours after the accident, the actual cautery was applied to the wound. The doctor was not present at this operation; but the part around the bite was rubbed with mercurial ointment immediately after, and the eschar was dressed with the same ointment. The eschar was separated on the first day, but the dressing was continued till the wound was cicatriced. The second day a bolus of four grains of turbit and eight grains of camphor was exhibited. This procured a considerable evacuation both by vomit and stool, and a spitting also came on. The third day the bitten leg was rubbed with mercurial ointment: in the space of a month the frictions were repeated five times on both legs, three drams of mercurial ointment being used in each friction. During the same time the bolus was five times repeated; and this treatment kept up a flight salivation to the 40th day. The evening of the third day he took the Tonquin medicine, called also Sir George Cobb's powder, in a bolus; which vomited him briskly. This powder was repeated seven or eight times in the month, generally with the same effect. During the first seven or eight days he got four times, in the morning, a dram of the anagallis flore punicea, fresh gathered and powdered. The 41st day, the turbit bolus was prescribed for the seventh time: he was bathed in the sea, and continued the bathing for two days more. On the 74th he was seized with the differmper; and died on the 76th, seemingly suffocated or strangled, his mouth covered with slaver, and his face bloated. He lost his senses not above half a quarter of an hour before his death. The pulse was quiet the whole time.

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

The fame author tells us, "there are many examples of the ineffectu of mercurial frictions. A Surgeon of Marcilles treated a girl about 12 years of age bit by a mad dog, with mercurial frictions; applying them as in the lues venerae: yet she died of the hydrophobia on the 5th day. Her wound was not cauterized."

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

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

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

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

On the 14th of February 1774, Mr Bellamy of Holborn, aged 40, was bit by a cat affected with rabies, which was killed the same morning. The following day he took the celebrated Ormikirk medicine, sold by Hill and Berry in Hill-Street, Berkeley-Square, and conformed in every respect to the directions given by the vender. A servant maid, who was bitten in the leg before her master was bitten, likewise took the same remedy. About the middle of April Mr Bellamy complained of a pain in his right knee, which he supposed to be rheumatic, and which continued and increased till the 7th of June, when he got some pills of calomel, ipecacuanha, and pil. sapon. from an apothecary, with Huxham's tincture of the bark in small doses. In fix days more he had a titillation in the urethra, a contraction of the forotum and penis to a degree of pain, and an emission of semen after making water, to which he had frequent calls. The medicines were discontinued; and on the 16th of that month the hydrophobia came on, and Dr Fothergill was called. Six ounces of blood were taken from his arm, and a bolus of a scruple of native cinnabar and half a scruple of mulk was given every four hours. The distemper manifestly increased through the day. In the evening a clyster was injected, and several times repeated during the night; he had been put into the warm bath, and two drams of strong mercurial ointment rubbed into his legs and thighs by himself. He was greatly relieved by the warm bath while he continued in it, but the symptoms returned with increased violence in the night. The next day being greatly worse, he was blooded to as great a quantity as he could bear, had the warm bath and clysters repeated, and half an ounce of mercurial ointment rubbed into his thighs and legs. Pills of opium were prescribed, but he did not take them. He died the same night, at half an hour after 12. This patient was a man of great resolution, and could in part conquer his aversion at water. He seemed to have totally forgot the accident of the bite; and causally said, that he thought this disorder resembled the hydrophobia, without supposing that he was afflicted with that distemper at the time.—The bite on the girl's leg refused to heal, baffled the art of a young surgeon who attempted to cure it, and continued a running ulcer for a long time. She did not fall into the hydrophobia. Hence Dr Fothergill thinks it probable, that keeping the wounds made by the teeth of mad animals open for a long time, would probably be of service as a preventive; but in some of Dr Wolf's patients these artificial drains appear not to have been attended with success.

On the 6th of November 1773, Thomas Neurfe, a strong healthy boy of 14, was admitted into the Leicester infirmary; having been that day month bitten by a mad fox-hound. The wound was a large lacerated one on the cheek, and bled very freely on being inflicted. The day after he was bit he went to the sea, where he was dipped with all the severity usually practised under so disagreeable an operation. The Ormikirk medicine was also administered with all due care. It was bought of the person in Leicester who is deputed by the proprietor to sell it for him. A common adhesive plaster was applied to the part after sea-bathing; and in the course of a month, without any further trouble, the wound was healed; excepting a small portion, somewhat more than an inch in length, and in breadth about one-tenth. This yielded no discharge, and was quite in a cicatrizing state. Five days before his admission into the infirmary, he began to complain of a tightness over his temples, and a pain in his head: in two days the hydrophobia began to appear; and at its commencement he complained of a boiling heat in his stomach, which was continually ascending to the fauces. The disease was pretty strong when he came to the infirmary. He got a bolus of a scruple of musk with two grains of opium; then a composition of 15 grains of musk, one of turpith mineral, and five grains of opium, was directed to be taken every third hour; an ounce of the stronger mercurial ointment was to be rubbed on the cervical vertebrae and shoulders, and an embrocation of two ounces of laudanum, and half an ounce of acetum saturninum, was directed to be applied to the throat. But by this last he was thrown into convulsions, and the same effect followed though his eyes were first covered with a napkin. The embrocation was therefore changed for a platter of three drams of powdered camphor, half an ounce of opium, and fix drams confectio Damocitis. By these medicines the disease seemed to be somewhat suspended, but the symptoms returned with violence in the evening. His medicine was repeated at seven; and at eight five grains of opium were exhibited without musk or turpith. At nine, another ounce of mercurial ointment was rubbed upon the shoulders, and half an ounce of laudanum with fix ounces of mutton-broth was injected into the intestines, but to no purpose. A larger dose of opium was then given, but with as little effect as the former, and he died the same night.

In the month of September 1774, a farmer, aged 25, was bit by a mad dog, whose teeth made a slight Hydrophobia wound in the fore finger of the left hand. He was dipped, as usual, in the sea; and drank the sea-water for some time on the spot, which operated briskly as a purge. He continued well till the 6th of June following, when he first felt a pain in that hand and arm; for which he bathed in a river that evening, supposing that it had been a rheumatic complaint. The next day he was sick; and in the evening was seized with a violent vomiting, which continued all that night and till the middle of the next day, when it was succeeded by the hydrophobia. He was treated with the warm bath; had a purgative clyster injected; and as soon as it had operated, a second was given, consisting of four ounces of oil, and half an ounce of laudanum; half an ounce of strong mercurial ointment was rubbed on the fauces, and the part was afterwards covered with the cataplasma e cynano, to which was added an ounce of opium. An embrocation was applied to the region of the stomach with continued friction, consisting of half an ounce of spirit of sal ammoniac, ten drams of olive oil, fix drams of oil of amber, and ten drams of laudanum. Two ounces of strong mercurial ointment were rubbed upon the shoulders and back; and as a further means of inducing a ptyalism speedily, he received the smoke of cinnabar into the mouth by throwing a dram of that substance now and then upon a hot iron: he was also directed to take every four hours a bolus of 15 grains of musk, three grains of turpith mineral, and four grains of opium. He was easier while in the warm bath, and during the application of the ointment; but died the same night about two o'clock.

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

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

Though these pills are principally used against the bite of the cobra de capello, yet they are said also to be successful in the cure of other venomous bites; and, for the prevention of rabies canina, one is taken every morning for some length of time. Of this remedy European practitioners have, we believe, as yet no experience; and if, in the accounts transmitted by by East India practitioners, it cannot be said that we have authentic evidence of its want of success; it can as little be pretended that there is indubitable evidence of its efficacy in any instance; and it is by no means improbable, that it will be found equally inefficacious with others at one time considered as infallible.

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

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

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

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

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

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

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

Sp. II. The Spontaneous Hydrophobia.

Hydrophobia spontanea, Sauv. fp. 2.

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

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

ORDER IV. VESANIAE.

Paranoiae, Vog. Clas. IX. Deliria, Sauv. Clas. VIII. Ord. III. Sag. Clas. XI. Ord. III. Ideales, Lin. Clas. V. Ord. I.

GENUS LXV. AMENTIA.

FOLLY, or Idiotism.

Amentia, Sauv. gen. 233. Vog. 337. Sag. 346. Morofis, Lin. 106. Stupiditas, Morofis, Fatuitas, Vog. 336. Amnesia, Sauv. gen. 237. Sag. 347. Oblivio, Lin. 107. Vog. 338. Memoriae debilitas, Junck. 120.

GENUS LXVI. MELANCHOLIA.

MELANCHOLY Madness.

Melancholia, Sauv. gen. 234. Lin. 71. Vog. 332. Sag. 347. Boerh. 1089. Junck. 121. Demonomania, Sauv. gen. 236. Sag. 348. Daemonia, Lin. 69. Velania, Lin. 70. Paraphobia, Lin. 75. Athymia, Vog. 329. Delirium melancholicum, Hoffm. III. 251. Erotomania, Lin. 82. Nostalgia, Sauv. gen. 226. Lin. 83. Sag. 338. Junck. 125. Melancholia nervosa, Cl. Lorry de melancholia, P. I.

GENUS LXVII. MANIA.

RAVING or FURIOUS Madness.

Mania, Sauv. gen. 235. Lin. 68. Vog. 331. Sag. 349. Boerh. 1118. Junck. 122. Battie on Madness. Paraphroyne, Lin. 66. Although these distempers may be considered as distinct genera, yet they are so nearly allied, and so readily change into each other, that it sufficiently justifies the treating all of them together.

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

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

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

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

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

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

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

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

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

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

Dr Monro assures us, that the evacuation by vomiting is infinitely preferable to any other: the prodigious quantity of phlegm with which the patients in this disease abound, he says, is not to be overcome but by repeated emetics; and he observes, that the purges have not their right effect, or do not operate to so good purpose, until the phlegm be broken and attenuated by frequent emetics. He mentions the case of a gentleman who had laboured under a melancholy for three years, from which he was relieved entirely by the use of vomits and a proper regimen. Increasing the discharge by urine, is also of the greatest moment, especially when any degree of fever is present. The cutaneous discharges are also to be promoted; for which purpose the hot bath is of the highest service in maniacal cases. Hoffman affirms, that he has seen numerous instances, both of inveterate melancholy and raging madness, happily cured by means of warm bathing; bleeding and nitrous medicines having been premised. Camphor has also been highly commended; but, if we can believe Dr Locker of Vienna, not very decidedly. Having found very good effects from a solution of this medicine in vinegar, he took it for granted that all the success was owing to the camphor; therefore, in order to give it a fair trial, he selected seven patients, and gave it in large doses of half a dram twice a-day. This was continued for two months, and the doctor was surprised to find that only one of his patients received any benefit. He then returned the other fix back to the camphorated julep made with vinegar, and in a few weeks four of them recovered the use of their reason. This inclined him to think that the virtue depended solely on the vinegar, and accordingly he began to make the trial. Common vinegar was first given: but after a little while he fixed on that which had been distilled, and gave about an ounce and a half of it every day; the patients having been previously prepared by bleeding and purging, which was repeated according as it was found necessary. He gives a list of eight patients who were cured by this method; some in six weeks, others in two months, and none of them took up more than three months in perfecting the cure. He does not indeed give the ages of the patients, nor mention the circumstances of the cases; he only mentions the day on which the use of the vinegar was begun and the day on which they were discharged; and he adds, that they all continued well at the time of his writing.

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

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

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

It is of great use in practice to bear in mind, that all mad people are cowardly, and can be awed even by the menacing look of a very expressive countenance; and when those who have charge of them once impress them with the notion of fear, they easily submit to any thing that is required. The physician, however, should never deceive them in any thing, but more especially with regard to their distemper: for as they are generally conscious of it themselves, they acquire a kind of reverence for those who know it; and by letting them see that he is thoroughly acquainted with their complaint, he may very often gain such an ascendant over them that they will readily follow his directions.

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

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

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

GENUS LXVIII. ONEIRODYNYA.

UNEASINESS in SLEEP.

Somnium, Vog. 339. Somnambulimus, Sauv. gen. 221. Lin. 77. Sag. 333. Hypnobatafis, Vog. 340. The greatest uneasiness which people feel in sleep is that commonly called the incubus or night-mare. Those seized with it seem to have a weight on their breasts and about their precordia. Sometimes they imagine they see spectres of various kinds which oppress or threaten them with suffocation. Neither does this uneasiness continue only while they are asleep; for it is some time after they awake before they can turn themselves in their beds or speak; nay, sometimes, though rarely, the distemper has proved mortal.—The incubus rarely seizes people except when the stomach is oppressed with ailments of hard digestion, and the patient lies on his back. It is to be cured by eating light suppers, and raising the head high; or, if it become very troublesome, antispasmodic medicines are to be administered, and the body strengthened by chalybeates. The same method is to be followed by those who are subject to walking in their sleep; a practice which must necessarily be attended with the greatest danger; and somnambulism may justly be considered as merely a different modification of this disease. Accordingly Dr Cullen has distinguished the one by the title of oneirodynia activa, and the other by that of oneirodynia gravans.

CLASS III. CACHEXIAE.

Cachexiae, Sauv. Clas X. and Clas VIII. Sag. Clas III. Deformes, Lin. Clas X.

ORDER I. MARCORES.

Macies, Sauv. Clas X. Order I. Sag. Clas III. Order I. Emaciantes, Lin. Clas X. Order I.

GENUS LXIX. TABES.

Wasting of the Body.

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

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

GENUS LXX. ATROPHIA.

NERVOUS CONSUMPTION.

Description. This affection consists principally in a wasting of the body, without any remarkable fever, cough, or difficulty of breathing; but attended with want of appetite and a bad digestion, whence the whole body grows languid, and wastes by degrees.—Atrophia. Dr Cullen, however, asserts, that some degree of fever, or at least of increased quickness of the pulse, always attends this disease.

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

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

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

ORDER II. INTUMESCENTIAE.

Intumescentiae, Sauv. Clas X. Ord. II. Sag. Clas III. Ord. II. Tumidof, Lin. Clas X. Ord. II.

GENUS LXXI. POLYSARCIA.

CORPULENCY.

Polyfarcia, Sauv. gen. 279. Lin. 213. Vog. 540. Sag. 160. Steatites, Vog. 390.

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

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

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

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

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

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

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

But Dr Fothergill observes, that a strict adherence to vegetable diet reduces exuberant fat more certainly than any other means that he knows; and gives two cases in which this regimen succeeded remarkably well. The famous Dr Cheyne brought himself down in this way, from a most unwieldy bulk to a reasonable degree of weight; as he himself informs us. It deserves, however, to be remarked, that every practice for the removal or prevention of fatness must be used with great caution and prudence: for not a few, anxious to prevent this affection, have had recourse to a regimen and to medicine which have proved fatal. This has particularly arisen from the excessive use of acids, probably operating by entirely destroying the action of the chylopoeic viterra.

GENUS LXXII. PNEUMATOSIS.

EMPHYSEMA, or Windy Swelling.

Pneumatosis, Sauv. gen. 280. Vog. 391. Seg. 107. Emphysema, Sauv. gen. 13. Lin. 288. Vog. 392. Leucophlegmatia, Lin. 214.

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

GENUS LXXIII. TYMPANITES.

TYMPANY.

Tympanites, Sauv. gen. 291. Lin. 219. Vog. 316. Seg. 118. Boerh. 226. Junck. 87. Affectio tympanitica, Hufn. III. 339. Meteoriformus, Sauv. gen 292.

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

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

Prognosis. This disease is generally very obstinate, and for the most part proves fatal by degenerating in- to an ascites. Sometimes, if the patient be healthy and strong, the disease may terminate favourably, and that the more readily if it has followed from some disorder. A hectic consumption, dry cough, and emaciated countenance in a tympany, with a swelling of the feet, denote approaching death in a very short time.

Cure. With a view to the prevention of this affection, it is necessary, in the first place, to avoid, as far as it can be done, causes giving rise to an uncommon extrication of air, by preserving the proper tone of the alimentary canal. After the affection has taken place, the indications are, first, to expel the air already extricated and confined in different cavities; and, secondly, to prevent further accumulation. On these grounds different remedies are employed. The cure, however, is principally attempted by carminative, reolvent, and stomachic medicines, gentle laxatives, and at last tonics, especially chalybeates. In the Edinburgh Medical Essays, vol. i. we have a very remarkable history of a tympany by Dr Monro senior. The patient was a young woman of 22 years of age, who fell into the dispensary after a tertian ague, in which she was badly treated. She became a patient in the Edinburgh Infirmary the 24th of March 1739; took several purgatives, and some doses of calomel; used the warm bath; and had an antihysteric plaster applied over the whole belly, but with very little effect. She was monstrously distended, insomuch that the skin seemed to be in danger of bursting: her breathing was much straitened: but the swelling sometimes gradually decreased without any evacuation. The returns and degree of this swelling were very uncertain; and when the belly was most detumefied, several unequal and protuberant balls could be felt over the whole abdomen, but especially at its sides. Her stomach was good, she had no thirst, and her urine was in proportion to the quantity she drank. She was very coughive, had her menses at irregular periods, but no oedematous swellings appeared in the feet or any where else. In this situation she continued from the time of her admission till the 21st of June, during which interval she had only menstruated twice. Throughout this space of time, the following circumstances were observed, 1. Several times, upon the falling of the swelling, she complained of a headache; once of pains throughout all her body, once of a giddiness, twice of a nausea and vomiting, and the last time threw up green bile; and once her stomach swelled greatly, whilst the rest of the abdomen subsided. 2. During the flowing of the menses she did not swell, but became very big upon their stopping. 3. Blood-letting and emetics, which were made use of for some accidental urgent symptoms, had no very sensible effect in making the tympany either better or worse. 4. She never had passage of wind either way, except a little belching some days before the monthly evacuation.

Some time before the last eruption of the menses, the purgatives were given more sparingly; and anti-hysteric's of the strongest kinds, such as aafactida, oleum corn. cerv. &c. mixed with soap, were given in large doses, accompanied with the hotter antiscorbutics as they are called, as horseradish and ginger-root infused in strong-ale with steel. The patient was ordered to use frequent and strong frictions to all the trunk of her body and extremities, and to use moderate exercise. Immediately before the menses began to flow, phytomecylers of the same kind of medicines were injected. The menses were in sufficient quantity; but as soon as they ceased, her belly increased in its circumference four inches and a half, but soon subsided. She then complained of pains, which a gentle sweat carried off. Borborygmii were for the first time observed on the same day, June 25th; and having taken some tinctura sacra at night, she passed a small quantity of blood next day by stool. This was the first appearance of the return of the haemorrhoids, to which she had been formerly subject.

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

GENUS LXXIV. PHYSOMETRA. WINDY SWELLING of the Uterus.

Phyometra, Sauv. gen. 293. Sag. 119. Hysterophyle, Vog. 317.

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

GENUS LXXV. ANASARCA. WATERY SWELLING over the Whole Body.

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

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

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

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

GENUS LXXVI. HYDROCEPHALUS.

WATER in the HEAD.

External or Chronic HYDROCEPHALUS.

Hydrocephalus, Sauv. gen. 285. Lin. 216. Boerh. 1217. Hydrocephalum, Vog. 384.

This differs from the hydrocephalus formerly treated of at some length under the title of Apoplectia Hydrocephalica, chiefly in the water being collected in the external parts of the head, whereas the former is entirely within the skull. In the fifth volume of the Medical Observations we have an account of a very extraordinary case of this kind. The patient was a child only of a few days old, and had a tumor on his head about the size of a common tea-cup, which had the appearance of a bladder distended with water; near the apex was a small opening, through which a bloody serum was discharged. In other respects the child was healthy. No application was used but a piece of linen dipped in brandy. The tumor continued to increase for many months; at the end of which time the membrane containing the water appeared equally thick with the other part of the scalp, except at one place about the size of a thimble, which continued thin, and at times appeared as if it would burst. He remained in this situation for about 17 months, when the circumference of the head was 20 inches, the base 16\frac{1}{2}, the middle 18\frac{1}{2}, and from the base to the apex near 8\frac{1}{2}. The water was then drawn off, and the child died in two days. Almost all other cases of this disorder have proved fatal; the futures of the skull generally give way, and the whole external part of the head is equally enlarged: but in the instance just now given there was a deficiency of part of the bones. Although, however, in some instances, where the head is thus enlarged to an enormous size, the water is exterior to the brain, and therefore entitled to the appellation of hydrocephalus exterior, yet much more frequently in those instances where there is a manifest separation of the bones of the cranium at the futures, the water is still contained within the ventricles; and accordingly the disease may be much more properly distinguished into the acute and chronic hydrocephalus, than as is commonly done into the internal and external. Although the latter be much flower in its progress, sometimes subsisting even for years, yet it is equally difficult of cure with the former, and very often it proves fatal in a few days if the water be drawn off by an artificial opening, which may be very easily performed by a mere puncture with a common lancet, without either pain or any immediate hazard from the operation itself, although the water be lodged in the ventricles; for these are distended to an enormous size, and the substance of the brain almost totally destroyed, so that hardly anything is to be punctured but membrane.

GENUS LXXVII. HYDRORACHITIS.

SPINA BIFIDA.

Hydrorachitis, Sauv. gen. 287. Morgagn. de fed. XII. g. et seq. Spinola, Lin. 289. Spina bifida, Vog. 386.

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

GENUS LXXVIII. HYDROTHERAX.

DROPSY of the BREAST.

Hydrotorax, Sauv. gen. 150. Vog. 311. Boerh. 1219.

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

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

That these symptoms are common attendants of this disease, is undeniable; and they are certainly the best characteristics of this affection with which we are yet acquainted; but it must be allowed that they are present in some cases where there is no water in the breast; and that in other instances where the disease exists, they are either altogether wanting, or occur only to a very slight degree. Certain diagnostics, therefore, of this disease still remain to be discovered.

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

GENUS LXXIX. ASCITES.

DROPSY of the Abdomen.

Ascites, Sawv. gen. 288. Lin. 217. Vog. 314. Sag. gen. 115. Baerh. 1226. Hoffm. III. 322. Junck. 87. Dr Monro on the Dropy, 1765. Milman, Animadverfions de Hydrope, 1779.

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

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

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

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

But another and much more sufficient cause for the production of dropy is an obstruction of the circulation; and this may take place from polypi in the heart or large vessels, and hard swellings in the abdomen. Instances have been observed of a dropy arising from seafatomatic tumors in the omentum, and many more from a feirrhou liver or spleen, and from an infarc- tion and obstruction of the mesenteric glands, by which means the lymph coming from the extremities is prevented from arriving at the heart. Scirrhosity of the liver, the most common cause of afeces, probably operates by augmenting effusion, in consequence of its preventing the return of the venous blood, the greater part of the veins from the abdomen going to the formation of the vena portarum.

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

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

It is moreover evident from experiments, that, in a healthy state, not only water is not deposited in the cavities, but that if it is injected into them it will be absorbed, unless some laxity of the solids has already taken place. Dr Mufgrave injected into the right side of the thorax of a dog four ounces of warm water; whence a difficulty of breathing and weakness immediately followed. But these symptoms continually lessened, and in the space of a week the animal seemed to be in as good health as before. Afterwards he injected 16 ounces of warm water into the left cavity of the thorax in the same dog; the same effects followed, together with great heat, and strong pulsation of the heart; but he again recovered in the space of a week. Lastly, He injected 18 ounces of water into one side of the thorax, and only fix into the other: the same symptoms followed, but vanished in a much shorter time; for within five days the dog was restored to perfect health. During this time, however, he observed that the dog made a greater quantity of urine than usual.

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

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

Cure. In the cure of this disease authors chiefly mention two indications: 1. To expel the effused water; and, 2. To prevent its being again collected. But before we proceed to speak of the remedies, it is necessary to take notice, that by the laws of the animal economy, if a great evacuation of a fluid takes place in any part of the body, all the other fluids in the body are directed towards that part, and those which lie, as it were, lurking in different parts will be immediately absorbed, and thrown out by the same passage. Hence the humours which in hydroptic persons sons are extravasated into the different cavities of the body will be thrown into the intestines, and evacuated by purgatives; or by diuretics will be thrown upon the kidneys, and evacuated by urine. It is, however, not only necessary to excite these evacuations in order to remove this malady, but they must be assiduously promoted and kept up till the abundant humour is totally expelled. For this reason Sydenham has advised purgatives to be administered every day, unless, either through the too great weakness of the body, or the violent operation of the purgative, it shall be necessary to interpose a day or two now and then; because if any considerable intervals be allowed to take place between the exhibition of the purgatives, an opportunity is given to the waters of collecting again. In this method, however, there is the following inconvenience, that, when the waters are totally evacuated, the strength is at the same time so much exhausted, that the distemper commonly returns in a very short time. Hence our chief hopes of curing a dropy consist in gently evacuating the waters by means of diuretics. But the efficacy of these is generally very doubtful. Dr Freind has long ago observed, that this part of medicine is of all others the most lame and imperfect; but a French physician, Mr Bacher, lately discovered, as he alleges, a method of making the diuretics much more successful. His reputation became at last so great, that the French king thought proper to purchase his secret for a great sum of money. The basis of his medicine was the black hellebore root, the malignant qualities of which he pretended to correct in the following manner: A quantity of the dried roots of black hellebore were pounded, and then put into a glazed earthen vessel, and afterwards sprinkled with spirit of wine. They were suffered to stand for twelve hours, stirring them about twice or thrice during that space of time. They were then sprinkled again, and at last good Rhenish wine was poured on till it stood fix fingers above the roots. The mixture was frequently agitated with a wooden spatula; and as the wine was imbibed by the roots, more was poured on, so as to keep it always at the same height for 48 hours. The whole was then put on the fire and boiled for half an hour, after which the decoction was violently pressed out; the same quantity of wine was added as at first, and the mixture boiled as before. After the second expression the woody residuum was thrown away as useless. Both the strained liquors were then mixed together with two parts of boiling water to one of the decoction. The whole is afterwards evaporated in a silver vessel to the consistence of a syrup. One part of the extract is again mixed with two parts of boiling water, and the whole infusified as before.—By this means, says he, the volatile nauseous acid particles are separated by evaporation, and the fixed ones remain corrected and prepared for medicinal uses; adding, towards the end, a ninth part of old brandy, and evaporating to the consistence of turpentine. Mr Bacher reasons a good deal on the way in which this process corrects the medicine; but tells us, that notwithstanding the improvement, his pills will not have the desired effect unless properly made up. For forming them, they ought to be mixed with matters both of an invigorating and indurating nature; yet so prepared that it will be readily soluble in the stomach, even of a person much debilitated. For answering these purposes, he chose myrrh and carduus benedictus, and he gives the following receipt for the formation of his pills:—

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

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

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

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

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

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

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

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

The water having been drawn off, we are to put the patient on a course of strengtheners; such as cinchona, with some of the warm aromatics, and a due proportion of rhubarb infused in wine and chalybeates. Gentle exercise, and frictions on the belly, with such a course of diet as shall be light and nourishing, are also to be enjoined: and it may be observed, that the use of tonic medicines is by no means to be delayed till a complete evacuation of the water can be obtained. On the contrary, by alternating, and even combining the use of evacuants and tonics, the influence of both is often very much promoted.

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

GENUS LXXX. HYDROMETRA.

DROPST of the Uterus.

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

GENUS LXXXI. HYDROCELE.

DROPST of the Scrotum.

Oscheoccele, Sauv. gen. 41. Vog. 388. Oscheophyma, Sag. 44. Hydrops scroti, Vog. 389. Hydrops testiculi, Boerh. 1227.

