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

Causes of, and persons subject to, the disease. The same general causes are to be assigned for the quotidian as for other intermittents. This kind occurs but rarely; and it is said to attack people of a phlegmatic temperament rather than any other: also old people rather than young, and women rather than men.

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

The Partial Quotidian, Sp. I. var. 1. B.

Quotidiana partialis, Sauv. sp. 16. Cnoffel, E. N. C. D. I. A. III. obs. 205. Edin. Med. Ess. vol. i. art. 31. vol. ii. art. 16. Quotidiana cephalalgica, Sauv. sp. 6. Mort. pyretol. exerc. i. hist. 27. Van Swieten in Boerh. p. 534. Cephalalgia intermittens, Sauv. sp. 7. Cephalæa febricosa, Sauv. sp. 4. Quotidiana ophthalmica, Morton, ibid. hist. 17. Van Swieten, ibid. Ophthalmia febricosa, Sauv. sp. 23.

These distempers attack only some particular part of the body, as the head, the eye, arm, &c. producing periodical affections of those parts returning once in 24 hours; they are to be cured by cinchona, as other intermittents. They are known to belong to this class, by the evident intermission of the pain or other affection of the part. The quotidiana hysterica, Sauv. sp. 3. quotidiana catarrhalis, Sauv. sp. 9. and quotidiana astranguriosa, Sauv. sp. 11. seem to be symptomatic disorders.

The Remitting Quotidian. Sp. II.

Amphimerina, Sauv. gen. 84. Lin. 20. Quotidiana continua, Vog. 15. Quotidiane remittentes et continua auctorum. Amphimerina latica, Sauv. sp. 1. Febris continua lymphatica, Etmuller, Coll. conf. cas. 32. River. Obs. cent. i. obs. 57. Amphimerina singultuosa, Sauv. sp. 14. Febris continua Lyngodes, Vog. 26.

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

**Sect. II. CONTINUED FEVERS.**

Continuus, Sauv. class ii. ord. i. Vog. class i. ord. 2. Sag. 666. Boerh. 727.

Continentes, Lin. class ii. ord. i. Stahl. Cas. mag. 35. Cas. 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, sive febris acuta sanguinea, Hoffm. II. 105. Synochus, Vog. 16. Continua non putris, Boerh. 720. Ephemeris, Sauv. g. 79. Boerh. 728. Junck. 57. Diaria, Lin. 11. Febris inflammatoria aetorum.

**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 lassitude of the limbs, with a strong, full, and frequent pulse. The urine is red, and deposits a sediment almost of the colour of orange-peel; and in the very first day of the disease, signs of concoction (according to the Hippocratic phrase) appear. The fever commonly goes off with a gentle sweat; but sometimes, though more rarely, with a hemorrhagy by the nose. Its shortest period is 24 hours: but if it goes beyond the fourth day, it is then a synocha properly so called.

The simple synocha, according to Vogel, begins with cold and shivering, succeeded by vehement heat, redness, and dryness of the skin. The face, especially, is very red, and the thirst intense. The head is either pained or heavy. The patient either doth not sleep at all, or is disturbed with dreams. A moist sweat then breaks out all over the skin. The pulse is full, quick, and frequent; the 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 costive; at the same time that a tensive kind of lassitude is perceived over the whole body. A complete crisis takes place either on the fourth or at the farthest on the eleventh day. The characteristic marks of the simple synocha, therefore, are, A redness of the face, moisture of the skin, a strong and frequent pulse.

**Causes of, and persons subject to, this disease.** As we have already remarked of 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 absorption of certain humours; wounds, fractures, luxations, &c.; so that in general we may reckon every thing tending to increase the action of the arterial system to be in certain circumstances a cause of inflammatory fever.—Hence we find those are most subject to the synocha whose constitution is either naturally robust, or who are exposed to those causes which tend to produce an increased action of the arterial system; such as hard labour, high living, &c.

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

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

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

I. The action of the heart and arteries may be diminished, 1. By avoiding or moderating those irritations which, in one degree or other, are almost constantly applied to the body. 2. By the use of certain sedative powers. 3. By diminishing the tension 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 aliments. The avoiding of these as much as possible, or the moderating their force, makes what is properly called the antiphlogistic regimen, proper to be employed in almost every continued fever. This regimen is to be directed in the following manner.

1. Impressions on the external senses, as stimulant to the system, and a chief support of its activity, should be avoided as much as possible; especially such as are of a stronger kind, and which give pain and uneasiness. No impression is to be more carefully guarded against than that of external heat; and at the same same time every other means of increasing the heat of the body is to be shunned. Both these precautions are to be taken as soon as a hot stage is fully formed; and to be attended to during its continuance, except in certain cases, where a determination to sweating is necessary, or where the stimulant effects of heat may be compensated by circumstances which determine it to produce 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 aerimony of all the humours, which is in most fevers to be suspected. These are to be removed by such methods as the urgency of the symptoms require, by diluting liquors, vomiting, the use of acids, laxative clysters, and large quantities of antiseptic drinks.

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

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

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

With regard to purging, when we consider the quantity of fluids constantly present in the cavity of the intestines, and the quantity which may be drawn off from the innumerable excretories that open into this cavity, it will be obvious, that a very great evacuation may be made in this way; and if this be done by a stimulus that is not at the same time communicated to the rest of the body, it may, by emptying both the cavity of the intestines and the arteries which furnish 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 spasms in any part of the system, and which are known under the title of Antispasmodics.

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

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

In a healthy state, also the fulness of the extreme vessels and the quantity of excretion are in proportion to the quantity of water present in the body. But in fever, though the excretions be in some measure interrupted, they continue in such quantity as to exhale the more fluid parts of the blood; and, while a portion of them is at the same time necessarily retained in the larger vessels, the smaller, and the extreme vessels, both from the deficiency of fluid and their own contracted state, are less filled, and therefore allowed to remain in that condition. To remedy this contracted state, nothing is more necessary than a large supply of water or watery fluids taken in by drinking or otherwise; for as any superfluous quantity of water is forced off by the several excretories, such a force applied may be a means of dilating the extreme vessels, and of overcoming the spasm affecting their extremities. Accordingly, the throwing in a large quantity of watery fluids, has been, at all times, a remedy much employed in fevers; and in no instance more remarkably than by the Spanish and Italian physicians, in the use of what they call the dieta aquosa. This practice consists in taking away every other kind of aliment and drink, and in giving, in divided portions, every day for several days together, six or eight pounds of plain water, generally cold, but sometimes warm. 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 a state of health, and which may render it doubtful whether the sweating can be safely excited by art. 2. That in many cases the practice has been attended with bad consequences. The means commonly employed have a tendency to produce an inflammatory diathesis; which, if not taken off by the sweat succeeding, must be increased with much danger. Thus sweating employed to prevent the accessions of intermitting fevers has often changed them into a continued form, which is always dangerous. 3. The utility of the practice is doubtful; as sweating, when it happens, does not always give a final termination, as must be manifest in the case of 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 sweating can be admitted very generally; but, at the same time, it is also very doubtful if the failure of the practice, or the mischief said to arise from it, hath not been owing to the improper conduct of the practitioner. With respect to the last, it is almost agreed among physicians, 1. That sweating has been generally hurtful when excited by stimulant, heating, and inflammatory medicines. 2. That it has been hurtful when excited by much external heat, and continued with a great increase of the heat of the body. 3. That it is always hurtful when it does not relieve; and rather increases the frequency and hardness of the pulse, the anxiety and difficulty of breathing, the headache, and delirium. 4. That it is always hurtful if it be urged when the sweat is not fluid, and when it is partial and on the superior parts of the body only.

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

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

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

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

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

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

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

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

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

The emetics chiefly in use at present are, ipecacuanha and antimony. The former may be employed for determining to the surface of the body: but, even in very small doses, it so readily excites vomiting, that it is with difficulty employed for the purpose of nauseating only; and in whatever manner employed, there is reason to suspect that its effects are less permanent, and less powerfully communicated from the stomach to the rest of the system, than those of antimony. This last is therefore generally preferred; and its preparations, seemingly various, may all be reduced to two heads; one comprehending those in which the reguline part is in a condition to be acted upon by acids, and therefore on meeting with acids in the stomach it becomes active; and another, comprehending those preparations in which the reguline part is already joined with an acid, rendering it active. Of each kind there are great numbers, but not differing essentially from one another; the two most worthy of notice are, the calx nitrata antimonii, and emetic tartar, or tartre 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-phosphoricum, 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 those medicines is a little before the accession, when that can be certainly known. In continued fevers the exacerbations are not always very observable; but there is reason to believe, that one commonly happens about noon or soon after it; and that these, therefore, are the most proper times for exhibiting emetics.

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

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

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

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

From this view of the matter, it will appear that the part of the body to which blisters ought to be applied is indifferent, except upon the suspicion of topical affection, when the blistering is to be made as near as possible to the part affected. Whether 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, it 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. Sug. 677.

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

Febris maligna hectica convulsiva, sive lues nervosa. Willis de morb. convulsiv. cap. 8.

Febris pestilens, Fracastor. de morb. contag. lib. ii. cap. 4.

Febris pestilens, sine charactere veneni, Forest, l. Typ. vi. obs. 26.

Febris hectica pestilens, Forest, l. vi. obs. 32.

Febris nova ann. 1685, Syaenham, Sched. monitor.

Febris putrida nervosa, Wintringh. Com. Nosolog. ad ann. 1720, 1721.

Febris lenta nervosa, Huxham on fevers, chap. 8.

Febris contagiosa, Lind on fevers and infection, passim.

Typhus nervosus, Sauv. sp. 2.

Typhus comatosus, Sauv. sp. 3.

Triticeophya typhodes Mangeti, Sauv. sp. 11. Raym.

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 disrelish of every thing soon follows, without any considerable thirst, but frequently with retching to vomit, though little but insipid phlegm is brought up. Though a kind of lucid interval of several hours sometimes intervenes, yet the symptoms return with aggravation, especially towards night; the head grows more giddy or heavy; the heat greater; the pulse quicker, but weak; with an oppressive kind of breathing. A great torpor, or obtuse pain and coldness, affects the hinder part of the head frequently, and oftentimes a heavy pain is felt on the top all along the coronary suture; this, and that of the back part of the head, generally attend nervous fevers, and are commonly succeeded by some degree of a delirium. In this condition the patient often continues for five or six days, with a heavy, pale, 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 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 subsultus 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 list 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 asleep; the extremities grow cold, the nails pale or livid; the pulse may be said to tremble and flutter, rather than to beat, the vibrations being so exceedingly weak and quick that they can scarce be distinguished; though sometimes they creep on surprisingly slow, and very frequently intermit. The sick become quite insensible and stupid, scarce affected with the loudest noise or the strongest light; though, at the beginning, strangely susceptible of the impressions of either. The delirium now ends in a profound coma, and that soon in death. The stools, urine, and tears, run off involuntarily, and denounce a speedy dissolution, as the tremblings and twitchings of the nerves and tendons are 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 salivations, too frequent purging, immoderate venery, &c. Hence we see how the disease is connected with an extreme debility of the nervous system; for when people are prepared for this fever by having their nerves already weakened, the contagious particles immediately attack the nervous system, without so much affecting the state of the blood or juices, though the latter are greatly affected in the putrid malignant fevers.

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

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

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

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

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

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

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

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

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

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

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

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

The putrid or putrescent matter already present in the body, may be evacuated partly by frequent evacuations of the contents of the intestines; and more effectually still by supporting the excretions of perspiration. ration and urine by the plentiful use of diluents. That which remains in the body may be rendered more mild and innocent by the use of diluents, or may be corrected by the use of antiseptics. These last are of many and various kinds; but which of them are conveniently applicable, or more particularly suited to the case of fevers, is not well ascertained. Those most certainly applicable and useful are acetic acid 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 Synoecia.

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 surprising 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, sickness and load at stomach are urgent, as is frequently the case in the beginning of this fever, a vomit is necessary. Clysters of milk, sugar, and salt, may be injected with safety and advantage every second or third day, if nature wants to be prompted to stool. The temperate, cordial, diaphoretic medicines, are certainly, according to our author, most proper in these fevers; and a well-regulated, supporting, diluting diet is necessary. The latter of itself, judiciously managed, will go a great way in the cure, especially if assisted by well-timed and well-applied blisters, and a due care to keep the patient as quiet as possible both in body and mind. But it should be noted, that strong opiates are commonly very pernicious, however much the want of sleep and restlessness may seem to demand them. Mild diaphoretics, such as neutral draughts or elixir paregoricum, have much better effects; which, by raising a gentle easy sweat, or at least a plentiful perspiration, calm the hurry of the spirits, and a refreshing sleep ensues. Where the confusion and dejection of spirits are very considerable, blisters have been advised to be applied to the neck, occiput, or behind the ears; and during all this a free use of thin wine whey, some pleasant pitan 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, sago, and panada, are useful, adding a little wine to them, and the juice of orange or lemon.

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

The above-mentioned difficulty of breathing, anxiety, and oppression, many times precede a 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 pustular eruptions of any kind in all sorts of fevers. This eruption should be promoted by soft easy cordials and proper diluents; to which should be sometimes added 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 so, 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 justly may be reckoned symptomatic rather than anything else, and the consequent eruption is often merely the symptom of a symptom.

In these profuse colliquative sweatings a little generous red wine (diluted somewhat, if necessary) may be given with the greatest advantage; as it presently moderates the sweats, supports the patient, and keeps up the military papule if they happen to attend. Towards the decline of the fever also, where the sweats are abundant and weakening, small doses of the tincture of cinchona with saffron and snakeroot may be given with the greatest advantage, frequently interposing a dose of rhubarb to carry off the putrid colluvies in the first passages; which withal makes the remissions or intermissions that often happen in the decline of nervous fever. 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.

II. Typhus gravior, or the putrid, pestilential, or malignant Fever. Sp. I. var. 2.

Febris pestilens, P. Sal. Divers. de febre pestilenti.

Febris pestilens Ægyptiorum, Alpin. de med. Ægypt. l. i. cap. 14.

Typhus Ægyptiacus, Sauv. sp. 6.

Febris pestilens maligna, Sennert. de febribus, l. iv. cap. 10.

Febris maligna pestilens, River, l. xvii. sect. iii. cap. 1.

Febris pestilens maligna, ann. 1643, Willis, de febribus, cap. 14.

Typhus carcerum, Sauv. sp. 1.

Febris nautica pestilentialis, Huxham de ære ad ann. 1740.

Miliaris nautica, Sauv. sp. g.

Febris putrida contagiosa in carcerebus genita, Huxham de ære ad ann. 1742.

Miliaris purpurata, Sauv. sp. h.

Febris carcerum et nosocomiorum, Pringle, Diseases of the army, p. 294. Van Swieten, Maladies des armes, p. 136.

Typhus castrensis, Sauv. sp. 5.

Febris castrensis, quam vulgo cephalalgiam epidemiam vocant, Henr. Maii et A. Ph. Koph. Diss. apud Hallerum, tom. v.

Febris Hungarica sive castrensis, Juncker, 74, et plurium auctorum.

Febris castrensis Gallorum in Bohemia, ann. 1742, Scriinci. Diss. apud Haller. tom. v.

Febris petechialis, Sennert. l. iv. cap. 13. River. prax. l. xvii. sect. iii. cap. 1. Hoffm. ii. p. 84.

Juncker, 73. Huxham on fevers, chap. 8. Ludwig. Inst. med. clin. N° 146. Schreiber von erkentniss, und cur der Krank heiten, p. 126.

Monro, Diseases of military hospitals, p. 1.

Febris catarrhalis maligna petechizans, Juncker, 72. Hoffm. ii. 75. Eller de cogn. et cur. morb. sect. vi.

Febris que lenticulas, puncticula, aut peticulas vocant, Fracastorius de morb. contag. lib. ii. cap. 6.

Febris petecularis Tridenti, ann. 1591. Roboretus de febr. peticuli.

Febris petechialis epidemica Coloniae, ann. 1672. Donckers, Ida febris petechialis.

Febris petechialis epidemica Posoni, 1683, C. F. Locu in App. ad A. N. C. vol. ii.

Febris petechialis epidemica Mutinæ, 1692. Ramazzini. Const. Mutinensis, oper. p. 177.

Febris maligna petechizans, ann. 1698. Hoffm. ii. p. 80.

Febris petechialis Wratislaviae, ann. 1699. Helwich, Ephem. Germ. D. III. A. VII. et VIII. obs. 132. p. 616.

Febris epidemica Lipsiae, 1718. M. Adolph. A. N. C. III. obs. 131. p. 296.

Febris endemicæ et epidemicae Corcagiensis, ann. 1708, 1718, et seq. Rogers, Essay on Epidemic Typhoid diseases.

Febris continua epidemica Corcagiensis, ann. 1719. et seq. M. O'Connell, Obs. de morbis.

Febris petechialis epidemica Cremonæ, 1734. Valcarenghi Med. ration. sect. 3.

Febris petechizans Petropolii, 1735. Weitbrecht. Diss. apud Haller. tom. v.

Febris petechialis, ann. 1740, 1741, in Hassia. Ritter. A. N. C. vol. vii. obs. 4.

Febris maligna petechialis Rintelli, 1741. Furstenau, A. N. C. vol. vii. obs. 5.

Febris petechialis epidemica Silesiae, 1741, et seq. Bandhorst. Diss. apud Haller. tom. v.

Febris petechialis epidemica Viennæ, 1757. Hasenohr. Hist. med. cap. 2.

Febris petechialis epidemica Lipsiae, 1757. Ludvig. Adversar. 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 see, during different seasons, and in different circumstances, various degrees of malignity in smallpox. Though every instance of the disease depends on the introduction of a peculiar and specific contagion into the body, yet this contagion in particular epidemics evidently possesses peculiar malignancy. The same is probably the case with the typhoid fever: But whether this observation be well founded or not, there cannot be a doubt that the typhus gravior or putrid fever is a disease of the most dangerous nature, as, besides the extreme debility of the nervous system, there is a rapid tendency of the fluids to putrefaction, which sometimes cuts off the patient in a few days, nay, in the warm climates, in 12 or 14 hours; or if the patient recovers, he is for a long time, even in this country, in an exceeding weak state, and requires many weeks to recover his former health.

The putrid fevers, according to Huxham, make their attack with much more violence than the slow nervous ones; the rigors are sometimes very great, though sometimes scarce felt; the heats much sharper and permanent; yet, at first, sudden, transient, and remittent: the pulse more tense and hard, but commonly quick and small; though sometimes slow, and seemingly regular for a time, and then fluttering and unequal. The headache, nausea, and vomiting, are much more considerable even from the beginning. Sometimes a severe fixed pain is felt in one or both temples, or over one or both eyebrows; frequently in the bottom of the orbits of the eyes. The eyes always appear very dull, heavy, sometimes yellowish, and very often a little inflamed. The countenance seems bloated, and more dead-coloured than usual. Commonly the temporal arteries throb much, and a tinnitus aurium is very troublesome: a strong vibration also of the carotid arteries frequently takes place in the advance of the fever, though the pulse at the wrist may be small, nay even slow: this is a certain sign of an impending delirium, The prostration of spirits, weakness, and faintness, are often surprisingly great and sudden, though no inordinate evacuation happens; and this too sometimes when the pulse seems tolerably strong. The respiration is most commonly laborious, and interrupted with a kind of sighing or sobbing, and the breath is hot and offensive.

Few or none of these fevers are without pain in the back and loins; always an universal weariness or soreness is felt, and often much pain in the limbs. Sometimes a great heat, load, and pain, affect the pit of the stomach, with perpetual vomiting of porraceous or black bile, and a most troublesome singultus; the matter discharged is frequently of a very nauseous smell. The tongue, though only white at the beginning, grows daily more dark and dry; sometimes of a shining livid colour, with a kind of dark bubble at top; sometimes exceeding black; and so continues for many days together; nor is the tinct 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 sordes. 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 vibices, or large dark blue or greenish marks, seldom appear till very near the fatal period. Frequently also we meet with an efflorescence like the measles in malignant fevers, but of a much more dull and livid hue; in which the skin, especially on the breast, appears as it were marbled or variegated. This in general is an ill symptom, and is often attended with fatal consequences.