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

GENUS LXXXII. PHYSCONIA.

SWELLING of the Belly.

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

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

GENUS LXXXIII. RACHITIS.

The RICKETS.

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

Description. This is one of the diseases peculiar to infancy. It seldom attacks children till they are nine months, nor after they are two years old; but it frequently happens in the intermediate space between these two periods. The disease shows itself by a flaccid tumor of the head and face, a loose flabby skin, a swelling of the abdomen, and falling away of the other parts, especially of the muscles. There are protuberances of the epiphyses of the joints; the jugular veins swell, while the rest decrease; and the legs grow crooked. If the child has begun to walk before he be seized with this disease, there is a flowness, debility, and tottering in his motion, which soon brings on a constant desire of sitting, and afterwards of lying down; inomuch that nothing at last is moveable but the neck and head. As they grow older, the head is greatly enlarged, with ample futures; the thorax is compressed on the sides, and the sternum rises up sharp, while the extremities of the ribs are knotty. The abdomen is protuberant, and the teeth black and carious. In such patients as have died of this disease, all the folds appear soft and flaccid, and the fluids diffused and mucous.

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

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

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

A German physician, Dr Strack, has lately published a paper, in which he recommends the filings of iron as a certain remedy in the rickets. This disease, he observes, in general begins with children when they are about 16 months old. It is seldom observed with children before they be one year old, and seldom attacks them after they pass two; and it is very generally worse where it begins early than where it begins late. For effecting a cure, it is, he affirms, a matter of the utmost consequence to be able to distinguish, very early, whether a child will be afflicted with rickets or not. And this, he assures us, may be determined by the following symptoms: Paleness and swelling of the countenance; and in that part of the cheeks which should naturally be red, a yellow colour approaching to that of sulphur. When that is the case, he directs that a medicine should be immediately had recourse to which will retard the further progress of the disease, and remove what has already taken place. For this purpose, he advises that five grains of the filings of iron, and as much rhubarb, should be rubbed up with ten grains of sugar, and given for a dose every morning fasting, and every evening an hour before supper. But if considerable looseness should be produced, it will be necessary, at first, to persist in the use of one dose only every day.

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

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

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

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

ORDER III. IMPETIGINES.

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

GENUS LXXXIV. SCROPHULA.

KING'S EVIL.

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

Description. This disease shows itself by hard, firn- rous, and often indolent tumors, which arise by degrees in the glands of the neck, under the chin, armpits, and different parts of the body, but most commonly in the neck, and behind the ears. In process of time, the cellular substance, ligaments of the joints, and even the bones themselves, are affected. In scrophula the swellings are much more moveable than those of the firn- rous kind; they are generally softer, and seldom attended with much pain; they are tedious in coming to suppuration; are very apt to disappear suddenly, and again to rise in some other part of the body. We may, likewise mention as characteristic circumstances of this disease, a remarkable softness of the skin, a kind of fulness of the face, generally with large eyes, and a very delicate complexion.

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

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

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

In the treatment of scrophula, different morbid conditions, existing in different parts, require, according to circumstances, various means of cure: but, upon the whole, the remedies directed may be considered as used with a view either to the tumours, to the ulcerations, or to the general state of the system. Gentle mercurials are sometimes of use as resolvents in scrophulous swellings; but nothing has such considerable influence as a frequent and copious use of cinchona. Cold bathing too, especially in the sea, together with frequent moderate exercise, is often of singular service here; as is likewise change of air, especially to a warm climate.

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

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

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

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

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

Dr Fothergill also acquaints us, that the cicuta even by itself is not without a considerable share of efficacy in removing scrophulous disorders. He mentions the cicuta case of a gentlewoman, about 28 years of age, afflicted from her infancy with scrophulous complaints, severe ophthalmies, glandular swellings, &c. cured by the extraction cicuta taken constantly for the space of a year. He observes, however, that when given to children, even in very small doses, it is apt to produce spasmodic affections; for which reason he rarely exhibits it to them when very young, or even to adults of very irritable habits.

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

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

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

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

GENUS LXXXV. SYPHILIS.

LUES VENEREA, or French Pox.

Sypilis, Sauv. gen. 3086. Lin. 6. Vog. 319. Sag. 126. Lues venerea, Boerh. 1440. Hoffm. III. 413. Junck. 96. Afrue de Lue Venerea.

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

The venereal infection, however, cannot, like the contagious miasma of the smallpox and some other diseases, be carried through the air, and thus spread from place to place: for unless it is transmitted from the parents to the children, there is no other way of contracting the disease but from actual contact with the infectious matter. Thus, when a nurse happens to labour under the disease, the infant that she suckles will receive the infection; as, on the other hand, when the child is infected, the nurse is liable to receive it: and there have even been instances known of lying-in women being infected very violently, from having employed a person to draw their breasts who happened to have venereal ulcers in the throat. It may be caught by touching venereal fores, if the cuticle be abraded or torn: and in this way accoucheurs and midwives have sometimes been infected severely. Dr Macbride says, the most inveterate pox he ever saw was caught by a midwife, who happened to have a whitlow on one of her fingers when she delivered a woman ill of the lues venerae.

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

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

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

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

Venereal ulcers affecting the mouth are distinguishable from those which are scorbutic, in the following manner: 1. Venereal ulcers first affect the tonsils, fau- ces and uvula; then the gums, but these very rarely: on the contrary, scrofulous ulcers affect the gums first of all; then the fauces, tonsils, and uvula. 2. Venereal ulcers frequently spread to the nose; scrofulous ones almost never. 3. Venereal ulcers are callous in the edges; scrofulous ones are not so. 4. Venereal ulcers are circumcised, and, for the most part, are circular, at least they are confined to certain places; scrofulous ones are of a more irregular form, spread wider, and frequently affect the whole mouth. 5. Venereal ulcers are for the most part hollow, and generally covered at bottom with a white or yellow flough; but scrofulous ones are more apt to grow up into loose fungi. 6. Venereal ulcers are red in their circumference, but scrofulous ones are always livid. 7. Venereal ulcers frequently rot the subjacent bones, the scrofulous ones seldom or never. 8. And lastly, Venereal ulcers are generally combined with other symptoms which are known to be venereal; scrofulous ones with the distinguishing signs of the scurvy, such as difficult breathing, littlefins, swelling of the legs, rotten gums, &c.

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

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

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

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

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

Prognosis. Being thoroughly convinced that the case is venereal, we are to consider, first of all, whether it be of a longer or shorter date; for the more recent it is, it will, catenis paribus, be less difficult to remove. But there are other circumstances which will assist us in forming a prognostic as to the event. As, 1. The age of the patient. This disorder is more dangerous to infants, and old people, than to such as are in the flower and vigour of life, in whom some part of the virus may be expelled by exercise, or may be subdued in some degree by the strength of the constitution. 2. The sex. Though women are for the most part weaker than men, and therefore should seem less able to resist the force of any disease, yet experience shows that this is easier borne by them than by men; perhaps owing to the menstrual and other uterine discharges, by which a good portion of the virus may be carried off immediately from the parts where it was first applied; for it is observable, that whenever these discharges are obstructed, or cease by the ordinary course of nature, all the symptoms of this disease grow worse. 3. The habit of body. Persons who have acrid juices will be liable to suffer more from the venereal poison than such as have their blood in a milder state; hence, when people of a scrofulous or scrophulous habit contract venereal disorders, the symptoms are always remarkably violent, and difficult to cure. And for the same reasons, the confirmed lues is much more to be dreaded in a person already inclined to an asthma, phthisis, dropsy, gout, or any other chronic disorder, than in one of a sound and healthy constitution. For as the original disease is increased by the accession of the venereal poison, to the lues is aggravated by being joined to an old disorder. The more numerous the symptoms, and the more they affect the bones, the more difficult the cure. Of all combinations the union of syphilis with scrophula is perhaps the most difficult to overcome; but if the acrimony should seize on the nobler internal parts, such as the brain, the lungs or the liver, then the disease becomes incurable, and the patient will either go off suddenly in an apoplectic fit, or sink under a consumption.

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

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

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

Corroible sublimate, or the murias hydrargyri corrosivus, is one of the most active of all the mercurial preparations, insomuch as to become a poison even in very small doses. It therefore cannot safely be given in substance; but must be dissolved in order to render it capable of a more minute division. We may see, by Siphilis looking into Wifeman, that this is an old medicine, though seldom given by regular practitioners. How it came to be introduced into to remote a part of the world as Siberia, is not easily found out; but Dr Clerc, author of the Histoire Naturelle de l'Homme Malade, assures us, that the sublimate solution has been in use there time out of mind.

It appears to have been totally forgotten in other places, until of late years, when Baron Van Swieten brought it into vogue; so that at one period, if we may credit Dr Locker, they used no other mercurial preparation at Vienna. The number of patients cured by this remedy alone in the hospital of St Mark, which is under the care of this gentleman, from 1734 to 1761 inclusive, being 4880.

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

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

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

If, therefore, it is determined to have recourse to the mercurial frictions, the patient may with advantage be prepared by going into the warm bath some days successively; having been previously blooded if of a plethoric habit, and taking a dose or two of some proper cathartic. The patient being fitted with the necessary apparatus of flannels, is then to enter on the course.

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

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

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

Where, after a long trial of mercury, distressing symptoms still remain, particularly obilitate ulcerations and severe pains, benefit has often been derived from the use of opium: but there is little reason to believe, as has been held by some, that of itself it affords an infallible cure of this disease; at least we are inclined to think, that all the facts hitherto brought in support of the cure of syphilis by opium are at the utmost very doubtful.

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

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

GENUS LXXXVI. SCORBUTUS.

SCURVY.

Scorbatus, Sauv. gen. 391. Lin. 223. Vog. 318. Sag. 127. Boerh. 1148. Hoffm. III. 369. Junck. 91. Lind on the Scurvy. Hulme de Scorbuto. Rouppé de Morbis Navigantium.

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

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

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

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

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

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

Dr Lind has, in a postscript to the third edition of his treatise on the scurvy, given the result of his observations drawn from the direction of a considerable number of victims to this fatal malady; from which it appears that the true scorbutic state, in an advanced stage of the distemper, consists in numerous effusions of blood into the cellular interstices of most parts of the body, superficial as well as internal; particularly the gums and the legs; the texture of the former being almost entirely cellular, and the generally dependent state of the latter rendering these parts, of all others in the whole body, the most apt to receive and retain the stagnant blood, when its crafts comes to be destroyed; and when it looses that glutinous quality which, during health, hinders it from escaping through the pores in the coats of the blood-vessels or through exhalant extremities.

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

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

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

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

Sir John Pringle, however, is of a very different opinion. He "is persuaded, after long reflection, and the opportunities he has had of conversing with those who to much eagacity had joined no small experience in nautical practice, that upon an examination of the several articles which have either been of old approved, or have of late been introduced into the navy, it will appear, that though these means may vary in form and in mode of operating, yet they all some way contribute towards preventing putrefaction; whether of the air in the closter parts of a ship, of the meats, of the water, of the clothes and bedding, or of the body itself."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But if the belly should not be loosened by the use of the fresh vegetables, nor the skin become soft and moist, then they must be assisted by stewed prunes, or a decoction of tamarinds with superpartite of petalh, in order to abate the colliciveness; and by drinking a little decoction of the woods, and warm bathing, in order to relax the pores of the skin; for nothing contributes more to the recovery of scorbutic patients than moderate sweating.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GENUS LXXXVII. ELEPHANTIASIS.

Elephantiasis, Sauv. gen. 322. Vog. 321. Sug. gen. 128. Elephantia Arabum, Vog. 322.

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

The features of the face swell and enlarge greatly; the part above the eyebrows seems inflated; the hair of the eyebrows falls off, as does the hair of the beard; but Dr Heberden has never seen any one whose hair has not remained on his head. The alae nasi are swelled and scabrous; the nostrils patulous, and sometimes affected with ulcers, which, corroding the cartilage and septum nasi, occasion the nose to fall. The lips are tumid; the voice is hoarse; which symptom has been observed when no ulcers have appeared in the throat, although sometimes both the throat and gums are ulcerated. The ears, particularly the lobes, are thickened, and occupied by tubercles. The nails grow scabrous and rugose, appearing something like the rough bark of a tree; and the distemper advancing, corrodes the parts gradually with a dry forbid scab or gangrenous ulcer; so that the fingers and toes rot and separate joint after joint. In some patients the legs seem rather posts than legs, being no longer of the natural shape, but swelled to an enormous size, and indurated, not yielding to the pressure of the fingers; and the furniture is covered with very thin scales, of a dull whitish colour, seemingly much finer, but not so white as those observed in the lepra Graecorum. The whole limb is overlaid with tubercles, interpered with deep ulcers; sometimes the limb is covered with a thick moist scabby crust, and not unfrequently the tubercles ulcerate. In others the legs are emaciated, and sometimes ulcerated; at other times affected with tubercles without ulceration. The muscular flesh between the thumb and forefinger is generally extenuated.

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

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

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

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

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

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

The LEPROSY.

Lepra, Sauv. gen. 303. Lin. 262. Sag. 129. Lepra Graecorum, Vog. 320.

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

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

GENUS LXXXIX. FRAMBOESIA.

The Yaws.

Framboesia, Sauv. gen. 125. Sag. 125.

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

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

M. Virgile describes the species of yaws that is common among the negroes of St Domingo, and which Sauvages has termed framboesia Americana, as beginning from an ulcer that breaks out indiscriminately in different parts of the body, though most commonly on the legs; at first superficial, and not different from a common ulcer in any other circumstance saving its not healing by the usual applications; sooner or later, numerous fungous excrescences break out on the surface of the body, as before described, like little berries, moist, with a reddish mucus. Besides these, the soles of the feet and palms of the hands become raw, the skin fretting off, so as to leave the mucles bare; these excoriations are sometimes moist with ichor and sometimes dry, but always painful, and consequently very distressing. They are mentioned also by the author of the article in the Medical Essays; and both he and M. Virgile observe, that there is always one excellence, or yaw, of an uncommon size, which is longer in falling off than the others, and which is considered as the major-yaw, and so termed. An ingenious inaugural dissertation on the subject of the yaws was lately published at Edinburgh by Dr Jonathan Anderson Ludford, now physician in Jamaica. The author of that dissertation considers Dr Cullen as improperly referring framboesia to the class of cachexie. He thinks that this disease ought rather to be referred to the exanthemata; for, like the smallpox, he tells us, it has its accession, height, and decline. It begins with some degree of fever either more or less violent; it may be propagated by inoculation; and it attacks the the same individual only once in the course of a lifetime, those who recover from the disease being never afterwards affected with it. These particulars respecting frambesia are rested not merely on the authority of Dr Ludford, but are supported also by the testimony of Dr William Wright, a physician of distinguished eminence, who, while he resided in Jamaica, had, in the course of extensive practice, many opportunities of observing this disease, and to whom Dr Ludford acknowledges great obligations for having communicated to him many important facts respecting it.

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

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

Cure. In attempting the cure of this disease, the four following indications are chiefly to be held in view: 1. To support the strength of the patient. 2. To promote excretion by the skin. 3. To correct the vitiated fluids. 4. To remove and counteract the injuries done either to the constitution in general, or to particular parts, by the disease.

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

As soon as you are convinced that it is the yaws, give a bolus of flowers of sulphur, with camphor and theriac. Repeat this bolus every night for a fortnight or three weeks, or till the yaws come to the height; that is, when they neither increase in size or number: then throw your patient into a gentle salivation with calomel given in small doses, without farther preparation; five grains repeated once, twice, or thrice a-day, is sufficient, as the patient can bear it. If he spits a quart in 24 hours, it is enough. Generally, when the salivation is at this height, all the yaws are covered with dry scaly crusts or scabs; which, if numerous, look terribly. These fall off daily in small white scales; and in ten or twelve days leave the skin smooth and clean. Then the calomel may be omitted, and the salivation permitted to go off spontaneously. A dram of corrosive sublimate dissolved in an ounce of rum or brandy, and the solution daubed on the yaws, will, it is said, in general clear the skin in two days time.

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

The matter yaw must be confined an eighth or a tenth part of an inch below the skin, with Mercur. cor. rub. et alum. aft. part. equal. and digested with Ung. basil. flav. 3j, and mercur. cor. rub. 3j, and criticized with lint pressed out of spirits of wine, and with the sulphate of copper.

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

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

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

GENUS XC. TRICHOMA.

The PLICA POLONICA, or Plaited Hair.

Trichoma, Savi. gen. 311. Sag. 137. Plica, Lin. 313. Plica sive Rhoalosis, Vog. 323.

This disorder is only met with in Poland and Lithuania, and consists of several blood-vessels running from the head into the ends of the hairs; which cleave together, and hang from the head in broad flat pieces, generally about an ell in length, but sometimes they are five or fix yards long; one patient has more or less of these, up to 29, and sometimes 30. They are painful to the wearer, and odious to every spectator. At the approach of winter an eruptive fever happens to many in these countries: the eruptions principally infest the head, and when at the height an ichorous humour flows from them. In this state they are too tender to admit of being touched, and the matter running down the hairs mats them together; the skin by degrees, breaking, the ramifications of the capillary vessels following the course of the hair, or prolonged out of the skin, are increased to a vast length.

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

GENUS XCI. ICTERUS.

The JAUNDICE.

Icterus, Lin. 224. Vog. 326. Boerh. 918. Junck. 90. Aurigo, Sauv. gen. 306. Sag. 132. Cachexia icterica, Hoffm. III. 301.

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

In like manner, all the secretions are affected with the yellow colour of the bile, which in this disease is diffused throughout the whole mass of fluids. The saliva becomes yellowish and bitter; the urine excessively high coloured, in such a manner as to appear almost black; nay, the blood itself is sometimes said to appear of a yellow colour when drawn from a vein; yet Dr Heberden says, that he never saw the milk altered in its colour, even in cases of very deep jaundice. In process of time the blood begins to acquire a tendency Icterus, to diffusion and putrefaction; which is known by the patient's colour changing from a deep yellow to a black or dark yellow. Haemorrhages ensue from various parts of the body, and the patients frequently die of an apoplexy; though in some the disease degenerates into an incurable dropy; and there have not been wanting instances of some who have died of the dropy after the jaundice itself had been totally removed.

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

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

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

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

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

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

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

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

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

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

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

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

CLASS IV. LOCALES.

Vitia, Sawv. Clas I. Lin. Clas XI. Vog. Clas X. Sag. Clas I. Plage, Sag. Clas II. Morbi organicici Auctorum.

ORDER I. DYSÆSTHESIÆ.

Dysæsthesiae, Sawv. Clas VI. Ord. I. Sag. Clas IX. Ord. I.

GENUS XCII. CALIGO.

The CATARACT.

Caligo, Sawv. gen. 153. Vog. 288'. Sag. gen. 259. Cataracta, Lin. 109.

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

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

GENUS XCIII. AMAUROSIS.

The GUTTA SERENA.

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

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

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

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

GENUS XCIV. DYSOPIA.

DEPRAVED VISION.

Amblyopia, Sauv. gen. 154. Sag. 258.

There are several species referred to this genus by Dr Cullen, viz. 1. Dysopia Tenebrarum; 2. Dysopia Luminis.—The former of these is properly the nyctalopia, or night- blindness, of ancient authors. But amongst both the Greek and Latin writers, there is a direct opposition in the use of this word nyctalopia; some saying it signifies "thoie who cannot see by night," and others express by it "thoie who cannot see during the day, but during the night."—The difference in the account of this dis- order, as to its appearing in the night or in the day, is reconciled by considering it as of the intermitting kind: the difference then will consist in the different times of its approach; so it may be called periodical blindness. Intermittents appearing in a variety of modes, and the success of einchona in some instances of this sort of blindness, both favour the opinion of its being an inter- mittent disease of the eyes; and this view has accordingly been taken of it by some late writers, parti- cularly in some papers in the London Medical Observa- tions, and Medical Transactions.

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

5. Dysopia Lateralis; a defect by which objects cannot be viewed distinctly but in an oblique position. —Thus, in viewing an object placed on the left, they turn their face and eyes to the right, and vice versa.—This disorder may proceed from various causes both natural and accidental, some of which admit of no remedy. If it be occasioned by a partial adhesion of the eyelids, the hand of the surgeon is required: if by a transverse position of the pupil, some mechanical con- trivance is necessary. If it be owing to an altus covering part of the pupil, or to a film rendering a por- tion of the cornea opaque, the remedies for these affec- tions are to be here applied.

GENUS XCV. PSEUDOBLEPSIS.

IMAGINARY VISION of Objects which do not exist.

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

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

GENUS XCVI. DYSECOEA.

DEAFNESS, or Difficulty of Hearing.

GENUS XCVII. PARACUSIS.

Depravation of HEARING.

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

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

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

If deafness proceeds from dryness of the ears, which may may be known by looking into them, half an ounce of the oil of sweet almonds, and the fame quantity of camphorated spirit of wine, or tincture of afafeida, may be mixed together, and a few drops of it put into the ear every night at bedtime, stopping them afterwards with a little wool or cotton. Some, instead of oil, put a small slice of the fat of bacon into each ear, which is said to answer the purpose very well.—When the ears abound with moifure, it may be drained off by an iilue or feton, which should be made as near the affected parts as poftible.

Some, for the cure of deafness, recommend the gall of an eel mixed with spirit of wine, to be dropped in to the ear; others, equal parts of Hungary water and spirit of lavender. Etmuller extols amber and musk; and Brookes says, he has often known hardnefs of hearing cured by putting a grain or two of mulk into the ear with cotton wool. Where, however, an application with confiderable stimulant power is neceffary, camphorated oil, with the addition of a few drops of volatile alkaline spirit, may be confidered as one of the beft. It is proper, however, to begin with a fmall quantity of the alkali, increafing it as the ear is found to bear it. In fome inftances, where deafnefs depends on a fiate of infenfibility in the nerves, electricity, particularly under the form either of sparks, or of the electric aura, has been employed with great fuccefs. Great benefit has also in fome cafes been derived from galvaniftm. But thefe and other applications muft be varied according to the caufe of the diforder.

Though thefe applications may sometimes be of fervice, yet they much oftener fail, and frequently they do hurt. Neither the eyes nor ears ought to be tampered with; they are tender organs, and require a very delicate touch. For this reafon, what we would chiefly recommend in deafnefs, is to keep the head warm. From whatever caufe this diforder proceeds, this is always proper; and more benefit has often been derived from it alone, in the moft obfinate cafes of deafnefs, than from any medicines whatever.

GENUS XCVIII. ANOSMIA.

Defect of SMELLING.

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

Caufes. Morbid affections in the fenfe of smelling, may be confidered with refepect to their caufes, as arifing from one of two fources; either from fome organic affection of the parts here principally concerned, or from a mere atomic state of the parts without any obvious affection. The fenfe of smelling may be diminished or destroyed by various difeafes of the parts; as, the moifure, drynels, inflammation or suppuration of that membrane which lines the infeide of the nofe, commonly called the olfactory membrane; the compreflion of the nerves which supply this membrane, or fome fault in the brain itfelf at their origin. A defect, or too great a degree of folidity, of the fmall fpongy bones of the upper jaw, the caverns of the forehead, &c. may likewife impair the fenfe of smelling. It may alfo be injured by a collection of fetid matter in thofe caverns, which keeps conftantly exhaling from them. Few things are more hurtful to the fenfe of Ageuftia, smelling than taking great quantities of fnuff.

Cure. When the nofe abounds with moifure, after gentle evacuations, fuch things as tend to take off irritation and coagulate the thin sharp ferum may be applied; as the oil of anife mixed with fine flour, camphire difolved in oil of almonds, &c. The vapours of amber, frankincence, gum-malic, and benzoïn, may likewife be received into the nofe and mouth. For moiftening the mucus when it is too dry, fome recommend fnuff made of the leaves of marjoram, mixed with oil of amber, and anifeed; or a fternutatory of calcined sulphate of zinc, 12 grains of which may be mixed with two ounces of marjoram-water and filtrated. The steam or vapour of vinegar thrown upon hot iron received up the nofhrls is likewife of ufe for foftening the mucus, opening obftructions, &c.

If there be an ulcer in the nofe, it ought to be dressed with fome emollient ointment, to which, if the pain be very great, a little laudanum may be added. If it be a venereal ulcer, it is not to be cured without mercury. In that cafe, the folution of the corrodive sublimate in brandy may be taken, as directed in the gutta pera. The ulcer ought likewife to be wafted with it; and the fumes of cinnabar may be received up the nofhrls.

If there be reafon to fufpect that the nerves which supply the organs of smelling are inert or want stimulating, volatile falts, strong fnuffs, and other things which occasion freezing, may be applied to the nofe. The forehead may likewife be anointed with balsam of Peru, to which may be added a little of the oil of amber.

GENUS XCIX. AGEUSTIA.

Defect of TASTING.

Ageuftia, Sauv. gen. 157. Sag. 263. Ageuftia, Lin. 114. Apogeusis, Vog. 449.

Caufe. This difeafe also may arife either from an organic affection, or an atomic state of the parts. The taste may be diminished by crufts, filth, mucus, aphthae, pollicles, warts, &c. covering the tongue; it may be depraved by a fault of the faliva, which, being difcharged into the mouth, gives the fame fenfation as if the food which the perfon takes had really a bad taste; or it may be entirely destroyed by injuries done to the nerves of the tongue and palate. Few things prove more hurtful either to the fenfe of tafling or smelling than obfinate colds, efpecially thoſe which affect the head.

Cure. When the taste is diminished by filth, mucus, &c. the tongue ought to be scraped, and frequently wafted with a mixture of water, vinegar, and honey, or fome other detergent. When the faliva is vitiated, which feldom happens unlefs in fevers or other difeafes, the curing of the diforder is the cure of this fymptom. To relieve it, however, in the mean time, the following practices may be of ufe: if there be a bitter taste, it may be taken away by vomits, purges, and other things which evacuate bile: what is called a nidorous taste, arising from putrid humours, Dysorexia is corrected by the juice of citrons, oranges, and other acids: a salt taste is cured by plentiful dilution with watery liquors: an acid taste is destroyed by absorbents and alkaline salts, as powder of oyster-shells, salt of wormwood, &c.

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

GENUS C. ANÆSTHESIA. Defect of the Sense of FEELING. Sauv. gen. 161. Lin. 218. Vog. 267.

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

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

ORDER II. DYSOREXIAE.

SECT. I. APPETITUS ERRONEI.

Morositites, Sauv. Clas VIII. Order II. Sag. Clas XIIII. Order II. Pathetici, Lin. Clas V. Order II. Hyperaestheses, Vog. Clas VII.

GENUS CI. BULIMIA.

INSATIABLE HUNGER, or Canine Appetite. Bulimia, Sauv. gen. 223. Lin. 79. Sag. gen. 335. Bulimus, Vog. 296. Addephagia, Vog. 297. Cynorexia, Vog. 298.