Sometimes about the 11th or 14th day, on the occurrence of profuse sweats, the petechiae disappear, and vast quantities of white miliary pustules break out. This is seldom found of any considerable advantage; but an itching, smarting, red rash, commonly gives great relief; and so do the large, fretting, watery bladders, which many times rise upon the back, breast, shoulders, &c. A scabby eruption likewise about the lips and nose is one of the 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 apthæ; 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, cesophagus, &c. and with an incessant singultus: the whole prime vice become at last affected; a bloody dysentery comes on, followed by a sphacelation of the intestines; as is evident from the black, sanious, 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 Febres. 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 sify, not only on the first attack, but after the fever is formed. The worst appearance is when the crassamentum is dissolved; though this does not happen till the advanced state of the fever: indeed this seems not easy to be ascertained, as blood has been so seldom taken away at that time. The urine is also various. Sometimes it is of a reddish or flame colour, which it preserves a long time; but it is oftener pale, and changes from time to time in colour as well as crudity, being sometimes clear, sometimes clouded: towards the end, upon a favourable crisis, it becomes thick, but does not always deposit a sediment. If the sick lie warm, and have had no preceding flux, the belly is generally bound; but when they lie cold, as they often do in field-hospitals, the pores of the skin being shut, a diarrhoea is a common symptom, but is not critical. In the worst cases, a flux appears in the last stage; then the stools are involuntary, colliquative, ichorous, or bloody, and have a cadaverous smell; the effects of a mortification of the bowels, and the sign of approaching death. When the hospitals are filled with dysenteric patients, some of the nurses will be infected with the flux only, and others with this fever, ending in these bloody and gangrenous stools.

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

The tongue is commonly dry; and, without constant care of the nurse, becomes hard and brown, with deep 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 slumberers are only half shut; and the voice, which is commonly low and slow, sinks to a degree scarce to be heard. From the beginning there is generally a great dejection and failure of strength. A tremor of the hands is more common than a starting of the tendons; and if the subsultus 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 subsultus tendinum, or violent actions, though their pulse be sunk, yet bear neither hot medicines, wine, nor the common cordials.

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

A petechial efflorescence is a frequent, though not an inseparable, attendant of this fever. It sometimes appears of a brighter or paler red, at other times of a livid colour, but never rises above the skin. The spots are small; but generally so confluent, that at a little distance the skin appears only somewhat redder than ordinary, as if the colour was uniform; but upon a nearer inspection interstices are seen. For the most part this eruption is so little conspicuous, that unless it be looked for attentively, it may escape notice. The spots appear thickest on the back and breast, less on the legs and arms, and Sir John Pringle never remembers to have seen any on the face. As to the time of their appearance, he agrees entirely with Dr Huxham. These spots are never critical, nor are they reckoned among the mortal symptoms; but only concur with other signs to ascertain the nature of the disease. The nearer they 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 intermitting form. The length of the disease is uncertain. Sometimes it was terminated, either in death or recovery, in seven days after the patient took to his bed: but in the hospitals it generally continued from 14 to 20, and some died or recovered after four weeks. From the time of the sinking of the pulse until death or a favourable crisis, there is perhaps less chance to be seen from day to day in this than in most other fevers. When its course is long, it sometimes terminates in suppurations of the parotid or axillary glands; and when these do not appear, it is probable that the fever is kept up by the formation of some internal abscess. The parotid glands themselves do not suppurate, but only some of the lymphatic glands that lie over them. Sir John Pringle observed one instance of a swelling of this kind on both sides, without any previous indisposition, when the person, not suspecting the cause, and applying discutient cataplasms, was, upon the 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 suppurated. The first of this kind Sir John Pringle met with at Ghent; but the man being brought into the hospital from the barracks no earlier than two days before he died, he could only conjecture from the symptoms and the imperfect accounts he had of him, that his death was owing to a fever of this kind, after lingering near a 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 convulsed. Of two other instances of men who undoubtedly died of this fever, in one the cerebrum was suppurated, in the other the cerebellum. In the former case, the patient was under a stupor, with deafness from the beginning; but was never delirious, nor altogether insensible. His pulse sunk early; and about ten days before his death his head began to swell, and continued very large till within two days before he died, when it subsided a little. For several days before his end, he would taste nothing but cold water, and during his illness he lay constantly upon one side. The head being opened, an abscess as large as an egg was found in the substance of the 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 looseness; and just before he died, an ichorous matter was discharged from his nose. In the military hospital at Ipswich, one who unexpectedly died of this fever after having been seemingly in a fair way of recovery, had no suppuration in his brain; but in another, who died after an abscess in both orbits, the brain was found flaccid, and about two ounces of a thin serum in the ventricles.

Causes of, and persons subject to, this disorder. The cause of this fever, as well as that of the slow nervous fever, is an infection or contagion from some diseased animal-body, or from corrupted vegetables; and therefore is very little, if at all, different from those pestilential disorders which have arisen after battles, where great numbers of dead bodies were allowed to lie above ground, and infect the air with their effluvia. This is confirmed by an observation of Forestus, 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 putrescent state than usual. 2. A putrid state of the air, arising either from a multitude of dead bodies left unburied, as after a battle, or from the evaporation of corrupted lakes and marshes.

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

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

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

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

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

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

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

2. Thick noisome fogs, chiefly after sunset, arising from the valleys, and particularly from the mud, slime, or other impurities. In hot countries, the smell of these these fogs may be compared to that of a new-cleaned ditch. Diseases, therefore, arising from this cause, generally take place in the night, or before 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 Pensacola, Whydah, and the island of Bonavista, which is found by experience to be injurious to health. The pestiferous vapour arising, during the summer months and in the heat of the day, from such a sandy soil, is best characterized by its effects in the extensive deserts of Asia and Africa. It there constitutes what is called the Sambal-wind; a blast which, in the parched desert, proves instantly fatal both to man and beast; but when it passes over a soil well covered with grass and vegetables, has its effects greatly mitigated; it is, however, even then, productive of sickness: thus the southerly winds, while they blow from the deserts of Libya during the summer, at Algiers, Tunis, and Tripoli, produce an unhealthy season; and at Madras the winds, which, in the months of April and May, pass over a large tract of sand, are always hot, disagreeable, and unwholesome.

During these land-winds, sudden gusts of a more hot and suffocating nature are often observed to come from these sands once or twice, or even more frequently, in a day, which seem to be this vapour in a purer form. These gusts pass very quickly, and affect persons who happen to stand with their faces towards them in the same manner as the hot air which issues from a burning furnace, or from a heated oven, and obliges them immediately to turn away from it in order to recover breath. The effect of this hot suffocating blast or vapour on the human body, even when mitigated by passing through a moist atmosphere, is the same as that of intense cold; it shuts up every pore of the skin, and entirely stops the perspiration of such as are exposed to it. These blasts come only in the daytime, and always from the deserts. Water is the only known corrector or antidote against them: hence, coarse thick 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 Hither Peninsula of India into two equal parts, and separate what is called the Malabar from the Coromandel coast. To the former they are very near, but at a great distance from the latter. The winds blowing from those hills are on the Malabar coast always remarkably cool; but on the coast of Coromandel, in the months of April, May, June, and July, are extremely hot and suffocating, as they pass over a large tract of intermediate sand, heated during those months by an almost vertical sun. Hence the Malabar coast is always covered with an agreeable verdure; whereas the Coromandel coast, during the continuance of these hot winds, seems a barren wilderness, nothing appearing green except the trees. On the contrary, the winds that pass over these sands, after being wet with the rains, are the coldest which blow at Madras. Bottles of liquor inclosed in bags of coarse cloth, kept constantly wet, and suspended in the shade, where those hot winds may have access to them, become as cold as if they had been immersed in a solution of nitre; an effect owing undoubtedly to the constant evaporation of water from the surface.

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

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

Having thus given an account of the signs of an unhealthy country, Dr Lind next proceeds to mention such employments as are particularly dangerous to Europeans on their first arrival. One of these is the cutting down of trees, shrubs, &c. or clearing the ground, as it is called. Of the unhealthiness of this employment he gives two instances. At the conclusion of the late peace, the captain of a ship of war went on shore at the island of Dominica, with 12 of his men, to cut down the wood, and to clear a piece of ground which he intended to have purchased: but, in a few days, sickness obliged him to desist from this dangerous work; the captain and 11 of his men being seized with violent fevers, which terminated in obstinate 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, also lost 25 of her men at Sierra Leonia, who were employed in cutting down wood for the ship. This is an occupation which has often proved destructive to Europeans in those climates, and in which they ought never to be employed, especially during the rainy season; there being numberless instances of white persons, when cutting down the woods at that season, who have been taken ill in the morning, and dead before night.

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

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

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

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

Persons on board any ship whatever, are much more safe, and their situation is much preferable to that of those who make distant inland excursions in small boats upon the rivers, and who are for the most part ignorant of the cause of those maladies which destroy them. The intolerable heat at noon often obliges such persons to go in a manner half naked; while a free and plentiful perspiration issues from every pore. A near approach to putrid swamps at this time is apt to produce an immediate sickness, vomiting, and afterwards... 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 miasmata with which the air abounds.—All those who are employed in cutting down woods, or in other laborious and dangerous services in hot climates, during the heat of the day, ought to have their heads covered with a bladder 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 centinels 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, renders the damp from the earth less noxious; of which Dr Lind gives the following remarkable instance. A Guinea ship being up one of the rivers for the sake of trade, it was found to be very dangerous to sleep on shore: without which their trade could not be so conveniently carried on. First the captain, then the mate, and two or three of the seamen, were taken ill; each of them the morning after they had lain on shore. By these accidents the men were greatly intimidated from lying ashore; till the surgeon boldly offered to try the experiment on himself. Next morning when he waked, he found himself seized, as the rest, with a giddiness and pain in the head. He immediately acquainted one of the negroes with his condition, who carried him to his hut, and set him down in the smoke of it; when his shiverings and giddiness soon left him. He then took a dram of the bark bitter; and found himself greatly relieved, especially by breathing some time in the smoke.—Thus instructed by the negro, he ordered a large fire to dry the hut he slept in; and afterwards had every night a small fire sufficient to raise a gentle smoke without occasioning a troublesome heat: and by this means he and several others, using the same precautions, slept many nights on shore without any inconvenience.

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

There are three methods practised for purifying vessels after the men have been removed out of them. The first is by burning of tobacco. A quantity of tobacco is spread on several fires, made with such old pieces of rope as are called junk. These are dispersed into different places of the ship, and their heat and smoke afterwards closely confined below for a considerable time.—The second method is by charcoal fires strewed with brimstone. The heat and steam of these burning materials must also be long and close shut up: but although this fume, properly applied, has been found by experience to purify most effectually tainted apartments, ships, clothes, &c., yet there are some kinds of vermin which it will not destroy, particularly lice. The third method of purification is performed by the addition of arsenic to the materials of the second 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, orloge, 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 cascara bark, when burning, gives a most agreeable scent to the chamber of the sick; thus it is at least an elegant preservative, and may prevent bad smells from taking effect. The steam of camphorated vinegar, warmed, is still more powerful for this purpose. But, besides correcting the ill quality of the air, and purifying the chamber, another good effect is produced from such steams and smoke as are inoffensive to the lungs. As soon as the vapour becomes dense, the nurses and patients become desirous of the admission of fresh air by the doors or windows.

Now it is certain, that the air in the chambers of the Typhus 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 consequences. 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-leses for several hours, that the filth may be washed off.

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

We must now proceed to give an account of the method of cure, after these means of preventing the infection from being received into the body have either been neglected or proved ineffectual. Here it is of the utmost importance to take the disease in the very beginning, before it has time to corrupt the fluids to such a degree as to endanger life. In slight degrees of infection, a vomit properly administered, especially if succeeded by a blister, never fails to remove the disorder, and prevent the fever which would otherwise unavoidably follow. Of this Dr Lind gives the following instances. A lady afflicted with the bilious cholic, had intolerably fetid discharges of corrupted matters upwards and downwards. A gentlewoman, only in passing the room, was immediately seized with a retching and sickness, which continued 24 hours. The nurse who attended was suddenly 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 so severe as to oblige the patients to have recourse to their beds once or twice a day; sometimes every other day. Among a number thus affected, it also appears, that such as are put into unseasoned chambers, or have sat down on the cold ground, lain in raw damp apartments, &c. are immediately seized with a sickness at stomach, sometimes with a dangerous purging, and often with fevers accompanied with bad symptoms, which others have entirely escaped.

It now remains to consider the proper method of curing putrid fevers, on the supposition that the infection has been allowed to operate till the blood becomes radically tainted, and of consequence the nervous system affected to such a degree, that its power cannot be restored by any of the simple practices above mentioned. Here all authors agree, that a change of air, when it can be effected, is highly advantageous, and often contributes more towards the removing the disease than all the medicines that can be exhibited. The utility of this change will appear from what has been formerly said; and we shall only further mention one instance from Dr Lind, in which the effects of bad air appear to a degree almost incredible. "It is remarkable (says he), that, in the last war, the English ships which touched at Batavia suffered more by the malignant and fatal diseases of that climate, than they did in any other part of India, if we except a fatal scurvy which once raged in that fleet at sea. Soon after the capture of Manila, the Falmouth, a ship of 50 guns, went to Batavia, where she remained from the latter end of July to the latter end of January; during which time she buried 100 soldiers of the 79th regiment, and 75 of the ship's company; not one person in the ship having escaped a fit of sickness, except her commander Captain Breerton. The Panther, a ship of 60 guns, was there in the years 1762 and 1764; and both times during the rainy season. In the former of these years, she buried 70 of her men; and 92 of them were very ill when she left the place. In the year 1764, during a short stay, 25 of her men died. The Medway, which was in company with her, lost also a great number of men. Nor was the sickness at that time confined to the ships: the whole city afforded a scene of disease and death: streets crowded with funerals, bells tolling from morning to night, and horses jaded with dragging the dead in hearse to their graves. At that time a slight cut of the skin, the least scratch of a nail, or the most inconsiderable wound, turned quickly to a spreading putrid ulcer, which in 24 hours consumed the flesh even to the bone. This fact is so extraordinary, that upon a single testimony, credit would hardly be given to it; yet on board the Medway and Panther they had the most fatal experience of it, and suffered much from it."

But where a change of air is impracticable or ineffectual, and where the fever has already made some progress, Sir John Pringle generally took away some blood if the pulse was full. When the symptoms run high, high, a plentiful evacuation of that kind seemed indicated; yet it was observed, that large bleedings generally did harm, by sinking the pulse, and affecting the head. Nor was a moderate bleeding to be repeated without caution; even those whose blood was syrupy, 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 serviceable. Even in very bad stages of the distemper, where a putrid and colliquative looseness has taken place, clysters of fixed air have been known to alleviate the symptoms. We must not, however, put too much confidence in medicines of this kind. Mild tonic cordials, especially wine and cinchona, are the only resources in these disorders. Concerning the former, Sir John Pringle observes, in the low state of these fevers, and in great sinkings, which either come after unseasonable bleedings or long want of nourishment, it was a most grateful and efficacious cordial, to which nothing was comparable. The common men had an allowance, from a quarter to half a pint in a day, of a strong kind made into whey, or added to the panada which was their ordinary food. But to others out of the hospital, he usually prescribed Rhenish or a small French wine, whereof some consumed near a quart per day, and part of that undiluted. Nay, so great was the virtue of wine in this stage of the fever, that several were known to recover from the lowest condition, when, refusing the bark on account of its taste, they took nothing but a little panada with wine, and a volatile diaphoretic mixture, every two or three hours by turns. Perhaps there is no rule more necessary in this state, than not to let the patient when low remain long without taking something cordial and nourishing; as many have been observed past recovery, by being suffered to pass a whole night without any support about the time of the crisis. In the advanced state of this fever the sick are remarkably low; and therefore Hoffman advises in such cases, that they should be constantly kept in bed, and not permitted even to sit up in it. In the last stage of this fever, as well as in that of the sea-scurvy, it would seem that the force of the heart was too small to convey the blood to the brain, except when the body is in a horizontal posture.

But, however necessary wine and cinchona may be in the low stage of this fever, we must remember, that these remedies are to be administered only as antiseptics and supporters of the vis 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, Typhus to change to a slight delirium. If this was all, nothing was done. But if the delirium increased upon using wine, if the eyes looked wild, or the voice became quick, there was reason to apprehend a phrenitis; and accordingly it was observed, that at such times all internal heating medicines aggravated the symptoms; and in these cases, blisters were of the greatest service. Fomentations of vinegar and warm water for the feet, Sir John Pringle is of opinion, would answer better than either sinapisms or blisters, provided they were long enough and often enough applied. In the inflammatory fevers, he has known these fomentations have little effect for the first hour, and yet succeed afterwards. For internal medicine, cinchona was omitted for some time, but the patient was continued with an acidulated drink, viz. barley-water and vinegar; and treated also with camphire, pulvis contrayervae 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 cordial medicines being taken too early. It appears, therefore, how nice the principles are that regard the cure; as neither a hot nor a cool regimen will answer with every patient, or in every state of the disease.

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

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

Almost every patient, after the fever, complained of want of rest, frequently of a vertigo or confusion of the head, of a continuation of the deafness, or of other symptoms commonly called nervous. An opiate was then given at night; and in the day some strengthening medicines, such as cinchona and the sulphuric acid. In these cases, the bark was found not only to be the best strengthener, but the surest preservative against a return of the disease. For this last intention the convalescent was ordered about three drams a-day for six or seven days together; and afterwards, if he remained longer in the hospital, some smaller quantity daily. But if there was any appearance of a 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 via. For it is easy to conceive, that after a long fever of such a putrid nature, often attended with languor of the bowels, the faeces may be so much accumulated, and so corrupted, as to occasion new disorders. In such cases, after proper evacuation by a purge, cinchona was almost an infallible remedy.

The Yellow Fever.

Typhus cum flavedine cutis. Typhus icteroides, Sauv. sp. 7. Febris flava Indic Occidentalis, Warren. Malignant Fever of Barbadoes, Hillary's Diseases of Barbadoes. Lining on the Yellow Fever of South Carolina, Edin. Phys. and Liter. Essays, vol. ii. McKitterick de Febre Flavâ Indic Occidentalis, Edin. 1766.

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

The yellow or putrid bilious fever has been in particular minutely described by Dr Hillary. It most commonly seizes the patient at first with a faintness, then with a sickness at stomach, accompanied in general with a giddiness of the head; and soon after with a slight chillness 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 praecordia, 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 till the third day, though sometimes not longer than the first or second; in others to the end of the fourth: the first shows the greater dissolution of the blood, and the greater malignity of the disease; the last, the contrary; which the improper manner of treating the disease sometimes hastens and increases, or the proper method retards. This may be called the first stadium of the disease, and generally ends on the third day.

Blood taken from the sick on the second or third day, is much more dissolved, the serum more yellow, and the crassamentum florid, loose, scarcely cohering, but undulates like syrupy water when shaken, and sometimes has dark blackish spots on its surface, showing a strong gangrenescent 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 duskyish 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 ushers in the most fatal symptoms of the disease, viz. a deep coma, a low, vermicular, and intermitting pulse, great hemorrhages from various parts of the body, a delirium with laborious and interrupted respiration, great anxiety, deep sighing, restlessness, a subsultus 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 nearer hard; the face flushed, eyes inflamed; the tongue dry, with great thirst and heat, till the second or last stage of the fever is come on, when the pulse has suddenly sunk, and death soon after ensued. Yet in others, who seemed to be of a plethoric habit, the tongue has been moist all along, though they have been delirious most of the time, and the heat of their skin and the strength and quickness of their pulse have continued, after the first stage of the disease was over, pretty near to that of their natural state in health, till within a few hours of death; and when they have had a coma on them, one who is not well acquainted with the nature of this disease would, from the pulse, heat, breathing, and other symptoms, have taken them to be in a natural sleep. Others, when the pulse has begun to sink, and the fatal period seemed to be just approaching, to the great surprise of all present have recovered their senses, sat up and talked pretty cheerfully for an hour or two, and in the midst of this seeming security have been suddenly seized with convulsions which carried them off immediately.