This disease is commonly owing to some fault in the stomach, by which the aliment are thrown out too soon; and unless the person be indulged in his desire for eating, he frequently falls into fainting fits. Sometimes it is attended with such a state of the stomach, that the aliment is rejected by vomit almost immediately after being swallowed; after which the appetite for food returns as violent as ever. But there are many circumstances which seem to render it probable that it more frequently arises from a morbid condition of the secreted fluid poured into the stomach, by means of which the aliment is dissolved. When the activity of this fluid is morbidly increased, it will both produce too sudden a solution of the solid aliment, and likewise operate as a powerful and peculiar stimulus to the stomach, giving an uneasy sensation, similar to that which takes place in natural hunger. Such things are proper for the cure as may enable the stomach to perform its office: chalybeates and other tonics will generally be proper. In some, brandy drunk in a morning has been useful; and frequent smoking tobacco has relieved others. Oil, fat meat, pork, opiates, and in short every thing which in a sound person would be most apt to pall the appetite, may also be used as temporary expedients, but cannot be expected to perform a cure. In some, the pylorus has been found too large; in which case the diet must have been incurable.

GENUS CII. POLYDIPSIA. EXCESSIVE THIRST. Polydipsia, Sauv. gen. 224. Lin. 80. Vog. 275. Sag. 336.

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

GENUS CIII. PICA. LONGING, or False Appetite. Pica, Sauv. gen. 222. Sag. 334. Citta, Lin. 78. Allotriophagia, Vog. 299. Malacia, Vog. 300.

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

GENUS CIV. SATYRIASIS. Satyriasis, Sauv. gen. 228. Lin. 81. Sag. 340.

Satyriasis is a violent desire of venery in men, even so that reason is depraved by it. The pulse is quick, and the breathing short; the patient is sleepless, thirsty, Dyforexis and loathes his food; the urine is evacuated with difficulty, and a fever soon comes on. These symptoms, however, are probably not so much the consequence of satyrifias, as merely concomitant effects resulting from the same cause. And indeed this affection is most frequently the concomitant of a certain modification of insanity. The nature and cause of this affection are in most instances very little ascertained; but as far as we are acquainted with the treatment, it agrees very much with the affection next to be mentioned, which, of the two, is the most common occurrence.

GENUS CV. NYMPHOMANIA.

FUROR UTERINUS.

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

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

GENUS CVI. NOSTALGIA.

Vehement Desire of revisiting one's Country.

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

This is to be reckoned a species of melancholy; and unless it be indulged, it very commonly proves not only incurable but even fatal. Although it cannot be considered as altogether peculiar to any nation, yet it is observed to be much more frequent with some than with others; and it has particularly been remarked among Swiss soldiers in the service of foreign states.

SECT. II. APPETITUS DEFICIENTES.

Anepithymiae, Sauv. Clas VI. Ord. II. Sag. IX. Ord. II. Privativi, Lin. Clas VI. Order III. Adynamiae, Vog. Clas VI.

GENUS CVII. ANOREXIA.

Want of Appetite.

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

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

GENUS CVIII. ADIPSIA.

Want of Thirst.

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

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

GENUS CIX. ANAPHRODISIA.

Impotence to Venery.

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

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

ORDER III. DYSCINESIAE.

GENUS CX. APHONIA.

Loss of Voice.

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

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

Since the motion of any part is destroyed, or lessened at least, by the interception of the nervous fluid in its passage thither, and since the nerves declined for the motion of the tongue arise principally from the fifth pair, it appears that the seat of this disorder is in the fifth pair of nerves, and that the immediate cause Dyscine is a diminution or total destruction of the nervous power in them. Hence a palsy of the tongue, which is either antecedent or subsequent to hemiplegic or apoplectic disorders, demand our utmost attention.

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

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

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

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

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

GENUS CXI. MUTITAS.

DUMBNESS.

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

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

GENUS CXII. PARAPHONIA.

Change in the Sound of the Voice.

Paraphonia, Sauv. gen. 168. Cacophonía, Sag. 274. Raucedo, Lin. 146. Raucitas, Vog. 232. Aphasia, &c. Vog. 259, 251, 254, 255, 256.

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

GENUS CXIII. PSELLISMUS.

Defect in Pronunciation.

Psellismus, Sauv. gen. 167. Lin. 139. Sag. 273. Traulotis, &c. Vog. 258, 259, 260, 261.

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

GENUS CXIV. STRABISMUS.

SQUINTING.

Strabismus, Sauv. gen. 116. Lin. 304. Vog. 514. Sag. 222. Dyscineae. Description. This disease shows itself by an uncommon contraction of the muscles of the eye; whereby the axis of the pupil is drawn towards the nose, temples, forehead, or cheeks, so that the person cannot behold an object directly.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GENUS CXV. CONTRACTURA.

Contractions of the Limbs.

Contractura, Sauv. gen. 119. Lin. 299. Sag. 225. Obliquitas, Sauv. gen. 11. Caput obfipum, Vog. 513. Digitium, Vog. 221.

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

ORDER IV. APOCENOSSES.

Apocenoses, Vog. Clas II. Ord. II. Fluxus, Sauv. Clas IX. Sag. Clas V. Morbi evacuatorii, Lin. Clas IX.

GENUS CXVI. PROFUSIO. FLUX of BLOOD.

Profusio, Lin. 239. Haemorrhagia, Vog. 81. Boerh. 218.

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

GENUS CXVII. EPHIDROSIS. Excessive Sweating.

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

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

GENUS CXVIII. EPIPHORA. FLUX of the LACHRYMAL HUMOUR.

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

This by Sauvages is described as an involuntary effusion of tears without any remarkable itching, heat, or pain. It follows long continued ophthalmias; or it may be occasioned by immoderate study, or anything that weakens the eyes: hence it comes on about the age of 50 years, when the eyesight naturally becomes weak. It in general grows worse in the winter-time, and is very hard to cure. Some authors recommend purgatives, and blisters on the nape of the neck, in order to draw off the abundant humours; but as the disease evidently proceeds from weakness, it would rather seem proper to pursue a contrary method. Sauvages recommends to the patients to abstain from study, wine, and salted meats; and also to avoid smoke or wind, and at night to foment the eyes with an infusion of four cloves in two ounces of proof-spirit.—Hungary water, rose water with sulphate of zinc dissolved in it, &c. have also been recommended.

GENUS CXIX. PTYALISMUS. SALIVATION.

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

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

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

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

To this substance he attributed the beginning of the salivation, notwithstanding that the disease did not immediately abate on the removal of the wool; as it appeared to be no improbable supposition that the dif- It seemed, therefore, expedient to introduce some other habit, in the place of the increased secretion of saliva; which habit might afterwards be gradually left off. With this intention, he prevailed on the patient to chew perpetually a little dry bread, and to swallow it with her spittle. In a few weeks, it became necessary for her to chew the bread only at certain hours in the day; and thus, after two months, she became entirely free from a most disagreeable and tedious disorder.

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

GENUS CXX. ENURESIS.

An involuntary FLUX of URINE.

Enuresis, Sauv. gen. 264. Lin. 195; Vog. 113. Sag. 200.

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

GENUS CXXI. GONORRHŒA.

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

The gonorrhœa is a flux of viscid matter of various colours, from the urethra in men and the vagina in women. It commonly proceeds from coition with a person infected with the venereal disease, and is one of the most common forms under which that disease shows itself.

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

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

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

In women, the external parts of generation being fewer and more simple, the disease is less complicated than Apocenoses, than in men. Sometimes the vagina only is affected; and when this happens, the symptoms are very trifling: but in general it comes on with an itching and sensation of heat as in the other sex; and is attended with inflammation of the nymphae, inside of the labia, chitoris, caruncula myrtiformes, the orifice and sometimes the whole of the meatus urinarus. Very often the deep-seated glands of the vagina are affected, and it is sometimes difficult to distinguish the discharge of a gonorrhoea from that of the fluor albus.

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

But while there have been disputes with regard to the peculiar nature of the matter in gonorrhoea, there have also been controversies with respect to the source from whence it is derived. While some suppose it to be principally purulent matter arising from ulcerations, others assert that no such ulceration is ever produced in the urethra by gonorrhoea. They contend that the increased secretion in these cases is exactly similar to what happens in the catarrh. But the comparison will by no means hold good in every particular: in the latter the whole membrane of the nose is equally irritated; whereas in the gonorrhoea, only particular parts of the urethra seem to be affected. The disease, in the generality of cases, seldom extends more than an inch and a half along that canal, and in many is confined (at least in the beginning) to a small spot about an inch from the extremity of the glans. The discharge is produced from that part of the urethra where Gonorrhoea pain is felt; and the patient, when he voids his urine, feels no smarting till it reaches the inflamed spot: but as the disorder increases, the inflammation affects a greater number of points, just in the same manner as chancres affect different parts of the glans. It might be supposed that dissection would at once clear up this matter, and put an end to the dispute; but this is far from being the case. Dr Simmons has seen several urethras opened in persons who had a gonorrhoea at the time of their death; in three of them the surface of the urethra, as in the cases related by Morgagni, appeared for some way down of a slight red colour, and in all of them was covered with mucus; but without any appearance of ulceration, except in two dissections at Paris, in which most of the gentlemen present were convinced that they saw evident marks of it: but Dr Simmons says that the appearances were to him not sufficiently satisfactory to enable him to decide with certainty on the subject. On the other hand, when we consider that the discharge in a gonorrhoea is sometimes tinged with blood, and that when this happens a little blood vessel is no doubt ruptured, we can have no reason to doubt that an ulceration may, and sometimes does, happen in these cases; especially as we often observe an excoriation near the orifice of the urethra. It is certain, that wherever there is considerable inflammation, there will be danger of ulceration. Besides, from a neglected or badly-treated gonorrhoea, we often see fistulas in perineo, and other ulcers of the urethra, penetrating through its substance, and affording a passage to the urine. And there can be no doubt that flight ulcerations of this canal often occur, and are afterwards perfectly obliterated, in a similar manner to what happens in the papille of the tongue, the tonsils, &c. Such an obliteration will the more readily take place in a part like the urethra, defended with mucus, and not exposed to the air, which is known to have no little effect in hardening a cicatrix.

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

Nothing can be more variable than the period at which the disease makes its appearance after infection. Perhaps, at a medium, we may place it between the 4th and 14th day; but in some cases it happens within Apecofes, 24 hours; and in others, not before the end of five or even six weeks: neither of these extremes, however, are common.

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

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

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

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

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

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

The drinking freely of mild, cooling, mucilaginous liquors, such as linseed-tea, orgeat, whey, milk and water, almond emulsion, and the like, will be extremely useful, by diluting the urine, and preventing its salts from stimulating the urethra. When the heat and pain in making water are very considerable, mucilaginous Apocynos. substances are found to have the best effect, particularly the gum tragacanth. It is a common practice to give equal quantities of this gum or gum-arabic and nitre, and to dissolve nitre in the patient's drink, with a view to lessen the inflammation. But in these cases nitre is always improper; it is known to be a powerful diuretic, its chief action being upon the urinary passages; so that the stimulus it occasions will only serve to increase the evil it is intended to alleviate. Suppurative tritie of potas, on account of its diuretic quality, will be equally improper. Our view here is not to promote a premature flow of urine; for the virus, being insoluble in water, cannot easily be washed away by such means; but our object ought to be, to render the urine that is secreted as mild and as little stimulating as possible.

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

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

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

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

A detergent injection, or one that will act upon the mucus of the urethra, increase the discharge of it, wash it away, and with it the venereal virus that is blended with it, can only be used as a prophylactic before the symptoms of infection have made their appearance. But great circumspection is necessary in the use of this kind of injection. If it be too weak, it can be of no efficacy; and if it be too strong, it may prove dangerous to the patient. A suppression of urine has been brought on by the improper use of an injection of this kind. When the symptoms of inflammation have once made their appearance, the stimulus of such an injection must be extremely hazardous. Excoriation of the urethra has but too often been produced by remedies of this sort in the hands of adventurous and unskilful practitioners.

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

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

Calomel, mixed with the mucus discharged in a gonorrhoea, has no more power in destroying the infectious properties of that mucus than ceruse or any other preparation would have. A diluted solution of sublimate injected into the urethra, will, like a solution of verdigris, or blue vitriol, or any other astringent, constringe the mouths of the lacunae; but this is all that it will do, for it will never lessen the infectious nature of the virus. The same thing may be observed of crude crude mercury extinguished by means of mucilage, or of mercurial ointment, blended with the yolk of an egg, and which, when thrown up into the urethra, will act nearly in the same manner as balsam of copaiva, or any other stimulating injection. The stimulus of mercury, however, has often been found of considerable efficacy; and in women, when the vagina only was affected, after washing the parts well, the cure has been accomplished by rubbing them repeatedly with mercurial ointment.

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

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

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

After a gonorrhoea proceeding from venereal causes has been removed, another kind of running without pain, called the gonorrhoea mucosa, or gleet, sometimes remains. Sometimes it arises from a concretion and excoriation of the urethra, and frequently it is the effect of an enlargement and diseased state of the prostate. In each of these cases, as the gleet is the effect of irritation, the cure will depend on the removal of the local disease that occasions it. But there is another species of gleet that seems to depend chiefly on relaxation. It is in general free from infection, and is most common in those who have had long and frequent gonorrhoeas. It is likewise often the effect of a debilitated habit, from severe purging, or a long continued use of mercurials. A discharge of this kind is more frequent in women than in men; or, at least, the fluor albus, after a gonorrhoea, will often be mistaken for a gleet.

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

ORDER V. EPISCHESES.

GENUS CXXII. OBSTIPATIO.

COSTIVENESS.

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

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

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

Persons who are generally costive should live upon a moltening and laxative diet; as roasted or boiled apples, pears, stewed prunes, raisins, gruels, with currants, butter, honey, sugar, and fish like. Broths with spinach, leeks, and other soft pot-herbs, are likewise proper. Rye-bread, or that which is made of a mixture of wheat and rye together, ought to be eaten. No person troubled with costiveness should eat white bread alone, especially that which is made of fine flour. Episcopess flour. The best bread for keeping the belly soluble is what in some parts of England they call melin. It is made of a mixture of wheat and rye, and is very agreeable to those who are accustomed to it.

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

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

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

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

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

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

GENUS CXXIII. ISCHURIA.

SUPPRESSION of Urine.

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

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

1. Ischuria renalis, or a suppression of urine from an affection of the kidneys, happens but rarely; however, Dr Home in his Clinical Experiments describes such a case. In the end of December 1774, a man of a full habit, aged 35, was seized with shivering, coldness, and severe cough. Three days after, his urine appeared high-coloured, was passed with pain, and in small quantity. About the 8th of January 1775, he was attacked with violent pains in the small of his back, over the whole abdomen, and in the ankles, with pain in the region of the liver when pressed. A general swelling was afterwards observed all over the body, but chiefly in the ankles and abdomen, which last was tense and hard. These were attended with vomiting, bad appetite, and considerable thirst. When he entered the clinical ward (January 21st), the cough, sickness, and vomiting, had gone off, but the suppression of urine remained. The little which he made was passed with his stools, so that Dr Home saw it but once; and then it was pale, and had a white powder at bottom. The pains and swellings which retained the impression of the finger, continued; he had a headache, and a very flow pulse, beating only 48 strokes in a minute. He had taken a great many diuretic medicines before his admission. The day after his reception, he was seized with a spontaneous diarrhoea, which continued during the remainder of his life. Crystals of tartar were exhibited in doses of half an ounce each morning; at bed-time he took 20 drops of tincture of opium with a scruple of nitre, and continued this course for eight days without any increase of urine. The stronger and heating diuretics were then tried, as an infusion of juniper berries and pills of garlic; but they were attended with no manifest advantage. Whenever the pulse became so strong that he could bear bleeding, eight ounces of blood were taken away, which was fizzy. This was thrice repeated; he appeared easier after each bleeding, his pulse bore it well, and the swellings and other symptoms abated. The heating diuretics, in this state, were given up, and a mixture of vinegar and nitre was substituted in their place, in each dose of which, taken every two hours, there was a scruple of nitre. Fomentations were applied to the region of the kidneys, and camphorated oil was afterwards rubbed on the part. He was ordered the femicupum, which, from a deficiency of water in the hospital at that time, he got only once; and which then seemed to have a good effect, as he passed a gill of urine when he was in it. Notwithstanding this, however, the disease continually gained ground; he became comatose, delirious, and died ten days after his admission. On dissection, the kidneys were found of an irregular form; some watery vehicles appeared on their surface, containing black gritty particles like fine sand; and the lower part of the right kidney was considerably inflamed. The pylorus, part of the duodenum, and a considerable part of the small intestines, were much inflamed. In the abdomen were found about five pounds of fluid, and in the cavities of the thorax about half a pound. The lungs were a little inflamed, and full of small tubercles on their surface and in their substance: the heart was large, and a polypus in each ventricle. About fix ounces of fluid were found in the pericardium: in the brain nothing preternatural appeared, except about an ounce of water in each ventricle.

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

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

The indications of cure are, to exclude the stone as easily as possible, and prevent the breeding of others. If the patient be of a fanguineous temperament, Sydenham recommends to take away ten ounces of blood from the affected side; and then to give the patient a gallon of posset-drink in which two ounces of marshmallow roots have been boiled, injecting at the same time an emollient glyther. After the posset drink has been vomited up, and the glyther returned, give a pretty large dose of an opiate. But if the patient be old or weak, or subject to nervous affections, bleeding may be omitted, especially if his urine at the beginning of the fit be coffee-coloured, and mixed with gravel; but as to other things, the cure is the same.—Huxham highly recommends an emollient bath prepared of a decoction of marshmallow root, linseed, fenugreek seed, and flowers of chamomile, to which may be added a few white poppy seeds. By the use of this bath he says he has seen the most cruel fit of the gravel suddenly ended, when neither copious bleeding nor opiates had the least effect. Mild diuretics are also of service. Hoffman recommends dulcified spirit of nitre as proper to relax the spastic stricture. It is to be taken with suitable distilled waters and syrup of poppies; or in broth, with a few spoonfuls of oil of sweet almonds. Turpentine glythers are also accounted very servieable; and may be prepared with ten ounces of a decoction of chamomile, with half an ounce of turpentine dissolved in the yolk of an egg, and about as much honey. The ful diureticus, or acris potafiae, is much esteemed by some, when taken along with an opiate. But when the stone is too big to pass, Arbuthnot recommends a cool and diluent diet to hinder the further growth of it. Whey, infusion of linseed, decoction of marshmallows, and gently resolving diuretics, are also proper. To put a stop to the vomiting, the compound tincture of benzoin, formerly named balsamum traumaticum, has sometimes been used with success, when almost every other means have failed.

3. The ichuria vesicalis may arise from a stone in the bladder; and this indeed is the most common cause of it: but there are certain cases, in which, though the usual quantity of urine, or perhaps more, be passed, the patient dies from the retention of a still greater quantity in the bladder. Of this Dr Home gives the following instances. A man of 58 years of age, of a strong spare habit, and never subject to the gravel, had, during the winter of 1777, a cough with expectoration, which went off in the beginning of 1778. About the 17th of February 1778 he felt some difficulty in passing his urine, and much pain about the region of the bladder. He continued in this way for ten days, after which he became easier on application of some medicines. The abdomen then swelled, and he had pains in his loins and thighs. On the 3d of March he was admitted into the clinical ward: his abdomen was then swelled and tense; and an evident fluctuation was felt, which some that touched him thought was sonorous and produced by wind. A tumor was discovered between the navel and spine of the os ilium on the left side, which gave him much pain, especially when pressed. This tumor became more easily felt after the swelling of the abdomen decreased, seemed round, and very near as large as the head of a child. It appeared very much on the left side, even when the patient lay on the right, and it then became dependent. He passed urine frequently, and rather more than in health, as it was computed at four pints a-day. It was always clear, and of a light colour. His body had a strong disagreeable smell; his skin was dry, belly bound, and his appetite entirely gone, so that he had hardly taken any food for 12 days. His legs swelled slightly for some days in the evening. His pulse was generally regular, sometimes slower than natural, and sometimes a little quicker; being once felt at 64, and another time at 92. He was often feized, especially after eating or drinking, with hiccough; which increased and lasted till his death. On the 20th day of his disease, after some doses of squills, the general swelling of his abdomen fell, became much softer, and more distinctly discovered the swelling of the left side. The next day a vomiting came on; he became delirious, and died the day following. The body being opened, it appeared that the tumor which was so distinctly felt on the left side of the abdomen, was owing to a distension of the bladder with urine. Its fundus reached to about the division of the aorta into the the iliacs; it entirely filled the pelvis, and contained between five and six pounds of urine of a pale colour. On examining the external surface, its neck, and the beginning of the urethra, were found to be surrounded with a scirrhosity, which impeded the evacuation of the urine. The bladder itself was much thickened, but not more in one part than another. The ureters entered naturally; but were much thickened in their upper half near the kidney. The kidneys were somewhat enlarged; particularly the left, which had several watery vesicles on its external surface. These organs were not in their usual situation; but lay close on each side of the spine, and very near the aorta: so that the renal vessels were very short. What was very singular, the lower end of each arose over the spine, and they were united together by their membranes, the aorta passing beneath the union. The bladder had pressed considerably on this part; and the peritoneum covering them was considerably thicker than natural. The lungs adhered every where to the pleura, and in some places very firmly: they were of a loose texture and black colour; and the veins of the lower extremities were turgid with blood. It does not appear that this patient got any medicines farther than a few dried squills, which diminished the swellings and brought off much wind. He also got a mixture of musk, and afterwards of opium, for his hiccough; but without success. His disease was mistaken for an afecies; and the catheter was not tried: but in another case the use of this instrument was apparently of more service than any internal medicines. This last patient was about 90 years of age, and laboured under symptoms very similar to those already mentioned. When admitted into the clinical ward, he had the hypogastric region swelled, and difficulty of passing his water; but without pain, vomiting, or hiccough. He had lost all appetite; was thirsty, and costive. His pulse was 110, and weak. In the evening about three English pints of pale clear urine were drawn off by means of the catheter: the next day all the symptoms were gone off or abated. After this he continued to pass some urine, sometimes voluntarily, sometimes involuntarily and insensibly; but so much always remained behind, that his bladder was constantly full, unless when the urine was drawn off, which was done twice every day. The urine was sometimes pale, sometimes of a deep red colour; and once there was some blood mixed with it, which perhaps might have been occasioned by the catheter. About the sixth day the urine was very putrid, with much purulent like matter at the bottom, and was passed with more pain. About the 11th, the putrid smell went off. The next day all the urine passed insensibly except what was drawn off; and an hiccough, though not very severe, had come on. In this way he continued without fever, though frequently troubled with the hiccough, especially during those nights in which the urine had not been drawn off. A month after admission, the bladder, with the assistance of the catheter, was almost entirely, though insensibly evacuated, and the hiccough had left him; he had no other complaint but that of voiding his urine insensibly, the natural effect of a scirrous bladder, and which was probably incurable. With this patient the hot bath and mercurials were tried, in order to soften the scirrhosity of the bladder, but without effect.

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

GENUS CXXIV. DYSURIA.

DIFFICULTY OF DISCHARGING URINE.

Dysuria, Sauv. gen. 265. Lin. 57. Vog. 164. Seg. 213. Stranguria auflorum.

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

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

STONE in the BLADDER.

Dysuria calculosa, Sauv. sp. 12.

The signs of a stone in the bladder are, pain, especially about the sphincter; and bloody urine, in consequence quence of riding or being jolted in a carriage; a fenfe of weight in the perineum; an itchiness of the glans penis; flimy sediment in the urine; and frequent stoppages in making water: a tenebrus also comes on while the urine is discharged: but the most certain sign is, when the stone is felt by the finger introduced into the anus, or by founding.

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

The gout and stone are generally supposed to have fome affinity, becaufe gouty people are for the moft part afflicted with the gravel. But perhaps this is in part owing to their long confinement, and to lying on the back, which people who labour under the gout are often obliged to submit to; fince the want of exercise, and this pofture, will naturally favour the stagnation of gros matters in the kidneys: befides, there are many infances of people feverely afflicted with the stone for the greatest part of a long life, who have never had the leaft attack of the gout.

There is, however, good reafon for believing, that fome farther connection takes place between the two difeafes; and when treating of the gout we have already given fome account of the opinion of an ingenious anonymous author, who has endeavoured to prove, that both the one and the other depend on a peculiar acid, the concreting, lithic, or uric acid, which is always prefent in blood; and which may be precipitated from thence by various caufes, fuch as the introduction of other acids, or the like. When thus precipitated, he fuppoſes it to produce the whole phenomena of both difeafes. The objections we formerly fated to his theory of gout, do not equally militate againft that of calculus; and it is at leaft certain, from the beft chemical analysis, that what are commonly called urinary calculi, and have been confidered as entirely an earthy matter, confift principally of acid in a solid state united only with a small proportion of earth or mucus. We may, therefore, whether this hypothesif be altogether well founded or not, juftly view lithiafis as depending, in a great meafure, on the separation of an acid from the blood.

Whatever may be the particular caufe of the difpofition to lithiafis, the kidneys appear to be the moft likely places for particles to concrete or run together, becaufe of the great quantity of blood which paffes through the renal arteries, and which comes immediately from the heart, fraught with various newly-received matters, that have not undergone much of the action of the veffels, and therefore cannot as yet be fuppoſed to be thoroughly affimilated.

Anatomifts who have carefully examined the kidneys in the human fubject, particularly M. Bertin, inform us, that there are two fets of tubuli uriniferi; the one continued direftly from the extremities of the renal artery, and the other springing from that vesicular texture which is confpicuous in the kidneys.

It is in this vesicular part of the kidney that we presume the particles of the concreting matter first stagnate and coalesce: for it is hardly to be fuppoſed, that fuch folid matters could be allowed to ftop in the extremities of the renal arteries, fince the blood, and the urine separated from it, muft flow through these veffels with great degrees of force and velocity; but in the intermediate veffules the particles may lie, and there attracting each other, foon come to acquire fenfible degrees of magnitude, and thus become iand or gravel. As long as this land or gravel formed in the vesicular part of the kidney lies quiet, there will be no pain or uneafines, until the concretions become large enough to preſs either on the adjoining tubuli, or on the blood-veffels; then a fenfe of weight, and a kind of obtufe pain in the loins, will be left. But when the fmall pieces of concreting matter fhall be diſlodged and waſhed off by the force of the circu¬lating fluids, or loofened by fome spasmotic action of the moving fibres in thefe parts, they will in their paſsage create pain, raife different degrees of inflammation, or perhaps lacerate fome blood veffels, and caufe bloody urine. When thefe little concretions happen to be detained in the pelvis of the kidney, or any other place where a flow of urine continually pafles, they foon increafe in fize, and become calculi, from the conflant acceflion of particles, which are attracted by the original bit of land, which thus becomes the nucleus of a stone.