In the latter stage of this fever, the blood is so attenuated and dissolved, that we frequently see it flowing not only out of the nose and mouth, but from the eyes, and even through the pores of the skin; great quantities also of black, half-baked, or half-mortified blood, are frequently voided both by vomiting and by stool, with great quantities of yellow and blackish putrid bile by the same passages; and the urine, which was before of a high icteritious colour, is now almost black, and is frequently mixed with a considerable quantity of half-dissolved blood. The pulse, which was much sunk before, now becomes very low, unequal, and intermittent; the breathing difficult and laborious; and the anxiety inexpressible; an oppression with a burning heat about the precordia comes on, though the extremities are cold, and often covered with cold clammy sweats; a constant delirium follows; and then a total loss of the outward senses as well as the 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, stomach, and adjoining parts, full of livid or blackish mortified spots; and the whole corpse soon putrefies after death, and can be kept but a few hours above ground.

Dr Lind is of opinion, that the remarkable dissolution of the blood, the violent hemorrhages, black vomit, and the other symptoms which characterize the yellow fever, are only accidental appearances in the common fever of the West Indies; that they are to be esteemed merely as adventitious, in the same manner as purple spots and bloody urine are in the smallpox, or as an hiccup in the dysentery: like these they only appear when the disease is attended with a high degree of malignity, and therefore always indicate great danger. This opinion, he thinks, is confirmed by an observation of Dr Wind's, that in 1750 the crew of a Dutch ship of war were distressed by the yellow 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 fortress of Gibraltar, from which, by proper attention, it had been excluded in former epidemics, demonstrates the contagious nature of this fever beyond all possibility of doubt.

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

In the description of the same fever by Dr Lining, as it appeared in South Carolina, there are several particulars considerably different from that by Dr Hillary. According to the former, people complained for a day or two before the attack, of a headache, pain in the loins and extremities, especially in the knees and calves of the legs, loss of appetite, debility, and a spontaneous lassitude. Some, however, were seized suddenly, without any such previous symptoms. After a chilliness and horror, with which this disease generally invades, a fever succeeded. The pulse was very frequent, till near the termination of the fever, and was generally full, full, hard, and consequently strong; in some, it was small and hard; in others, soft and small; but in all those cases, it frequently varied in its fulness and hardness. Towards the termination of the fever, the pulse became smaller, harder, and less frequent. In some there was a remarkable throbbing in the carotids and in the hypochondria; in the latter of which it was sometimes so great, that it caused a constant tremulous motion of the abdomen. The heat generally did not exceed 102 degrees of Fahrenheit's thermometer; in some it was less; it varied frequently, and was commonly nearly equal in all parts, the heat about the precordia being seldom more intense than in the extremities when these were kept covered. On the first day of the disease, some had frequent returns of a sense of chilliness, though there was not any abatement of the heat. In a few, there happened so great a remission of the heat for some hours, when at the same time the pulse was soft and less frequent, and the skin so moist, that one from these circumstances might reasonably have hoped that the fever would only prove a remittent or intermittent. About the end of the second day, the heat began to abate. The skin was sometimes (though rarely) dry; but oftener, and indeed generally, it was moist, and disposed to sweat. On the first day, the sweating was commonly profuse and general; on the second day, it was more moderate; but on both these, there happened frequent and short remissions of the sweatings; at which times the febrile heat increased, and the patient became more uneasy. On the third day, the disposition to sweat was so much abated, that the skin was generally dry; only the forehead and backs of the hands continued moist. The respiration was by no means frequent or difficult; but was soon accelerated by motion, or the fatigue of drinking a cup of any liquid. The tongue was moist, rough, and white, even to its tip and edges. On the second day, its middle in some was brown. On the third day, the whiteness and roughness of the tongue began to abate. The thirst in very few was great. A nausea, vomiting, or frequent retchings to vomit, especially after the exhibition of either medicines or food, came on generally the third day, as the fever began to lessen; or rather as the fulness of the pulse, heat, and disposition to sweat, began to abate. Some indeed, but very few, on the first day, had a vomiting, either bilious or phlegmatic. Very few complained of anxiety or oppression about the precordia or hypochondria, nor was there any tension or hardness about the latter. On the first day they generally dozed much, but were afterwards very watchful. Restlessness and almost continual jactations came on the second day. A great despondency attended the sick, and the strength was much prostrated from the first attack. The pain in the head, loins, &c. of which they had complained before the attack, was much increased, and in some the pain in the forehead was very acute and darting; but those pains went generally off the second day. The face was flushed; and the eyes were hot, inflamed, and unable to bear much light. On the first day, many of them at times were a little delirious, but afterwards not until the recess of the fever. The blood drawn by venesection had not any inflammatory crust; in warm weather, it was florid like arterial blood, and continued in one soft homogeneous-like mass, without any separation of the serum after it was cold. When there was any separation, the crassamentum was of a very lax texture. The stools, after the first day, were fetid, inclined to a black colour, and were very rarely bilious, soft, or liquid, excepting when forced by art; for an 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 scarce perceptible; and this, notwithstanding all the means used to support and fill it; and when this was the case, the icteritious-like suffusion, the vomiting delirium, restlessness, &c. increased to a great degree. In some, the pulse, after being exceedingly small and scarce perceptible, recovered considerably its fulness; but that favourable appearance was generally of but short continuance. The heat did not exceed the natural animal heat; and when the pulse subsided, the skin became cold, and the face, breast, and extremities acquired somewhat of a livid colour. The skin was dry when the weather was cold, but was moist and clammy when the weather was hot, the respiration was Febres 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 *contra*. The inquietude was very obstinate; and when they dozed their slumber were but short and unrefreshing. There were some who were drowsy; but these always awaked, after the shortest slumber, with a great dejection of spirits and strength. The jactations or restlessness were surprising: it was frequently scarce possible to keep the patients in bed; though at the same time, they did not complain of any anxiety or uneasiness; but if asked how they did? the reply was, Very well. The debility was so great, that, if the patient was raised erect in the bed, or, in some, if the head was only raised from the pillow, while a cup of drink was given, the pulse sunk immediately, and became sometimes so small, that it could scarce be felt; at this time, they became cold, as in a horripilatio, but without the anserine-like skin: their lips and skin, especially about the neck, face, and extremities, together with their nails, acquired a livid colour. The delirium returned and increased; it was generally constant in those whose pulse was small and subsiding. The inflammation of the tunica conjunctiva or white of the eyes increased much, but without pain. A yellowness in the white of the eyes, if it did not appear before in the febrile state, became now very observable, and that icteritious tinct was soon diffused over the whole surface of the body, and was continually acquiring a deeper saffron-like colour. In some, indeed, no yellowness was observable, excepting in the white of the eyes, until a little before death, when it increased very quickly, especially about the breast and neck. There were many small specks, not raised above the skin, which appeared very thick in the breast and neck, but less so in the extremities, and were of a scarlet, purple, or livid colour. In women the menstrua flowed, and sometimes excessively, though not at their regular period.

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

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

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

When this stadium of the disease terminated in health, it was by a recess or abatement of the vomiting, hemorrhages, delirium, inquietude, jactations, and icteritious-like suffusion of the skin and white of the eyes; while, at the same time, the pulse became fuller, and the patient gained strength, but very slowly. But when it terminated in death, those symptoms not only continued, but sooner or later increased in violence, and were succeeded with the following, which may be termed the third stadium of the disease, which quickly ended in death. The pulse, though soft, became exceedingly small and unequal; the extremities grew cold, clammy, and livid; the face and lips, in some, were flushed; in others, they were of a livid colour; the livid specks increased so fast, that in some the whole breast and neck appeared livid; the heart palpitated strongly; the heat about the precordia increased much; the respiration became difficult, with frequent sighing; the patient now became anxious, and extremely restless; the sweat flowed from the face, neck, and breast; blood flowed from the mouth, or nose, or ears, and in some from all those parts at once; the deglutition became difficult; the hiccoughs and sub-sultus 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, 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 valentiniarins, or to those who had been weakened by any previous disease.

Causes of, and persons subject to, this disease. The yellow fever attacks principally Europeans, especially those who have but lately arrived in the hot climates. Negroes are entirely exempt from it, though the mulattoes and tawnies are as liable to be seized with it as the whites themselves. The cause of the disease seems to be a particular kind of contagion; but Dr Lind seems to be of opinion, that the immediate cause of the symptoms is a disposition in the glutinous part of the blood to separate from the others, and to become putrescent. In some persons who have been bled in the yellow fever, the blood has been observed very viscid; the crassamentum covered with a yellow gluten half an inch in thickness, and impenetrable to the finger unless cut by the nail; the serum being at the same time of the consistence of a thin syrup, and of a deep yellow tinct. This serum tasted bitter, and resembled a composition of soot. 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 sound; the liver and spleen were remarkably so; as also the stomach and intestines. There was no suffusion of the bile either in the intestines or stomach. The gall-bladder, of the natural size, contained the usual quantity of bile, somewhat thicker than common, and grumous (b).

Upon examining further, this disease was found to have lain wholly on the left side, where, within the breast, was found near a quart of yellowish water, in which were many large flakes of yellowish gluten, appearing, by comparison, precisely the same with the thick pellicle which had covered the blood taken from his arm. These flakes bore in several places a resemblance to a membranous substance beginning to be converted into a purulent jelly. The pleura, both on its inside and outside, as also its continuation, the investing membrane of the lungs, were covered with cakes of this gluten, hanging in some places loosely, in others adhering more strongly; and all in different states of yellow or purulent corruption. The 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 was 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 size, which spreads itself on the top of the red concretion. Some time ago, when making experiments with the blood taken from persons in the scurvy, I was surprised to find it often covered with that sity crust. This induced me to extend my experiments to large quantities of blood from different subjects, which I had opportunities of inspecting at once in so large an hospital. For this purpose I one morning ordered ten patients in the scurvy to be bled, taking two ounces from each. A larger quantity was taken, for its inspection, from two men in health. That day I had occasion to prescribe bleeding to a woman in labour, two hours before her delivery; to a girl of sixteen years of age afflicted with a lunacy proceeding from the chlorosis; to three patients in the rheumatism; and to a person labouring under an obstruction of the liver.

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

(b) In others who died in this yellow state, the bile in the gall-bladder was found of a thick ropy consistence like pitch, but the liver never appeared in the least affected. Dr Lind at first in several bodies opened the head only; but afterwards judged that all the cavities ought to be inspected. 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 vessel, and less compact in its different parts, in proportion to their distance from the surface, towards which this whitish portion had ascended.

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

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

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

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

"But as, in the limbs of scorbutic persons, it is extremely difficult to make a good dissection by reason of such quantities of extravasated blood that everywhere obstruct the operator; so, on the contrary, the lower extremities of those who have died consumptive, with swelled legs, are, of all subjects, in the best state to afford a satisfactory view of the muscles. The water enclosed in their legs having insinuated itself, by passing the tela cellulosa, into the spaces between the muscles, the muscles are easily separated from each other; and their several origins and insertions may be distinctly traced by means of their having been cleansed and washed by the water in the investing cellular membrane. Thus there are extravasations of three sorts; viz. First, The grumous mass in the scurvy; and this I have often remarked where no serum was observed. Secondly, The serum alone in anasarcurous 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 issues and setons are most excellent preservatives against receiving an infection, even that of the plague itself. And indeed a suppuration and plentiful discharge from a proper ulcer, whether produced by nature or by art, seems to open a channel the best appropriated for an exit out of the body to some of the most malignant poisons. Thus the most favourable crisis in the plague, and in most pestilential fevers, happens when nature excites tumors kindly suppurating in the groin or armpits, by whose beneficial and plentiful discharge the deadly poison is expelled from the constitution.

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

Prognosis. This 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 putrescent disposition of the fluids, and to prevent the gangrenes from coming on, by suitable antiseptics.

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

After bleeding, we come to the second indication of cure, namely, to evacuate as much of the bilious and putrid humours as soon and as safely as we can. The great irritation of the stomach, by the putrid bilious humours constantly attending this fever, with almost continual retchings and violent vomitings, seem to indicate the giving of an emetic: but the stomach is always observed to be so violently stimulated and irritated, and most commonly inflamed, by the acrimony of the putrescent bile, that any emetic, even the most mild and gentle, given in the smallest dose, brings on an incessant vomiting, which continues in spite of all remedies, till a mortification and death ensue. Instead of this, it is proper to give large draughts of warm water, which, without any additional stimulus to the stomach, evacuates its acrid and putrid contents, commonly with great relief to the patient: the warm water also acts as an emollient 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 thebaic extract is given, in order to procure some respite from the violent retching, vomiting, and anxiety. The person is desired to take nothing into his stomach for two hours after this, by which means it is seldom or never rejected; and thus all the symptoms are considerably abated, the retching and vomiting either totally cease or are very much lessened, so that medicines may now be exhibited which the stomach would not have retained before. These are cooling acid juleps, or other antiseptic remedies; but neither nitre nor any of its preparations will commonly be found to stay on the stomach, nor, according to Dr Hilary, are the nitrous medicines, or even the common antiemetic draughts, proper to be given in this disease, even though they should agree with the stomach, on account of their attenuating property.

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

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

Rs Rad. serpent. Virginian. 3ij. Croc. Ang. 3ss. M. et infunde vase clauso in aq. bul. q. per horam unam ut col. 3vj. Adde aq. menth. simp. 3ij. Vin. Maderiens. 3iv. Syr. croc. vel syr. & mecon. 3i. Elixir vitrioli. acid. q. s. ad grat. acid. sap. Exhibe cochlearia duo vel tria singulis horis vel biloris, vel sepius pro re nata.

By the use of this medicine, and soft light nourishment taken in small quantities, the pulse is usually kept up 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 cardiana*, or the like, but not by the use of volatile spirits and salts, which hurt by their stimulating and dissolving qualities. Blisters Dr Hilary reprobrates in the strongest terms, and affirms that he has seen the place where a blister was applied turned perfectly black and sphacelated; so that if the spine and end of the ribs had not hindered, a large square passage would have been opened into the cavity of the thorax, had the patient lived a few hours after it.

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

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

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

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

To the genus of *typhus* also belong all those fevers attended with very profuse and debilitating sweats, and which have sometimes, not without good reason, been accounted plagues; such as the English sweating-sickness, *Miliaris sudatoria*, *Sauv.* sp. 5. *Ephemeris sudatoria*, *Sauv.* sp. 7. *Ephemeris Britannica*, *Caius de ephem. Britan.*

**Genus VI. SYNOCHUS.**

*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 Hectic Fever.**

*Hectica*, *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 constant 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 chiliness of the hectic fever is sometimes succeeded by heat, and sometimes immediately by a sweat without any intermediate state of heat. The hicat will sometimes come on without any remarkable chiliness preceding; and the chiliness 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 chiliness or heat. When the sweat is over, the fever will sometimes continue; and in the middle of the fever the chiliness 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 chiliness of a new fit will follow immediately the sweat of the former. It is not unusual to have many threatenings of a shivering in the same day; and some degree of drowsiness is apt to attend the cessation of a fit.

The urine in a true intermittent is clear during the fits and turbid during the intervals; but in the 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 every part of the body, or else return constantly to the same part; which is often at a great distance from the seat of the principal disorder, and, as far as is known, without any peculiar connection with it. Those pains are so violent in some patients, as to require a large quantity of opium. As far as Dr Heberden has observed, they are most common where the hectic arises from some ulcer open to the external air, as in cancers of the face, breast, &c. Joined with this fever, and arising probably from one common cause, he has been surprised to see swellings of the limbs, neck, or trunk of the body, rise up almost in an instant, as if the part was all at once grown fatter. These swellings are not painful, hard, or discoloured, and they continue for several hours.

Dr Heberden has seen this fever attack those who seemed in tolerable health, in a sudden and violent manner, like a common inflammatory one; and like that, also, in a very short time bring them into imminent danger of their lives; after which it has begun to abate, and to afford hopes of a perfect recovery. But though the danger might be over for the present, and but little of a fever remain; yet that little has soon demonstrated, that it was kept up by some great mischief within, and, proving unconquerable by any remedies, has gradually undermined the health of the patient, and never ceased except with his life. This manner of its beginning, however, is a rare occurrence. It much oftener dissembles its strength at first; and creeps on so slowly, that the subjects of it, though they be not perfectly well, yet for some months hardly think themselves ill; complaining only of being sooner tired with exercise than usual, of want of appetite, and of falling away. But gentle as the symptoms may seem, if the pulse be quicker than ordinary, so as to have the artery to beat 90 times and perhaps 120 times in a minute, there is the greatest reason to be apprehensive of the event. In no disorder, perhaps, is the pulse of more use to guide our 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 scirrhouss 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 scirrhouss 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 scirrhouss, and proceed to be cancerous. Not only these, but the glandular parts of all the abdominal viscera, are supposed 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 scirrhouss 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 scirrhouss 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 asafoetida and opium has in some persons seemed singularly serviceable in this fever, when brought on by a small wound; but in most other cases the principal if not the sole attention of the physician must be employed in relieving the symptoms, by tempering the heat, by preventing both costiveness and purging, by procuring sleep, and by checking the sweats. If, at the same time, continues Dr Heberden, he put the body into as good general health as may be, by air, exercise, and a proper course of mild diet, he can perhaps do nothing better than to leave all the rest to nature. In some few fortunate patients, nature appears to have such resources, as may afford reason for entertaining hopes of cure, even in very bad cases. For some have recovered from this fever attended with every symptom of an abdominal viscus incurably diseased, after all probable methods of relief from art had been tried in vain, and after the flesh and strength were so exhausted as to leave scarce any hopes from nature. In those deplorable Phlegmasiae circumstances, there has arisen a swelling not far from the probable seat of the disorder, and yet without any discoverable communication with it. This swelling has come to an abscess; in consequence of which the pulse has soon returned to its natural state, as have also the appetite, flesh, and strength. What nature has performed in those rare cases, Dr Heberden acquaints us, he has often endeavoured to imitate, by making issues or applying blisters near the seat of the disease; but he cannot say with the same success.

It seems at present, Dr Heberden observes, to be the opinion of many practitioners, that gangrenes will be stopped, and suppuration become more kindly, by the use of Peruvian bark; and therefore this remedy is always either advised or permitted in the irregular fever joined with suppurations and gangrenes. But he affirms he does not remember ever to have seen any good effect from cinchona in this fever unattended with an apparent ulcer; and even in gangrenes it so often fails, that in successful cases, where it has been administered, there must be room for suspicion that the success was owing to another cause. Dr Heberden acknowledges, at the same time, that he never saw any harm from cinchona, in these, or indeed in any other cases, except a slight temporary purging or sickness, where it has happened to disagree with the stomach, or where the latter has been loaded by taking the medicine too fast, especially in dry boluses wrapped in wafer-paper.

In hectic illnesses, where all other means have proved ineffectual, a journey to Bath is usually proposed by the friends, and wished for by the sick; but Dr Heberden justly observes, that, besides the fatigue and many inconveniences of a journey to a dying person, the Bath waters are peculiarly hurtful in this fever, which they never fail to increase, and thereby aggravate the sufferings and hasten the death of the patient.

**ORDER II. PHLEGMASIÆ.**

Phlegmasiae membranose et parenehymatosae, Sauv. Class III. Ord. I. II. Sag. 605.

Morbi febriles phlogistici, Lin. Class III.

Fehres continuae composite inflammatoriae, Vog.

Morbi acuti febriles, Boerh. 770.

Fehres 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 bulky coat. Under this order, many important genera are comprehended, each requiring a separate consideration.

**GENUS VII. PHLOGOSIS.**

Sp. I. Phlogosis phlegmone.

Phlegmone aetorum, Sauv. gen. 15. Lin. 39. Vog. 351.

Inflammatio, Lin. 231. Boerh. 370. Junck. 20.

This disease is a synocha fever, accompanied with an inflammation of some particular part either external or internal, and consequently it varies very much in its form and the degree of danger attending it, according to the situation and functions of the part affected with topical inflammation. To this species, therefore, belong the following diseases:

- Furunculas, Sauv. gen. 18. Vog. 352. - Terminthus, Vog. 381. - Pupula, Lin. 275. Sauv. p. 6. - Varus, Vog. 436. Lin. 269. Sauv. p. 7. - Baechia, Lin. 270. - Gutta rosea, Sauv. gen. 4. - Gutta rosacea, Vog. 437. - Hordeolum, Sauv. gen. 27. Lin. 276. Vog. 434. - Otalgia, Sauv. gen. 197. Lin. 44. Vog. 148. - Dolor otalgicus, Hoffm. II. 336. - Parulis, Vog. 362. - Mastodynia, Sauv. gen. 210. Vog. 153. - Paronychia, Sauv. gen. 21. Lin. 258. Vog. 345. - Arthroceae, Sauv. gen. 78. Lin. 256. - Pudarthroceae, Vog. 419. - Spina ventosa, Boerh. 526. - Phimosis, Sauv. gen. 22. Lin. 297. Vog. 348. - Paraphimosis, Vog. 349.