It is an opinion which Hippocrates firft advanced, and which has been almoft univerfally adopted by his followers, and has remained till lately uncontroverted, that the stone and gravel are generated by the ufe of hard water. From the quality, which the waters of certain fprings prefent, of depositing a large earthy fefiment, either in the aqueducts through which they are conveyed, or in the veffels in which they are boiled or preferved, it was conjectured, that in paffing through the kidneys, and efpecially whilft retained in the bladder, they would let fall their greater particles, which by the continued appofition of fresh matter, connected by the animal gluten, and compafted by the mucular action of that organ, would in time form a calculus fufficiently large to produce a train of the moft excruciating symptoms. And this reafoning a priori has been fuppoſed to be confirmed by facts and experience; for not to mention the authority of Hippocrates, Dr Lifter has obferved, that the inhabitants of Paris are peculiarily fubject to the ftone in the bladder. Nicholas de Blegny has related the history of one who was difectcd at Paris, in whom the pylorus, a great part of the duodenum, and the ftomach itfelf, were found incrufcated with a flony matter, to the thicknefs of a finger's breadth. And it is well known, that the water of the river Seine, with which that city is fupplied, is fo impregnated with calcareous matter, as to incrufcate, and in a fhort time to choke up, the pipes through which it runs. But on the other hand it is objected, that the human calculus is of animal origin, and by chemical analysis appears to bear very little analogy to the flony concretions of water: and though it be allowed, that more perfonf are cut for the ftone in the hopitals at Paris than in moft other places; yet upon inquiry it is found, that many of thofe patients come from different provinces, and from towns and villages far diftant from the Seine.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In the Edinburgh Medical Commentaries, vol. iii. we have an account of a method used by the inhabitants of Arabia Petraea for curing the stone, to which they are very much subject, and which the author (an English gentleman of experience and candour) affirms he has seen frequently performed with success. By means of a catheter, they inject into the bladder a weak ley of alkali with the purified fat of a sheep's tail, and a proper quantity of opium, all put together. Their catheters are made of gold; and in performing the operation they introduce them quite into the bladder; so that the composition is safely conveyed to the stone without hurting any other part. But when a stone is situated in the kidney, they have no method of cure.

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

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

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

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

GENUS CXXV. DYSPERMATISMUS.

Difficult Emission of Semen.

Dyspermatismus, Sauv. gen. 260. Sterilitas, Lin. 171. Sag. 211. Ageneia, Vog. 283.

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

GENUS CXXVI. AMENORRHoeA.

Suppression of the Menses.

Amenorrhoea, Vog. 130. Dysmenorrhoea, Lin. 168. Sag. 218.

This obstruction, with many other symptoms, as dysepfia, yellowish or greenish colour of the skin, unusual appetites, &c. constitutes the chlorosis already treated of, a disease which seldom or never appears without a suppression of the menses. In Dr Hume's Clinical Experiments we find the virtues of several emmenagogues set forth in the following manner. Chalybeates seldom or never succeeded: they were always found more useful in diminishing the evacuation when too violent, than in restoring it when deficient. The American tincture of black hellebore proved successful only in one of nine or ten cases, though given to the length of four tea-spoonfuls a-day, which is double the quantity recommended by Dr Mead. Compression of the crural artery, recommended by Dr Hamilton in the Physical and Literary Essays, vol. ii. proved successful only in one of six cases. From the effects produced by this compression, it has the strongest appearance of loading the uterus with blood; from the sensations of the patient it produces the same effects as the approach of the menses, and has every appearance in its favour; yet does not succeed. Dr Hume supposes that the uterus is most frequently in too plethoric and inflammatory a state; in which case, this remedy will do more hurt than in a state of inaction; however, he owns, that in the case in which it did succeed, the patient was plethoric and inflammatory. Venefication is recommended as an excellent remedy; the doctor gives three instances of its success, and says he could give many more. It acts by removing the plethoric state of the uterus, relaxing the fibres, and giving the vessels full play; so that their action overcomes all resistance, and the evacuation takes place. It is of no great moment from whence the blood is taken: the saphenous vein has been supposed to empty the uterus most; but it is difficult to get the proper quantity from it, and the quantity of the discharge cannot be so well measured. The powder of faviine is a most powerful remedy; and proved successful in three cases out of four in which it was tried. It was given to the quantity of half a dram twice a-day. It is a strong topical stimulus, and seems improper in plethoric habits. Madder-root, according to Dr Hume, is a very powerful medicine in this disease; and proved successful in 14 out of 19 cases in which it was tried, being sometimes exhibited in the quantity of two scruples, or a dram, four times a-day. It has scarcely any sensible effects; never quickens the pulse, or excites inflammatory symptoms: on the contrary, the heat, thirst, and other complaints abate; and sometimes these symptoms are removed, though the disease be not cured; but when it succeeds, the menses appear from the third to the 12th day.

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

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

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

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

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

The youngest subject that Dr Fothergill ever saw afflicted with this disorder was about 30 years of age; and this person was cured. The method that succeeded with him was a course of pills, composed of the masts of gum pill, soap, and native cinnabar; with a light ealybiate bitter: this was continued for some months, after which he went to Bath several successive seasons, and acquired his usual health: he was ordered to be very sparing in his diet; to keep the bowels open; and to use moderate exercise on horseback, but not to take long or fatiguing walks.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"In 1767, (then 48 years of age), he was taken, without any evident cause, with a sudden and very dispiriting throbbing under the sternum. It soon afterwards increased, and returned upon him every third or fourth week, accompanied with great anxiety, very laborious breathing, choking, a sensation of fulness and distension in the head, a bloated and flushed countenance, turgid and watery eyes, and a very irregular and unequal pulse. The paroxysm invaded, vaded, almost constantly, while he was sitting after dinner: now and then he was feized with it in the morning, when walking a little faster than usual; and was then obliged to stop, and rest on any object at hand. Once or twice it came on in bed; but did not oblige him to sit up, as it was then attended with no great difficulty in breathing. In the afternoon fits, his greatest ease was from a supine posture; in which he used to continue motionless for some hours, until, quite spent and worn out with anguish, he dropt into a slumber. In the intervals between these attacks, which at length grew so frequent as to return every fourth or fifth day, he was, to appearance, in perfect health.

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

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

"Having found the total inefficacy of blisters and the whole class of nervous medicines in the treatment of this anomalous pain, I thought it right to attempt the correcting or draining off of the irritating fluid in the case now before us. To this purpose, I ordered a mixture of lime-water with a little of the compound juniper-water, and an alterative proportion of Huxham's antimonial wine: I put the patient on a plain, light, perishable diet; and restrained him from all viscid, flatulent, and acrimonious articles. By pursuing this course, he was soon apparently mended; but after he had persifted regularly in it for at least two months, he kept for some time at a stand. I then ordered a large issue to be opened on each of his thighs. Only one was made. However, as soon as it began to discharge, his amendment manifly increased. The frequency and severity of the fits abated considerably: and he continued improving gradually, until, at the end of 18 months he was restored to perfect health: which he has enjoyed, without the least interruption, till now, except when he has been tempted (perhaps once in a twelvemonth) to transgres rules, by making a large meal on salted meat, or indulging himself in ale or rum-punch, each of which never failed to disorder him from the beginning of his illness: and even on these occasions, he has felt no more than the slightest motion of his former sufferings; insomuch that he would despise the attack, if it did not appear to be of the same stock with his old complaint. No other cause has had the least ill effect on him.

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

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

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

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

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

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

"Doctor Smyth also showed me, in his adverfaria, the case of a gentleman who had been under his care in 1760, which he had forgotten when my book went went to the pro's, and which he was reminded of the other day by a visit from his patient. It was a genuine angina pectoris, brought on by a very sedentary life, and great vexation of mind, clearly marked by the exquisite pain under the sternum, that extended acutely to the upper extremities, particularly along the left arm, together with the other symptoms of dyspnoea, anxiety, palpitation of the heart, &c. recited in the case above. The disorder went off in 1762, by large spontaneous discharges from the piles, but returned upon him severely in 1765. Issues in his thighs were then recommended to him, but not made. But, whether it was by the peroration of some friend, or of his own accord, he went into a course of James's powder, in small alterative doses, combined with a little caffor and aafestida. This he persisted in for about six weeks; in the meanwhile, he had large acrimonious gleetings from the ferotum, and a plentiful discharge of ichor from the anus.—From this time he began to find his complaints grow less and less distressing, and he has now been totally free from them for six years past."

The PUERPERAL, or Childbed Fever.

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

This fever is most generally incident to women within 48 hours after delivery, though it may supervene on the fourth or fifth day, and sometimes considerably later. It is preceded, like other fevers, by a rigor, which is commonly violent; and when happening during the time of labour, may be confounded with the pains of parturienty. In its earlier stage it is attended with the signs of inflammation. A great pain is felt in the back, hips, and the region of the uterus; which, in the part last mentioned, is accompanied with the sense of heat and throbbing. A sudden change in the quality or quantity of the lochia now also takes place; the patient is frequently troubled with a tenesmus; and the urine, which is very high-coloured, is discharged in small quantity and with pain. At the first attack of the fever, the woman is generally seized with a vomiting of poraceous matter, as in the cholera morbus, to which disease it then bears a strong resemblance.—But instead of this symptom, there is sometimes only a nausea, or loathing at the stomach, with a disagreeable taste in the mouth. The belly swells to a considerable bulk, and becomes susceptible of painful sensations from the slightest impression. The tongue is generally dry, though sometimes moist, and covered with a thick brownish fur. When the fever has continued a few days, the symptoms of inflammation usually subside, and the disease acquires a more putrid form. At this period, if not at the very beginning of the disorder, a bilious or putrid diarrhoea, of a dangerous and obstinate nature, intervenes, and accompanies it through all its future progress; each motion to stool being preceded by a temporary increase, and followed by an alleviation of pain. The patient usually nauseates all kind of food and drink, except what is cold and acidulated. A brown or blackish froth, the consequence of putrid exhalations, adheres to the edges of the teeth; a troublesome hiccup is at length produced, which greatly exasperates the pains of the abdomen; petechiae or vibices also appear, with sometimes a miliary eruption, but which produces no mitigation of the disease. Through the whole course of the fever, the patient is affected with great anxiety and dejection of spirits.

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

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

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

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

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

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

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

Within these few years this fever has been treated of by several writers, most of whom have differed from each other in their sentiments of the nature of the disease. The first in the order of publication is Dr Denman, who seems to be of opinion, that it may derive its origin either from a redundancy or too great acrimony of the bile, the secretion of which appears to be much interrupted in the time of gestation. In Dr Manning's treatise on this fever, he mentions its being highly probable that such a cause contributes greatly to produce the disease, especially where the putrid tendency of the humours is increased by unwholesome air and diet.

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

One of the most essential points to be ascertained in the cure of the childbed fever, respects the propriety of bleeding. A free use of the lancet has been generally regarded as the most successful expedient in practice; and there are some instances of critical hemorrhages which would seem to confirm its utility. But Dr Denman thinks we may safely affirm from experience, that for one who will be benefited by large bleeding, a much greater number will be injured, and that even almost irretrievably. Nor can this seem surprising, when we consider the situation of childbed women. In most, the evacuations consequent upon delivery are sufficient to diminish any undue superabundance of the fluids; and if, as frequently happens, the disease be produced by too hasty a separation of the placenta, the consequence of which is generally a very copious discharge of blood, we can never suppose that nature will be afflicted in overcoming the febrile commotion, by the farther evacuation of the vital fluid, through the defect of which she is now rendered unequal even to the ordinary support of the animal economy. We may appeal to every practical physician, how much he has known the pulse to sink, and what a train of nervous symptoms he has observed to succeed an excess of the discharge above mentioned. Besides, it is an axiom in physic, that a remedy which cures any disorder, will always prove sufficient to prevent it; and therefore, if bleeding were the proper cure in the childbed fever, the disease ought to have been prevented by a large evacuation of blood, when that happened previous to its attack. Experience, however, in this, as in all other diseases, is the only unerring guide we can follow; and whoever regulates his practice by fact and observation, will be convinced that bleeding, especially in a larger quantity, is, in general, very far from being attended with success. Exceeding is seldom proper, except in women of plethoric constitutions, and in whom the signs of inflammation rise high. Nor even in such patients ought it to be repeated without great caution, and the existence of strong indications. Bleeding, when used in proper circumstances, may unquestionably palliate the fever; but that it often shortens the duration of it, appears to be a matter of much doubt. On this account the practice becomes still more suspicious and exceptionable, when we consider that by venesection improperly used the patient's strength may be so far reduced as not to support the tedious loofenes by which the disease is generally carried off. Though bleeding, however, ought in general to be used with great caution, there are certainly many cases in which it is both necessary and advantageous.

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

It is so seldom a physician is called during the rigor preceding the puerperal fever, that he has few opportunities of trying the effects of remedies in that early state of the disease. When such occur, however, we should endeavour as much as possible to abate and shorten that period, as the succeeding fever is generally found to bear a proportion to the violence and duration of it. For this purpose, warm diluting drinks should be plentifully used, with a small quantity of volatile spirits or brandy. When Dr Manning apprehended such an accident, he sometimes ordered the nurse to give immediately a dish or two of warm fack-whey; taking care that it was not too strong, which is a caution that ought always to be remembered: for though a free use of the more cordial and spirituous kinds of liquors might perhaps soon abate the rigor, there is danger to be feared from their influence on the approaching fever, especially in women of a strong and healthy constitution. In all cases, warm applications to the extremities, such as heated bricks, towels, or toasted grains in a linen bag, may be used with perfect safety, and some advantage.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mr White imputes the puerperal fever to a putrefactive disposition of the humours, contracted during pregnancy, and fomented by the hot regimen commonly used by women in childbirth. In conformity to this opinion, the chief means which he recommends for preventing the disease is a cool regimen and free circula- tion of air, which he evinces to be of the greatest importance. In respect of bleeding, he informs us, that, upon the strictest inquiry, he cannot find that those who have bled the most copiously have had the greatest success, either in private or hospital practice. He even seems to question the propriety of this evacuation in any case; but approves of emetics, cathartics, and clysters, for cleansing the prime vae, and likewise of such medicines and diet as will correct the putrid humours: adding, that an upright posture and free ventilation are at all times useful, and absolutely necessary, both for the prevention and cure of the disease.

Another writer who treats of the childbed fever is Dr Leake, who has published the result of his observations on this disease from April 1768 to the autumn of the year 1775; but chiefly from December 1769 to May 1770, during which period the childbed fever prevailed much about London.

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

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

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

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

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

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

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

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

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

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

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

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

The late Dr Thomas Young professor of midwifery in the university of Edinburgh, although he published nothing on the subject of the puerperal fever, wrote a very ingenious dissertation respecting it, which was read in the Philosophical Society of Edinburgh. In that dissertation, after giving a very accurate account of the symptoms of the disease, which coincides very nearly with the account given by others, he endeavours to show, that the puerperal fever, strictly so called, is in every instance the consequence of contagion; but he contends, that the contagious matter of this disease is capable only of producing its effect, in consequence of a peculiar predisposition given by delivery and its consequences. In support of this doctrine, he remarks, that for many years the disease was altogether unknown in the lying-in ward of the Royal Infirmary at Edinburgh; but that after it was once accidentally introduced into the hospital, almost every woman was in a short time after delivery attacked with it; although prior to her delivery, she may have lain, even for weeks together, not only in the same ward with the infected, but even in the very next bed. He remarks, that it was only eradicated from the hospital in consequence of the wards being entirely emptied, thoroughly ventilated, and new painted. After these processes, puerperal females in the hospital remained as free from this disease as formerly. The puerperal fever, according to Dr Young, has very generally a strong tendency to the typhoid type; although he allows, that in the beginning it is not unfrequently attended with inflammatory symptoms, and even with topical inflammation, particularly in the intestinal canal. On this idea, he considers the puerperal fever as admitting of the same variety of treatment with other affections depending on contagion, in which sometimes an inflammatory, sometimes a putrefactive tendency, prevails; such, for example, as smallpox or erysipelas. But from the prevailing putrefactive tendency in this affection, he considers the free access of cool air, with the liberal use of antiseptics, as being very generally requisite.

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

WORMS.

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

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

In the Medical Transactions, vol. i. Dr Heberden gives a very accurate account of the symptoms produced by the acaridier, from an eminent physician who was troubled with them all his life. They brought on an uneasiness in the rectum, and an almost intolerable itching in the anus; which sensations most usually came on in the evening, and prevented sleep for several hours. They were attended with heat, sometimes so considerable as to produce a swelling in the rectum. both internally and externally; and if these symptoms were not soon relieved, a tenesmus was brought on, with a mucous dejection. Sometimes there was a gripping pain in the lower part of the abdomen, a little above the os pubis. If this pain was very severe, a bloody mucus followed, in which there were often found ascarides alive. They were also sometimes suspected of occasioning disturbed sleep, and some degree of headach.

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

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

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

From Dr Heberden's observations, we may easily see why it is so difficult to destroy these animals; and why anthelmintics, greatly celebrated for some kinds, are yet so far from being specific in the disease. As the worms which reside in the cavities of the human body are never exposed to the air, by which all living creatures are invigorated, it is evident, that in themselves they must be the most tender and easily destructible creatures imaginable, and much less will be requisite to kill them than any of our common insects. The most pernicious substances to any of the common insects are oil, caustic fixed alkali, lime, and lime-water. The oil operates upon them by shutting up the pores of their bodies; the lime-water, lime, and caustic alkali, by dissolving their very substance. In the case of intestinal worms, however, the oil can have very little effect upon them, as they are defended from it by the moisture and mucus of the intestines; the like happens with lime-water; and therefore it is necessary that the medicine should be of such a nature as to destroy both mucus and insects together; for which purpose the caustic fixed alkali is at once safe and efficacious; nor is it probable that any cafe of worms whatever could resist the proper use of this medicine. A very large dose of any salt indeed will also destroy the mucus and destroy the worms; but it is apt to inflame and excoriate the stomach and intestines, and thus to produce worse distempers than that which it was intended to cure. Dr Heberden gives the following remarkable case of a patient cured of worms by enormous doses of common salt, after trying many other remedies in vain. In February 1757, the patient was seized with uncommon pains in his stomach, attended with nausea, vomiting, and constipation of bowels, and an almost total loss of sleep and appetite: Worms He soon became much emaciated, and could neither stand nor walk upright; his belly grew small and hard, and closely retracted, insomuch that the sternum covered the navel, and the latter could scarce be discovered or felt by the finger: his urine was always milky, and soon deposited a thick white sediment; his excrements were very hard and lumpy, resembling those of sheep, only of a brown colour; nor had he ever a stool without some medicine or other to procure it. In this situation he continued four years; during which time he had been in an infirmary, attended by eminent physicians, but was dismissed as incurable. At last he was advised by a neighbour to drink salt and water, as he said he knew one cured by it who had for many years been afflicted with the same kind of pains in the belly and stomach. As his distemper was now almost insupportable, he willingly tried the experiment. Two pounds of common salt were dissolved in as little water as possible, all which he drank in less than an hour. Soon afterwards he found himself greatly oppressed at the stomach, grew extremely sick, and vomited violently; on the fourth straining he brought up about half a pint of small worms, part ascarides, and the rest resembling those worms which are called the botas, and frequently met with in the stomach of horses, but much smaller, and about the size of a grain of wheat. The salt soon began to operate downwards, and he had five or six very copious fetid stools, tinged with blood; and in them discharged near an equal quantity of the same kind of worms he had vomited. Being greatly fatigued with the violence of the operations, he fell into a calm sleep, which lasted two hours, during which he sweated profusely, and awoke much refreshed. Instead of his usual pains, he now only complained of a rawness and soreness of his gullet, stomach, and bowels, with an almost unquenchable thirst; to allay which, he drank large quantities of cold water, whey, butter-milk, or whatever he could get. The urine he now passed was small in quantity, and rendered with very great difficulty, being highly saturated with the salt, from whence arose a most troublesome dysuria and strangury. However, these symptoms gradually abated by a free use of the liquors above mentioned; and on the third morning he was so well recovered, that he took two pounds more of salt, dissolved in the like quantity of water. The effects were nearly similar to the former; only that most of the worms were now burnt, and came away with a considerable quantity of slime and mucus. The drought, strangury, &c. returned with their former violence, but soon yielded to the old treatment. He sweated very copiously for three days, slept easily, and by that time could extend his body freely: on the fifth day he left his bed, and, though very weak, could walk upright; his strength and appetite soon returned, and he became robust and well.

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

1. Quicksilver. This is very efficacious against all kinds of worms, either taken in the form of calomel or corrosive sublimate. Even the crude metal boiled in water, and the water drunk, has been recommended as an almost certain cure. But this, it is evident, can receive no impregnation from the mercury. If, therefore, it have any effect, it must be from some foreign and accidental impregnation. In most instances there can be no objection to mercury, but only that it is not endowed with any attenuating quality whereby the mucus in which these insects reside can be diluted. It therefore fails in many cases, though it will most certainly destroy worms where it can get at them.

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

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

Mr Anderson, surgeon in Edinburgh, has also given an account of this bark and its operation, in a letter to Dr Duncan, published in the Edinburgh Medical Commentaries, volume iv. p. 84. From this account it appears, that there are two different kinds of cabbage bark; the one much paler than the other: the pale kind operates much more violently than the other. It often occasions loose stools, great nausea, and such like symptoms, attended with great uneasiness in the belly: in one or two instances it was suspected of inducing syncope. The darker coloured kind resembles the casia lignea, though it is of a much coarser texture. This kind, Mr Anderson thinks, may be exhibited in any case where an anthelmintic is necessary; the dangerous symptoms might have followed either from the use of the first kind, or from an over-dose of the second. The usual method of preparing the medicine is by boiling two ounces and a half of the bark in two quarts of water to a pint and a half. Of this a tea-spoonful may be given at first in the morning, gradually increasing the quantity till we come to four or five table-spoonfuls in a day. When exhibited in this manner, Mr Anderson informs us, that he never saw it produce any violent symptoms, and has experienced the best effects from it as an anthelmintic. After the use of this decoction for eight- Worms. or nine mornings successively, a dose of jalap with calomel must be given, which seldom fails to bring away the worms, some dead, some alive. If at any time the decoction produce more than one or two loose stools, a few drops of liquid laudanum may be given; and, in general, Mr Anderson gave 15 or 20 drops of the spirit of lavender with each dose.

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

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

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

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

5. Indian pink. This plant, which is the Spigelia marilandica of Linnaeus, is also an American plant, and was first recommended in the Edinburgh Physical and Literary Essays by Dr Garden of Charlestown in South Carolina. He is of opinion that a vomit ought always to precede the use of it; and informs us, that half a dram of it purges as briskly as the same quantity of rhubarb. At other times he has known it produce no effect on the belly though given in very large quantity: In such cases it becomes necessary to add a grain or two of sweet mercury, or some grains of rhubarb; but then it is less efficacious than when it proves purgative without addition. The use of it, however, in small doses, is by no means safe; as it frequently produces giddiness, dimness of sight, convulsions, &c. The addition of a purgative, indeed, prevents these effects; but at the same time, as already observed, it diminishes the virtue of the medicine. The doctor therefore recommends large doses, as from them he never knew any other effect than the medicine's provoking emetic or violently cathartic. The dose is from 12 to 60 or 70 grains of the root in substance, or two, three, or four drams of the infusion, twice a-day. This medicine has also had its day, and is now very far from being considered as a specific.

The long round worms seem to be the most dangerous which infest the human body, as they often pierce through the stomach and intestines, and thus bring on a miserable death. The common symptoms of them are nausea, vomiting, loofenes, fainting, slender intermitting pulse, itching of the nose, and epileptic fits. By the consumption of the chyle they produce hunger, paleness, weakness, cativeness, tumor of the abdomen, eruptions, and rumbling of the intestines; but it is from the perforation of the intestines that the disease proves so frequently fatal. A child may be known to have worms from his cold temperament, paleness of the countenance, livid eyelids, hollow eyes, itching of the nose, voracity, startings, and grinding of the teeth, in sleep; and more especially by a very fetid breath. Very frequently, however, they are voided by the mouth and anus, in which case there is no room for doubt. In the Medical Commentaries, vol. ii. we have an account of the intestines being perforated by a worm, and yet the patient recovered. The patient was a woman troubled with an inflammation in the lower part of the abdomen. The pain was so violent, that for six days she slept none at all; the tumor then broke, discharged upwards of a pound of thin watery faeces, immediately after which the excrements followed. The next day she was extremely low; her pulse could scarcely be felt; the extremities were cold: and there was a considerable discharge from the wound, which had already begun to mortify. She got a decoction of cinchona with wine, which alleviated the symptoms; but in removing the mortified parts a worm was found among them nine inches long, and as thick as an eagle's quill. By proper applications, the discharge of excrements ceased, and she recovered perfect health. She was sensible of no accident giving rise to the inflammation; so that in all probability it arose entirely from the worm itself.

The tenia, or tape-worm as it is called, is one of those most difficult to be removed from the human body. It is of two kinds, tenia folium and tenia lata; for a description of which see the article TENIA.—The reason of its being so difficult to cure is, that though portions of it are apt to break off and be discharged, it is endowed with a power of reproduction, so that the patient is little or nothing better. The symptoms occasioned by it are not different from those above described. A specific against the tenia lata has been lately so much celebrated in France, that the king thought proper to purchase it from the proprietor (Madame Nouffer), and the account of it has been translated into English by Dr Simmons. The patients are required to observe no particular regimen till the day before they take the specific. That day they are to take nothing after dinner till about 7 o'clock; after which, they are to take the following soup: "Take a pint and a half of water, two or three ounces of good fresh butter, and two ounces of bread cut into thin slices: add to this salt enough to season it, and then boil it to the consistence of panada." About a quarter of an hour after this, they take a biscuit and a glass of white wine, either pure or mixed with water; or even water alone, if they have not been accustomed to wine. If the patient has not been to stool that day, (which, however, is not usual with patients in this way), the following clyster is to be injected. "Take a small quantity of the leaves of mallow, and boil them in a sufficient quantity of water, mixing with it a little salt, and when strained off add two ounces of olive oil." Next morning, about eight or nine hours after the supper above mentioned, the specific is to be taken. This is no other than two or three drams of the root of male fern, polypodium flix mas of Linnaeus, gathered in autumn, and reduced to fine powder. It is to be taken in any distilled water, or in common water. This medicine is apt to occasion a nausea: to avoid which, Madame Nouffer allows her patients to chew any thing that is agreeable, but forbids any thing to be swallowed; or they may smell to vinegar, to check the sickness: but if, notwithstanding this, the specific be thrown up, a fresh dose must be swallowed as soon as the sickness is gone off, and then they must try to sleep. About two hours after this the following bolus is to be taken. "Take of the panacea of mercury 14 times sublimed, and select resin of scammony, each ten grains; of fresh and good gamboge fix or seven grains: reduce each of these substances separately into powder, and then mix them with some conserve into a bolus." This composition is to be swallowed at two different times, washing it down with one or two dishes of weak green-tea, after which the patient must walk about his chamber. When the bolus begins to operate, he is to take a dish of the same tea occasionally, until the worm be expelled; then, and not before, Madame Nouffer gives him broth or soup, and he is directed to dine as is usual after taking physic. After dinner he may either lie down or walk out, taking care to conduct himself differently, to eat but little supper, and to avoid every thing that is not of easy digestion.

The cure then is complete; but it is not always effected with the same quickness in every subject. He who has not kept down the whole bolus, or who is not sufficiently purged by it, ought to take, four hours after it, from two to eight drams of Epsom salt dissolved in boiling water. The dose of this salt may be varied according to the temperament and other circumstances of the patient.

If the worm should not come away in a bundle, but in the form of a thread (which particularly happens when the worm is involved in much tenacious mucus), the patient must continue to sit upon the close-toilet without attempting to draw it away, drinking at the same time warm weak tea: sometimes this alone is not sufficient, and the patient is obliged to take another dose of purging salt, but without varying his position till the worm be wholly expelled.

It is unusual for patients who have kept down both the specific and purging dose, not to discharge the worm before dinner-time. This, however, sometimes happens when the dead worm remains in large bundles in the intestines, so that the faeces becoming more limpid towards the end of the purging, pals by it without drawing it with them. The patient may in this case eat his dinner; and it has been observed, that the food, joined to the use of a clyster, has brought about the expulsion of the worm.

Sometimes the worm is brought away by the action of the specific alone, before the patient has taken the purging bolus: when this happens, Madame Nouffer gives only two-thirds of it, or substitutes the salt in its stead.

Patients must not be alarmed by any sensation of heat or uneasiness they may feel during the action of the remedy, either before or after a copious evacuation, or just as they are about to void the worm. These sensations are transitory, and go off spontaneously, or by the affluence of the vapour of vinegar drawn in at the nose.

They who have vomited both the specific and bolus, or who have kept down only a part of them, sometimes do not void the worm that day. Madame Nouffer therefore directs them to take again that night the soup, the wine and biscuit; and if circumstances require it, the clyster. If the worm do not come away during the night, she gives them early the next morning another dose of the specific, and, two hours afterwards, fix drams or an ounce of purging salt, repeating the whole process of the preceding day; excepting the bolus, which she supposes.

She observes, that very hot weather diminishes in some degree the action of her remedy; she therefore prefers the month of September for administering it; but as she has not been always able to choose the season, and has been sometimes obliged to undertake the cure of patients in the hottest days of summer, she then gave her specific very early in the morning; and with this precaution she saw no difference in its effects.

On the day appointed for the trial of this medicine before the commissioners nominated by the king of France, it was exhibited to five different persons; but only one of them was certainly known to have the tenia lata by having discharged parts of it before. That person was cured; the second voided a portion of the tenia folium; the third some acarides, with a part of the tenia folium; the fourth and fifth voided no worms; but the last considered much of the viscid slime he voided to be worms in a diluted state.

This trial was thought sufficient to ascertain the efficacy of the medicine, and further trials were made by those to whom the secret was communicated. The first voided two tenia, after much vomiting and 18 or 20 stools; the second had no vomiting, but was as violently purged, and discharged two worms; the third had 20 copious stools during the night, and discharged the worm in the morning; and the fifth was affected in much the same manner. Some others who were not relieved, were supposed not to have a tenia.

This specific, however, is not to be considered as a new discovery; the efficacy of fern in cases of tenia having been known long ago. Theophrastus prescribes its root, in doses of four drams, given in water sweetened with honey, as useful in expelling flat worms.—Dioecorides orders it in the same dose, and adds, that its effects are more certain when it is mixed with four oboli (40 grains) of scammony or black hellebore; he particularly requires that garlic should be taken before hand. Pliny, Galen, Oribasius, and Aëtius, ascribe this fame virtue to fern; and are followed in this by Avicenna, and the other Arabian physicians. Dornfleins, Valerius Cordus, Dodonaeus, Mathiolas, Dallechamps, who commented on Dioscorides, or copied him in many things, all mention the fern-root as a specific against the tenia. Sennertus, and Burnet after him, recommended in similar cases an infusion of this plant, or a dram of its powder, for young persons, and three drams for adults. Simon Paulus, quoted by Ray and Geoffroy, considers it as the most efficacious of all poisons against the flat worm, and as being the basis of all the secret remedies extolled by empirics in that disease. Andry prefers distilled fern-water to the root in powder, or he employs it only in the form of an opiate, or mixed with other substances.

These are not the only authors who have mentioned the tenia; many others have described this worm, the symptoms it excites, and the treatment proper to expel it. Almost all of them mention the fern-root, but at the same time they point out other remedies as possessing equal efficacy. Amongst these we find the bark of the root of the mulberry-tree, the juice of the auricula marina, the roots of chameleon niger, ginger, zedoary; decoctions of mugwort, southernwood, wormwood, penny-royal, origanum, hyssop, and in general all bitter and aromatic plants, &c. Some of them direct the specific to be simply mixed and taken in wine or honey and water; others join to it the use of some purgative remedy, which they lay adds to its efficacy. Oribasius, Sylvius, &c. distinguish the specific that kills the worm, from the purgative that evacuates it, and direct them to be given at different times. Sennertus gives a very satisfactory reason for adopting this method. If we give, says he, the purgative medicine and the specific at the same time, the latter will be hastily carried off before it can have exerted its powers on the worm: whereas, if we give the specific first, and thus weaken the worm, it will collect itself into a bundle, and, being brought away by means of the purge, the patient will be cured. The cure will be more speedy if the prime vire have been previously lubricated. These precautions are all of them essential to the success of the remedy, nor are they neglected by Madame Nouffer in her method of treatment. The panada and injection she prescribes the night before, to lubricate the intestines, and prepare the prime vire. The fern root, taken in the morning, kills and detaches the worm; of this the patients are sensible by the cessation of the pain in the stomach, and by the weight that is felt in the lower belly. The purgative bolus administered two hours after this, procures a complete evacuation; it is composed of substances that are at once purgative and vermifuge, and which, even when administered alone, by different physicians, sometimes succeeded in expelling the worm. If this purgative appear to be too strong, the reader is desired to recollect, that it produced no ill effects in either of the cases that came under the observation of the physicians appointed to make the trials; and that in one of those cases, by diminishing the dose, they evidently retarded the evacuations.—Regard however, they observe, is to be had both to the age and the temperament of the patient, and the treatment should always be directed by a prudent and experienced physician, who may know how to vary the proportions of the dose as circumstances may require. If the purgative be not of sufficient strength, the worm, after being detached by the specific, remains too long a time in the intestines, and becoming soon corrupted, is brought away only in detached portions: on the other hand, if the purgative be too strong, it occasions too much irritation, and evacuations that cannot fail to be inconvenient.

Madame Nouffer's long experience has taught her to distinguish all these circumstances with singular adroitness.

This method of cure is, as we have seen, copied in a great measure from the ancients: it may be possible to produce the same effects by varying the remedies; but the manner of applying them is by no means indifferent: we shall be always more certain of success if the intestines be previously evacuated, and if the specific be given some time before the purgative bolus. It is to this method that Madame Nouffer's constant success is attributed.

Her remedy has likewise some power over the tenia folium; but as the rings of this worm separate from each other more easily than those of the tenia lata, it is almost impossible for it to be expelled entire. It will be necessary therefore to repeat the treatment several times, till the patient cease to void any portions of worms. It must likewise be repeated, if, after the expulsion of one tenia folium, another should be generated in the intestinal canal. This last case is so rare, that it has been supposed that no person can have more than one of these worms; and for this reason it has been named solitary worm, which, being once removed, could never be renewed or replaced by a second: but experience has proved, that this notion is an ill-founded prejudice; and we know that sometimes these worms succeed each other, and that sometimes several of them exist together. Two living teniae have frequently been expelled from the same patient. Dr De Haen relates an instance of a woman who voided 18 teniae at once. In these cases the symptoms are usually more alarming; and the appetite becomes excessive, because these worms derive all their nourishment from the chyle. If too austere and ill-judged a regimen deprives them of this, they may be expected to attack even the membranes of the intestines themselves. This evil is to be avoided by eating frequently.

Such are the precautions indicated in this disease. The ordinary vermifuge remedies commonly procured only a palliative cure, perhaps because they were too often improperly administered. But the efficacy of the present remedy, in the opinion of the French physicians, seems to be sufficiently confirmed by experience. To the above account, however, it seems proper to addjoin the following observations by Dr Simmons.

"A Swiss physician, of the name of Herrenfchwand, more than 20 years ago, acquired no little celebrity by distributing a composition of which he styled himself the inventor, and which was probably of the same nature as Madame Nouffer's. Several very eminent men, as Tronchin, Hovius, Bonnet, Cramer, and others, have written concerning the effects of this remedy. It seems that Dr Herrenfchwand used to give a powder by way of preparation, the night before he administered his specific. Nothing could be said with certainty concerning the composition either of one or the other. The treatment was said sometimes to produce most violent effects, and to leave the patients in a valetudinary state. Dr De Haen was diffused by his friends from using it, because it disordered the patients too much. It will be readily conceived, now that we are acquainted with Madame Nouffer's method, that these effects were occasioned wholly by the purgative bolus. It is not strange, that resin of scammony or jalap, combined with mercurius dulcis and gamboge, all of them in strong doses, should in many subjects occasion the greatest disorders. It seems likely, however, that much of the success of the remedy depends on the use of a drastic purge. Some of the ancients who were acquainted with the virtues of the fern root, observed that its efficacy was increased by scammony. Resinous purges, especially when combined with mercury, have often been given with success in cases of tænia. Dr De Haen saw a worm of this sort five ells long expelled by the resin of jalap alone. Dr Gaußius knew a woman who had taken a variety of anthelmintic remedies without any effect, though she had voided a portion of tænia an ell and a half long previous to the use of these medicines: but at length, after taking a purge of singular strength, she voided the worm entire. Many other instances of the same kind are to be met with in authors. Other remedies have occasionally been given with success. In Sweden, it has been a practice to drink several gallons of cold water, and then to take some drastic purge. Boerhaave says, that he himself saw a tænia measuring 300 ells expelled from a Russian by means of the sulphate of iron.

From some late accounts, there is reason to believe that Dr Herrenfchwand's remedy for tænia does not so exactly agree with that of Madame Nouffer as Dr Simmons seems to imagine. According to the account given us by a gentleman who had his information from Dr Herrenfchwand himself, it consists entirely of gamboge and fixed vegetable alkali.

Of POISONS.

Of many poisons we have already treated, but there are some of which nothing has hitherto been said. Among the most fatal of these are the bites and stings of serpents, scorpions, &c. According to Dr Mead, the symptoms which follow the bite of a viper are, an acute pain in the place wounded, with a swelling, at first red, but afterwards livid, which by degrees spreads farther to the neighbouring parts; with great faintness, and a quick, low, and sometimes interrupted pulse; great sickness at stomach, with bilious convulsive vomitings; cold sweats, and sometimes pains about the navel. Frequently a fœnous liquor runs from the small wound, and little pustules are raised about it: the colour of the whole skin in less than an hour is changed yellow, as if the patient had the jaundice. These symptoms are very frequently followed by death, especially if the climate be hot, and the animal of a large size. This is not, however, the case with all kinds of serpents. Some, we are assured, kill by a fatal sleep; others are said to produce an universal hemorrhage and dissolution of the blood; and others an unquenchable thirst. But of all the species of serpents hitherto known, there is none whose bite is more expeditiously fatal than that of the rattle-snake. Dr Mead tells us, that the bite of a large serpent of this kind killed a dog in a quarter of a minute; and to the human species they are almost equally fatal. Of this serpent it is said, that the bite makes the person's skin become spotted all over like the skin of the serpent; and that it has such a motion as if there were innumerable living serpents below it. But this is probably nothing more than a dissolution of the blood, by which the skin becomes spotted as in petechial fevers, at the same time that the muscles may be convoluted as in the distemper called hierarcos, which was formerly thought to be the effect of evil spirits: but it is even not improbable that observers have been somewhat aided by fancy and superstition when they thought that they detected such appearances.

It has justly appeared surprising to philosophers, how such an inconsiderable quantity of matter as the poison emitted by a viper at the time of biting should produce such violent effects. But all inquiries into this matter must necessarily be uncertain; neither can they contribute any thing towards the cure. It is certain that the poison produces a gangrenous disposition of the part itself, and likewise seemingly of the rest of the body; and that the original quantity of poison continues some time before it exerts all its power on the patient, as it is known that removing part of the poisonous matter by suction will alleviate the symptoms. The indications of cure then are three: 1. To remove the poisonous matter from the body: Or, 2. If this cannot be done, to change its destructive nature by some powerful and penetrating application to the wound: And, 3. To counteract the effects of that portion already received into the system.

The poisonous matter can only be removed from the body by sucking the wound either by the mouth, or by means of a cupping glass; but the former is probably the more efficacious, as the saliva will in some measure dilute and perhaps obviate the poison. Dr Mead directs the person who sucks the wound to hold warm oil in his mouth, to prevent inflammation of the lips and tongue: but as bites of this kind are most likely to happen in the fields, and at a distance from houses, the want of oil ought by no means to retard the operation, as the delay of a few minutes might prove. prove of the most fatal consequence; and it appears from Dr Mead's experiments, that the taking the poison of a viper into the mouth undiluted, is attended with no worse consequences than that of raising a flight inflammation. A quick excision of the part might also be of very great service.

The only way of answering the second indication is, by destroying the poisoned part by a red-hot iron, or the application of alkaline salts, which have the power of immediately altering the texture of all animal substances to which they are applied, provided they are not covered by the skin; and as long as the poison is not totally absorbed into the system, these must certainly be of use.

To answer the third indication, Dr Mead recommends a vomit of ipecacuanha, encouraged in the working with oil and warm water. The good effects of this, he says, are owing to the thake which it gives to the nerves, whereby the irregular spasms into which their whole system might be drawn are prevented. After this the patient must go to bed, and a sweat must be procured by cordial medicines; by which the remaining effects of the poison will be carried off.

It has been confidently asserted by many, that the American Indians are possessed of some specific remedy by which they can easily cure the bite of a rattle-snake. But Mr Cateby, who must have had many opportunities of knowing this, positively denies that they have any such medicine. They make applications indeed, and sometimes the patient recovers; but these recoveries he ascribes to the strength of nature overcoming the poison, more than to the remedies made use of. He says, they are very acute in their prognostics whether a person that is bit will die or not; and when they happen to receive a bite in certain parts of the body, when the teeth of the animal enter a large vein, for instance, they quickly resign themselves to their fate, without attempting anything for their own relief. Indeed, so violent and quick is the operation of this poison, that unless the antidote be instantly applied, the person will die before he can get to a house. It would seem therefore eligible for those who are in danger of such bites, to carry along with them some strong alkaline ley, or dry alkaline salt, or both, which could be instantly clapt on the wound, and by its dissolving power would destroy both the poison and the infected parts. Strong cordials also, such as ardent spirits, volatile alkali, &c. might possibly excite the languid powers of nature, and enable her to expel the enemy, which would otherwise prove too powerful. This seems to be somewhat confirmed from the account we have in the Philosophical Transactions of a gentleman bit by a rattle-snake, who was more relieved by a poultice of vinegar and vine-ashes put to his wound than any thing else. The vine ashes being of an alkaline nature, must have saturated the vinegar, so that no part of the cure could be attributed to it: on the other hand, the ashes themselves could not have been saturated by the small quantity of acid necessary to form them into a poultice; of consequence they must have operated by their alkaline quality.—Soap ley, therefore, or very strong salt of tartar, may reasonably be thought to be the best external application, not only for the bites of vipers, but of every venomous creature; and in fact we find dry salt universally recommended both in the bites of serpents and of mad dogs. Dr Mead recommends the fat of vipers immediately rubbed into the wound; but owns that it is not safe to trust to this remedy alone.

Some years ago the volatile alkali was strongly recommended by M. Sage of the French academy, as a powerful remedy against the bite of the viper: and, by a letter from a gentleman in Bengal to Dr Wright, it would appear that this article, under the form of the eau de luce, which is very little if any thing different from the spiritus ammoniae succinatus of the London Pharmacopoeia, has been employed with very great success against this affection in the East Indies: but from the trials made with it by the abbé Fontana, published in his Treatise on the Poison of the Viper, it would appear that it by no means answered his expectation; and the efficacy of this, as well as of the snake pills mentioned under the article HYDROPHOBIA, still requires to be confirmed by further experience.

MELÆNE.

This is a distemper not very common, but it has been observed by the ancient physicians, and is described by Hippocrates under the name of morbus niger. It shows itself by a vomiting and purging of black tar-like matter, which Hippocrates, Boerhaave, and Van Swieten, supposed to be occasioned by atra bilis. But Dr Home, in his Clinical Experiments, endeavours to shew that it is owing to an effusion of blood from the mesenteric vessels, which, by its stagnation and corruption, assumes that strange appearance. The disease, he says, frequently follows hemorrhage; and those of a scorbutic habit are most subject to it. It is an acute disease, and terminates soon; yet it is not attended with any great degree of fever. In one of Dr Home's patients the crisis happened on the eighth day by diarrhoea; in another, on the 14th, by sweat and urine; and a third had no evident critical evacuation.

As to the cure, Dr Home observes, that bleeding is always necessary where the pulse can bear it; nor are we to be deterred from it by a little weakness of the pulse, more than in the enteritis. Emetics are hurtful, but purgatives are useful. But the most powerful medicine for checking this haemorrhage is the sulphuric acid: and, that this might be given in greater quantity, he mixed it with mucilage of gum arabic; by which means he was enabled to give double the quantity he could otherwise have done. The cold bath was tried in one instance, but he could not determine whether it was of any service or not. The cure was completed by exercise and cinchona.

Of the DISEASES of CHILDREN.

Dr Buchan observes, that from the annual registers of the dead, it appears that about one half of the children born in Great Britain die under twelve years of age; and this very great mortality he attributes in a great measure to wrong management. The particulars of this wrong management enumerated by him are,

1. Mothers not suckling their own children. This, he owns, it is sometimes impossible for them to do; Appendix.

Diseases of Children.

but where it can be done, he affirms that it ought never to be omitted. This, he says, would prevent the unnatural custom of mothers leaving their own children to suckle those of others; on which he passes a most severe censure, and indeed fears any censure can be severe enough upon such inhumanity. Dr Buchan informs us, "He is sure he speaks within bounds, when he says not one in a hundred of these children live who are thus abandoned by their mothers." For this reason he adds, that no mother should be allowed to suckle another's child till her own be fit to be weaned. A regulation of this kind would save many lives among the poorer sort, and would do no harm to the rich; as most women who make good nurses are able to suckle two children in succession upon the same milk.

2. Another source of the diseases of children is the unhealthiness of parents: and our author insists that no person who labours under an incurable malady ought to marry.

3. The manner of clothing children tends to produce diseases. All that is necessary here, he says, is to wrap the child in a soft loose covering; and the softness of every part of the infant's body sufficiently shows the injury which must necessarily ensue by pursuing a contrary method.

4. A new-born infant, instead of being treated with syrups, oils, &c. ought to be allowed to suck the mother's milk almost as soon as it comes into the world. He condemns the practice of giving wines and spirituous liquors along with the food soon after birth; and says, that if the mother or nurse has a sufficient quantity of milk, the child will need little or no other food before the third or fourth month. But to this it may reasonably be objected, not only that the nursing would thus be very severe on the mother; but if the child be left thus long without other food, it will not easily relish that food for some time, and its stomach is apt to be easily hurt by a flight change of diet after it has been long accustomed to one thing. The human species are unquestionably fitted by nature for a mixed aliment, both from the vegetable and animal kingdom. And the analogy of other animals belonging to the class of mammalia for whom milk is equally provided at the earliest periods of life, would lead us to the conclusion, that mixed aliment is well fitted for the human species even in the earliest periods of infancy. The lamb is no sooner dropt than, by natural instinct, it crops the grass as well as it sucks its mother. And the stomach in the human species, immediately after birth, can digest other food as well as milk. Neither can it be shewn, that the strongest and most healthy infants are those which get no other food but the mother's milk during the first months of their life. In fact, children are evidently of a weak and lax habit of body, so that many of their diseases must arise from that cause; all directions which indiscriminately advise an antiphlogistic regimen for infants as soon as they come into the world, must of necessity be wrong. Many instances in fact might be brought to show, that by the preposterous method of starving infants, and at the same time treating them with vomits and purges, they are often hurried out of the world. Animal food indeed, particularly under the form of broths, is exceedingly agreeable to children, and they ought to be indulged with it in moderation. This will prove a much better remedy for those acidities with which children are often troubled, than magnesia alba, crabs eyes, or other absorbents, which have the most pernicious effects on the stomachs of these tender creatures, and pull the appetite to a surprising degree. The natural appetites of children are indeed the best rule by which we can judge of what is proper or improper for them. They must no doubt be regulated as to the quantity; but we may be assured that what a child is very fond of will not hurt it, if taken in moderation. When children are sick, they refuse every thing but the breast; and if their distemper be very severe, they will refuse it also, and in this case they ought not to be precluded to take food of any kind; but when the sickness goes off, their appetite also returns, and they will require the usual quantity of food.

According to Dr Armstrong, inward fits, as they are called, are in general the first complaint that appears in children; and as far as he has observed, most, if not all infants, during the first months, are more or less liable to them. The symptoms are these: The child appears as if it was asleep, only the eyelids are not quite closed; and if you observe them narrowly, you will see the eyes frequently twinkle, with the white of them turned up. There is a kind of tremulous motion in the muscles of the face and lips, which produces something like a smirp or a smile, and sometimes almost the appearance of a laugh. As the disorder increases, the infant's breath seems now and then to stop for a little; the nose becomes pinched; there is a pale circle about the eyes and mouth, which sometimes changes to livid, and comes and goes by turns; the child starts, especially if you attempt to stir it though ever so gently, or if you make any noise near it. Thus disturbed, it sighs, or breaks wind, which gives relief for a little, but presently it relapses into the dozing. Sometimes it struggles hard before it can break wind, and seems as if falling into convulsions; but a violent burst of wind from the stomach, or vomiting, or a loud fit of crying, sets all to rights again. As the child increases in strength, these fits are the more apt to go off spontaneously and by degrees; but in case they do not, and if there is nothing done to remove them, they either degenerate into an almost constant drowsiness, (which is succeeded by a fever and the thrush), or else they terminate in vomitings, four, curdled, or green stools, the watery gripes, and convulsions. The thrush indeed very often terminates in these lait symptoms. As these complaints naturally run into one another, or succeed one another, they may be considered, in a manner, as only different stages of the same disease, and which derive their origin from the same cause. Thus, the inward fits may be looked upon as the first stage of the disorder; the fever, and thrush (when it happens), as the second; the vomitings, four, curdled, green or watery stools, as the third; and convulsions, as the last.

As to the cause of these complaints, he observes, that in infants the glandular secretions, which are all more or less glutinous, are much more copious than in adults. During the time of sucking, the glands of the mouth and fauces being squeezed by the contraction of the muscles, pour forth their contents plentifully; which afterwards mixing with the mucus of the gullet and stomach, render the milk of a flinty consistence, by which means it is not so readily absorbed into the lacteals; and as in most infants there is too great an acidity in the stomach, the milk is thereby curdled, which adds to the load; hence sickness and spasms, which, being communicated by sympathy to the nerves of the gullet and fauces, produce the convulsive motions above described, which go commonly by the name of inward fits. The air, likewise, which is drawn in during suction mixing with the milk, &c. in the stomach, perhaps contributes towards increasing the spasms above mentioned. Dr Armstrong is the more induced to attribute these fits to the causes now assigned, that they always appear immediately after sucking or feeding; especially if the child has been long at the breast, or fed heartily, and has been laid down to sleep without having first broken wind. Another reason is, that nothing relieves them so soon as belching or vomiting; and the milk or food they throw up is generally either curdled, or mixed with a large quantity of heavy phlegm. If they be not relieved by belching or vomiting, the fits sometimes continue a good while, and gradually abate, according as the contents of the stomach are pushed into the intestines; and as soon as the former is pretty well emptied, the child is waked by hunger, cries, and wants the breast; he sucks, and the same process is repeated.—Thus, some children for the first weeks are kept almost always in a doze, or seemingly so; especially if the nurses, either through laziness or want of skill, do not take care to rouse them when they perceive that it is not a right sleep, and keep them awake at proper intervals. This dozing is reckoned a bad sign amongst experienced nurses; who look upon it as a forerunner of the thrush, as indeed it often is; and therefore, when it happens, we ought to be upon our guard to use the necessary precautions for preventing that disorder.

For these disorders, the only remedy recommended by Dr Armstrong is antimonial wine, given in a few drops according to the age of the infant. By this means the superabundant mucus will no doubt be evacuated; but at the same time we must remember, that this evacuation can only palliate, and not cure the disease. This can only be effected by tonics; and, when from inward fits and other symptoms it appears that the tone of the stomach is very weak, a decoction of cinchona, made into a syrup, will readily be taken by infants, and may be safely exhibited from the very day they come into the world, or as soon as their bowels are emptied of the meconium by the mother's milk or any other means.

Dr Clarke observes, that fractures of the limbs and compressions of the brain, often happen in difficult labours; and that the latter are often followed by convulsions soon after delivery. In these cases, he says, it will be advisable to let the navel-string bleed two or three spoonfuls before it be tied. Thus the oppression of the brain will be relieved, and the disagreeable consequences just mentioned will be prevented. But if this has been neglected, and fits have actually come on, we must endeavour to make a revolution by all the means in our power; as by opening the jugular vein, procuring an immediate discharge of the urine and meconium, and applying small blisters to the back, legs, or behind the ears. The femicupium, too, would seem to be useful in this case, by driving the oppressive load of fluids from the head and upper parts.

It sometimes happens after a tedious labour, that the child is so faint and weak as to discover little or no figus of life. In such a case, after the usual cleansing, the body should be immediately wrapped in warm flannel, and briskly tossed about in the nurse's arms, in order, if possible, to excite the languid circulation. If this fail, the breast and temples may be rubbed with brandy or other spirits; or the child may be provoked to cry, by whipping, or other stimulating methods, as the application of onion, or salt and spirit of hartshorn, to the mouth and nostrils. But after all these expedients have been tried in vain, and the recovery of the child absolutely despaired of, it has sometimes been happily revived by introducing a short catheter or blowpipe into the mouth, and gently blowing into the lungs at different intervals. Such children, however, are apt to remain weak for a considerable time, so that it is often no easy matter to rear them; and therefore particular care and tenderness will be required in their management, that nothing may be omitted which can contribute either to their preservation or the improvement of their strength and vigour.

All the disorders which arise from a retention of the meconium, such as the red gum, may easily be removed by the use of gentle laxatives; but the great source of mortality among children is the breeding of their teeth. The usual symptoms produced by this are fretting; reflexeffects; frequent and sudden startings, especially in sleep; colliciveness; and sometimes a violent diarrhoea, fever, or convulsions. In general, those children breed their teeth with the greatest ease, who have a moderate laxity of the bowels, or a plentiful flow of saliva during that time.

In mild cases, we need only, when necessary, endeavour to promote the means by which nature is observed to carry on the business of dentition in the easiest manner. For this purpose, if a colliciveness be threatened, it must be prevented, and the body kept always gently open; the gums should be relaxed by rubbing them frequently with sweet oils, or other softening remedies of that kind, which will greatly diminish the tension and pain. At the same time, as children about this period are generally disposed to chew whatever they get into their hands, they ought never to be without something that will yield a little to the pressure of their gums, as a crust of bread, a wax candle, a bit of liquorice root, or such like; for the repeated mucular action, occasioned by the constant biting and gnawing at such a substance, will increase the discharge from the salivary glands, while the gums will be so forcibly pressed against the advancing teeth, as to make them break out much sooner, and with less uneasiness, than would otherwise happen. Some likewise recommend a slice of the rind of fresh bacon, as a proper masticatory for the child, in order to bring moisture into its mouth, and facilitate the eruption of the teeth by exercising the gums. If these means, however, prove ineffectual, and bad symptoms begin to appear, the patient will often be relieved immediately by cutting the inflamed gum down to the tooth, where a small white point shows the latter to be coming forward. When the pulse is quick, the skin hot and dry, and the child of a sufficient age and strength, emptying the vessels by bleeding, Appendix.

Diseases of ing., especially at the jugular, will frequently be necessary here, as well as in all other inflammatory cases; and the belly should be opened from time to time by emollient, oily, or mucilaginous clysters. But, on the contrary, if the child be low, sunk, and much weakened, repeated doses of the spirit of hartshorn, and the like reviving medicines, ought to be prohibited. Blisters applied to the back, or behind the ears, will often be proper in both cases. A prudent administration of opiates, when their use is not forbid by coifvenes or otherwise, is sometimes of great service in difficult teething, as, by mitigating pain, they have a tendency to prevent its bad effects, such as a fever, convulsions, or other violent symptoms; and often they are absolutely necessary, along with the tinctures powders, for checking an immoderate diarrhea.