For the cure of inflammations, Dr Cullen lays down the following indications. 1. To remove the remote causes when they are evident and continue to operate. 2. To take off the phlogistic diathesis affecting the whole system, or the particular part. 3. To take off the spasm of the particular part, by remedies applied to the whole system, or to the part itself.

The means of removing the remote causes will readily occur, from considering the particular nature and circumstances of the different kinds. Acrid matters must be removed, or their action must be prevented, by the application of demulecens. 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 synoeca. 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 searifications, applying leeches, &c. are in this case much more indicated; and that some of the other remedies are to be directed more particularly to the part affected, as shall be more fully considered when we treat of those diseases attended with particular inflammations.

When a tendency to suppuration is perceived, the proper indication is to promote the production of perfect pus as much as possible. For this purpose various remedies, supposed to possess a specific power, have been proposed; but it does not appear that any of them are possessed of a virtue of this kind; and, in Dr Cullen's opinion, all that can be done is to favour the suppuration by such applications as may support a moderate heat in the part, by some tenacity confine the perspiration, and by an emollient quality may weaken the cohesion of the teguments, and favour their erosion. As all abscesses are occasioned by the effusion of fluids, and as in the case of certain effusions a suppuration becomes comes not only unavoidable but desirable, it may be supposed that most of the means of procuring a resolution, by diminishing the force of circulation, &c., ought to be avoided. But as we observe, on the one hand, that a certain degree of increased impetus, or of the original symptoms of inflammation, is necessary to produce a proper suppuration; so it is then especially necessary to avoid those means of resolution which may diminish too much the force of circulation. And on the other hand, as the impetus of the blood, when violent, is found to prevent the proper suppuration; so, in such cases, though a tendency to suppuration may have begun, it may be proper to continue those means of resolution which moderate the force of the circulation. With respect to the opening of abscesses when completely formed, see the article SURGERY.

When an inflammation has taken a tendency to gangrene, that event is to be prevented by every possible means; and these must be different according to the nature of the several causes: but after a gangrene has in some degree taken place, it can be cured only by the separation of the dead from the living parts. This in certain circumstances can be performed, and most properly, by the knife. In other cases it can be done by exciting a 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 searify 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 oedema; or in those cases where a loss of tone takes place after the original inflammatory symptoms are removed.

On the other hand, Mr Bell is of opinion, that incisions made with a view to admit the operation of antiseptic remedies in gangrenes, as well as the remedies themselves, must be pernicious from the irritation they occasion, and from the danger of wounding blood-vessels, nerves, or tendons, and also by allowing a free passage for the putrescent fluids into the parts not yet affected. And unless they be carried so deep as to reach the sound parts, applications of the antiseptic kind can never have any effect in answering the purpose for which they were intended. The same author also remarks, that all the advantages commonly observed from the great number of applications recommended for gangrene, are obtained with more ease, and generally too with more certainty, from the use of some gentle stimulating embrocation; which, by exciting a slight irritation upon the surface, especially when assisted by a free use of cinchona, produces for the most part such a degree of inflammation as is wished for. With this view he has frequently known a weak solution of sal ammoniac, a dram of the salt to two ounces of vinegar and six of water, form a mixture of very proper strength for every purpose of this kind. But the degree of stimulus can easily be either increased or diminished according to circumstances, by using a larger or smaller proportion of the salt.

Whenever, either by the means recommended, or by a natural exertion of the system, a slight inflammation appears between the diseased and sound parts, we may in general, with tolerable certainty, expect, that in due time the parts will be separated; and when a full suppuration is once fairly established, there can be little doubt that the mortified parts will be soon and easily removed.

A complete separation being effected, the sore is to be treated in the manner described under the article SURGERY; with a proper attention, at the same time, to the support of the general system by the continuance of nourishing diet, and cinchona with such quantities of wine as may seem necessary.

With regard to the bark, however, it is proper to take notice of another case of mortification in which it is likewise unsuccessful, as well as in that attended with a high degree of inflammation; and that is, in those mortifications of the toes and feet, common in old people, or which arise from any cause increasing the rigidity of the vessels to such a degree as to prevent the motion of the fluids through them. In this case Mr Pott has discovered, that all kinds of warm applications are very unsuccessful; but by the free use of opium, together with sedatives and relaxants externally applied, he has frequently seen the tumefaction of the feet and ankles subside, the skin recover its natural colour, and all the mortified parts separate in a very short time, leaving a clean sore. But as to scarifications, or any other attempt to separate artificially the mortified from the sound parts, he thinks them very prejudicial, by giving pain; which is generally of itself violent in this disease, and which seems to have a great share in producing the other evils.

The other terminations of inflammation either do not admit of any treatment except that of preventing them by resolution, or properly belong to the article SURGERY.

Sp. II. PHLOGOSIS ERYTHEMA.

Erythema, Sauv. gen. ii.

uctorum, Vog. 343.

Hieropyr. Vog. 344.

Anthrax, Sauv. gen. 19. Lin. 272. Vog. 353.

Carbo et carbunculus auctorum.

Erythema gangrenosum, Sauv. sp. 7.

Erythema à frigore.

Erythema pernio, Sauv. sp. 4.

Pernio, Lin. 259. Vog. 350.

Erythema Erythema ambustio, Sauv. sp. 2. Erysipelas ambustio, Sauv. sp. 4. Combustura, Lin. 245. Combustio, Boerh. 476. Encausis, Vog. 347. Erythema ab acri alieno applicato. Erysipelas Sinense, Sauv. sp. 7. Erythema ab acri inquinillo. Erythema intertrigo, Sauv. sp. 5. Intertrigo, Lin. 247. Vog. 502. Erythema à compressione. Erythema paratrima, Sauv. sp. 6. Erythema à punctua, Sauv. sp. 9. Erysipelas à vespis, Sauv. sp. 19. Psyracia à vespis, Sauv. sp. 2. Erythema cum phlegmonc. Erysipelas phlegmonodes auctorum. Erythema cum oedemate. Erysipelas 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 erysipelas, or "St Anthony's fire;" and which being commonly symptomatic of some other inflammation or disorder, are to be removed only by removing the primary disease: the erythema is found scarcely to bear any kind of warm application to itself; and is very apt, if treated as a primary disease, to terminate in a gangrene of the part affected, or some other disorder still more dangerous. The difference between the phlegmon or preceding species, and erythema, according to Dr Cullen, is, that, in the former, the inflammation seems particularly to affect the vessels on the internal surface of the skin, communicating with the lax adjacent cellular texture; whence a more copious effusion, and that too of serum convertible into pus, takes place. In the erythema the affection is of the vessels on the external surface of the skin communicating with the rete mucosum. This affection does not admit of any effusion but what separates the cuticle, and gives occasion to the formation of a blister, while the smaller size of the vessels admits only of the effusion of a thin fluid very seldom convertible into pus. For the cure of the fever attended with erythema or erysipelas, see below; and for the external treatment of erythema, see Surgery.

Genus VIII. OPTHALMIA.

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 chemosis, Sauv. sp. 12. Ophthalmia crysiplatosa, Sauv. sp. 7. Ophthalmia pustulosa, Sauv. sp. 6. Ophthalmia phlyctenodes, Sauv. sp. 21. Ophthalmia choroides, Sauv. sp. 13. Ophthalmia tenebricosa, Sauv. sp. 10. Ophthalmia trachoma, Sauv. sp. 4. Ophthalmia sicca, Sauv. sp. 5.

Ophthalmia angularis, Sauv. sp. 14. Ophthalmia tuberculosa, Sauv. sp. 3. Ophthalmia trichiasis, Sauv. sp. 2. Ophthalmia cancrosa, Sauv. sp. 15. Ophthalmia à synchia, Sauv. sp. 16. Ophthalmia à lagophthalmos, Sauv. sp. 17. Ophthalmia ab elomate, Sauv. sp. 18. Ophthalmia ab ungue, Sauv. sp. 19. Ophthalmia à cornæe fistula, Sauv. sp. 20. Ophthalmia uvæ, Sauv. sp. 22. Ophthalmia metastatica, 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 tarsus, or edges of the eyelids, in which case it may be termed ophthalmia tarsi. These two kinds are very frequently connected together, as the one may excite the other; but they are still to be distinguished according as the one or the other may happen to be the primary affection.

1. The inflammation of the membranes of the eye affects especially, and most frequently, the adnata, and appears in a turgescence of its vessels; so that the red vessels which are naturally there, become not only increased in size, but many more appear than in a natural state. This turgescence of the vessels is attended with pain, especially upon the motion of the ball of the eye; and this irritation, like every other, applied to the surface of the eye, produces an effusion of tears from the lachrymal gland.

The inflammation commonly, and chiefly, affects the adnata spread on the anterior part of the bulb of the eye; but usually spreads also along the continuation of the adnata on the inside of the palpebrae; and as that is extended on the tarsus palpebrarum, the excretories of the sebaceous glands opening there are also frequently affected. When the affection of the adnata is considerable, it may be communicated to the subjacent membranes of the eye, and even to the retina itself; which thereby acquires so great sensibility, that every impression of light becomes painful. The inflammation of the membranes of the eye is in different degrees, according as the adnata is more or less affected, or according as the inflammation is either of the adnata alone, or of the subjacent membranes also; and upon these differences, different species have been established; but they seem all to differ only in degree, and are to be cured by the same remedies more or less employed.

The proximate cause of ophthalmia is not different from that of inflammation in general; and the different circumstances of ophthalmia may be explained by by the difference of its remote causes, and by the different parts of the eye which it happens to affect; as may be understood from what has been already said. We shall therefore proceed to give an account of the method of cure.

The great objects to be aimed at in the treatment of ophthalmia, are, in the first place, the resolution of the inflammation which has already taken place; and, secondly, the removal of those consequences which frequently arise from the inflammation, especially if it have been of long standing. But besides these, while it has appeared from former observation, that there is a peculiar disposition to the disease, practices may often be successfully employed to combat this disposition, and thus prevent the return of the affection.

The ophthalmia membranarum requires the remedies proper for inflammation in general; and when the deeper-seated membranes are affected, and especially when a pyrexia is present, large general bleedings may be necessary. But this last is seldom requisite, and, for the most part, the ophthalmia is an affection merely local, accompanied with little or no pyrexia. General bleedings therefore have little effect upon it, and the cure is chiefly to be obtained by topical bleedings, that is, blood drawn from the vessels near the inflamed part; and opening the jugular vein, or the temporal artery, may be considered as in some measure of this kind. It is commonly sufficient to apply a number of leeches round the eye; but it is perhaps still better to draw blood by cupping and scarifying from the temples. In many cases, the most effectual remedy is to scarify the internal surface of the inferior eyelid, and to cut the turgid vessels upon the adnata itself.

Besides blood-letting, purging, as a remedy suited to inflammation in general, has been considered as peculiarly adapted to inflammation in any part of the head, and therefore to ophthalmia; and it is sometimes useful: but, for the reasons given before with respect to general bleeding, purging in the case of ophthalmia does not prove useful in any proportion to the evacuation excited.—For relaxing the spasm in the part, and taking off the determination of the fluids to it, blistering near the part has commonly been found useful. When the inflammation does not yield to the application of blisters after topical bleeding, great benefit is often obtained by supporting a discharge from the blistered part, under the form of an issue, by which means a more permanent determination of blood from the part is obtained.

It is probably also on the same principle that the good effects obtained from the use of errhine medicines in obstinate cases of ophthalmia are to be accounted for. By these errhines, in particular, which occasion and support for some time a great discharge from the nose, great benefit has often been obtained. The powder of asarabacca, or the infusion of hippocastanum, snuffed up the nose at bedtime in proper doses, are often productive of the best effects, when many other remedies have been tried in vain.

Ophthalmia, as an external inflammation, admits of topical applications. All those, however, which increase the heat and relax the vessels of the part, prove hurtful; and the admission of cool air to the eye, and the application of cooling and astringent medicines, which at the same time do not produce irritation, prove useful. Of all these the solution of acetite of lead, assiduously applied, is perhaps the best. In the cure of this distemper, indeed, all irritation must carefully be avoided, particularly that of light; and the only certain means of doing this is by keeping the patient in a very dark chamber.

2. In the ophthalmia tarsi, the same medicines may be necessary, as have been already recommended for the ophthalmia membranarum. However, as the ophthalmia tarsi may often depend upon an acrimony deposited in the sebaceous glands of the part, so it may require various internal remedies according to the variety of the acrimony in fault; for which we must refer to the consideration of scrophula, syphilis, or other diseases with which this ophthalmia may be connected; and where these shall not be evident, certain remedies more generally adapted to the evacuation of acrimony, such as mercury, may be employed. In the ophthalmia tarsi, it almost constantly happens that some ulcerations are formed on the tarsus. These require the application of mercury and copper, which alone may sometimes cure the whole affection; and they may be useful even when the disease depends upon a fault of the whole system.

Both in the ophthalmia membranarum, and in the ophthalmia tarsi, it is necessary to obviate that glueing together of the eyelids which commonly happens in sleep; and which may be done by insinuating a little of any mild unctuous medicine between the eyelids before the patient shall go to sleep.

The slighter kinds of inflammations from the dust or the sun, may be removed by fomenting with warm milk and water, adding a small portion of brandy; and by anointing the borders of the eyelids with unguentum tutiae, 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 cataplasm aluminis of the London Pharmacopoeia spread on lint, and applied at bedtime, has been found the best external remedy. Before the use of the latter, the solution of sulphate of zinc is prescribed 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 slighter cases it may often be removed by the application of different gentle escharotics; and in this way, without the least danger of any inconvenience, goods effects are often obtained, from gently introducing into the eye at bedtime a powder consisting of equal parts of supertartrite of potass 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 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 sound.

or Chronic Rheumatism.

Rheumatismus chronicus Auctorum.

Description. When the pyrexia attending the acute rheumatism has ceased; when the swelling and redness of the joints are entirely gone, but pains still continue to affect certain joints, which remain stiff, feel uneasy upon motion, changes of weather, or in the night time only, the disease is then called the chronic rheumatism, as it often continues for a very long time.

The limits between the acute and chronic rheumatisms are not always exactly marked. When the pains are still ready to shift their place; when they are especially severe in the night time; when, at the same time, they are attended with some degree of pyrexia, and with some swelling, and especially some redness of the joints; the disease is to be considered as partaking of the nature of the acute rheumatism. But when there is no longer any degree of pyrexia remaining; when the pained joints are without redness; when they are cold and stiff; when they cannot easily be made to sweat; or when, while a free and warm sweat is brought out on the rest of the body, it is only clammy and cold on the pained joints; and when, further, the pains of these are increased by cold, and relieved by heat, applied to them; the case is to be considered as that of a purely chronic rheumatism: or, perhaps more properly, the first of the conditions now described may be termed the state of irritability, and the second the state of atony.

The chronic rheumatism, or rather the atonic, may affect different joints; but is especially apt to affect those which are surrounded with many muscles, and those of which the muscles are employed in the most constant and vigorous exertions. Such is the case of the vertebrae of the loins, the affection of which is named lumbago; or of the hip joint, when the disease is named ischias or sciatica.

Violent strains and spasms occurring on sudden and somewhat violent exertions, bring on rheumatic affections, which at first partake of the acute, but very soon change into the nature of the chronic, rheumatism.—Such are frequently the lumbago, and other affections, which seem to be more seated in the muscles than in the joints. The distinction of the rheumatic pains from those resembling them which occur in the syphilis and scurvy must be obvious, either from the seat of the pains, or from the concomitant symptoms peculiar to those diseases. The distinction of the rheumatism from the gout will be more fully understood from what is laid down under the genus Podagra.

Causes, &c. The phenomena of the purely chronic rheumatism lead us to conclude, that its proximate cause is an atony both of the blood-vessels and of the muscular fibres of the part affected, together with such a degree of rigidity and contraction in the latter as frequently attend them in a state of atony: and indeed this atony, carried to a certain extent, gives rise to a state of paralysis, with an almost total loss of motion in the affected limbs. The paralytic state of rheumatism therefore may be pointed out as a fourth condition of the disease, often claiming the attention of rheumatismus the practitioner.

Cure. From the view just now given of the proximate cause of chronic rheumatism, the chief indication of cure must be, to restore the activity and vigour of the part, which is principally to be done by increasing the tone of the moving fibres, but which may sometimes also be aided by giving condensation to the simple solid. When, however, the disease has degenerated into the state of paralysis, the objects to be aimed at are, the restoration of a due condition to the nervous energy in the part affected; the obtaining free circulation of blood through the vessels of the part; and the removal of rigidity in membranes and ligaments.

For answering these purposes, a great variety of remedies, both external and internal, are had recourse to. The chief of the external are, the supporting the heat of the part, by keeping it constantly covered with flannel; the increasing the heat of the part by external heat, applied either in a dry or humid form; the diligent use of the 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 Petersburgh, 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 Bardsley 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 stomachica, Sauv. sp. 9.

Description. This well-known disease makes its attack by a most violent pain in the teeth, most frequently in the molares, more rarely in the incisores, reaching sometimes up to the eyes, and sometimes backward into the cavity of the ear. At the same time there is a manifest determination to the head; and a remarkable tension and inflation of the vessels takes place, not only in the parts next to that where the pain is seated, but over the whole head.

Causes, &c. The toothach is sometimes merely a rheumatic affection, arising from cold, but more frequently from a carious tooth. It is also a symptom of pregnancy, and takes place in some nervous disorders; it may attack persons at any time of life, though it is most frequent in the young and plethoric.

Cure. Many empirical remedies have been proposed for the cure of the toothach, but none have in any degree answered the purpose. When the affection is purely rheumatic, blistering behind the ear will almost always remove it; but when it proceeds from a carious tooth, the pain is much more obstinate. In this case it has been recommended to touch the pained part with a hot iron, or with sulphuric acid, in order to destroy the aching nerve; to hold strong spirits in the mouth; to put a drop of oil of cloves into the hollow of the tooth, or a pill of equal parts of opium and camphor: but one of the most useful applications of this kind is strong nitrous acid, diluted with three or four times its weight of spirit of wine, and introduced into the hollow of a tooth from which great pain arises, either by means of a hair pencil or a little cotton. Cinchona has also been recommended, and perhaps with more justice, on account of its tonic and antiseptic powers; but very often all these remedies will fail, and the only infallible cure is the extraction of the tooth. See Surgery.

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 verus, Hoffm. II. 339. Dolores arthritici, Hoffm. II. 317. Affectus spasitico-arthritici, Junck. 46.

Sp. I. The Regular Gout. Arthritis podagrica, Sauv. sp. 1.

Arthritis rachialgica, Sauv. sp. 11. Arthritis aestiva, Sauv. sp. 4.

Sp. II. The Atonic Gout. Arthritis melancholica, Sauv. sp. 6. Arthritis hiemalis, Sauv. sp. 2. Arthritis chlorotica, Sauv. sp. 5. Arthritis asthmatica, 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 pricking along the whole of the lower extremities; frequent cramps of the muscles of the legs; and an unusual turgescence of the veins.

While these symptoms take place in the lower extremities, the body is affected with some degree of torpor and languor, and the functions of the stomach in particular are more or less disturbed. The appetite is diminished; and flatulency, or other symptoms of indigestion, are felt. These symptoms take place for several days, sometimes for a week or two, before a paroxysm comes on; but commonly, upon the day immediately preceding it, the appetite becomes keener than usual.

The circumstances of paroxysms are chiefly the following. They come on most commonly in the spring, and sooner or later according as the vernal heat succeeds sooner or later to the winter's cold, and, perhaps, sooner or later also, according as the body may happen to be more or less exposed to vicissitudes of heat and cold.