When cathartics are necessary, if the child seems too tender and weak to bear their immediate operation, they should be given to the nurse; in which case they will communicate so much of their active powers to the milk as will be sufficient to purge the infant. This at least certainly holds with regard to some cathartics; such, for example, as the infusion of senna, particularly if a very weak infusion be employed, and not used to such an extent as to operate as a purgative to the nurse.

As most young children, if in health, naturally sleep much, and pretty soundly, we may always be apt to suspect that something is amiss when they begin to be subject to watching and frights; symptoms which seldom or never occur but either in consequence of some present disorder not perceived, or as the certain forerunners of an approaching indisposition. We should immediately, therefore, endeavour to find out the cause of watchfulness, that we may use every possible means to remove or prevent it; otherwise the want of natural rest, which is so very prejudicial to persons of all ages, will soon reduce the infant to a low and emaciated state, which may be followed by a hectic fever, diarrhea, and all the other consequences of weakness. These symptoms, being always the effects of irritation and pain, may proceed, in very young infants, from eruptions or other affections of the prime vis producing flatulencies or gripes; about the sixth or seventh month, they may be owing to that uneasiness which commonly accompanies the breeding of the teeth; and after a child is weaned, and begins to use a different kind of food, worms become frequently an additional cause of watchings and disturbed sleep. Hence, to give the necessary relief on these occasions, the original complaint must first be ascertained from the child's age and other concomitant circumstances, and afterwards treated according to the nature of the case. Women and nurses are too apt to have recourse to opiates in the watchings of children, especially when their own rest happens to be much disturbed by their continual noise and clamour. But this practice is often prejudicial, and never ought to have place when the belly is in the least obstructed.

There is no complaint more frequent among children than that of worms, the general symptoms of which have been already enumerated; but it must be observed, that all the symptoms commonly attributed to worms, may be produced by a foulness of the bowels. Hence practitioners ought never to rest satisfied with administering to their patients such medicines as are possessed only of an anthelmintic quality, but to join them with those which are particularly adapted for cleansing the prime vis; as it is uncertain whether a foulness of the bowels may not be the cause of all the complaints. This practice is still the more advisable, on account of vicious humours in the intestines affording lodgement to the ova of worms; which, without the convenience of such a receptacle, would be more speedily discharged from the body.

The difficulty of curing what is called a worm fever, arises, according to Dr Mugrave, from its being frequently attributed to worms, when the cause of the disorder is of a quite different nature. He does not mean to deny that worms do sometimes abound in the human body, nor that the irritation caused by them does sometimes produce a fever; but he apprehends these cases to be much more uncommon than is generally imagined, and that great mischief is done by treating some of the disorders of children as worm cases, which are really not so. Dr Hunter is of the same opinion on this point. He has, we are told, dissected great numbers of children who have been supposed to die of worm fevers, and whose complaints were of course treated as proceeding from worms, in whom, however, there appeared, upon dissection, to be not only no worms, but evident proofs of the disorder's having been of a very different nature.

The spurious worm fever, as Dr Mugrave terms it, has, in all the instances he has seen of it, arisen evidently from the children having been indulged with too great quantities of fruit. Every sort of fruit eaten in excess will probably produce it; but an immoderate use of cherries seems to be the most common cause of it. The approach of this disorder has a different appearance, according as it arises from a habit of eating fruit in rather too large quantities, or from an excessive quantity eaten at one time. In the former case, the patient gradually grows weak and languid: his colour becomes pale and livid; his belly swells and grows hard; his appetite and digestion are destroyed; his nights grow restless, or at least his sleep is much disturbed with startings, and then the fever soon follows, in the progress of which, the patient grows comatose, and at times convolved; in which state, when it takes place to a high degree, he often dies. The pulse at the wrist, though quick, is never strong or hard; the carotids, however, beat with great violence, and elevate the skin so as to be distinctly seen at a distance. The heat is at times considerable, especially in the trunk; though at other times, when the brain is much oppressed, it is little more than natural. It is sometimes accompanied by a violent pain of the epigastric region, though more commonly the pain is slight, and terminates in a coma; some degree of pain, however, seems to be inseparable from it, so as clearly to distinguish this disorder from other comatose affections.

When a large quantity of fruit has been eaten at once, the attack of the disorder is instantaneous, and its progress rapid; the patient often passing, in the space of a few hours, from apparently perfect health, to a fluid, comatose, and almost dying state. The symptoms of the fever, when formed, are in both cases nearly the same; except that, in this latter fort, a little purulent matter is sometimes discharged, both by vomit. Diseases of mit and stool, from the very first day. The stools, in both cases, exhibit sometimes a kind of curd resembling curdled milk, at other times a floating substance is observed in them; and sometimes a number of little threads and pellicles, and now and then a single worm.

Strong purgatives, or purges frequently repeated, in this disorder, are greatly condemned by Dr Armstrong, as they in general not only aggravate the symptoms already present, but are sometimes the origin of convulsions. Bloodletting is not to be thought of in any stage of the disorder.

Although frequent purging, however, be not recommended, yet a single vomit and purge are advised in the beginning of the disorder, with a view to evacuate such indigested matter and mucus as happens to remain in the stomach and bowels. These having operated properly, there is seldom occasion for repeating them; and it is sufficient, if the body be cative, to throw up, every second or third day, a clyster, composed of some grains of aloes, dissolved in five or six ounces of infusion of chamomile.

The principal part of the cure, however, depends upon external applications to the bowels and stomach; and as the cause of the disorder is of a cold nature, the applications must be warm, cordial, and invigorating; and their action must be promoted by constant actual heat.

When any nervous symptoms come on, or remain after the disorder is abated, they are easily removed by giving a pill with a grain or two of asafoetida once or twice a-day.

The diagnostics of worms are very uncertain; but, even in real worm cases, the treatment above recommended would, it is imagined, be much more efficacious than the practice commonly had recourse to. As worms either find the constitution weakly, or very soon make it so, the frequent repetition of purges, particularly mercurials, cannot but have a pernicious effect. Bear's-foot is still more exceptionable, being in truth to be ranked rather among poisons than medicines. Worm feed and bitters are too offensive to the palate and stomach to be long persisted in, though sometimes very useful. The powder of coralline creates disgust by its quantity; and the infusion of pink root is well known to occasion now and then vertiginous complaints and fits.

Fomenting the belly night and morning with a strong decoction of rue and wormwood, is much recommended. It is a perfectly safe remedy, and, by invigorating the bowels, may therefore have some influence in rendering them capable of expelling such worms as they happen to contain. After the fomentation, it is advised to anoint the belly with a liniment, composed of one part of essential oil of rue, and two parts of a decoction of rue in sweet oil. It is, however, a matter of great doubt whether these external applications, in consequence of the articles with which they are impregnated, exert any influence on the worms themselves.

The diet of children disposed to worms should be warm and nourishing, consisting in part at least of animal food, which is not the worse for being a little seasoned. Their drink may be any kind of beer that is well hopped, with now and then a small draught of porter or negus. A total abstinence from butter is Medical, not so necessary, perhaps, as is generally imagined. Poor cheese must by all means be avoided; but such as is rich and pungent, in a moderate quantity, is particularly serviceable. In the spurious worm fever, the patient should be supported occasionally by small quantities of broth; and, at the close of it, when the appetite returns, the first food given should be of the kinds above recommended.

The diet here recommended will, perhaps, be thought extraordinary, as the general idea is at present, that, in the management of children, nothing is so much to be avoided as repletion and rich food. It is no doubt an error to feed children too well, or to indulge them with wine and rich sauces; but it is equally an error to confine them to too strict or too poor a diet, which weakens their digestion, and renders them much more subject to disorders of every kind, but particularly to disorders of the bowels. In regard to the spurious worm fever, if it be true that acid fruits too plentifully eaten are the general cause of it, it follows as a consequence, that a warm nutritious diet, moderately used, will most effectually counteract the mischief, and soonest restore the natural powers of the stomach. Besides, if the disorder does not readily yield to the methods here directed, as there are many examples of its terminating by an inflammation and suppuration of the navel, it is highly advisable to keep this probability in view, and, by a moderate allowance of animal food, to support those powers of nature, from which only such a happy crisis is to be expected.

Besides these, many other diseases might here be mentioned, which, if not peculiar to infants, are at least peculiarly modified by the infant state. But into details respecting these we cannot propose to enter. It is sufficient to say, that due regard being paid to age and constitution, the cure is to be conducted on the same general principles as in the adult state.

MEDICAL JURISPRUDENCE.

During the progress of science in Europe this subject has not been altogether neglected. But we may safely venture to assert, that even from many enlightened governments it has hitherto claimed much less attention than its importance merits. At the British universities this has been too much the case. It is indeed true, that for near 20 years a few lectures on this subject have been delivered at the university of Edinburgh, by the professor of the institutions of medicine. But he could by no means consider the subject on that extensive scale which its importance merited. And he had often expressed his regret, that, as in several of the foreign universities, a professorship had not been instituted for the express purpose of giving a course of lectures on medical jurisprudence. That defect, however, in medical education at Edinburgh is now supplied. When that able and upright statesman Lord Grenville, to whom every thing that regarded the laws of his country was an object of peculiar attention, was at the head of his majesty's councils, a regius professorship of juridical and political medicine was established in the university of Edinburgh by a royal warrant. Appendix.

Medical Jurisprudence. And there is every reason to hope, that this appointment will be attended with many effects highly beneficial to the nation.

A short view of the extent and importance of this subject will, we presume, not be unacceptable to the intelligent reader.

Whatever aid the science of medicine can contribute towards the good of the state, and the execution of its laws, has been by the Germans denominated State Medicine; a new, but not improper, appellation, for that branch of knowledge which many writers have termed Medical Jurisprudence.

It comprehends both medical police and juridical medicine. The former consists of the medical precepts which may be of use to the legislature or to the magistracy. The latter is the aggregate of all the information, afforded by the different branches of medicine, which is necessary for elucidating doubtful questions in courts of law.

Although there are some traces of juridical medicine in the Justinian code; such as determining the real period of birth, with a view to prevent the impostion of spurious children: it properly originated with the code of laws enacted by the emperor Charles V. under the name of Constitutio criminalis Carolina; in which it is ordained, that the opinions of physicians should be taken, with regard to the danger of wounds, child-murder, murder, poisoning, procured abortion, concealed pregnancy, &c. These directions, and the impossibility which was found of determining many questions by simply legal means, induced some legislators to enjoin, that all tribunals and judges should procure from sworn physicians, appointed to this office, their opinions concerning all the subjects to be mentioned hereafter.

Since that time, it has been treated systematically by many learned men; such as Fortunatus Fidelis, Zacchias, Alberti, Hohenfretit, Haller, Ludwig, Plenck; and lastly, in the most masterly manner, by Metzger. Numberless dissertations have been written on all its parts; and among those who contributed to its advancement, we may reckon Ambrofe Parry, Bohn, Butener, Morgagni, Camper, and Gruner. Collections of cases, illustrating its principles, have been made by Amman, Daniel, Bucholz, Pyl, Scherf and Metzger. These are only a few of the principal writers who have attended to this science: to enumerate more would be unnecessary.

From its very nature, it is evident how necessary a knowledge of this science must be to every medical practitioner, who is liable to be called upon to illustrate any question comprehended under it before a court of justice. On his answers, the fate of the accused person must often depend; both judge and jury regulating their decision by his opinion. On the other hand, while he is delivering his sentiments, his own reputation is before the bar of the public. The acuteness of the gentlemen of the law is universally acknowledged; the veracity of their genius, and the quickness of their apprehension, are rendered almost inconceivable, by constant exercise. It is their duty to make every possible exertion for the interest of their client, and they seldom leave unnoticed any inaccurate or contradictory evidence. How cautious must, then, a medical practitioner be, when examined before such men, when it is their duty to expose his errors, and magnify his uncertainties, till his evil judgment seem contradictory and absurd? How often must he expose himself to such severe criticism, if he be not master of the subject on which he is giving evidence, and have not arranged his thoughts on it according to just principles? On the other hand, he may deserve and gain much credit, by so public a display of judgment and professional knowledge.

Some acquaintance with this part of medical science must be useful at least, and sometimes necessary, to judges and lawyers. They will thus be enabled to estimate how much they may depend on the opinion of any physician, and will know how to direct their questions, so as to arrive at the truth, and avoid being misled by his partiality or favourite opinions. To the lawyer who conducts the defence of an accused person, in a criminal case, it is almost indispensable; without it, he cannot do justice to the cause of his client.

Before criminal courts, the questions which occur most generally are, respecting

1. The cause of death, as ascertained from the examination of the body. 2. The sufficiency of the supposed cause to have produced death. 3. Probable event of wounds, contusions, &c. 4. The importance of the part injured. 5. Supposed child-murder; whether still-born or not. 6. Whether death accidental or intended. 7. Abortion; its having occurred, 8. Spontaneously, from habit; accidentally, from external violence or passions of the mind; or intentionally, from the introduction of a sharp instrument, use of certain drugs, &c. 9. Rape; its being attempted or consummated; recent or previous defloration. 10. The responsibility of the accused for his actions.

Before civil courts the questions generally regard,

1. The state of mind; madness, melancholy, idiocy. 2. Pregnancy; concealed, pretended. 3. Parturition; concealed, pretended, retarded, premature. 4. The first-born of twins. 5. Diseases; concealed, pretended, imputed. 6. Age and duration of life.

Before consistorial courts, the subjects investigated are,

1. Impotence; general, relative, curable, incurable. 2. Sterility; curable, relatively incurable, absolutely incurable. 3. Uncertainty of sex; hermaphrodites. 4. Diseases preventing cohabitation; venereal disease, leprosy, &c.

MEDICAL POLICE.

Of incomparably greater consequence, and more widely extended influence, is the second division of this subject. It regards not merely the welfare of individuals, but the prosperity and security of nations. It is perhaps the most important branch of general police; for its influence is not confined to those whom accidental circumstances bring within its sphere, but extends over the whole population of the state. Many of its principles have been long acknowledged, and considered as necessary consequences of medical and political truths; and some few of them have acquired the authority of laws. But it was reserved for the philanthropic Frank, to collect the whole into one vast and beneficent system, and to separate it from juridical medicine; in the old systems of which, it was neglected, or mentioned only in a few short paragraphs. His enlarged mind perceived at once, and fully vindicated its importance. The very name of Medical Police, is now sufficient to attract the attention of legislators and of magistrates, and to make them desirous of becoming acquainted with its principles, and anxious to see them carried into execution. In fact, its influence is already visible in the countries where it is cultivated. If the principles of medical police were separated from the professional part of medicine, and communicated in a form generally intelligible, in what country have we reason to expect more beneficial effects from its influence than this? Where is the spirit of patriotism and benevolence so prevalent? What nation is more generous in its public institutions. Where does the individual sacrifice a part of his wealth so willingly for the benefit of the community? It seems only necessary to prove that an undertaking will be of advantage to the state, to have it carried into instant execution. But, can medical knowledge be more usefully employed than in pointing out the means of preserving or improving health; or supplying healthy nourishment to the poor, especially in times of scarcity; of opposing the introduction of contagious diseases, and of checking their progress; of securing to the indigent the advantages intended by their benefactors; of rearing the orphan to be the support of the nation which has adopted him; and of diminishing the horrors of confinement to the poor maniac and the criminal? These good effects are not to be promoted so much by rigid laws, as by recommendation and example. Nor can it be reasonably objected to a system of medical police, that it is a pleasing dream, which flatters the imagination, but the execution of which is in reality impracticable. As well might we entirely throw aside the rules of humanity, because no one is able to observe them all; or live without laws, because no existing code is unexceptionable.

Medical police may be defined,—The application of the principles deduced from the different branches of medical knowledge, for the promotion, preservation and reformation of general health.

The effects to be expected from it are the general welfare of the state, and increase of healthy population; and are to be attained by means of public institutions, express laws, and popular instruction. Instructing the people, and convincing them of the propriety of certain precautions and attentions, in regard to their own and the general state of health, are necessary to secure the good effects of our public institutions and regulations; to obtain respect and obedience in many things, to which no express law can be adapted; and, to induce them to forego what may be prejudicial to the safety of the community, and of themselves.

Public medical institutions and laws, must be adapted to the country for which they are intended. Many local circumstances, national character, habits of life, prevalent customs and professions, situation, climate, &c., make considerable varieties necessary. And many institutions, many a law which would be highly beneficial to the public health, in some circumstances, would be useless, impracticable, and even hurtful, in others. These causes and their effects, must, therefore, be particularly attended to.

The principal authors who have written on this subject, are Alberti, Heitler, Plaz, Frank, Huffly, Metzger, and Hebenfrecit; to whom we may add Howard and Rumford

The subjects which it comprehends, cannot be clasped very regularly or systematically. Its views will be different, according to occasional and temporary causes; and its interference may sometimes be advantageously extended beyond what may seem the strict limits of a branch of the medical profession.

MEDICAL POLICE RELATES TO

THE SITUATION OF PLACES OF ABODE. Construction of houses.

AIR. Means of counteracting its impurity—Its various impregnations.

WATER. Its necessity and purity.

FOOD. Its various kinds—Comparative quantities of nourishment afforded by them—Cheaper kinds, which may be safely substituted in times of scarcity—Bread—Animal food—Butcher meat—Fish—Vegetables—Vessels Cookery; Healthy; Economical.

DRINK. Beer—Ale—Porter—Cyder—Spiritous liquors—Wine—Warm drinks—Adulterations of these liquors—Hurtful additions—Vessels.

FIRE and LIGHT.

CLOTHING.

CLEANLINESS.

PROFESSIONS. Manufacturers—Mechanics—Soldiers—Sailors—Men of letters.

HEALTHY PROPAGATION.

PREGNANT and Puerperal Women.

NEW-BORN INFANTS. Registers of birth.

PHYSICAL EDUCATION.

PREVENTION of ACCIDENTS. From poison—Hurtful Effluvia—Maniacs—Rabid animals.

RESTORATION of the APPARENTLY DEAD. Humane Societies—Care of the dying—Danger of too early—too late burial—Places of interment—manner of conducting it—Bills of mortality.

CONTAGIOUS and EPIDEMIC DISEASES. Plague—Putrid fever—Dysentery—Smallpox—Inoculation—Extirpation of them—Leprosy—Itch and pox—Precautions to be taken, to prevent their introduction, to diminish their violence, to destroy their cause, and to counteract their effects.

MANAGEMENT of PUBLIC INSTITUTIONS in which many people are collected under the care of the public.

Hospitals for the Indigent: 1. Lying-in Hospitals. 2. Foundling ditto. 3. Orphan ditto. 4. Hospitals for Education. Appendix.

Means of preserving Health.

5. Aged. 6. Blind. 7. Maimed.

Military Hospitals: Prisoners of War. Lazarettos. Work-houses. Prisons.

Hospitals for the Sick. Maniacs. Convalescents. Incurables.

Observations on the Means of preserving Health.

Having now treated of all the most important diseases to which the human body is subjected, we shall conclude the article MEDICINE, with a few observations on the means of preserving health, both for the general management of valetudinarians, and of those also who wish to obtain long life and good health by avoiding the causes of those diseases which the human species often bring upon themselves. On this subject much has been written at almost every period of medicine. And we may refer those readers who wish for a full and extensive view of this interesting subject to a very elaborate work lately published by Sir John Sinclair, Bart. entitled the Code of Health and Longevity. Here we cannot propose to give even an abridged view of this extensive inquiry; but must content ourselves with offering only a very few general observations.

I. RULES for the Management of VALETUDINARIANS.

That part of the medical system which lays down rules for the preservation of health, and prevention of diseases, termed Hygienne, is not to be strictly understood as if it respected only those people who enjoy perfect health, and who are under no apprehensions of disease, for such seldom either desire or attend to medical advice; but is rather considered as relating to valetudinarians, or such as, though not actually sick, may yet have sufficient reason to fear that they will soon become so: hence it is that the rules must be applied to correct morbid dispositions, and to obviate various particulars which were shown to be the remote or possible causes of diseases.

From the way in which the several temperaments are commonly mentioned by hygienic writers, it should seem as if they meant that every particular constitution might be referred to one or other of the four; but this is far from being the case, since by much the greater number of people have temperaments so indistinctly marked, that it is hard to say to which of the temperaments they belong.

When we actually meet with particular persons who have evidently either, 1. Too much strength and rigidity of fibre, and too much sensibility; 2. Too little strength, and yet too much sensibility; 3. Too much strength, and but little sensibility; or, 4. But little sensibility joined to weakness; we should look on such persons as more or less in the valetudinary state, who require that these morbid dispositions be particularly watched, lest they fall into those diseases which are connected with the different temperaments.

People of the first-mentioned temperament being liable to suffer from continued fevers, especially of the inflammatory species, their scheme of preserving health should consist in temperate living, with respect both to diet and exercise; they should studiously avoid immoderate drinking, and be remarkably cautious lest any of the natural discharges be checked. People of this habit bear evacuations well, especially bleeding: they ought not, however, to lose blood but when they really require to have the quantity lessened; because too much of this evacuation would be apt to reduce the constitution to the second-mentioned temperament, in which strength is deficient, but sensibility redundant.

Persons of the second temperament are remarkably prone to suffer from painful and spasmodic diseases, and are easily ruffled; and those of the softer sex who have this delicacy of habit, are very much disposed to hysterical complaints. The scheme here should be, to strengthen the solids by moderate exercise, cold bathing, cinchona, and chalybeate waters; particular attention should constantly be had to the state of the digestive organs, to prevent them from being overloaded with any species of tubera which might engender flatus, or irritate the sensible membranes of the stomach and intestines, from whence the disorder would soon be communicated to the whole nervous system. Persons of this constitution should never take any of the drastic purges, or strong emetics; neither should they lose blood but in cases of urgent necessity. But a principal share of management, in these extremely irritable constitutions, consists in avoiding all sudden changes of every sort, especially those with respect to diet and clothing, and in keeping the mind as much as possible in a state of tranquillity: hence the great advantages which people of this frame derive from the use of medicinal waters drank on the spot, on account of that freedom from care and ferious blemishes of every kind, which generally obtains in all the places planned for the reception of valetudinarians.

The third-mentioned temperament, where there is an excess of strength and but little sensibility, does not seem remarkably prone to any distempering or dangerous species of disease; and therefore it can hardly be supposed that persons so circumstanced will either of themselves think of any particular scheme of management, or have recourse to the faculty for their instructions: such constitutions, however, we may observe, bear all kinds of evacuations well, and sometimes require them to prevent an over-fulness, which might end in an oppression of the brain or some other organ of importance.

But the fourth temperament, where we have weakness joined to want of sensibility, is exceedingly apt to fall into tedious and dangerous diseases, arising from a defect of absorbent power in the proper sets of vessels, and from languor of the circulation in general: whence corpulency, droopy, jaundice, and different degrees of febrile affection. In order to prevent these, or any other species of accumulation and deprivation of the animal fluids, the people of this constitution should use a generous course of diet, with brisk exercise, Means of exercise, and be careful that none of the secretions be interrupted, nor any of the natural discharges suppressed.

These constitutions bear purging well, and often require it; as also the use of emetics, which are frequently found necessary to supply the place of exercise, by agitating the abdominal viscera, and are of service to prevent the stagnation of bile, or the accumulation of mucous humours, which hinder digestion, and clog the first passages. The free use of mustard, horseradish, and the like sort of stimulating dietetics, is serviceable in these torpid habits.

When the general mass of fluids is increased beyond what is conducive to the perfection of health, there arises what the writers term a plethora, which may prove the source of different diseases; and therefore, when this overfullness begins to produce languor and oppression, care should be taken in time to reduce the body to a proper standard, by abridging the food and increasing the natural discharges, using more exercise, and indulging less in sleep.

But in opposite circumstances, where the fluids have been exhausted, we are to attempt the prevention of further waste by the use of strengthening stomachics, nourishing diet, and indulgence from fatigue of body or mind.

Vitiated fluids are to be considered as tainted either with the different kinds of general acrimony, or as betraying signs of some of the species of morbid matter which give rise to particular diseases, such as calculus, scurvy, &c.

During the state of infancy, we may sometimes observe a remarkable acidity, which not only shows itself in the first passages, but also seems to contaminate the general mass of fluids. As it takes its rise, however, from weak bowels, our views, when we mean to prevent the ill consequences, must be chiefly directed to strengthen the digestive organs, as on their soundness the preparation of good chyle depends; and hence small doses of rhubarb and chalybeates (either the natural chalybeate waters mixed with milk, or the murias ammoniae et ferri in doses of a few grains, according to the age of the child), are to be administered; and the diet is to be so regulated as not to add to this acid tendency: brisk exercise is likewise to be enjoined, with frictions on the stomach, belly, and lower extremities.

Where the fluids tend to the putrefactive state, which shows itself by fetid breath, sponginess and bleeding of the gums, a bloated look and livid cast, the diet then should be chiefly of fresh vegetables and ripe fruits, with wine in moderation, due exercise, and strengthening bitters.

Where acrimony shows itself by itching eruptions, uncommon thirst, and flushing heats, nothing will answer better than such sulphureous waters as the Harrogate and Moffat, at the same time using a course of diet that shall be neither acrid nor heating.

So far with respect to those kinds of morbid matter which do not invariably produce a particular species of disease: but there are others of a specific nature, some of which are generated in the body spontaneously, and seem to arise from errors in diet, or other circumstances of ill management with respect to the animal economy; and hence it is sometimes possible, to a certain degree if not altogether, to prevent the ill consequences. Thus, there are instances where returns of the gout have been prevented by adhering strictly to a milk diet.

The rheumatism has also been sometimes warded off by wearing a flannel shirt, or by using the cold bath without interruption.

Calculus may be retarded in its progress, and prevented from creating much distress, by the internal use of soap and lime-water, by soap-les taken in milk or in veal-broth, or by the use of aerated alkaline water, which may perhaps be considered as being both more safe and more efficacious, and at the same time more pleasant, than any of the other practices.

The scurvy may be prevented by warm clothing and perseverance in brisk exercise, by drinking wine or cider, and eating freely of such vegetable substances as can be had in those situations where this disease is most apt to show itself.

In constitutions where there is an hereditary disposition to the scrophula, if early precautions be taken to strengthen the solids by cold bathing, a nourishing course of diet, and moderate use of wine, the constitution which gives rise to the disease will probably be prevented from producing any very bad effects.

The other kinds of morbid matter, which are of the specific nature, are received into the body by infection or contagion.

The infection of a putrid fever or dysentery is best prevented by immediately taking an emetic on the first attack of the sickness or shivering; and if that do not completely answer, let a large blister be applied between the shoulders: by this method the nurses and other attendants on the sick in the naval hospitals have often been preserved. As to other infectious morbid matter, we must refer to what has already been said when treating of hydrophobia, poisons, gonorrhoea, &c.

The ill effects which may arise from the different species of saburra, are to be obviated, in general, by the prudent administration of emetics, and carefully abstaining from such kinds of food as are known to cause the accumulation of noxious matters in the first passages.