The attacks are sometimes felt first in the evening, but more commonly about two or three o'clock in the morning. The paroxysm begins with a pain affecting one foot, most frequently in the ball or first joint of the great toe, but sometimes in other parts of the foot. With the attack of this pain, there is commonly, more or less of a cold shivering; which, as the pain increases, gradually ceases; and is succeeded by a hot stage of pyrexia, which continues for the same time with the pain itself. From the first attack, the pain becomes, by degrees, more violent, and continues in this state with great restlessness of the whole body till next midnight, after which it gradually remits; and, after it has continued for twenty-four hours from the commencement of the first attack, it commonly ceases almost entirely; and, with the coming on of a gentle sweat, allows the patient to fall asleep. The patient, upon coming out of this sleep in the morning, finds the pained part affected with some redness and swelling, which, after having continued for some days, gradually abate.

When a paroxysm has thus come on, although the violent pain after 24 hours be considerably abated, the patient is not entirely relieved from it. For some days days he has every evening a return of more considerable pain and pyrexia, and these continue with more or less violence till morning. After going on, in this manner, for several days, the disease sometimes goes entirely off, not to return till after a long interval.

When the disease, after having thus remained for some time in a joint, ceases entirely, it generally leaves the person in very perfect health, enjoying greater ease and alacrity in the functions of both body and mind than he had for a long time before experienced.

At the beginning of the disease, the returns of it are sometimes only once in three or four years; but as it advances, the intervals become shorter, and at length the attacks are annual; afterwards they come twice each year; and at length recur several times during the course of autumn, winter, and spring; and as, when the fits are frequent, the paroxysms become also longer, so, in the advanced state of the disease, the patient is hardly ever tolerably free from it, except perhaps for two or three months in summer.

The progress of the disease is also marked by the parts which it affects. At first, it commonly affects one foot only; afterwards every paroxysm affects both feet, the one after the other; and as the disease proceeds, it not only affects both feet at once, but, after having ceased in the foot which was last attacked, returns again into the first, and perhaps a second time also into the other. Its changes of places are not only from one foot to another, but from the feet into other joints, especially those of the upper extremities; so that there is hardly a joint of the body which, on one occasion or another, is not affected. It sometimes affects two different joints at the very same time; but more commonly it is at any one time severe in a single joint only, and passes in succession from one joint to another; so that the patient's affliction is often protracted for a long time.

When the disease has often returned, and the paroxysms have become very frequent, the pains are commonly less violent than they were at first; but the patient is more affected with sickness, and the other symptoms of the atonic gout, which shall be hereafter mentioned.

After the first paroxysm of the disease, the joints which have been affected are entirely restored to their former suppleness and strength: but after the disease has recurred very often, the joints affected do neither so suddenly nor entirely recover their former state, but continue weak and stiff; and these effects at length proceed to such a degree, that the joints lose their motion entirely.

In many persons, but not in all, after the disease has frequently recurred, concretions of a chalky nature are formed upon the outside of the joints, and for the most part immediately under the skin. The matter seems to be deposited at first in a fluid form, afterwards becoming dry and firm. In their firm state, these concretions are a hard earthy substance, very entirely soluble in acids. After they have been formed, they contribute, with other circumstances, to destroy the motion of the 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 Podagra, 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; so every appearance which we can perceive to depend upon that same disposition, we still consider as symptomatic, and view the disease to be a case of the gout. The principal circumstance, in what we term the regular gout, is the inflammatory affection of the joints; and whatever symptoms we can perceive to be connected with, or to depend upon, the disposition which produces that inflammatory affection, but without its taking place or being present at the same time, we name the irregular gout.

Of such irregular gout there are three different states, which may be named the atonic, the retrocedent, and the misplaced gout.

The first is, when the gouty diathesis prevails in the system; but, from certain causes, does not produce the inflammatory affection of the joints. In this case, the morbid symptoms which appear, are chiefly affections of the stomach, such as loss of appetite, indigestion, and its various attendant symptoms of sickness, 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 costiveness; but sometimes a looseness, with colic pains. These affections of the alimentary canal are often attended with all the symptoms of hypochondriasis, such as dejection of mind, a constant and anxious attention to the slightest feelings, an imaginary aggravation of these, and an apprehension of danger from them.

In the same atonic gout, the viscera of the thorax also are sometimes affected, and palpitations, faintings, and asthma occur.

In the head also occur headaches, giddiness, apoplectic and paralytic affections.

When the several symptoms now mentioned occur in habits having the marks of a gouty disposition, this may be suspected to have laid the foundation for them; and especially when either, in such habits, a manifest tendency to the inflammatory affection has formerly appeared, or when the symptoms mentioned are 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 vesice: the other is an affection of the rectum, sometimes indicated by pain alone in that part, and sometimes by hemorrhoidal symptoms. In gouty persons such affections have been known to alternate with inflammatory affections of the joints; but whether these belong to the retrocedent or to the misplaced gout, Dr Cullen pretends not to determine.

It is commonly supposed, that there are some cases of rheumatism which are scarcely to be distinguished from the gout: but these, Dr Cullen thinks, are but few; and that the two diseases may be for the most part distinguished with great certainty, by observing the predisposition, the antecedent circumstances, the parts affected, the recurrences of the disease, and its connection with the system; which circumstances, for the most part, appear very differently in the two diseases.

Causes, &c. The gout is generally an hereditary disease: but some persons, without any hereditary 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 choleric-sanguine temperament. It is, however, very difficult to treat this matter with precision. The gout seldom attacks persons employed in constant bodily labour, or those who live much upon vegetable aliment. It does not commonly attack men till after the age of 35; and generally not till a still later period. There are indeed instances of the gout appearing more early, but these are few in comparison of the others. When the disease does appear early in life, it seems to be in those who have the hereditary disposition very strong, and to whom the remote causes hereafter mentioned have been applied in a very considerable degree.

As the gout is an hereditary disease, and affects men particularly of a certain habit, its remote causes may be considered as predisponent and occasional. The predisponent cause, as far as expressed by external appearances, has been already marked; and physicians have been very confident in assigning the occasional causes: but in a disease depending so much upon a predisposition, the assigning occasional causes must be uncertain; as in the predisposed the occasional causes may not always appear, and in persons not predisposed they may appear without effect; and this uncertainty must particularly affect the case of the gout.

The occasional causes of the disease seem to be of two kinds. First, Those which induce a plethoric state of the body. Secondly, Those which in plethoric habits, induce a state of debility. Of the first kind are a sedentary, indolent manner of life, and a full diet of animal food. Of the second kind of occasional causes which induce debility are excess in venery; intemperance in the use of intoxicating liquors; indigestion, produced either by the quantity or quality of the aliments; much application to study or business, night watching, excessive evacuations; the ceasing of usual labour; a sudden change from a very full to a very spare diet; the large use of acids and acescents; and, lastly, cold applied to the lower extremities. The former seem to act by increasing the predisposition; the latter are commonly the exciting causes, both of the first attacks, and of the repetitions of the disease.

With respect to the proximate cause of the gout, it has generally been thought that it depends on a cer- 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.

Eightly, The supposition of a morbid matter is quite superfluous: for it explains nothing, without supposing that matter to produce a change in the state of the moving powers; and a change in the state of the moving powers, produced by other causes, explains every circumstance without the supposition of a morbid matter; and it may be observed, that many of the causes exciting the gout, do not operate upon the state of the fluids, but directly and solely upon that of the moving powers.

Lastly, Dr Cullen contends that the supposition of a morbid matter is superfluous; because, without that, the disease can be explained, he thinks, in a manner more consistent with its phenomena, with the laws of the animal economy, and with the method of cure which experience has approved. We now proceed to give this explanation; but, before entering upon it, we must premise some general observations which Dr Cullen states.

The first observation is, That the gout is a disease of the whole system, or depends upon a certain general conformation and state of the body, which manifestly appears from the facts above mentioned. But the general state of the system depends chiefly upon the state of its primary moving powers; and therefore the gout may be supposed to be an affection of these.

The second observation is, That the gout is manifestly an affection of the nervous system; in which the primary moving powers of the whole system are lodged. The occasional or exciting causes are almost all such as act directly upon the nerves and nervous system; and the greater part of the symptoms of the atomic 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 atomic 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 atonic gout.

A second case of variation in the course of the gout is, when to the atony the reaction and inflammation have to a certain degree succeeded, but from causes either internal or external the tone of the extremities and perhaps of the whole system is weakened; so that the inflammatory state, before it had either proceeded to the degree, or continued for the time, requisite for restoring the tone of the system, suddenly and entirely ceases: whence the stomach, and other internal parts, relapse into the state of atony; and perhaps have that increased by the atony communicated from the extremities: all which appears in what has been termed the retrocedent state of the gout.

A third case of variation from the ordinary course of the gout, is, when to the atony, usually preceding, an inflammatory reaction fully succeeds, but has its usual determination to the joints prevented by some circumstances; and is therefore directed to some internal part, where it produces an inflammatory affection, and that state of things which we have named the misplaced gout.

Though this theory of Dr Cullen's be supported with much ingenuity, yet we may confidently venture to assert, that on this subject he has been less successful in establishing his own opinions, than in combating those of others; and this theory, as well as others formerly proposed, is liable to numerous and unsurmountable 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 unsurmountable objections; and it by no means, any more than former hypotheses, explains the phenomena of the disease, particularly what Dr Cullen has himself so accurately pointed out, the connection of gouty with calculous complaints.

A very ingenious work has lately been published by an anonymous author, entitled "A Treatise on Gravel and upon Gout," in which the sources of each are investigated, and effectual means of preventing or removing these diseases recommended. In this treatise an attempt is made to prove, that both diseases depend upon a peculiar 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, cider, &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 curving the gout, the Doctor is not able to say. There are histories of cases of the gout, in which it is said, that by great emotions of mind, by wounds, and by other accidents, the symptoms have been suddenly relieved, and never again returned; but how far these accidental cures might be imitated by art, or would succeed in other cases, is at least extremely uncertain.

The practices proper and necessary in the treatment of the gout, are to be considered under two heads: First, As they are to be employed in the intervals of paroxysms; or, secondly, As during the time of these. In the intervals of paroxysms, the indications are, to prevent altogether the return of paroxysms; or at least to render them less frequent and more moderate. During the time of paroxysms, the indications are, to moderate the violence and shorten the duration of them as much as can be done with safety.

It has been already observed, that the gout may be entirely prevented by constant bodily exercise, and by a low diet; and Dr Cullen is of opinion, that this prevention may take place even in persons who have a hereditary disposition to the disease. Even when the disposition has discovered itself by several paroxysms of inflammatory gout, he is persuaded that labour and abstinence will absolutely prevent any returns of it for the rest of life. These, therefore, are the means of answering the first indication to be pursued in the intervals of paroxysms.

Exercise in persons exposed to the gout, in Dr Cullen's opinion, operates by answering two purposes: One of these is the strengthening of the tone of the extreme vessels; and the other, the guarding against a plethoric state. For the former, if exercise be employed early in life, and before intemperance has weakened the body, a very moderate degree of it will answer the purpose; and, for the latter, if abstinence be at the same time observed, less exercise will be necessary.

With respect to exercise, this in general is to be observed, that it should never be violent; for if violent, it cannot be long continued, and must always endanger the bringing on an atony in proportion to the violence of the preceding motions.

It is also to be observed, that the exercise of gestation, though considerable and constant, will not, if it be entirely without bodily exercise, answer the purpose of preventing the gout. For this end, therefore, the exercise must be in some measure that of the body; and must be moderate, but at the same time constant and continued through life.

In every case and circumstance of the gout in which the patient retains the use of his limbs, bodily exercise, in the intervals of paroxysms, will be always useful; and in the beginning of the disease, when the disposition to it is not yet strong, exercise may prevent a paroxysm which otherwise would have come on. In more advanced states of the disease, however, when there is some disposition to a paroxysm, much walking will bring it on; either as it weakens the tone of the lower extremities, or as it excites an inflammatory disposition in them; and thus it seems to be that sprains or contusions often bring on a paroxysm of the gout.

Abstinence, the other part of the regimen for preventing the gout, is of more difficult application. If an abstinence from animal food be entered upon early in life, while the vigour of the system is yet entire, Dr Cullen has no doubt of its being both safe and effectual; but if the motive for this diet shall not have occurred till the constitution has been broken by intemperance, or by the decline of life, a low diet may then endanger the induction of an atonic state.

Further, If a low diet be entered upon only in the decline of life, and be at the same time a very great change from the former manner of living, the withdrawing of an accustomed stimulus of the system may readily throw it into an atonic state.

The safety of an abstemious course will be greater or less according to the management of it. Animal food especially disposes to the plethoric and inflammatory state, and that food is to be therefore especially avoided; but on the other hand, vegetable aliment of the lowest quality is in danger of weakening the system too much by not affording sufficient nourishment, and more particularly of weakening the tone of the stomach by its 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 seeds 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. 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 paroxysms, or at least for rendering them less frequent and more moderate. But many circumstances prevent the steadiness necessary in pursuing these measures; and therefore in such cases, unless great care be taken to avoid the exciting causes, the disease may frequently return, and, in many cases, the preventing of paroxysms is chiefly to be obtained by avoiding those exciting causes already enumerated.

A due attention in avoiding these different causes will certainly prevent fits of the gout; and the taking care that the exciting causes be never applied in a great degree, will certainly render fits more moderate when they do come on. But, upon the whole, it will appear, that a very strict attention to the general conduct of life is in this matter necessary; and therefore, when the predisposition has taken place, it will be extremely difficult to avoid the disease.

Dr Cullen is firmly persuaded, that by obviating the predisposition, and by avoiding the exciting causes, the gout may be entirely prevented: but, as the measures necessary for this purpose will, in most cases, be pursued with difficulty, and even with reluctance, men have been very desirous to find a medicine which might answer the purpose without any restraint on their manner of living. To gratify this desire, physicians have proposed, and, to take advantage of it, empirics have feigned, many remedies. Of what nature several of these remedies have been, it is difficult to say: but of those which are unknown, we conclude, from their having been only of temporary fame, and from their having soon fallen into neglect, that they have been either inert or pernicious. We shall therefore make no inquiry after them; and shall now remark only upon one or two known remedies for the gout which have been lately fashionable.

One of these is what has been named in England the Portland powder. This is not a new medicine, but is mentioned by Galen, and, with some little variation in its composition, has been mentioned by the writers of almost every age since that time. It appears to have been at times in fashion, and to have again fallen into neglect; and Dr Cullen thinks that this last has been owing to its having been found to be, in many instances, pernicious. In every instance which he has known of its exhibition for the length of time prescribed, the persons who had taken it were indeed afterwards free from any inflammatory affection of the joints; but they were affected with many symptoms of the atomic gout; and many, soon after finishing their course of the medicine, have been attacked with apoplexy, asthma, or dropsy, which proved fatal.

Another remedy which has had the appearance of preventing the gout, is alkali in various forms; such as Podagro, the fixed alkali, both mild and caustic, lime water, soap, and absorbent earths; and of late the alkaline aerated water has been more fashionable than any other. Since it became common to exhibit these medicines in nephritic and calculous cases, it has often happened that they were given to those who were at the same time subject to the gout; and it has been observed, that under the use of these medicines, gouty persons have been longer free from the fits of their disease. That, however, the use of these medicines has entirely prevented the returns of gout, Dr Cullen does not know; because he never pushed the use of them for a long time, being apprehensive that the long-continued use of them might produce a hurtful change in the state of the fluids.

As the prevention of gout depends very much on supporting the tone of the stomach, and avoiding indigestion; so costiveness, by occasioning this, is very hurtful to gouty persons. It is therefore necessary for such persons to prevent or remove costiveness, by a laxative medicine, when needful; but it is at the same time proper, that the medicine employed should be such as may keep the belly regular, without much purging. Aloeticks, rhubarb, magnesia alba, oleum ricini, or flowers of sulphur, may be employed, as the one or the other may happen to be best suited to particular persons.

These are the several measures to be pursued in the intervals of the paroxysms; and we are next to mention the measures proper during the time of them.

As during the time of paroxysms the body is in a feverish state, no irritation should then be added to it; every part, therefore, of the antiphlogistic regimen, except the application of cold, ought to be strictly observed.

An exception to the general rule, however, may occur when the tone of the stomach is weak, and when the patient has been much more accustomed to the use of strong drink; for then it may be allowable, and even necessary, to give some animal food and a little wine.

That no irritation is to be added to the system during the paroxysms of gout, except in the cases mentioned, is agreed upon among physicians: but it is a more difficult matter to determine, whether, during the time of paroxysms any measures may be pursued to moderate the violence of reaction and of inflammation. Dr Sydenham has given it as his opinion, that the more violent the inflammation and pain, the paroxysm will be the shorter, as well as the interval between the present and the next paroxysm longer; and, if this opinion be admitted as just, it will forbid the use of any remedies which might moderate the inflammation; which is, to a certain degree, undoubtedly necessary for the health of the body. On the other hand, acute pain presses for relief; and although a certain degree of inflammation may seem absolutely necessary, there is reason to believe, a moderate degree of it may answer the purpose; and it is even probable, that in many cases the violence of inflammation may weaken the tone of the parts, and thereby invite a return of paroxysms. It seems to be in this way, that, as the disease advances, the paroxysms become more frequent. From these last considerations, it seems probable, that, during the time of paroxysm some measures may be taken to moderate the violence of the inflammation and pain, and particularly, that in first paroxysms, and in the young and vigorous, blood-letting at the arm may be practised with advantage; but this practice cannot be repeated often with safety; because blood-letting not only weakens the tone of the system, but also contributes to produce plethora. However, bleeding by leeches on the foot, and upon the inflamed part, may be practised and repeated with greater safety; and instances have been known of its having been employed with safety to moderate and shorten paroxysms; but how far it may be carried, we have not had experience enough to determine.

Besides blood-letting and the antiphlogistic regimen, it has been proposed to employ remedies for moderating the inflammatory spasm of the part affected, such as warm bathing and emollient poultices. These have sometimes been employed with advantage and safety; but, at other times, have been found to give occasion to a retrocession of the gout.

Blistering is a very effectual means of relieving and discussing a paroxysm of the gout; but has also frequently had the effect of rendering it retrocedent. The stinging with nettles is analogous to blistering; and probably would be attended with the same danger. The burning with moxa, or other substances, is a remedy of the same kind; but though not found hurtful, there is no sufficient evidence of its proving a radical cure.

Camphor, and some aromatic oils, have the power of allaying the pain, and of removing the inflammation from the part affected; but these remedies commonly make the inflammation only shift from one part to another, and therefore with the hazard of its falling upon a part where it may be more dangerous; and they have sometimes rendered the gout retrocedent.

Among other remedies which have of late been highly extolled during a paroxysm of gout, some have recommended the use of strong purgatives frequently repeated; others have highly extolled the assiduous application of cold water to the affected foot. But we may safely venture to assert that both practices are very doubtful, if not very dangerous.

From these reflections it will appear, that some danger must attend every external application to the parts affected during a paroxysm; and that therefore the common practice of committing the person to patience and flannel alone, is established upon the best foundation. Opiates give the most certain relief from pain; but, when given in the beginning of gouty paroxysms, it has by some been thought that they occasion these to return with greater violence. When, however, the paroxysms shall have abated in their violence, but still continue to return, so as to occasion painful and restless nights, opiates may be given with safety and advantage; especially in the case of persons advanced in life, and who have been often affected with the disease. When, after paroxysms have ceased, some swelling and stiffness still remain in the joints, these symptoms are to be discussed by the diligent use of the flesh-brush. Purging immediately after a paroxysm will be always employed with the hazard of bringing it on again; but keeping the belly gently open even during the continuance of the paroxysm is highly proper.

Thus far of the regular gout. We now proceed to consider the management of the disease when it has become irregular.

In the atonic gout, the cure is to be accomplished by carefully avoiding all debilitating causes; and by employing, at the same time, the means of strengthening the system in general, and the stomach in particular.

For strengthening the system in general, Dr Cullen recommends frequent exercise on horseback, and moderate walking. Cold bathing also may answer the purpose; and may be safely employed, if it appear to be powerful in stimulating the system, and be not applied when the extremities are threatened with any pain.

For supporting the tone of the system in general, when threatened with atonic gout, some animal food ought to be employed, and the more acescent vegetables ought to be avoided. In the same case, some wine also may be necessary; but it should be in moderate quantity, and of the least acescent kinds, and if every kind of wine shall be found to increase the acidity of the stomach, ardent spirits and water must be employed.

For strengthening the stomach, bitters and the Peruvian bark may be used; but care must be taken that they be not constantly employed for any great length of time.

The most effectual medicine for strengthening the stomach is iron, which may be employed under various preparations; but the best appears to be the rust in fine powder, which may be given in large doses.

For supporting the tone of the stomach, aromatics may be exhibited; but should be used with caution, as the frequent and copious use of them 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 costiveness.

In the atonic gout, or in persons liable to it, to guard against cold is especially necessary; and the most certain means of doing this, is by repairing to a warm climate during the winter season. In the more violent cases, blistering the lower extremities may be useful; but that remedy should be avoided when any pain threatens the extremities. In persons liable to the atonic gout, issues may be established in the extremities as in some measure a supplement to the disease.

A second case of the irregular gout, is the retrocedent.

When this affects the stomach and intestines, relief is to be instantly attempted by the free use of strong wines, joined with aromatics, and given warm; or, if these shall not prove powerful enough, ardent spirits must be employed, and are to be given in a large dose. In moderate attacks, ardent spirits, impregnated with garlic or with asafoetida, may be used; or, even without the ardent spirits, a solution of asafoetida with the volatile alkali, may answer the purpose. Opiates are often an effectual remedy; and may be joined 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 so frequently made from the extremities to the kidneys, is to be considered as an instance of the misplaced gout, seems uncertain: but Dr Cullen is disposed to think it something different; and therefore is of opinion, that, in the nephralgia calclosa produced upon this occasion, the remedies of inflammation are to be employed no farther than they may be sometimes necessary in that disease, arising from other causes than the gout.

Besides what have been mentioned, a variety of other practices may be necessary and proper against the various anomalous symptoms, which are at times produced by irregular gout. But of these we cannot propose to treat. And we may conclude with observing, that in every form of gout, the cure principally depends on avoiding occasional causes, particularly luxury and laziness.

**Genus XXV. ARTHROPUOSIS.**

Lumbago psoadica, Sauv. sp. 6. Fordyce, Practice of Physic, part ii. p. 70. Lumbago apostematosa, Sauv. sp. 12. Lumbago ab arthrocace, Sauv. sp. 17. Ischias 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. Class. X. Phlegmasiae exanthematicae, Sauv. Class III. Ord. I. Morbi exanthematici, Lin. Class I. Ord. II. Fibrés exanthematicae, Vog. Class I. Ord. II.

**Genus XXVI. ERYSIPELAS.**

St Anthony's Fire.

Erysipelas, Sauv. gen. 97. Lin. 10. Sag. gen. 296. Fibrés erysipelacea, Vog. 68. Hoffm. II. 98.

**Sp. I. ERYSIPELAS with Blisters.**

Erysipelas roseum, Sauv. sp. 1. Sennert. de febr. lib. ii. c. 15. Fibrés erysipelatosa, Sydenham, sect. vi. cap. 5. Erysipelas typhodes, Sauv. sp. 2. Erysipelas pestilens, Sauv. sp. 5. Erysipelas contagiosum, Sauv. sp. 9.

**Description.** The erysipelas of the face, where this affection very frequently appears, comes on with a cold shivering, and other symptoms of pyrexia. The hot stage of this is frequently attended with a confusion of the head, and some degree of delirium; and almost always with drowsiness, and perhaps coma. The pulse is always frequent, and commonly full and hard.—When these symptoms have continued for one, two, or at most three days, an erythema appears on some part of the face. This at first is of no great extent, but gradually spreads from the part it first occupied to the other parts of the face, till it has affected the whole; and frequently from the face it spreads over the hairy scalp, or descends on some part of the cheek. As the redness spreads, it commonly leaves, or at least is abated in the parts it had before occupied. All the parts which the redness affects are also affected with some swelling, which continues for some time after the redness has abated. The whole face becomes considerably turgid; and the eyelids are often so much swelled as entirely to shut up the eyes. When the redness and swelling have continued for some time, there commonly arise, sooner or later, blisters of a larger or smaller size on several parts of the face. These contain a thin colourless liquor, which sooner or later runs out. The surface of the skin, in the blistered places, sometimes becomes livid and blackish; but this seldom goes deeper, or discovers any degree of gangrene affecting the cutis vera. On the parts of the face not affected with blisters, the cuticle suffers, towards the end of the disease, a considerable desquamation. Sometimes the tumour 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- tion commonly continues for eight or ten days; and for the same time, the fever and symptoms attending it also continue. In the progress of the disease, the delirium and coma attending it sometimes go on increasing, and the patient dies apoplectic on the seventh, ninth, or eleventh day of the disease. In such cases it has been commonly supposed, that the disease is translated from the external to the internal parts. But Dr Cullen thinks that the affection of the brain is merely a communication from the external affection, as this continues increasing at the same time with the internal. When a fatal event does not take place, the inflammation, after having affected the whole face, and perhaps the other external parts of the head, ceases, and with that the fever also; and, without any other crisis, the patient returns to his ordinary health. This disease is not commonly contagious; but as it may arise from an acrid matter externally applied, so it is possible that the disease may sometimes be communicated from one person to another; and certainly there are several well authenticated instances of its prevailing in such a manner, even in particular wards of hospitals, as to leave no doubt respecting its contagious nature. Persons who have once laboured under this disease are liable to returns of it.

Prognosis. The event of this disease may be foreseen from the state of the symptoms which denote more or less the affection of the brain. If neither delirium nor coma come on, the disease is seldom attended with any danger; but when these symptoms appear early in the disease, and are in a considerable degree, the utmost danger is to be apprehended.

Cure. The erysipelas of the face is to be cured, according to the opinion of most practitioners, much in the same manner as phlegmonic inflammations; by blood-letting, cooling purgatives, and by employing every part of the antiphlogistic regimen. Many observations, however, would lead us to conclude, that in not a few cases the concomitant fever has here a tendency to the typhoid type; and therefore evacuations, apparently serviceable in the first instance, have afterwards a bad effect. The evacuations of blood-letting and purging are to be employed more or less according to the urgency of symptoms; particularly those which mark an affection of the brain. As the pyrexia continues, and often increases with the inflammation of the face, so the evacuations above mentioned are to be employed at any time of the disease. When, however, the fever, in place of marks of the phlogistic diathesis, particularly a full, hard, and strong pulse, is attended with symptoms of great debility, and with a small pulse easily compressible; evacuations, particularly under the form of blood-letting, must be used with very great caution. Even in such cases, however, the use of refrigerant cathartics may still be persisted in with more safety and greater advantage. But whether evacuants have been employed or not, when symptoms of debility run to a great height, and marks of a putrescent tendency appear, recourse must be had to wine and the cinchona. In cases which at the commencement require evacuation, these are often in the after periods employed with very great benefit.

In this, as in other diseases of the head, when that part happens to be the seat of erysipelas, it is proper to put the patient, as often as he can easily bear it, into somewhat of an erect posture; and as there is always an external affection, so various external applications have been proposed to be made to the part affected; but almost all of them are of doubtful effect.

An erysipelas frequently appears on other parts of the body besides the face, and such other 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 Phlyctena.

Erysipelas zoster, Sauv. sp. 8. Zona; Anglis, The Shingles, Russel de tab. gland. p. 124. Hist. 35. Herpes zoster, Sauv. sp. 9.

This differs from the former in no other way than in being attended with an eruption of phlyctene or small watery bladders on several parts of the body.—The method of cure is the same.

Genus XXVII. Pestis, the Plague.

Pestis, Sauv. gen. 91. Lin. 2. Junck. 78. Febris pestilentialis, Vog. 33. Hoffm. II. 93. Pestis benigna, Sauv. sp. 2. Pestis Massiliensis, Class 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 Massil. Cl. II. Traité, p. 38. Ejusd. Cl. III. et IV. Traité, p. 225, &c. Waldeinschmidt. de peste Holsatica, apud Haller Diss. Pract. Tom. V. Chenot. de peste Transylvanica, 1755, 1759, De Haen, Rat. Meds pars xiv. Pestis Egyptiaca, Sauv. sp. 11. Alpin. de Med. Egypt. Pestis interna, Sauv. sp. 3. Pest. Massil. 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 staggering, which resembles drunkenness, or the headache and various delirium, all of them denoting a great disorder in the functions of the brain. 3. Anxiety, 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 petechiae, hemorrhages, and colliquative diarrhoea, which denote a putrescent tendency prevailing in a great degree in the mass of blood.

To these characteristics of the plague enumerated by Dr Cullen, we shall add one mentioned by Sir John Pringle, which, though perhaps less frequent than the others, yet seems worthy of notice. It is this, That in the plague there is an extraordinary enlargement of the heart and liver. In nine dissections of bodies dead of the plague at Marseilles, this extraordinary enlargement of the heart is taken notice of in all of them, and of the liver in seven of them. The account was sent to the Royal Society by M. Didier, one of the physicians to the king of France, and has been published in the Philosophical Transactions. In the first case, the author takes notice, that "the heart was of an extraordinary bigness; and the liver was of double the natural size."—Case 2. The heart was of a prodigious bigness, and the liver much enlarged.—Case 3. The heart double the natural bigness.—Case 4. The heart was very large, and the liver was bigger and harder than ordinary.—Case 5. The heart was of a prodigious bigness. Case 6. The heart was larger than in its natural state; the liver also was very large.—Case 7. The heart was of a prodigious size, and the liver was very large.—Case 8. The heart was much larger than natural, and the liver of a prodigious size.—Case 9. The heart was double the natural bigness, and the liver was larger than ordinary."

This preternatural enlargement, Sir J. Pringle thinks, is owing to the relaxation of the solid parts, by which means they become unable to resist the impetus of blood, and therefore are easily extended; as in the case of infancy, where the growth is remarkably quick. And a similar enlargement he takes notice of in the scurvy, and other putrid diseases.

A very elaborate work has lately been published on the subject of the plague by Dr Patrick Russel, formerly physician to the British factory at Aleppo. In this work, a very full history is given of the various forms and varieties of the disease. He makes particular observations on the following symptoms, which, in addition to the pestilential eruptions, he considers as the most important concomitants of plague, viz. fever, delirium, coma, impediment or loss of speech, deafness, muddiness of the eyes, white tongue, state of the pulse, respiration, anxiety, pain at the heart, inquietude, debility, fainting, convulsion, appearances of the urine, perspiration, vomiting, looseness, and hemorrhage; and he concludes these remarks with some observations on the occurrence of the plague with pregnant women.

To point out more distinctly the stable varieties of the disease, he arranges the pestilential cases which fell under his observation at Aleppo under six classes: and he concludes his description with a very minute and particular account of the pestilential eruptions, appearing under the form either of buboes, carbuncles, or other exanthemata. The presence of the two first, he observes, either separately or conjunctly, leaves the nature of the distemper unequivocal. But fatal has been the error of rashly pronouncing a distemper not to be a plague from their absence. Buboes affected the inguinal, axillary, parotid, maxillary, and cervical glands. But the first were the most commonly affected, and the two latter seldom observed to swell, without either the parotid swelling at the time, or soon after. Of the carbuncles, Dr Russel describes five different varieties. The other exanthemata, which he observed sometimes, though less frequently, attending the plague, were petechiae, a marbled appearance of the skin, an erysipelasous redness, streaks of a reddish purple or livid colour, vibices or weals, and large blue or purple spots, the maculae magnae of authors. In some cases, an extraordinary concurrence of eruptions took place, which was chiefly observed among children under 10 years of age.

Causes, &c. From a consideration of the symptoms above mentioned, Dr Cullen concludes, that the plague is owing to a specific contagion, often suddenly producing the most considerable debility in the nervous system, or moving powers, and a general putrescence in the fluids. Dr Russel also considers the disease as being universally the consequence of what may be called pestilential contagion; and has judiciously repelled the objections which have been brought against this doctrine.

Prevention. Here we must refer to all those methods of preventing and removing the incipient contagion of putrid fevers, which have been so fully enumerated. Dr Cullen is persuaded that the disease never arises in the northern parts of Europe, but in consequence of being imported from some other country. The magistrate's first care, therefore, ought to be, to prevent the importation; and this may generally be done by a due attention to bills of health, and to the proper performance of quarantines.—With respect to the latter, he is of opinion, that the quarantines of persons may with safety be much less than 40 days; and if this were allowed, the execution of the quarantine would be more exact and certain, as the temptation to break it would be in a great measure avoided. With respect to the quarantine of goods, it cannot be perfect unless the suspected goods be unpacked, duly ventilated, and other means be employed for correcting the infection they may carry; and if all this be properly done, it is probable that the time commonly prescribed for quarantine may 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 to 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. Practice.

Exposure. 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 expense, all infected goods. 7. By avoiding hospitals, and providing separate apartments for infected persons.

The fourth and last part of the business of prevention respects the conduct of persons necessarily remaining in infected places, especially those obliged to have some communication with persons infected. Those obliged to remain in places infected, but not to have any near communication with the sick, must avoid all near communication with other persons or their goods; and it is probable, that a small distance will serve, if, at the same time, there be no stream of air to carry the effluvia of persons or goods to some distance. Those who are obliged to have a near communication with the sick ought to avoid any of the debilitating causes which render the body susceptible of infection, as a spare diet, intemperance in drinking, excess in venery, cold, fear, or other depressing passions of the mind. A full diet of animal food is also to be avoided, because it increases the irritability of the body, and favours the operation of contagion; and indigestion, whether from the quantity or quality of the food, contributes very much to the same 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 anything 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 issues 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 putrescent matter frequently present in the intestines; but a large evacuation in this way may certainly be hurtful.

The moderating the violence of reaction, as far as it can be done, by taking off the spasm of the 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 Ash, and some other of the Russian practitioners, represent the early and repeated used 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 Synochia; 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. Variola, Berth. 1371. Junck. 76.

Sp. I. Distinct Smallpox.

Variola discreta benigna, Sauv. sp. 2. Variola regularis discreta, Sydenh. sect. iii. cap. 2. Variola discreta simplices, Helvet. Obs. sp. 1. Variola discreta complicata, Sauv. sp. 2. Helvet. sp. 2. Variola anomala, Sydenh. sect. iv. cap. 6. Variola discreta dysenteriodes, 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 siliquosa, Sauv. sp. 7. Freind Oper. p. 358. Variola discreta miliaris, Sauv. sp. 8. Helvet. Obs. sp. 3.

Sp. II. The Confluent Smallpox.

Variola confluens, Sauv. sp. 9. Variola regulares confluences, ann. 1667. Sydenham, sect. iii. cap. 2. Variola confluences simplices, Helvet. Obs. sp. 1. Variola confluens crystallina, Sauv. sp. 10. Variola japonica, Kempfer. Vesiculae divae Barbarae, C. Pis. Obs. 149. Variola confluens maligna, Helvet. Obs. sp. 1. Variola confluens cohaerens, Sauv. sp. 11. Variola confluens maligna, Helvet. sp. 2. Variola confluens nigra, Sauv. sp. 12. Sydenham, sect. v. cap. 4. Variola confluens maligna, Helvet. sp. 3. Variola sanguinea, Mead de variolis, cap. 2. Variola confluens corymbosa, Sauv. sp. 13. Variola confluens maligna, Helvet. sp. 4.

Description. In the distinct smallpox, the disease begins with a synocha or inflammatory fever. This fever generally comes on about mid-day, with some symptoms of a cold stage, and commonly with a considerable languor and drowsiness. A hot stage is soon formed, and becomes more considerable on the second and third day. During this course children are liable to frequent startings from their slumber; 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 neighboring 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 eyelids particularly are so much swelled, that the eyes are entirely shut. As the disease proceeds, the matter in the pustules becomes by degrees more opaque and white, and at length assumes a yellowish colour. On the 11th day the swelling of the face is abated, and the pustules seem quite full. On the top of each a darker spot appears; and at this place the pustule, on the 11th day, or soon after, is spontaneously broken, and a portion of the matter oozes out; in consequence of which the pustule is shrivelled, and subsides; while the matter oozing out dries, and forms a crust upon its surface. Sometimes only a little of the matter oozes out, and what remains in the pustule becomes thick and even hard. After some days, both the crusts and the hardened pustules fall off, leaving the skin which they covered of a brownish red colour; nor doth it resume its natural colour till many days after. In some cases, where the matter of the pustules has been more liquid, the crusts formed from it are later in falling off, and the part they covered suffers some desquamation, which occasions a small hollow or pit.

On the legs, and hands the matter is frequently absorbed; so that at the height of the disease, these pustules appear as empty as vesicles. On the 10th and 11th days, as the swelling of the face subsides, a swelling arises in the hands and feet; but which again subsides as the pustules come to maturity.—When the pustules on the face are numerous, some degree of pyrexia appears on the 10th and 11th days; but disappears again after the pustules are fully ripened, or perhaps remains in a very slight degree till the pustules on the feet have finished their course; and it is seldom that any fever continues longer in the distinct smallpox. When the pustules are numerous on the face, upon the sixth or seventh day some uneasiness of the throat, with a hoarseness of the voice, comes on, and a thin liquid is poured out from the mouth. These symptoms increase with the swelling of the face; and the liquids of the mouth and throat becoming thicker, are with difficulty thrown out; and there is at the same time some difficulty in swallowing, so that liquids taken in to be swallowed are frequently rejected or thrown out by the nose. But all these affections of the fauces are abated as the swelling of the face subsides.

In the confluent smallpox all the symptoms above mentioned are much more severe. The eruptive fever particularly is more violent; the pulse is more frequent and more contracted, approaching to that state of pulse which is observed in typhus. The coma is more considerable, and there is frequently a delirium. Vomiting also frequently attends, especially at the beginning of the disease. In very young infants epileptic fits are sometimes frequent on the first days of the disease, and sometimes prove fatal before any eruption appears, or they usher in a very confluent and putrid smallpox. But at the same time, it has been justly remarked by Dr Sydenham, and other accurate observers, that epileptic attacks more frequently precede distinct and mild than malignant and confluent smallpox. The eruption appears in the confluent more early on the third day, and it is frequently preceded or accompanied with an erysipelasous efflorescence. Sometimes 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 arises to a greater height, but abates considerably on the tenth or eleventh day. At this time the pustules or vesicles break and shrivel; pouring out at the same time a liquor, which is formed into brown or black crusts, which do not fall off for a long time after. Those of the face, in falling off, leave the skin subject to a desquamation, which pretty certainly produces pit-tings. On the other parts of the body the pustules of the confluent smallpox are more distinct than on the face; but never acquire the same maturity and 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 putrescence of the fluids, as appears from petechiae, from serous vesicles, under which the skin shows a disposition to gangrene, and from bloody urine or other hemorrhages; all of which symptoms frequently attend this disease. In the confluent smallpox also, the fever, which had only suffered a remission from the eruption to the maturation, at or immediately after this period is frequently renewed again with considerable violence. This is what has been called the secondary fever, and is of various duration and event.

Causes, &c. It is evident that the smallpox is originally produced by a contagion; and that this contagion is a ferment with respect to the fluids of the human body, which assimilates a considerable portion of them to its own nature: or, at least, we have every reason to believe that a small quantity of contagious matter introduced, is sometimes 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 putrescent 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 putrescence, approaching to the circumstances of the confluent, that the distinct kind is attended with any danger.

In the confluent kind the danger is always very considerable; and the more violent and permanent the fever is, the greater the danger; and especially in proportion to the increase of the symptoms of putrefaction. When the putrid disposition is very great, the disease sometimes proves fatal before the eighth day; but in most cases death happens on the eleventh, and sometimes not till the fourteenth or seventeenth day.

Though the smallpox may not prove immediately fatal, the more violent kinds are often followed by a morbid state of the body, sometimes of very dangerous event. These consequences, according to Dr Cullen, may be imputed sometimes to an acrid matter produced by the preceding disease, and deposited in different parts; and sometimes to an inflammatory diathesis produced and determined to particular parts of the body.

Since the introduction of smallpox into Europe, there is perhaps no disease which has produced a greater number of deaths. But, fortunately, a discovery is now made, by which there is reason to hope that this loathsome disease may be altogether exterminated; its prevention, viz. by the inoculation of the vaccine or cowpox.