Crude vegetables, milk, butter, and other oily substances, are to be avoided by persons troubled with a sourness in the stomach; brisk exercise, especially riding, is to be used, and they are to refrain from fermented liquors: the common drink should be pure water; or water with a very little of some ardent spirit, such as rum or brandy. Seltzer and Pyrmont waters are to be drunk medicinally; and aromatic bitters, infusions, or tinctures, acidulated with sulphuric acid, will be found serviceable, in order to strengthen the fibres of the stomach, and promote the expulsion of its contents, thereby preventing the too hasty fermentation of the alimentary mixture. In order to procure immediate relief, magnesia alba, or creta preparata, will seldom fail; the magnesia, as well as the chalk, may be made into lozenges, with a little sugar and mucilage; and in that form may be carried about and taken occasionally by people afflicted with the acid saburra.

In constitutions where there is an exuberance or flagration of bile, and a troublesome bitterness in the mouth, it is necessary to keep the bowels always free, by taking occasionally small doses of pure aloes, oleum risini, Appendix.

Means of preserving Health.

ricini, supertartrite of potas, some of the common purging salts, or the natural purging waters.

When there is a tendency to the empyreumatic and rancid faubura, people should carefully avoid all the various kinds of those oily and high-leafloned articles of diet generally termed made-difter, and eat sparingly of plain meat, without rich sauces or much gravy; and in these cases the most proper drink is pure water.

II. RULES for those who enjoy perfect HEALTH.

There can be no doubt, that, in general, temperance is the true foundation of health; and yet the ancient physicians, as we may see in the rules laid down by Celsus, did not scruple to recommend indulgence now and then, and allowed people to exceed both in eating and drinking; but it is farer to proceed to excess in drink than in meat; and if the debauch should create any extraordinary or distressing degree of pain or sickness, and a temporary fever should ensue, there are two ways of shaking it off, either to lie in bed and encourage perspiration, or to get on horseback, and by brisk exercise restore the body to its natural state. The choice of these two methods must always be determined by the peculiar circumstances of the parties concerned, and from the experience which they may before have had which agrees best with them.

If a person should commit excess in eating, especially of high-leafloned things, with rich sauces, a draught of cold water, acidulated with sulphuric acid, will take off the sense of weight at the stomach, and assist digestion by moderating and keeping within bounds the alimentary fermentation, and thus preventing the generation of too much flatus. The luxury of ices may be here of real service at the tables of the great, as producing similar effects with the cold water acidulated. Persons in these circumstances ought not to lay themselves down to sleep, but should keep up and use gentle exercise until they are sensible that the stomach is unloaded, and that they no longer feel any oppressive weight about the precordia.

If a man be obliged to fast, he ought, if possible, during that time, to avoid laborious work: after suffering severe hunger, people ought not at once to gorge and fill themselves; nor is it proper, after being overfilled, to enjoy an absolute fast: neither is it safe to indulge in a state of total rest immediately after excessive labour, nor suddenly fall hard to work after having been long without motion: in a word, all changes should be made by gentle degrees; for though the constitution of the human body be such that it can bear many alterations and irregularities without much danger, yet, when the transitions are extremely sudden, there is a great risk of producing some degree of disorder.

It is also the advice of Celsus to vary the scenes of life, and not confine ourselves to any settled rules: but as inaction renders the body weak and little, and exercise gives vigour and strength, people should never long omit riding, walking, or going abroad in a carriage. Fencing, playing at tennis, dancing, or other similar engagements, which afford both exercise and amusement, as each shall be found most agreeable or convenient, are to be used in turn, according to the circumstances and tendency to any particular species of disease. But when the weakness of old age shall have rendered the body incapable of all these, then dry frictions with the flesh-brush will be very requisite to preserve health, by accelerating the flow of humours through the smallest orders of vessels, and preventing the fluids from stagnating too long in the cellular interstices of the fleshy parts.

Sleep is the great restorer of strength; for, during this time, the nutritious particles appear to be chiefly applied to repair the waste, and replace those that have been abraded and washed off by the labour and exercise of the day; but too much indulgence in sleep has many inconveniencies, both with respect to body and mind, as it blunts the senses, and encourages the fluids to stagnate in the cellular membrane; whence corpulency, and its necessary consequences languor and weakness.

The proper time for sleep is the night, when darkness and silence naturally bring it on: sleep in the daytime, from noise and other circumstances, is in general not so found or refreshing; and to some people is really distresful, as creating an unusual giddiness and languor, especially in persons addicted to literary pursuits. Custom, however, frequently renders sleep in the day necessary; and in those constitutions where it is found to give real refreshment, the propensity to it ought to be indulged, particularly in very advanced age.

With regard to the general regimen of diet, it has always been held as a rule, that the softer and milder kinds of aliment are most proper for children and younger subjects: that grown persons should eat what is more substantial; and old people lessen their quantity of solid food, and increase that of their drink both of the diluent and cordial kind.

INDEX.

A. Adipsia, Gen. 108. 376 Ageustia, Gen. 99. 366 Amaurosis, Gen. 93. 360 Amenorrhoea, Gen. 126. 402 Amentia, Gen. 65. 326 Anaphrodisia, Gen. 109. 377 Anasarca, Gen. 75. 339 Anesthesia, Gen. 100. 366

Anorexia, Gen. 107. Anosima, Gen. 98. Aphonia, Gen. 110. Aphtha, Gen. 35. Apollexia, Gen. 42. Arthropoisis, Gen. 25. Ascites, Gen. 79. Asthma, Gen. 55. Atrophia, Gen. 70.

No 375 Abortus, Abscess of the lungs, Acute rheumatism, Acrimony of the blood, Adynamie, Egyptian physicians, Aesculapius, Eutius, Alexander,

No 247 186 205 103 271 2 4 43 44

Amenita, Amentia, 326 Amphimerina cardiaca, paludosa, 151 Anaphrodisia, 152 Angina pectoris, 377 Animal fat, 403 Anxiety, 72 Apocenofers, 76 Apoplexy, sanguineous, ferous, 385 hydrocephalic, 256 Appearance of the venereal disease, 257 Arabians, 53 Arthrosynia, 46 Asclepiades, 209 Atomic gout, 35 Bulima, Gen. 101. Bafford pleurify, 369 Bleeding at the nose, 208 Bloody flux, 235 Bronks, 254 Buff-coloured crust on the blood, 182 Burning fever, 99 C. Caligo, Gen. 92. Carditis, Gen. 13. Catarhuss, Gen. 40. Chlorosis, Gen. 47. Cholera, Gen. 60. Chorea, Gen. 51. Colica, Gen. 59. Contractura, Gen. 115. Convulso, Gen. 50. Cynanche, Gen. 10. Cystitis, Gen. 20. Cachexie, Canine appetite, madnefs, 322 Cardiac syncope, 273 Catalepsis, 263 Cataract, 359 Catarrh, from cold, 251 from contagion, 253 Causes of affections of the solids, 70 Caufue, 140 Celsus, 40 Cellular texture, 71 Cephalalgia, 405 Chemical analysis of the animal folid, 68 Chickenpox, 226 Childbed fever, 404 Children, discares of, 410 Chincough, 299 Cholera, 308 f spontaneous, 309 accidental, 310 Chronic rheumatism, 209 Circulation, 95 Coeliac passion, 315 College of Salernum, 48 Confirmed phthisis, 239 Continued fevers, 164 Constantine, 49 Consumption, pulmonary, 237 No 326 Convulsive tertian, Corpuency, 151 Coffirence, 152 Cough, 377 Cowpox, 403 Group, 72 D. Diabetes, Gen. 62. Diarrhoea, Gen. 61. Dyscoea, Gen. 96. Dysenteria, Gen. 41. Dysopia, Gen. 94. Dyspepsia, Gen. 45. Dyspermatismus, Gen. 125. Dyspnœa, Gen. 56. Dysuria, Gen. 124. Deafness, 369 Debility, 84 Delirium, 208 Difficulty of discharging urine, 235 Digestion, 254 depraved, Discovery of the circulation, 99 Diseases from accidents, 140 from passions of the mind, 359 from age and sex, 188 from climate, 251 in the muscular power, 277 Distillation of diseases, 301 Division of the functions, 284 Double quartan, 384 Dropfy, 283 of the brain, 176 of the breast, 201 of the abdomen, 330 of the uterus, 369 of the scrotum, 322 Dumbness, 273 Duplicated quartan, tertia, 263 Dysarthre, 359 Dyscinejie, 251 Dysentery, 253 Dysorexia, 70 Dyspermatismus, 140 E. Elephantiasis, Gen. 87. Enteritis, Gen. 16. Enuresis, Gen. 120. Ephidrosis, Gen. 117. Epilepsia, Gen. 53. Epiphora, Gen. 118. Epistaxis, Gen. 36. Erysipelas, Gen. 26. Emphysema, 309 Empirics, 310 Empyema, 209 Epilepsy, 95 Epilephes, 315 Erafhbratus, 48 Eruptive tertian, 239 Erythema, 164 Exanthemata, 49 Excessive perspiration, 237 No 133 Excessive thirst, Excessive cause of diseases, 335 F. Framboesia, Gen. 89. 108, 393 Fainting, 105 False appetite, 224 Febres, 180 Feeling, 318 depraved, 311 Fever, continued, 363 remittent, 254 intermittent, 361 scarlet, 275 childbed, 401 Flooding, 292 Flour albus, 399 Favor uterinus, 303 G. Gastritis, Gen. 15. 91 Gonorrhoea, Gen. 121. 84 Galen, 107 Gont, 275 Greek physicians, 55 Green sickness, 65 Gutta serena, 66 H. Haemoptysis, Gen. 37. 64 Haemorrhoides, Gen. 38. 87 Hepatitis, Gen. 17. 57 Hydrocele, Gen. 81. 56 Hydrocephalus, Gen. 76. 156 Hydrometra, Gen. 80. 128 Hydrophobia, Gen. 64. 339 Hydrorachitis, Gen. 77. 258 Hydrothorax, Gen. 78. 342 Hyponchondriasis, Gen. 46. 343 Hysteria, Gen. 63. 344 Hystérites, Gen. 21. 345 Haemorrhagia, 380 Hearing, 154 depraved, 129 Heartburn, 358 Helic fever, 378 Hemiplegia, 254 Hepatic flux, 368 Hereditary diseases, 401 Herophilus, 352 Hippocrates, 195 Hoopingcough, 390 Hydrocephalic apoplecty, 286 I. Icterus, Gen. 91. 388 Ischuria, Gen. 123. 235 Idioifm, 86, 326 Iliae passion, 218 Impetigines, 336 Incipient phthisis, 187 Incontinence of urine, 286 Incubus, 392 Inflammation of the bladder, 31 of the brain, 176 of the heart, 188 of the intestines, 193 of the kidney, 200 of the liver, 198 Inflammation Index.

Inflammation of the lungs, of the mesentery, of the omentum, of the peritoneum, of the spleen, of the stomach, of the uterus,

Inflammatory tertian, Inoculation, Intermittent, Intumescientia, Irregular tertian, Itching, Jaundice, Jew's physicians, King's evil, Lepra, Gen. 88. Leucorrhaea, Liavery, Locules, Lochial discharge, immoderate, Locked jaw, Loosefet, Loss of voice, Lues venera, Lumbago,

Mania, Gen. 67. Melancholia, Gen. 66. Menorrhagia, Gen. 39. Miliaria, Gen. 31. Mutitas, Gen. III. Madness, melancholy, furious, Malignant sore throat, Marcores, Measles, Melancholy and mania, Melane, Memory, Menses, immoderate flow of, Methodical feet, Misplaced gout, Mobility, Moderns, Morbid thinness of the blood, thickness of the blood, Mumps,

Nephritis, Gen. 19. Nostalgia, Gen. 106. Nymphomania, Gen. 105. Nausea, Nettle rash, Nervous consumption, fever, Nightmare, Nirles,

Obstipatio, Gen. 122. Odontalgia, Gen. 23. Oneirodynia, Gen. 68.

No 183 OPHTALMIA, Gen. 8. 191 Olfactory perforation, 190 Occasional lyncope, 189 Oesophagus, dangerous affection of, 199 Orbitalis, 192 Origin of diseases, 204 P. 135 PALPITATIO, Gen. 54. 225 PARACUSIS, Gen. 97. 125 PARALYSIS, Gen. 43. 334 PARAPHONIA, Gen. 112. 127 PEMPHIGUS, Gen. 34. 77 PERITONITIS, Gen. 14. 336 PERTUSIS, Gen. 57. 1 PESTIS, Gen. 27. 349 PHLOGOSIS, Gen. 7. 353 PHRENITIS, Gen. 9. 250 PHYSCONIA, Gen. 82. 316 PICA, Gen. 103. 357 PNEUMATOSIS, Gen. 72. 248 PNEUMONIA, Gen. 11. 280 POLYDIPSIA, Gen. 102. 109 POLYSARCA, Gen. 71. 379 PROFUSIO, Gen. 116. 350 PSEUDOBLEPSIS, Gen. 95. 206 PSELLISMUS, Gen. 113. 328 PYRISIS, Gen. 58. 327 Pain, 245 Palpitation, 229 Palsy, 386 from poisons, 327 Paracelsus, 328 Paraplegia, 179 Peripneumonia, 331 Phlegmasia, 227 Phlegmone, 85 Phthisis, 409 Pilae, 83 external, 246 from a proedientia ani, 36 running, 215 blind, 88 Plague, 54 Plethora, 101 Plica polonica, 102 Pleuritis, 182 Podagra, 200 Poisons, 374 Praxagoras, 373 Predyphont caule, 112 Proximate caule, 231 Puerperal fever, 333 Pulmonary consumption, 166 Pulsatior of the arteries, 329 Putrid fever, 228 Pyrexie,

No 174 Qualities of the animal folids, 115 Quartan with symptoms of other dif- eases, 274 complicated with other dif- eases, 306 Quotidian, genuine, 42 partial, 62 remitting, 130 Quotidiana deceptiva, R. 347 Rachitis, Gen. 83. 285 Raphania, Gen. 52. 205 Rheumatismus, Gen. 22. 227 Rubiola, Gen. 30. 212 Regular gout, 138 Remittent tertian, 160 Remitting quartan, 104 Respiration, 214 Retrocedent gout, 206 Rheumatism in the loins, 207 in the hip-joint, 208 in the thorax, 47 Rhazes, 347 Rickets, 414 Rules for preserving health, 413 for valetudinarians, S. 372 Satyrasis, Gen. 104. 203 Scarlatina, Gen. 32. 351 Scorbutas, Gen. 86. 349 Scrophula, Gen. 84. 350 Sphyllis, Gen. 85. 199 Splenitis, Gen. 18. 383 Strabismus, Gen. 114. 272 Syncope, Gen. 44. 163 Synocha, Gen. 4. 168 Synochus, Gen. 6. 218 St Anthony's fire, 284 St Vitus's dance, 256 Sanguineous apoplexy, 389 Sublotion, 207 Sciatica, 122 Sicirhus, 351 Scurvy, ib. 401 Semen, difficult emission of, 131 Semi-tertian, 34 Seration, 257 Serous apoplexy, 81 Sight, 94 Sleep, 132 Sleepy tertian, 222 Smallpox, 223 distinct, 224 confluent, 225 inoculated, 79 Smell, 365 Smelling, depraved, 106 Sneezing, 39 Soranus, 93 Spasm, 278 Spasmodic colic, 133 tertian, Spina Spina bifida, Spitting of blood, Squibious tertian, Stone in the bladder, Strangury, State of medicine in the 15th and 16th centuries, in the 17th and 18th centuries, Suppression of menses, of urine, Sweating sickness, Symptoms of disease,

T. TABES, Gen. 69. TERTIANA, Gen. 1. TETANUS, Gen. 48. TRICOMA, Gen. 90. TRISMUS, Gen. 49. TYMPANITES, Gen. 73. TYPHUS, Gen. 5. Taile, Toiling, depraved, Tenebrus,

No. 341 236 127 400 119 50 54 402 117, 394 51 58

Tertian complicated with other disorders, varied from its origin, Themifon, Theflalus, Thrajb, Toothach, Turpor, Tremor, Triple quartan, Triplicated quartan, Triple tertian, Triteophya Americana, apodcs, carotica, deceptiva, elodes, leipyrja, fynccopaljs, typhodes, vratillavienfis, U.

No. 136 137 37 38 233 210 90 270 157 155 130 148 144 145 147 143 146 139 142 141

VARICELLA, Gen. 29. VARIOLA, Gen. 28. Vaccine inoculation, Variolodes, Venereal disease, Vertigo, Vefunia, Vigour, Vis medicatrix naturae, Vifon depraved, Vital todls, Vonica,

No. 226 222 224 228 350 82 325 80 67 361 73 186 375 376 333 300 349 259 407 354 168

GENUS LXVII. MANIA.

RAVING or FURIOUS Madness.

Mania, Sauv. gen. 235. Lin. 68. Vog. 331. Sag. 349. Boerh. 1118. Junck. 122. Battie on Madness. Paraphroyne, Lin. 66. Although these distempers may be considered as distinct genera, yet they are so nearly allied, and so readily change into each other, that it sufficiently justifies the treating all of them together.

The distinguishing characteristic of madness, according to Dr Bathe, is a false perception; and under this general character may be comprehended all kinds of what is called madness, from the most filthy stupidity and idiotsim to the most furious lunacy. Frequently the different kinds of madness are changed into each other by the casual excitement of some passion: thus, an idiot may become furiously mad, by being put in a violent passion; though this does not so often happen as the change of melancholy into the raving madness, and vice versa.

It is a very surprising circumstance, that mad people are not only less liable to be seized with infectious disorders than those who are in perfect health; but even when labouring under other diseases, if the patients chance to be seized with madness, they are sometimes freed from their former complaints. Of this kind Dr Mead relates two very remarkable instances.

On the other hand, it has been known, that an intermittent fever, supervening upon madness of long standing, has proved a cure for the madness; the fevers having returned when the fever terminated. Dr Monro saw two instances of this himself; and mentions it as an observation made also by his predecessor in the care of Bethlehem hospital.

Another remarkable circumstance is, that immoderate joy, long continued, as effectually disorders the mind as anxiety and grief. For it was observable in the famous South Sea year, when so many immense fortunes were suddenly gained, and as suddenly lost, that more people had their heads turned, from the prodigious flow of unexpected riches, than from the entire loss of their whole substance.

Mad people, especially of the melancholic kind, sometimes obstinately persevere in doing things which must excite great pain; whence it should seem as if their minds were troubled with some distracting notions, which make them patiently bear the present distresses, left more severe tortures should be inflicted; or possibly they may think, that, by thus tormenting the body, they render themselves more acceptable to the divine Being, and expiate the heinous sins of which they may imagine themselves to have been guilty.

It is, however, also highly probable that their feelings differ exceedingly from what they are in a natural state; at least they are every day observed to endure, apparently without the smallest uneasiness, watching, hunger, and cold, to an extent which in a state of health would not only be highly distressing, but to the greater part of individuals would even prove fatal. And this resistance of hunger, cold, and sleep, affords perhaps the best test for distinguishing cases of real insanity, from cases where the disease is only feigned, and appearances of it put on, to answer particular purposes; at least where this power of resistance is present, we have good reason to conclude that the affection is not feigned.

Cure. Although we be well acquainted with many of the remote causes of this disease, some of the principal of which have already been mentioned, yet we are still so ignorant of the influence of these upon the system, as giving a derangement of the mental faculties, that no general principles on which the cure may be conducted, can with any confidence be pointed out.

It may, however, be observed, that while some remedies seem to operate by producing an artificial termination of this complaint, many others have effect only as aiding a natural termination. And where a recovery from this disease does take place, it most frequently happens in consequence of a natural convalescence. All the species and degrees of madness which are hereditary, or that grow up with people from their early youth, are out of the power of physic; and so, for the most part, are all maniacal cases of more than one year's standing, from whatever source they may arise. Very often mere debility, the drugs of some particular disease, such as an ague, the small-pox, or a nervous fever, shall occasion different degrees of foolishness or madness. In these cases, the cure must not be attempted by evacuations; but, on the contrary, by nourishing diet, clear air, moderate exercise, and the use of wine: whereas, in almost all the other maniacal cases, which arise from different sources, and which come on in consequence of intemperate living, violent passions, or intense thinking, it is generally held, that evacuations of every kind are necessary, unless the constitution of the patient be such as absolutely forbids them.

Blood is most conveniently drawn either from the arm or jugulars; and if the weakness be such as renders it improper to take away much blood, we may apply cupping-glasses to the occiput.

Vomiting, in weakly people, must be excited by the vinum ipecacuanhae; but in the more robust by emetic tartar or antimonial wine: the most efficacious cathartics are the infusion or tincture of black hellebore, or infusion of senna quickened with tincture of jalap; but if there be suppression of the menses, or of an habitual haemorrhoidal discharge, then aetie purges will be more proper; and in some instances cooling saline purgatives, such as lixiviated tartar, are of great service. In general, mad people require very large doses, both of the emetics and cathartics, before any considerable operation ensues.

Dr Monro assures us, that the evacuation by vomiting is infinitely preferable to any other: the prodigious quantity of phlegm with which the patients in this disease abound, he says, is not to be overcome but by repeated emetics; and he observes, that the purges have not their right effect, or do not operate to so good purpose, until the phlegm be broken and attenuated by frequent emetics. He mentions the case of a gentleman who had laboured under a melancholy for three years, from which he was relieved entirely by the use of vomits and a proper regimen. Increasing the discharge by urine, is also of the greatest moment, especially when any degree of fever is present. The cutaneous discharges are also to be promoted; for which purpose the hot bath is of the highest service in maniacal cases. Hoffman affirms, that he has seen numerous instances, both of inveterate melancholy and raging madness, happily cured by means of warm bathing; bleeding and nitrous medicines having been premised. Camphor has also been highly commended; but, if we can believe Dr Locker of Vienna, not very decidedly. Having found very good effects from a solution of this medicine in vinegar, he took it for granted that all the success was owing to the camphor; therefore, in order to give it a fair trial, he selected seven patients, and gave it in large doses of half a dram twice a-day. This was continued for two months, and the doctor was surprised to find that only one of his patients received any benefit. He then returned the other fix back to the camphorated julep made with vinegar, and in a few weeks four of them recovered the use of their reason. This inclined him to think that the virtue depended solely on the vinegar, and accordingly he began to make the trial. Common vinegar was first given: but after a little while he fixed on that which had been distilled, and gave about an ounce and a half of it every day; the patients having been previously prepared by bleeding and purging, which was repeated according as it was found necessary. He gives a list of eight patients who were cured by this method; some in six weeks, others in two months, and none of them took up more than three months in perfecting the cure. He does not indeed give the ages of the patients, nor mention the circumstances of the cases; he only mentions the day on which the use of the vinegar was begun and the day on which they were discharged; and he adds, that they all continued well at the time of his writing.

Dr Locker informs us, that this medicine acts chiefly as a sudorific; and he observed, that the more the patients sweated, the sooner they were cured: it was also found to promote the menstrual discharge in such as had been obstructed, or had too little of this salutary evacuation.

Both reason and experience show the necessity of confining such as are deprived of their senses; and no small share of the management consists in preventing them from hurting either themselves or others. It has sometimes been usual to chain and to beat them: but this is both cruel and absurd; since the contrivance called the strait waistcoat answers every purpose of restraining the patients without hurting them.

These waistcoats are made of ticken, or some such strong stuff; are open at the back, and laced on like a pair of stays; the sleeves are made tight, and long enough to cover the ends of the fingers, where they are drawn close with a string like a purse mouth, by which contrivance the patient has no power of his fingers; and when laid on his back in bed, and the arms brought across the chest, and fastened in that position by tying the sleeve strings round the waist, he has no use of his hands. A broad strap of girth web is then carried across the breast, and fastened to the bedstead, by which means the patient is confined on his back; and if he should be so outrageous as to require further restraint, the legs are secured by ligatures to the foot of the bed; or they may be secured by being both put into one bag not very wide, which may be more easily fixed than the feet themselves, at least without giving pain.

It is of great use in practice to bear in mind, that all mad people are cowardly, and can be awed even by the menacing look of a very expressive countenance; and when those who have charge of them once impress them with the notion of fear, they easily submit to any thing that is required. The physician, however, should never deceive them in any thing, but more especially with regard to their distemper: for as they are generally conscious of it themselves, they acquire a kind of reverence for those who know it; and by letting them see that he is thoroughly acquainted with their complaint, he may very often gain such an ascendant over them that they will readily follow his directions.

It is a more difficult matter to manage those whose madness is accompanied either with excessive joy or with great dejection and despondency, than those who are agitated with rage: and all that can be done is to endeavour to excite contrary ideas, by repressing the immoderate fits of laughter in the one kind by chiding or threatening (taking care, however, not absolutely to terrify them, which can never be done without danger, and has often added to the misery of the unhappy sufferer); and dispelling the gloomy thoughts in the other, by introducing pleasing concerts of music, or any other species of entertainment which the patients have been known to delight in while they had the use of their reason. Upon the whole, in the cure of insanity, more is perhaps to be effected by moral than by medical treatment. And this moral treatment should be as gentle as is consistent with safety. Chains, bolts, and severity of every kind are to be avoided as much as possible. But while great benefit is often derived from company and amusement, so also, on the other hand, solitary confinement is in not a few cases productive of the best effects.

Though blistering the head has generally been directed, Dr Mead says he has oftener found it to do harm than service: but he recommends shaves in the back; and advises to keep the head always close shaved, and to wash it from time to time with warm vinegar. Opium has by many been forbidden in maniacal cases, from a supposition that it always increases the disturbance; but there are instances where large doses of this medicine have been found to prove a cure, and perhaps if it were tried oftener we should find powerful effects from it: there certainly cannot much harm ensue from a few doses, which may be immediately diffused if they should be found to exasperate the disease.

The diet of maniacal patients ought to be perfectly light and thin: their meals should be moderate; but they should never be suffered to live too low, especially while they are under a course of phyle: they should be obliged to observe great regularity in their hours: even their amusements should be such as are best suited to their disposition. After the disease appears to be subdued, chalybeate waters and the cold bath will be highly proper to strengthen their whole frame and secure them against a relapse.

GENUS LXXXV. SYPHILIS.

LUES VENEREA, or French Pox.

Sypilis, Sauv. gen. 3086. Lin. 6. Vog. 319. Sag. 126. Lues venerea, Boerh. 1440. Hoffm. III. 413. Junck. 96. Afrue de Lue Venerea.

Dr Afruc, who writes a very accurate history of the lues venerea, is fully convinced that it is a new disease, which never appeared in Europe till some time between the years 1494 and 1496, having been imported from America by the companions of Christopher Columbus; though this opinion is not without its opponents. Dr Sanches in particular has contended with much learning and ability, that it appeared in Europe at an earlier period: But it is at least certain that it was altogether unknown to the medical practitioners of Greece and Rome, and that it was a very common disease in America when the Europeans first visited that country. But at whatever period it may have been introduced into Europe, or from whatever source it may have been obtained, there can be no doubt that, as well as smallpox or measles, syphilis depends on a peculiar specific contagion; on a matter sui generis, which is alone capable of inducing this disease.

The venereal infection, however, cannot, like the contagious miasma of the smallpox and some other diseases, be carried through the air, and thus spread from place to place: for unless it is transmitted from the parents to the children, there is no other way of contracting the disease but from actual contact with the infectious matter. Thus, when a nurse happens to labour under the disease, the infant that she suckles will receive the infection; as, on the other hand, when the child is infected, the nurse is liable to receive it: and there have even been instances known of lying-in women being infected very violently, from having employed a person to draw their breasts who happened to have venereal ulcers in the throat. It may be caught by touching venereal fores, if the cuticle be abraded or torn: and in this way accoucheurs and midwives have sometimes been infected severely. Dr Macbride says, the most inveterate pox he ever saw was caught by a midwife, who happened to have a whitlow on one of her fingers when she delivered a woman ill of the lues venerae.