This most important discovery we owe to the successful exertions of Dr Edward Jenner; to whom, for these exertions, repeated rewards have been voted by the British legislature, but who unquestionably enjoys a much higher reward in the satisfaction of having conferred an 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 pustular disease on their udders, somewhat resembling smallpox; that this disease was communicated by contact to the fingers of those employed in milking the cows; and, finally, that those thus infected with cowpox, were completely protected against the contagion of smallpox.

Founding on these observations, Dr Jenner ascertained by experiment, that the inoculation of vaccine matter was an infallible preventive of smallpox; and that this vaccine matter had equal power in preventing variola when transferred from one human subject to another, as when obtained immediately from the cow. It is not therefore wonderful that this practice of vaccine inoculation should soon have become general, both in Britain and in every quarter of the world. Nor is it perhaps surprising, that it should have been violently opposed by ignorant and obstinate men. Hence numerous publications have of late appeared both for and against this practice. Many mistakes have undoubtedly been committed by ignorance and inattention; and thus the preventive has been supposed to fail. For the best account both of the method of performing the operation, of conveying the vaccine matter from one place to another, and of the tests of constitutional affection in those cases in which the inflammation is slight, and in which no fever is perceptible, we may refer our readers to a treatise published at Edinburgh in 1802, by Mr James Bryce, entitled Practical Observations on the Inoculation of Cowpox.

Of the efficacy of vaccine inoculation as a preventive of smallpox, few candid men will entertain any doubt, after the following report on vaccination, from the Royal College of Physicians in London, ordered to be printed on the 8th of July 1807, by the British parliament.

REPORT, &c.

The Royal College of Physicians of London, having received his majesty's commands in compliance with an address from the house of commons, "to inquire into the state of vaccine inoculation in the united kingdom, to report their opinion and observations upon that practice, upon the evidence which has been adduced in its support, and upon the causes which have hitherto retarded its general adoption;" have applied themselves diligently to the business referred to them.

Deeply impressed with the importance of an inquiry which equally involves the lives of individuals, and the public prosperity, they have made every exertion to investigate the subject fully and impartially. In aid of the knowledge and experience of the members of their own body, they have applied separately to each of the licentiates of the college; they have corresponded with the colleges of physicians of Dublin and Edinburgh; with the colleges of surgeons of London, Edinburgh, and Dublin; they have called upon the societies established for vaccination, for an account of their practice, to what extent it has been carried on, and what has been the result of their experience; and they have, by public notice, invited individuals to contribute whatever information they had severally collected. They have in consequence been furnished with a mass of evidence communicated with the greatest readiness and candour, which enables them to speak with confidence upon all the principal points referred to them.

I. During eight years which have elapsed since Dr Jenner made his discovery public, the progress of vaccination has been rapid, not only in all parts of the united kingdom, but in every quarter of the civilized world. In the British islands some hundred thousands have been vaccinated, in our possessions in the East Indies upwards of 800,000, and among the nations of Europe the practice has become general. Professional men have submitted it to the fairest trials, and the public have, for the most part, received it without prejudice. A few indeed have stood forth the adversaries of vaccination, on the same grounds as their predecessors who opposed the inoculation for the smallpox, falsely led by hypothetical reasoning in the investigation of a subject which must be supported, or rejected, upon facts and observation only. With these few exceptions, the testimony in favour of vaccination has been most strong and satisfactory, and the practice of it, though it has received a check in some quarters, appears still to be upon the increase in most parts of the united kingdom.

II. The college of physicians, in giving their observations and opinions on the practice of vaccination, think it right to premise, that they advance nothing but what is supported by the multiplied and unequivocal evidence which has been brought before them, and they have not considered any facts as proved but what have been stated from actual observation.

Vaccination appears to be in general perfectly safe; the instances to the contrary being extremely rare. The disease excited by it is slight, and seldom prevents those under it from following their ordinary occupations. It has been communicated with safety to pregnant women, to children during dentition, and in their earliest infancy; in all which respects it possesses material advantages over inoculation for the smallpox; which though productive of a disease generally mild, yet sometimes occasions alarming symptoms, and is in a few cases fatal.

The security derived from vaccination against the smallpox, if not absolutely perfect, is as nearly so as can perhaps be expected from any human discovery; for amongst several hundred thousand cases, with the results of which the college have been made acquainted, the number of alleged failures has been surprisingly small, so much so, as to form certainly no reasonable objection to the general adoption of vaccination; for it appears that there are not nearly so many failures, in a given number of vaccinated persons, as there are deaths in an equal number of persons inoculated for the smallpox. Nothing can more clearly demonstrate the superiority of vaccination over the inoculation of the smallpox, than this consideration; and it is a most important fact, which has been confirmed in the course of this inquiry, that in almost every case, where the smallpox has succeeded vaccination, whether by inoculation or by casual infection, the disease has varied much from its ordinary course; it has neither been the same in the violence, nor in the duration of its symptoms, but has, with very few exceptions, been remarkably mild, as if the smallpox had been deprived, by the previous vaccine disease, of all its usual malignity.

The testimonies before the college of physicians are very decided in declaring, that vaccination does less mischief to the constitution, and less frequently gives rise to other diseases, than the smallpox, either natural or inoculated.

The college feel themselves called upon to state this strongly, because it has been objected to vaccination, that it produces new, unheard-of, and monstrous diseases. Of such assertions no proofs have been produced, and, after diligent inquiry, the college believe them to have been either the inventions of designing, or the mistakes of ignorant men. In these respects then, in its mildness, its safety, and its consequences, the individual may look for the peculiar advantages of vaccination. The benefits which flow from it to society are infinitely more considerable, it spreads no infection, and can be communicated only by inoculation. It is from a consideration of the pernicious effects of the smallpox, that the real value of vaccination is to be estimated. The natural smallpox has been supposed to destroy a sixth part of all whom it attacks; and that even by inoculation, where that has been general in parishes and towns, about one in 300 has usually died. It is not sufficiently known, or not adverted to, that nearly one-tenth, some years more than one-tenth of the whole mortality in London, is occasioned by the smallpox; and however beneficial the inoculation of the smallpox may have been to individuals, it appears to have kept up a constant source of contagion, which has been the means of increasing the number of deaths by what is called the natural disease. It cannot be doubted that this mischief has been extended by the inconsiderate manner in which great numbers of persons, even since the introduction of vaccination, are still every year inoculated with the smallpox, and afterwards required to attend two or three times a-week at the places of inoculation, through every stage of their illness.

From this, then, the public are to expect the great and uncontroverted superiority of vaccination, that it communicates no casual infection, and, while it is a protection to the individual, it is not prejudicial to the public.

III. The college of physicians, in reporting their observations and opinions on the evidence adduced in support of vaccination, feel themselves authorised to state that a body of evidence so large, so temperate, and so consistent, was perhaps never before collected upon any medical question. A discovery so novel, and to which there was nothing analogous known in nature, though resting on the experimental observations of the inventor, was at first received with diffidence: it was not, however, difficult for others to repeat his experiments, by which the truth of his observations was confirmed, and the doubts of the cautious were gradually dispelled by extensive experience. At the commencement of the practice, almost all that were vaccinated were afterwards submitted to the inoculation of the smallpox; many underwent this operation a second, and even a third time, and the uniform success of these trials quickly bred confidence in the new discovery. But the evidence of the security derived from vaccination against the smallpox does not rest alone upon those who afterwards underwent variolous inoculation, although amounting to many thousands; for it appears, from numerous observations communicated to the college, that those who have been vaccinated are equally secure against the contagion of epidemic smallpox. Towns, indeed, and districts of the country in which vaccination had been general, have afterwards had the smallpox prevalent on all sides of them without suffering from the contagion. There are also in the evidence a few examples of epidemic smallpox having been subdued by a general vaccination. It will not, therefore, appear extraordinary that many who have communicated their observations should state, that though at first they thought unfavourably of the practice, experience had now removed all their doubts.

It has been already mentioned, that the evidence is not universally favourable, although it is in truth nearly so, for there are a few who entertain sentiments differing widely from those of the great majority of their brethren. The college, therefore, deemed it their duty, in a particular manner, to inquire upon what grounds and evidence the opposers of vaccination rested their opinions. From personal examination, as well as from their writings, they endeavoured to learn the full extent and weight of their objections. They found them without experience in vaccination, supporting their opinions by hearsay information and hypothetical reasoning; and, upon investigating the facts which they advanced, they found them to be either misapprehended or misrepresented; or that they fell under the description of cases of imperfect smallpox, before noticed, and which the college have endeavoured fairly to appreciate.

The practice of vaccination is but of eight years standing, and its promoters, as well as opponents, must keep in mind, that a period so short is too limited to ascertain every point, or to bring the art to that perfection of which it may be capable. The truth of this will readily be admitted by those acquainted with the history of inoculation for the smallpox. Vaccination is now, however, well understood, and its character accurately described. Some deviations from the usual course have occasionally occurred, which the author of the practice has called spurious cowpox, by which the public have been misled, as if there were a true and a false cowpox; but it appears, that nothing more was meant, than to express irregularity or difference from that common form and progress of the vaccine pustule from which its efficacy is inferred. Those who perform vaccination ought therefore to be well instructed, and should have watched with the greatest care the regular progress of the pustule, and learnt the most proper time for taking the matter. There is little doubt that some of the failures are to be imputed to the inexperience of the early vaccinators, and it is not unreasonable to expect that farther observation will yet suggest many improvements that will reduce the number of anomalous cases, and furnish the means of determining, with greater precision, when the vaccine disease has been effectually received.

Though the college of physicians have confined themselves in estimating the evidence to such facts as have occurred in their own country, because the accuracy of them could best be ascertained, they cannot be insensi- ble to the confirmation these receive from the reports of the successful introduction of vaccination, not only into every part of Europe, but throughout the vast continents of Asia and America.

IV. Several causes have had a partial operation in retarding the general adoption of vaccination; some writers have greatly undervalued the security it affords, while others have considered it to be of a temporary nature only; but if any reliance is to be placed on the statements which have been laid before the college, its power of protecting the human body from the smallpox, though not perfect indeed, is abundantly sufficient to recommend it to the prudent and dispassionate, especially as the smallpox, in the few instances where it has subsequently occurred, has been generally mild and transient. The opinion that vaccination affords but a temporary security is supported by no analogy in nature, nor by the facts which have hitherto occurred. Although the experience of vaccine inoculation be only of a few years, yet the same disease, contracted by the milkers of cows in some districts, has been long enough known, to ascertain that, in them at least, the unsusceptibility of the smallpox contagion does not wear out by time.

Another cause, is the charge against vaccination of producing various new diseases of frightful and monstrous appearance. Representations of some of these have been exhibited in prints in a way to alarm the feelings of parents, and to infuse dread and apprehension into the minds of the uninformed. Publications with such representations have been widely circulated, and though they originate either in gross ignorance, or wilful misrepresentation, yet 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 surprise, they will excite contempt, and not fear.

Though the college of physicians are of opinion that the progress of vaccination has been retarded in a few places by the above causes, yet they conceive that its general adoption has been prevented by causes far more powerful, and of a nature wholly different. The lower orders of society can hardly be induced to adopt precautions against evils which may be at a distance; nor can it be expected from them, if these precautions are attended with 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 salutary practice has come to a stand. It is not easy to suggest a remedy for an evil so deeply imprinted in human nature. To inform and instruct the public mind may do much, and it will probably be found that the progress of vaccination in different parts of the united kingdom will be in proportion to that instruction. Were encouragement given to vaccination, by offering it to the poorer classes without 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 consulting the gratification of their own feelings, be prevented from doing mischief to their neighbours.

From the whole of the above considerations, the college of physicians feel it their duty strongly to recommend the practice of vaccination. They have been led to this conclusion by no preconceived opinion, but by the most unbiased 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.

JA. HERVEY, Register.

APPENDIX.

No I.

To the Royal College of Physicians of London.

Gentlemen,

I am ordered by the King and Queen's College of Physicians, in Ireland, to thank the Royal College of Physicians of London for the communication they have had the honour to receive from them, of certain propositions relative to vaccination, whereon his majesty has been pleased to direct an enquiry 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, Register.

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 respectability 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.

| Patients Inoculated | Packets issued to Practitioners in general | Packets to Army Surgeons | |--------------------|------------------------------------------|-------------------------| | 1804 | 578 | 776 | | 1805 | 1032 | 1124 | | 1806 | 1356 | 1340 | | Total | 2966 | 3240 |

"In the above statement, the numbers are averaged to the end of the present year, on the supposition of patients resorting 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 have 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. At a special court of assistants of the Royal College of Surgeons, convened by order of the Master, and held at the College on Tuesday the 17th day of March 1807;

Mr Governor Lucas in the chair:

Mr Long, as chairman of the board of curators, reported, that the board are now ready to deliver their report on the subject of vaccination.

It was then moved, seconded, and resolved, that a report from the board of curators, on the subject of vaccination, which was referred to their consideration by the court of assistants, on the 21st day of November last, be now received.

Mr Long then delivered to Mr Governor Lucas (presiding in the absence of the master) a report from the board of curators.

It was then moved, seconded, and resolved, that the report, delivered by Mr Long, be now read; and it was read accordingly, and is as follows.

To the Court of Assistants of the Royal College of Surgeons in London.

THE report of the Board of Curators, on the subject of vaccination, referred to them by the court, on the 21st day of November 1806; made to the court on the 17th of March 1807.

The court of assistants having received a letter from the Royal College of Physicians of London, addressed to this college, stating, that his majesty had been graciously pleased, in compliance with an address from the honourable House of Commons, to direct his Royal College of Physicians of London to enquire into the state of vaccination in the united kingdom, to report their observations and opinion upon that practice, upon the evidence adduced in its support, and upon the causes which have hitherto retarded its general adoption; that the college were then engaged in the investigation of the several propositions thus referred to them, and requesting this college to co-operate and communicate with them, in order that the report thereupon might be made as complete as possible.

And having, on the 21st day of November last, referred such letter to the consideration of the board of curators, with authority to take such steps respecting the contents thereof as they should judge proper, and report their proceedings thereon, from time to time, to the court: the board proceeded with all possible dispatch to the consideration of the subject.

The board being of opinion, that it would be proper to address circular letters to the members of this college, with a view of collecting evidence, they submitted to the consideration of the court, held 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 vesicle? How was it preserved? How long before it was inserted? What was the appearance of the inflammation? And what the interval between vaccination and the 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. Instances of smallpox after vaccination. Supposed bad consequences. Publications against the practice. Popular prejudices.

And such report having been considered, it was moved, seconded, and

Resolved, That the report now read be adopted by this court, as the answer of the court to the letter of the Royal College of Physicians, of the 23d day of October last, on the subject of vaccination.

Resolved, That a copy of these minutes and resolutions, signed by Mr Governor Lucas (presiding at this court in the presence of the master) be transmitted by the secretary to the register of the Royal College of Physicians.

(Signed) Wm. Lucas.

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 23rd 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, insomuch 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.

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

I have the honour to be,

Sir,

Your most obedient humble servant,

James Henthorn, Secretary.

At a meeting of the Royal College of Surgeons in Ireland, 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, 11,504 persons have been inoculated with vaccine infection at the dispensary for infant poor, and 2831 at the cowpox institution, making a total of 14,335, exclusive of the number inoculated at hospitals and other places, where no registry is made and preserved.

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

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

To which report the College agreed.

Extract from the minutes,

James Henthorn, Secretary.

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

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

In the mild or distinct smallpox, the strictest antiphlogistic regimen is to be enjoined. Gentle refrigerant cathartics are often useful, and mild diluents should be copiously employed. Under these remedies the disease will generally run its course without much inconvenience. But it will sometimes be necessary to employ remedies for obviating particular urgent symptoms, such as garganisms 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 shows 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. sp. 1.

Anglis The CHICKENPOX, Edin. Med. Essays, vol. ii. art. 2. near the end. Heberden, Med. Transac. art. 17. The WATERY-POX.

This is in general a very slight disease; and it 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 chillness, lassitude, cough, broken sleep, wandering pains, loss of appetite, and feverish state for three days.

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

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

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

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

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

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

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

Foreign medical writers hardly ever mention the name of this distemper: and the writers of our own country scarce mention any thing more of it than its name. Morton speaks of it as if he supposed it to be a very mild genuine smallpox. But these two distempers are certainly totally different from one another, not only on account of their different appearances above mentioned, but because those who have had the smallpox are capable of being infected with the chickenpox; but those who have once had the chickenpox are not capable of having it again, though to such as have never had this distemper, it seems as infectious as the smallpox. Dr Heberden wetted a thread in the most concocted pus-like liquor of the chickenpox which he could find; and after making a slight inci- From the great similitude between the two distemper, it is probable, that instead of the smallpox, some persons have been inoculated from the chickenpox; and that the distemper which has succeeded, has been mistaken for the smallpox by hasty or unexperienced observers.

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

This disorder is preceded for three or four days by all the symptoms which forerun the chickenpox; but in a much higher degree. On the fourth or fifth day the eruption appears, with a very little abatement of the fever: the pains likewise of the limbs and back still continue, to which are joined pains of the gums. The pox are redder than the chickenpox, and spread wider; and hardly rise so high, at least not in proportion to their size. Instead of one little head or vesicle of a 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 pocks, are circumstances never happening in the smallpox.

**Genus XXX. Rubeola.**

**Measles.**

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

Sp. I. The Regular Measles.

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

Var. 1. The Anomalous Measles.

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

Var. 2. The Measles attended with Quinsy.

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

Sp. II. The Variolodes.

In Scotland commonly called the Nirles.

Rubeola variolodes, Sauv. sp. 3.

**Description.** This disease begins with a cold stage, which is soon followed by a hot, with the ordinary symptoms of thirst, anorexia, anxiety, sickness, and vomiting; and these are more or less considerable in different cases. Sometimes from the beginning the fever is sharp and violent; often, for the first two days, it is obscure and inconsiderable; but always becomes violent before the eruption, which commonly happens on the fourth day. This eruptive fever, from the beginning of it, is always attended with hoarseness, a frequent hoarse dry cough, and often with some difficulty of breathing. At the same time, the eyelids are somewhat swelled; the eyes are a little inflamed, and pour out tears; and with this there is a coryza, and frequent sneezing. For the most part, a constant drowsiness attends the beginning of this disease. The eruption, as we have said, commonly appears upon the fourth day, first on the face, and successively on the lower parts of the body. It appears first in small red points; but soon after, a number of these appear in clusters, which do not arise in visible pimples, but, by the touch, are found to be a little prominent. This is the case on the face; but, in other parts of the body, the promineney, 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 pneumonic affection. This may happen at any period of the disease; but very often it does not come on till after the desquamation of the eruption.

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

It is common for measles, even when they have not been of a violent kind, to be followed by inflammatory affections, particularly ophthalmia and phthisis. If blood be drawn from a vein in the measles, with circumstances necessary to favour the separation of the fibrine, this always appears separated, and lying on the surface of the crassamentum, as in inflammatory diseases. For the most part, the measles, even when violent, are without any putrid tendency; but in some cases, such a tendency appears both in the course of the disease, and especially after the ordinary course of it is finished.

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

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

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

From the consideration mentioned in the prognosis, it will be obvious, that the remedies especially necessary are those which may obviate and diminish the inflammatory diathesis; and therefore, in a particular manner, blood-letting. This remedy may be employed at any time in the course of the disease, or after the ordinary course of it is finished. It is to be employed more or less according to the urgency of the symptoms of fever, cough, and dyspnea; and generally may be employed very freely. But as the symptoms of pneumonic inflammation seldom come on during the eruptive fever, and as this is sometimes violent immediately before the eruption, though a sufficiently mild disease be to follow; bleeding is seldom very necessary during the eruptive fever, and may often be reserved for the times of greater danger which are perhaps to follow.