But by far the most ready way of contracting this disease is by coition, the genital parts being much more bibulous than the rest of the body. When the disorder is communicated, the places where the morbid matter enters are generally those where it first makes its appearance; and as coition is the most usual way of contracting it, so the first symptoms commonly appear on or near the pudenda.

The patient's own account will, for the most part, help us to distinguish the disease: but there are sometimes cases wherein we cannot avail ourselves of this information, and where, instead of confessing, the parties shall conceal all circumstances; while, on the other hand, there are now and then people to be met with, who perjured themselves that symptoms are venereal, which in reality are owing to some other cause: and therefore it is of the utmost importance to inform ourselves thoroughly of the nature of those symptoms and appearances which may be considered as pathognomic signs of lues venerae.

In the first place, when we find that the local symptoms, such as chancres, buboes, phymosis, and the like, do not give way to the usual methods; or when these complaints, after having been cured, break out again without a fresh infection; we may justly suspect that the virus has entered the whole mass of fluids: but if at the same time ulcers break out in the throat, and the face is deformed by callous tubercles, covered with a brown or yellow scab, we may be assured that the case is now become a confirmed lues, which will require a mercurial course.

When eruptions of the furfuraceous and superficial kind are venereal, they are not attended with itching; and the scab being picked off, the skin appears of a roddish brown, or rather copper colour, underneath; whereas leprous eruptions are itchy, throw off a greater quantity of scales, and rise in greater blotches, especially about the joints of the knees and elbows. Venereal tubercles or pustules are easily distinguished from carbuncles of the face, by not occupying the cheeks or the nose, nor as having a purulent apex, but are covered at top, either with a dry branny scurf like the superficial eruptions just now mentioned, or else with a hard dry scab of a tawney yellow hue; they particularly break out among the hair or near to it, on the forehead or on the temples.

Venereal ulcers affecting the mouth are distinguishable from those which are scorbutic, in the following manner: 1. Venereal ulcers first affect the tonsils, fau- ces and uvula; then the gums, but these very rarely: on the contrary, scrofulous ulcers affect the gums first of all; then the fauces, tonsils, and uvula. 2. Venereal ulcers frequently spread to the nose; scrofulous ones almost never. 3. Venereal ulcers are callous in the edges; scrofulous ones are not so. 4. Venereal ulcers are circumcised, and, for the most part, are circular, at least they are confined to certain places; scrofulous ones are of a more irregular form, spread wider, and frequently affect the whole mouth. 5. Venereal ulcers are for the most part hollow, and generally covered at bottom with a white or yellow flough; but scrofulous ones are more apt to grow up into loose fungi. 6. Venereal ulcers are red in their circumference, but scrofulous ones are always livid. 7. Venereal ulcers frequently rot the subjacent bones, the scrofulous ones seldom or never. 8. And lastly, Venereal ulcers are generally combined with other symptoms which are known to be venereal; scrofulous ones with the distinguishing signs of the scurvy, such as difficult breathing, littlefins, swelling of the legs, rotten gums, &c.

Another strong sign of the confirmed lues is often afforded from certain deep-seated nocturnal pains, particularly of the shins, arms, and head. As for any superficial wandering pains that have no fixed seat, and which affect the membranes of the muscles, and ligaments of the joints, they, for the most part, will be found to belong to the gout or rheumatism, and can never be considered as venereal, unless accompanied with some other evident signs; but with regard to the pains that are deeply-seated, and always fixed to the same place, and which affect the middle and more solid part of the ulna, tibia, and bones of the cranium, and rage chiefly and with greatest violence in the forepart of the night, so that the patient can get no rest till morning approaches, these may serve to convince us that the disease has spread itself throughout the whole habit, whether they be accompanied with other symptoms of the lues or not. Gummatous in the fleshly parts, nodos in the periosteum, ganglion upon the tendons, tophi upon the ligaments, exostoses upon the bones, and foci at the verge of the anus, are all of them signs of the confirmed lues: these are hard indolent swellings; but as they sometimes arise independently of any venereal infection, and perhaps may proceed from a scrophulous taint, unless they be accompanied or have been preceded by some of the more certain and evident symptoms of the lues, we must be cautious about pronouncing them venereal. When these swellings are not owing to the syphilitic virus, they are very seldom painful, or tend to inflame and suppurate, whereas those that are venereal usually do, and if they lie upon a bone generally bring on a caries.

These curious ulcers are most commonly met with upon the ulna, tibia, and bones of the cranium; and when accompanied with nocturnal pains, we can never hesitate about declaring their genuine nature. Frequent abortions, or the exclusion of scabby, ulcerated, half-rotten, and dead fetuses, happening without any manifest cause to disturb the fetus before its time, or to destroy it in the womb, may be reckoned as a sign that at least one of the parents is infected.

These then are the principal and most evident signs of the confirmed lues. There are others which are more equivocal, and which, unless we can fairly trace them back to some that are more certain, cannot be held as signs of the venereal disease: Such are, 1. Obtinate inflammations of the eyes, frequently returning, with great heat, itching, and ulceration of the eyelids. 2. A ringing and hissing noise in the ears, with ulcers or caries in the bones of the meatus auditorius. 3. Obstinate headaches. 4. Obstinate cutaneous eruptions, of the itchy or leprous appearance, not yielding to the milder methods of treatment. 5. Swellings of the bones; and, 6. Wandering and obstinate pains. None of these symptoms, however, can be known to be venereal, except they happen to coincide with some one or other of the more certain signs.

It may, perhaps, be considered as a singularity in this disease, that the diagnosis is often more difficult in the advanced than in the early periods of the affection. That is, with those who have been certainly subjected to syphilis, it is often very difficult to say whether certain symptoms, remaining after the ordinary modes of cure have been employed, be syphilitic or not. Very frequently, as appears from the sequel, nocturnal pains, ulcerations, and the like, remaining after a long course of mercury has been employed, are in no degree of a venereal nature, but are in reality to be considered as consequences rather of the remedy than of the disease; and are accordingly best removed by nourishing diet, gentle exercise, and tonics. But as long as any symptoms of any kind remain, it is often impossible to convince some patients that they are cured; and it is often impossible for a physician with certainty to affirm that the disease is altogether overcome.

Upon the whole, we are first to distinguish and consider the several symptoms apart; and then, by comparing them with each other, a clear judgment may be formed upon the general review.

Prognosis. Being thoroughly convinced that the case is venereal, we are to consider, first of all, whether it be of a longer or shorter date; for the more recent it is, it will, catenis paribus, be less difficult to remove. But there are other circumstances which will assist us in forming a prognostic as to the event. As, 1. The age of the patient. This disorder is more dangerous to infants, and old people, than to such as are in the flower and vigour of life, in whom some part of the virus may be expelled by exercise, or may be subdued in some degree by the strength of the constitution. 2. The sex. Though women are for the most part weaker than men, and therefore should seem less able to resist the force of any disease, yet experience shows that this is easier borne by them than by men; perhaps owing to the menstrual and other uterine discharges, by which a good portion of the virus may be carried off immediately from the parts where it was first applied; for it is observable, that whenever these discharges are obstructed, or cease by the ordinary course of nature, all the symptoms of this disease grow worse. 3. The habit of body. Persons who have acrid juices will be liable to suffer more from the venereal poison than such as have their blood in a milder state; hence, when people of a scrofulous or scrophulous habit contract venereal disorders, the symptoms are always remarkably violent, and difficult to cure. And for the same reasons, the confirmed lues is much more to be dreaded in a person already inclined to an asthma, phthisis, dropsy, gout, or any other chronic disorder, than in one of a sound and healthy constitution. For as the original disease is increased by the accession of the venereal poison, to the lues is aggravated by being joined to an old disorder. The more numerous the symptoms, and the more they affect the bones, the more difficult the cure. Of all combinations the union of syphilis with scrophula is perhaps the most difficult to overcome; but if the acrimony should seize on the nobler internal parts, such as the brain, the lungs or the liver, then the disease becomes incurable, and the patient will either go off suddenly in an apoplectic fit, or sink under a consumption.

Care. Viewing this disease as depending on a peculiar contagious matter introduced into the system, and multiplied there, it is possible to conceive that a cure may be obtained on one of three principles; either by the evacuation of the matter from the system, by the destruction of its activity, or by counteracting its influence in the system. It is not impossible that articles exist in nature capable of removing this complaint on each of these grounds; but we may venture at least to assert, that few such are yet discovered. Notwithstanding numbers of pretended infallible remedies for syphilis, mercury is perhaps the only article on which dependence is placed among European practitioners; and with regard to its mode of operation, all the three different opinions pointed out have been adopted and supported by different theorists.—But although many ingenious arguments have been employed in support of each, we are, upon the whole, inclined to think it more probable that mercury operates by destroying the activity of the venereal virus, than that it has effect either by evacuating it, or by exciting a state of action by which its influence is counteracted. Some practitioners have affirmed, that the disease may be totally extirpated without the use of mercury; but, excepting in flight cases, it appears from the most accurate observations, that this grand specific is indispensable; whether it be introduced through the pores of the skin, in the form of ointments, plasters, washes, &c.; or given by the mouth, disguised in the different shapes of pills, troches, powders, or solutions.

Formerly it was held as a rule, that a salivation ought to be raised, and a great discharge excited. But this is now found to be unnecessary: for as mercury probably acts by some specific power in subduing and correcting the venereal virus, all that is required is to throw in a sufficient quantity of the medicine for this purpose; and if it can be diverted from the salivary glands to much the better, since the inconveniences attending a spitting are such as we should always wish to avoid.

Mercury, when combined with any saline substance, has its activity prodigiously increased; hence the great variety of chemical preparations which have been contrived to unite it with different acids.

Corroible sublimate, or the murias hydrargyri corrosivus, is one of the most active of all the mercurial preparations, insomuch as to become a poison even in very small doses. It therefore cannot safely be given in substance; but must be dissolved in order to render it capable of a more minute division. We may see, by Siphilis looking into Wifeman, that this is an old medicine, though seldom given by regular practitioners. How it came to be introduced into to remote a part of the world as Siberia, is not easily found out; but Dr Clerc, author of the Histoire Naturelle de l'Homme Malade, assures us, that the sublimate solution has been in use there time out of mind.

It appears to have been totally forgotten in other places, until of late years, when Baron Van Swieten brought it into vogue; so that at one period, if we may credit Dr Locker, they used no other mercurial preparation at Vienna. The number of patients cured by this remedy alone in the hospital of St Mark, which is under the care of this gentleman, from 1734 to 1761 inclusive, being 4880.

The method of preparing the solution is, to dissolve as much sublimate in any kind of ardent spirit (at Vienna they use only corn brandy) as will give half a grain to an ounce of solution. The dose to a grown person is one spoonful mixed with a pint of any light pitan or barley water, and this is to be taken morning and evening: the patients should keep principally in a warm chamber, and lie in bed to sweat after taking the medicine; their diet should be light; and they ought to drink plentifully throughout the day, of whey, pitian, or barley water. If the solution does not keep the belly open, a mild purge must be given from time to time; for Locker observes, that those whom it purges two or three times a-day, get well sooner than those whom it does not purge: he also says, that it very seldom affects the mouth, but that it promotes the urinary and cutaneous discharges. This course is not only to be continued till all the symptoms disappear, but for some weeks longer. The shortest time in which Locker used to let the patients out was six weeks; and they were continued on a course of decoction of the woods for some weeks after they left off the solution.

This method has been introduced both in Britain and Ireland, though by no means to the exclusion of others; but it appears, that the solution does not turn out so infallible a remedy, either in these kingdoms, or in France, as they say it has done in Germany. It was seldom if ever found to perform a radical cure, and the frequent use of it proved in many cases highly prejudicial. It has therefore been succeeded in practice, even at Vienna, by mercury exhibited in other forms; and, among the rest, by a remedy first recommended by Dr Plenck, and since improved by Dr Saunders; consisting of mercury united with mucilage of gum arabic, which is said to render its exhibition perfectly mild and safe. For particulars, we refer to Dr Saunders's treatise.

But a late French writer, supposed to be Dr Petit, in a small book, entitled, A parallel of the different methods of treating the venereal disease, infers, that there is neither certainty nor safety in any other method than the repeated frictions with mercurial ointment.

If, therefore, it is determined to have recourse to the mercurial frictions, the patient may with advantage be prepared by going into the warm bath some days successively; having been previously blooded if of a plethoric habit, and taking a dose or two of some proper cathartic. The patient being fitted with the necessary apparatus of flannels, is then to enter on the course.

If he be of a robust habit and in the prime of life, we may begin with two drams of the unguentum hydrargyri fortius, (Ph. Lond.) which is to be rubbed in about the ankles by an assistant whose hands are covered with bladders: then having intermitted a day, we may expend two drams more of the ointment, and rest for two days; after which, if no soreness of the mouth comes on, use only one dram; and at every subsequent friction ascend till the ointment shall reach the trunk of the body; after which the rubbings are to be begun at the wrists, and from thence gradually extended to the shoulders. In order to prevent the mercury from laying too much hold of the mouth, it must be diverted to the skin, by keeping the patient in a constant perspiration from the warmth of the room, and by drinking plentifully of barley-water, whey, or pifian; but if, nevertheless, the mercury should tend to raise a spitting, then, from time to time, we are either to give some gentle cathartic, or order the patient into a vapour or warm bath; and thus we are to go on, rubbing in a dram of the ointment every second, third, or fourth night, according as it may be found to operate; and on the intermediate days either purging or bathing, unless we should choose to let the salivation come on; which, however, it is much better to avoid, as we shall thus be able to throw in a larger quantity of mercury.

It is impossible to ascertain the quantity of mercury that may be necessary to be rubbed in, as this will vary according to circumstances: but we are always to continue the frictions, for a fortnight at least, after all symptoms of the disease shall have totally disappeared; and when we have done with the mercury, warm bathing, and sudorific decoctions of the woods, are to be continued for some time longer.

This is a general sketch of the methods of treatment for the confirmed lues; but for a complete history of the disease, and for ample directions in every situation, we refer to Atricre, and his abridger Dr Chapman.—We have to add, however, that a method of curing this disease by mercurial fumigation has been lately recommended in France, but it seems not to meet with great encouragement. One of the most recent proposals for the cure of the venereal disease is that of Mr Clare, and consists in rubbing a small quantity of mercury under the form of the tubumurias hydrargyri, or calomel as it is commonly called, on the inside of the cheek; by which means it has been supposed that we will not only avoid the inconveniences of unction, but also the purgative effects that are often produced by this medicine when taken into the stomach. But after all, the introduction of mercury under the form of unction, as recommended by the latest and best writers in Britain on the venereal disease, Dr Swediaur, Mr John Hunter, and others, is still very generally preferred to any mode that has yet been proposed.

Where, after a long trial of mercury, distressing symptoms still remain, particularly obilitate ulcerations and severe pains, benefit has often been derived from the use of opium: but there is little reason to believe, as has been held by some, that of itself it affords an infallible cure of this disease; at least we are inclined to think, that all the facts hitherto brought in support of the cure of syphilis by opium are at the utmost very doubtful.

The same observation may perhaps be made with regard to another remedy which has of late been highly extolled in syphilis, viz. the nitric acid. This article seems to have been first introduced both against affections of the liver and venereal complaints by Dr Scott of Bombay. It has since been highly extolled by Dr Beddoes and other writers in Britain. And there are many well authenticated cases on record in which it has produced a cure. But it is very rarely preferable to mercury; and it is chiefly useful when, from some peculiarity of constitution, mercury cannot be exhibited.

In obstinate ulcerations, remaining probably after the venereal virus has been overcome, and resulting the use of mercury, a complete cure has in many instances been obtained from the use of the root of the mezereon, the daphne mezereum of Linnaeus. This article has been chiefly employed under the form of decoction; and it now appears that it is the basis of an article at one time highly celebrated in venereal complaints, under the title of Ljbon diet drink. But, upon the whole, these sequelae of this disease are perhaps more readily overcome by country air, gentle exercise, and nourishing diet, particularly a milk diet, than by the use of any medicine whatever. It must indeed be allowed, that for combating different sequelae, various practices accommodated to the nature of these will on particular occasions be requisite. But into the consideration of these we cannot here propose to enter.

GENUS XCI. ICTERUS.

The JAUNDICE.

Icterus, Lin. 224. Vog. 326. Boerh. 918. Junck. 90. Aurigo, Sauv. gen. 306. Sag. 132. Cachexia icterica, Hoffm. III. 301.

Description. The jaundice first shows itself by a lassitude and want of appetite, the patient becomes dull, oppressed, and generally coughive. These symptoms have continued but a very short time, when a yellow colour begins to diffuse itself over the tunica albuginea, or white part of the eye, and the nails of the fingers; the urine becomes high coloured, with a yellowish sediment capable of giving a yellow tinct to linen; the stools are whitish or gray. In some there is a most violent pain in the epigastric region, which is considerably increased after meals. Sometimes the patient has a continual propensity to sleep; but in others there is too great watchfulness; and sometimes the pain is so great, that though the patient be sleepy he cannot compose himself to rest. The pains come by fits; and most women who have had the jaundice and born children, agree, that they are more violent than labour-pains. As the disease increases, the yellow colour becomes more and more deep; an itching is felt all over the skin; and even the internal membranes of the viscera, the bones, and the brain itself, become tinged, as hath been shewn from dissections, where the bones have been found tinged sometimes for years after the jaundice has been cured.

In like manner, all the secretions are affected with the yellow colour of the bile, which in this disease is diffused throughout the whole mass of fluids. The saliva becomes yellowish and bitter; the urine excessively high coloured, in such a manner as to appear almost black; nay, the blood itself is sometimes said to appear of a yellow colour when drawn from a vein; yet Dr Heberden says, that he never saw the milk altered in its colour, even in cases of very deep jaundice. In process of time the blood begins to acquire a tendency Icterus, to diffusion and putrefaction; which is known by the patient's colour changing from a deep yellow to a black or dark yellow. Haemorrhages ensue from various parts of the body, and the patients frequently die of an apoplexy; though in some the disease degenerates into an incurable dropy; and there have not been wanting instances of some who have died of the dropy after the jaundice itself had been totally removed.

Cause. As the jaundice consists in a diffusion of the bile throughout the whole system, it thence follows, that whatever may favour the diffusion is also to be reckoned among the causes of jaundice. Many disputes have arisen concerning the manner in which the bile is introduced into the blood; but it is now generally agreed that it is taken up by the lymphatics of the gall-bladder and biliary ducts. Hence, a jaundice may arise from anything obstructing the passage of the bile into the duodenum, or from anything which alters the state of the lymphatics in such a manner as to make them capable of absorbing the bile in its natural state. Hence the jaundice may arise from searhri of the liver or other viscera pressing upon the biliary ducts, and obstructing the passage of the bile; from flatus distending the duodenum, and shutting up the entrance of the ductus communis choledochus into it; from the same orifice being plugged up by viscid bile, or other bodies; but by far the most frequent cause of jaundice is the formation of calculi, or more properly biliary concretions; for although they were long considered as being of a calcareous nature, yet more accurate experiments have now demonstrated, that they consist principally of a siccaceous matter; accordingly, while they are so light as to swim in water, they are also highly inflammable. These are found of almost all sizes, from that of a small pea to that of a walnut, or bigger: they are of different colours; and sometimes appear as if formed in the inward part by crystallization, but of lamelle on the outer part; though sometimes the outward part is covered with rough and shining crystals, while the inward part is lamellated. These enter into the biliary ducts, and obstruct them, causing a jaundice, with violent pain for some time; and which can be cured by no means till the concretion is either passed entirely through the ductus communis or returned into the gall-bladder. Sometimes, in the opinion of many celebrated physicians, the jaundice is occasioned by spasmodic contractions of the biliary ducts; but this is denied by others, and it is not yet ascertained whether these ducts are capable of being affected by spasm or not, as the existence of muscular fibres in them has not with certainty been discovered. It cannot, however, be denied, that violent fits of passion have often produced jaundice, sometimes temporary, but frequently permanent. This has been by some deemed a sufficient proof of the spasmodic contraction of the ducts; but their opponents supposed, that the agitation occasioned by the passion might push forward some biliary concretion into a narrow part of the duct, by which means a jaundice would certainly be produced, till the concretion was either driven backward or forward into the duodenum altogether. But even supposing the ducts themselves to be incapable of spasm, yet there can be no doubt that by a spasm of the intestines biliary concretions may be retained in the ducts; and indeed it is principally where the duct entering obliquely into the intestines forms as it were a species of valve that these concretions are retained.

In a very relaxed state of the body there is also an absorption of the bile, as in the yellow fever; and indeed in all putrid disorders there is a kind of yellowish tinct over the skin, though much less than in the true jaundice. The reason of this is, that in these disorders there is usually an increased secretion of bile, commonly of a thinner consistency than in a healthy state, while the orifices of the lymphatics are probably enlarged, and thus ready to absorb a fluid somewhat thicker than what they ought to take up in a healthy state; but these disorders are of short duration in comparison with the real jaundice, which sometimes lasts for many years. These affections, however, cannot with propriety in any case be considered as real instances of jaundice; for, to constitute that disease, bile must not only be present in the blood, but wanting in the alimentary canal.

It is observable, that women are more subject to jaundice than men, which probably arises from their more sedentary life; for this, together with some of the depressing passions of the mind, is found to promote the accession of the disease, if not absolutely to produce it. Pregnant women also are frequently attacked by the jaundice, which goes off after their delivery.

Prognosis. As jaundice may arise from many different causes, some of which cannot be discovered during the patient's life, the prognosis must on this account be very uncertain. The only cases which admit of a cure are those depending upon biliary concretions, or obstructions of the biliary ducts by viscid bile; for the concretions are seldom of such a size that the ducts will not let them pass through, though frequently not without extreme pain. Indeed this pain, though often violent, and almost intolerable to the sick person, affords the best prognostics; as the physician may readily assure his patient that there is great hope of his being relieved from it. The coming on of a gentle diarrhoea, attended with bilious stools, together with the cessation of pain, are signs of the disease being cured. We are not, however, always to conclude, because the disease is not attended with acute pain, that it is therefore incurable; for frequently the passage of a concretion through the biliary ducts is accompanied only with a sensation of slight uneasiness.

Cure. The great object to be aimed at in the cure of jaundice is unquestionably the removal of the cause which obstructs the passage of bile into the intestines: But before this can be accomplished, practices are often necessary for alleviating urgent symptoms; which may be done sometimes by supplying the want of bile in the alimentary canal, sometimes by affording an exit for bilious matter from the general mass of blood, but most frequently by obviating the effects of dilatation and obstruction to the circulation in the system of the liver.

The measures to be employed for the removal of the obstruction must depend very much on the nature of the obstructing cause.

When the jaundice arises from indurated swellings or scirrhi of the viscera, it is absolutely incurable; nevertheless, as these cannot always be discovered, the physician ought to proceed in every case of jaundice as if it arose from calculi. The indications here are, 1. To dissolve the concretions; and, 2. To prevent their formation a second time. But unhappily the medical art has not yet afforded a solvent for biliary concretions. They cannot even be dissolved when tried out of the body either by acids or alkalies, or any thing but a mixture of oil of turpentine and spirit of wine; and these fubstances are by far too irritating to be given in sufficient quantity to affect a concretion in the biliary ducts. Boerhaave observes, that diseases of the liver are much more difficult to cure than those in any other part of the body; because of the difficulty there is in getting at the part affected, and the tedious and round-about passage the blood has to it. The juice of common grass has indeed been recommended as a specific in the jaundice, but on no good foundation. Glisson observes, that black cattle are subject to biliary concretions when fed with hay or dried straw in winter, but are cured by the succulent grass in the spring; and Van Swieten tells a strange story of a man who cured himself of the jaundice by living almost entirely on grass, of which he devoured such quantities, that the farmers were wont to drive him out of their fields; but other practitioners have by no means found this in any degree effectual. The only method of cure now attempted in the jaundice is to expel the concretion into the intestines; for which vomits and emetics are the principal medicines. The former are justly reckoned the most efficacious medicines, as they powerfully shake all the abdominal and thoracic viscera; and thus tend to dislodge any obstructing matter that may be contained in them. But if there be a tendency to inflammation, vomits must not be exhibited till bleeding has been promised. We must also proceed with caution if the pain be very sharp; for in all cases where the disease is attended with violent pain, it will be necessary to allay it by opiates before the exhibition of an emetic. There is also danger, that, by a continued use of vomits, a concretion which is too large to pass, may be so impacted in the ducts that it cannot even be returned into the gall-badder, which would otherwise have happened. In all cases, therefore, if no relief follows the exhibition of the second or third emetic, it will be prudent to forbear their farther use for some time.

Of all kinds of exercise, that of riding on horseback is most to be depended upon in this disease. It operates in the same manner with vomits, namely, by the concussion it gives to the viscera; and therefore the cautions necessary to be observed in the use of vomits are also necessary to be observed in the use of riding. Cathartics also may be of service, by cleansing the prime vasa, and facilitating a discharge of the bile into the intestines; but they must not be of too drastic a nature, else they may produce incurable obstructions, by bringing forward concretions that are too large to pass. Anodynes and the warm bath are serviceable by their relaxing quality; and there can be no doubt, that, from acting as powerful antispasmodics, they often give an opportunity for the discharge of concretions by very slight caustics, when they would otherwise be firmly retained. Soap has been supposed to do service as a solvent; but this is now found to be a mistake, and it acts in no other way than as a relaxant or as a gentle purgative.

But when all means of relief fail, as in cases of scirrhous, we can then only attempt to palliate the symptoms, and preserve the patient's life as long as possible. This is best accomplished by diuretics; for thus a great quantity of bilious matter is evacuated, and the system is freed from the bad consequences which ensue on its stagnation in the habit. But even this is by no means equal to the common evacuation by stool; nor can all the attempts to supply the want of bile in the intestines by bitters and other stomachics restore the patient to his wonted appetite and vigour. If the pain be very violent, we must on all occasions have recourse to opiates; or if the blood has acquired a tendency to diffusion, it must be counteracted by proper antiseptics.

If the disease goes off, its return must be prevented by a course of tonic medicines, particularly the cinchona and antiseptics: but we can by no means be certain that the jaundice will not return, and that at any interval; for there may be a number of concretions in the gall-bladder, and though one has passed, another may very quickly follow, and produce a new fit of jaundice; and thus some people have continued to be affected with the distemper, at short intervals, during life.

In the East Indies, mercury has been lately recommended as exceedingly efficacious in disorders of the liver, especially those which follow intermitting and remitting fevers. Dr Monro, in his Observations on the means of preserving the health of soldiers, acquaints us, that he has seen some iatric cases which, he thought, received benefit from taking a few grains of the submurias hydrargyri at night, and a purge next morning; and this repeated two or three times a-week.

Infants are subject to a temporary jaundice, commonly called the gum, soon after birth; the cause of which is not well understood. It differs remarkably from the common jaundice; as, in the latter, the disease is first discoverable in the white of the eyes; but though the skin of infants in the gum is all over yellow, their eyes always remain clear. The disorder goes off spontaneously, or by the use of a gentle purgative or two.