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

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

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

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

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

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

**GENUS XXXI. MILIARIA.**

*The Miliary Fever.*

Miliaria, Lin. 7. Miliaris, Sauv. gen. 95. Sag. gen. 295. Febris miliaris, Vog. 37. Febris purpurata rubra et alba miliaris, Hoffm. II. 68. Febris purpuraca seu miliaris, Junck. 75. Germanus der Friescl. God. Welsch. Hist. Med de novo puerperarum morbo, qui der Friescl dicitur, Lips. 1655. Hamilton, de febr. miliar. 1710. Fontanus, de febr. mil. 1747. Allioni de miliar. 1758. Fordyce, de febr. mil. 1748. Fischer, de febr. mil. 1767. De Haen, de divis. febr. 1760, et in Ration. med. passim. Matt. Collin ad Baldinger de miliar. 1764. Miliaris 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 sudatoria, Sauv. sp. e. Miliaris nautica, Sauv. sp. g. Miliaris purpurata, Sauv. sp. h. Miliaris lactea, Sauv. sp. c. Miliaris puerperarum, Sauv. sp. k. Miliaris scorbutica, Sauv. sp. l. Miliaris critica, Sauv. sp. b.

History and Description. This disease is said to have been unknown to the ancients, and that it appeared for the first time in Saxony about the middle of the last century. It is said to have since spread from thence into all the other countries of Europe; and since the period mentioned, to have appeared in many countries in which it had never appeared before.

From the time of its having been first taken notice of, it has been described and treated of by many different writers; and by all of them, till very lately, has been considered as a peculiar idiopathic disease. It is said to have been constantly attended with peculiar symptoms. It comes on with a cold stage, which is often considerable. The hot stage, which follows, is attended with great anxiety, and frequent sighing. The heat of the body becomes great, and soon produces profuse sweating, preceded, however, with a sense of pricking, as of pin points in the skin; and the sweat is of a peculiar rank and disagreeable odour. The eruption appears sooner or later in different persons, but at no determined period of the disease. It seldom or never appears upon the face; but appears first upon the neck and breast, and from thence often spreads over the whole body.

The eruption named military, is said to be of two kinds; the one named the red, the other the white military. The former, which in English is strictly named a rush, is commonly allowed to be a symptomatic affection; and as the latter is the only one that has any pretensions to be considered as an idiopathic disease, it is this only that we shall more particularly describe and treat of under this genus.

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

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

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

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

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

The antecedent symptoms of anxiety, sighing, and pricking of the skin, which have been spoken of as peculiar to this disease, are, however, common to many others: and perhaps to all those in which sweatings are forced out by a warm regimen. Of the symptoms said to be concomitant of this eruption, there are none which can be affirmed to be constant and peculiar but that of sweating. This, indeed, always precedes and accompanies the eruption: and, while the miliary eruption attends many different diseases, it never, however, appears in any of these but after sweating; and in persons labouring under the same 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 fever; fever, and that such eruptions frequently recur in the course of the same person's life. All this renders it very probable, that, in the miliary fever, the morbid matter is not a subsisting contagion communicated to the blood, and thence, in consequence of fever and assimilation, thrown out upon the surface of the body, but a matter occasionally produced in the skin itself by sweating.

This conclusion is further rendered probable from hence, that, while the miliary eruption has no symptoms or 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 childbirth, but who had been much subjected to a frequent and copious menstruation, and to an almost constant florid 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 Millari symptomatic and factitious affection, that Dr Cullen is persuaded it may be, in most cases, prevented merely by avoiding sweats. Spontaneous sweatings, in the beginning of diseases, are very rarely critical; and all sweatings not evidently critical should be prevented, or at least moderated; and the promoting them, by increasing external heat, is commonly very pernicious. Even critical sweats should hardly be encouraged by such means. If, therefore, spontaneous sweats arise, they are to be checked by the coolness of the chamber; by the lightness and looseness of the bedclothes; by the persons laying out their arms and hands; and by their taking cold drink: and in this way Dr Cullen thinks he has frequently prevented miliary eruptions, which were otherwise likely to have appeared, particularly in puerperal women.

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

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

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

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

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

**GENUS XXXII. SCARLATINA.**

**SCARLET FEVER.**

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

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 distemper has been published by Dr Withering in the year 1778. This disease made its appearance, we are told, at Birmingham and the neighbouring villages, about the middle of May 1778. It continued in all its force and frequency to the end of October; varying, however, in some of its symptoms, as the air grew colder. In the beginning of November it was rarely met with; but towards the middle of that month, when the air became warmer, it increased again, and in some measure resumed those appearances it possessed in the summer months, but which it had lost during the cold winds in October.

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

**Description.** With various general symptoms of fever, the patient at first complains of a dejection of spirits, a slight soreness or rather stiffness in the neck, with a sense of straitness in the muscles of the neck and shoulders, as if they were bound with cords. The second day of the fever this soreness in the throat increases, and the patients find a difficulty in swallowing; but the difficulty seems less occasioned by the pain excited in the attempt, or by the straitness of the passage, than by an inability to throw the necessary muscles into action. The skin feels hot and dry, but not hard; and the patients experience frequent, small pungent pains, as if touched with the point of a needle. The breath is hot and burning to the lips, and thirst makes them wish to drink; but the tendency to sickness, and the exertions necessary in deglutition, are so unpleasant, that they seldom care to drink much at a time. They have much uneasiness also from want of rest during the night. In the morning of the third day, the face, neck, and breast, appear redder than usual; in a few hours this redness becomes universal; and increases to such a degree of intensity, that the face, body, and limbs, resemble a boiled lobster in colour, and are evidently swollen. Upon pressure the redness vanishes, but soon returns again. The skin is smooth to the touch, nor is there the least appearance of pimples or pustules. The eyes and nostrils partake more or less of the general redness; and in proportion to the intensity of this colour in the eyes, the tendency to delirium prevails.

Things continue in nearly this state for two or three days longer, when the intense scarlet gradually abates, a brown colour succeeds, and the skin becoming rough, peels off in small scales. The tumefaction subsides at the same time, and the patients gradually recover their strength and appetite.

During the whole course of the disease, the pulse is quick, small, and uncommonly feeble, the urine small in quantity; the sub-maxillary glands somewhat enlarged and painful to the touch. The velum pendulum palati, the uvula, the tonsils, and gullet, as far as the eye can reach, partake of the general redness and tumefaction; but although collections of thick mucus, greatly resembling the specks or sloughs in the putrid sore throat, sometimes occur, yet those are easily washed off; and real ulcerations of those parts were never observed.

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

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

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

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

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

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

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

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

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

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

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

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

But notwithstanding the attention which Dr Withering has bestowed upon this subject, we are still decidedly of opinion, that the disease which he has so accurately described under the title of scarlatina anginosa, is in reality the same affection with the malignant ulcerous sore throat of Huxham and Fothergill. During different epidemics, this disease, like smallpox and measles, in different seasons, is considerably varied in its appearance. But still there occurs such a similarity as clearly marks the sameness of the affection. And indeed this, as in the case of the smallpox, is abundantly demonstrated by infection from one contagion giving protection against succeeding ones, although the appearances be much varied. This has particularly appeared at Edinburgh, where the disease has of late prevailed as an epidemic on five different years, viz. 1774-75, 1782-83, 1789-90, 1797-98, and 1804-5. During the first of these occasions, in the greater part of patients, the sore throats were of a very gangrenous and malignant nature; during the second, the disease more commonly appeared under the form of what might be called simple scarlatina; and during the other epidemics, the contagion was, if we may be allowed the expression, of an intermediate nature. But it is farther to be remarked, that during every one of those epidemics, when several children of a family were at the same time subjected... subjected to the infection, in one the disease would have been attended with almost all the symptoms mentioned in the column of *scarlatina anginosa*, with respect to skin, eyes, throat, breath, bowels, termination of the affections, &c. In another, would have occurred all the symptoms with respect to those particulars which he has mentioned under the column of *angina gangrenosa*. While at the same time, in numberless instances, even in the same patient, the disease at its commencement has shown evident marks of an inflammatory, and at its termination of a putrid tendency. And there cannot be a doubt, that both the scarlatina anginosa of Withering, and the cynanche maligna, as described by Fothergill and Huxham, have occurred in every season and situation, and have affected persons of every age and constitution not before subject 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 stomach, &c., and at length acts upon the system at large.

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

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

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

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

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.

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

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

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

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

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

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

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

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

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

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

With respect to the dropsical 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 dropsical 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 dropsical 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 anginosus, is the oxygenated muriatic acid. This has been particularly extolled by Mr John Ayrey 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 very 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. sp. 2. Erysipelatis species altera, Sydenham, sect. vi. cap. 6. Febris scarlatina, et febris urticata, Meysercy, Mal. des armées, 291 et seq.

Description. This disease has its English name of nettle-rash from the resemblance of its eruption to that made by the stinging of nettles. These little elevations upon the skin in the nettle-rash often appear instantaneously, especially if the skin be rubbed or scratched, and seldom stay many hours in the same place, and sometimes not many minutes. No part of the body is exempt from them; and where many of them rise together, and continue an hour or two, the parts are often considerably swelled; which particularly happens in the face, arms, and hands. These eruptions will continue to 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, will produce something like this effect on the parts Urticaria, which they touch; and undoubtedly from the same cause.

Dr Heberden asks, Is it impossible that the nettle-rash should arise from the same causes, or from others similar, which we miss by looking too deeply for them in the blood and humours? Such, says he, may have been its origin in some instances, where it has lasted only a few days; but where this affection has continued for some years, in persons who change their linen every day, and who bathe frequently all the time, it can hardly be ascribed to such an external cause. He has observed it frequently to arise from cantharides: but though it has continued many weeks after the removal of the blister, yet it might be suspected that this arose from the fine spicules of the cantharides sticking all this time about the skin; it being customary to strew much of the dry powder of the cantharides over the blister-plaster, whence it may readily be carried to other parts of the body. But it is certain that similar effects will sometimes follow the internal use of wild valerian root, or the eating of fish not sufficiently dressed; muscles, shrimps, and even honey, and the kernels of fruits, will also sometimes produce symptoms of a similar kind. But whatever be its cause, Dr Heberden never saw any reason to suppose that the nettle-rash had in any way vitiated the humours to such a degree as to require the use of internal remedies; and if the itching could be certainly and expeditiously allayed, there would be no occasion for any farther cure. He concludes this history of the disorder with a case communicated to him by Dr Monsey, physician of Chelsea College, and in which the disease appeared with uncommon violence.

W. A., aged near 30, of a thin spare habit, was seized with a disorder attended with symptoms of a very uncommon kind. Whenever he went into the air, if the sun shined bright, he was seized with a tickling of his flesh on those parts exposed to the sun; this tickling, by his continuing in the air, increased to a violent itching, attended with great heat and pain; the skin would then be almost as red as vermilion, and thicken like leather; and this remained till he went out of the open air, and then abated in about 15 or 20 minutes. This happened only when the sun was above the horizon; at other times he was what he called quite well.—But it was not owing to the heat of the sun; for the sun in winter affected him full as much, if not more, and the heat of the fire had no such effect. Thus he was confined to the house for 10 years. He tried several hospitals, and had advices from many physicians, without the least abatement of his complaints. At last it was agreed by a consultation of physicians, that he should try dipping in salt water; which he did at Yarmouth for 13 weeks, without any visible amendment. One hot day, having pulled off his clothes and gone into the sea in the middle of the day, the heat diffused itself so violently all over his body, that, by the time he had put on his clothes, his eyesight began to fail, and he was compelled to lie down upon the ground to save himself from falling. The moment he lay down, the faintness went off; upon this he got up again; but had no sooner arisen, than he found himself in the former condition; he therefore lay down Exanthemata.

down again, and immediately recovered. He continued alternately getting up and lying down, till the disorder began to be exhausted, which was in about half an hour; and he was frequently obliged to have recourse to the same expedient.

Having at last accidentally met with Dr Monsey, this physician questioned him concerning the cause of the disorder; but nothing could be guessed at, excepting that the patient had 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. The patient was then first put upon a course of Dover's sweating powder without any effect, and afterwards tried a course of nitrous ones with the same bad success. At last Dr Monsey determined to try the effect of mercury, which happily proved effectual in removing this obstinate and uncommon distemper. The patient began with taking five grains of calomel for three nights running, and a cathartic next morning. In this course he went on for near a fortnight, at the end of which he found himself very sensibly relieved. This encouraged him to go on rather too boldly, by which means a slight salivation ensued; however, that went off soon, and in about six weeks he was quite well.—Some time after, he was threatened with a return of his disorder; but this was effectually relieved by a dose of calomel, which he had afterwards occasion to repeat for the same reason, and with the same success; but at last the disorder seemed to be radically cured, by his having no further symptoms of a relapse.

GENUS XXXIV. PEMPHIGUS.

Pemphigus, Sauv. gen. 93. Sag. 291. Morta, Lin. i. Febris bullosa, Vog. 41. Pemphigus major, Sauv. sp. i. Exanthemata serosa, C. Pison. Obs. 150. Febris pemphylodes, Ephem. Germ. D. I. A. viii. Obs. 56. Pemphigus castrensis, Sauv. sp. 2. Febrés syncches, cum vesiculis per pectus et colum sparsis, Morton. App. ad Exerc. II. Pemphigus Helveticus, Sauv. sp. 3. Langhans in Act. Helvet. vol. ii. p. 260. et in Beschreibung des Siementhals, Zurich 1753.

This is a very rare disease, in somuch 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 damp, ill-aired, under-ground apartment. He then complained of sickness at stomach, great oppression about the precordia, headache, lassitude, and weariness, on the least exertion; with stiffness and rigidity of his knees and other joints. The surgeon of the regiment visited him: he was purged, but with little benefit. About ten days before, he observed on the inside of his thighs a number of very small, distinct, red spots, a little elevated above the surface of the skin, and much resembling the first appearance of smallpox. This eruption gradually spread itself over his whole body, and the pustules continued every day to increase in size.

Upon being received into the hospital, he complained of headache, sickness at stomach, oppression about the precordia, thirst, sore throat, with difficulty of swallowing; his tongue was foul, his skin felt hot and feverish; pulse from 110 to 122, rather depressed; belly costive; eyes dull and languid, but without delirium. The whole surface of his skin was interspersed with vesicles, or phlyctenae, of the size of an ordinary walnut; many of them were larger, especially on the arms and breast. In the interstices, between the vesicles, the appearance of the skin was natural, nor was there any redness round their base; the distance from one to another was from half an inch to a hand-breadth or more. In some places two or three were joined together, like the pustules in the confluent smallpox. A few vesicles had burst of themselves, and formed a whitish scab or crust. Those 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, semipellucid serum, formed this appearance. Nor was the surface of the cutis ulcerated or livid; but of a red florid colour, as when the cuticle is separated by a blister, or superficial burning. No other person labouring 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 sores on the trunk of the body looked clean. Others, particularly where the vesicles were confluent, seemed beginning to ulcerate, and to have a bluish sublivid appearance. They were dressed afresh with cerate, and he was ordered the following medicines:

Rp Decoct. Cort. Peruvian, 3vj. Vini rubr. Lusitan. 3ijj. M. Hujus mixture capiat 3B, tertia quaque hora.

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

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

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

\[ \text{Rp. Pulv. subtiliss. Cort. Peruv. 3S. Vini rubri Lusitan. Aque fontan. ad 3ss. M. ft. Haust. tertia quaque hora repetend.} \]

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 pem-

phigus have lately been published in the London Medical Journal by Mr Thomas Christie. From a case which Mr Christie describes, he is disposed to agree with Mr 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. Hoffm. II. 478. Junck. 137. Febris aphthosa, Vog. 44.

The only idiopathic species is the thrush to which infants are subject; (Aphtha lactucimen, Sauv. sp. i.)

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, sending forth a glutinous mucus, and the pustules covering all or the greatest number of the parts above mentioned, with a thick whitish crust adhering most tenaciously. This crust does not induce an eschar on the parts on which it lies by eating into them, but comes off in whole pieces after the pustules have arrived at maturity. This will often happen in a short time, so that the throat and internal parts of the mouth are frequently observed to be clean, which a few hours 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 aphthae 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 aphthae 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 fall off; off; but in the mean time we are not to neglect applications to the aphthae themselves, such as detergent and softening gargles made of the decoction of figs, with the addition of honey of roses, a little vinegar, and some tincture of myrrh.

**ORDER IV. HÆMORRHAIGÆ.**

**Hæmorrhages.**

Hæmorrhagia, Vog. Class. II. Ord. I. Hoffm. II. 194. Junck. 5. Sanguifluxus, Sauv. Class IX. Ord. I. Sag. Class 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 plethorica, Sauv. sp. 22. Hoffm. II. 198.

The other species enumerated by authors are all symptomatic.

**Description.** The milder species of this hemorrhage comes on more frequently in summer than in winter, and for the most part without giving any warning, or being attended with any inconvenience; but the less benign kind is preceded by several remarkable symptoms. These are, congestions of the blood sometimes in one part, and sometimes in another, and which are often very troublesome in the sides of the head: there is a redness of the cheeks; an inflation of the face, and of the vessels of the neck and temples; a tinnitus aurium; a heavy pain of the eyes, with a prominence, dryness, and sparks; there is a vertiginous affection of the head, with an itching of the nostrils, and a sense of weight, especially about the root of the nose. In some the sleep is disturbed with dreams about blood, fire, &c. Frequently the belly is costive, 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 azura 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 hemorrhage, and depending upon an arterial plethora; but it sometimes occurs in the decline of life, and may then be considered as the sign of a venous plethora in the vessels of the head. It often happens at any period of life in certain febrile diseases, which are altogether or partly of an inflammatory nature, and which show a particular determination of the blood to the vessels of the head. As by this evacuation, 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 frequently and in great quantity, it is alarming; and is to be considered as a mark of an arterial plethora, which in the decline of life may give the blood a determination to parts from which the hemorrhage would be more dangerous; and this will require more particular attention, as the marks of plethora and congestion preceding the hemorrhage are more considerable, and as the flowing of the blood is attended with a more considerable degree of febrile disorder. These consequences are more especially to be dreaded, when the epistaxis happens to persons after their azura, 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 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 generally be considered as critical and salutary; but it is very apt to be too profuse, and thus becomes dangerous. It sometimes occurs during the eruptive fever of some exanthemata, and is in such cases sometimes salutary; but if these exanthemata be accompanied with any putrid disposition, this hemorrhage, 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 hemorrhage, by pressing the nostril from which the blood flows, washing the face with cold water, or applying this to some other parts of the body. These measures Dr Cullen judges to be proper even on the first attacks, and even in young persons where the disease is in the least hazardous; but they will still be more requisite if the disease frequently recurs without any external violence; if the returns happen to persons not disposed... disposed to a plethoric habit; and more particularly if no signs of plethora appear in the symptoms preceding the discharge.

When the bleeding is so profuse that the pulse becomes weak and the face pale, every means must be used to put a stop to it, and that whether the patient be young or old. Besides those methods above mentioned, we must use astringents both internal and external; but the latter are the most powerful, and the choice of these may be left to the surgeon. The internal astringents are either vegetable or fossil; but the vegetable astringents are seldom powerful in the cure of any 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 saturnina, 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 bystanders, who have supposed that the spontaneous cessation of the haemorrhage 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. Junck. 8.

Hæmoptoe, Boerh. 1198.

Sanguinis fluxus ex pulmonibus, Hoffm. II. 202.

Sp. I. HÆMOPTYSIS from Plethora.

Sp. II. HÆMOPTYSIS from External Violence.

Hæmoptysis accidentalis, Sauv. sp. 1.

Hæmoptysis 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 catamenisialis, Sauv. sp. 4.

Hæmoptysis periodica, Sauv. sp. 5.

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

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

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

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

2. When blood proceeds from the fauces, or adjoining cavities of the nose, it may be brought out by hawking, and sometimes by coughing. In this case, there may be a doubt concerning its real source, and the patient may be allowed to please himself with the 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 haemorrhage, 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 predisponent cause of haemoptysis; and the disease may happen merely from the predisponent cause arising to a considerable height. But in those who are already predisposed, it is often brought on by the concurrence of various occasional and exciting causes. One of these, and perhaps a frequent one, is external heat; which, even when in no great degree, brings on the disease in spring, and the beginning of summer, while the heat rarifies the blood more than it relaxes the solids, which had before been contracted by the cold of winter. Another exciting cause is a sudden diminution of the weight of the atmosphere, especially when concurring with any effort in bodily exercise. The effort 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 haemorrhage 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 venesection. A cool regimen, and quiet of body and mind, are certainly useful; but Dr Cullen observes that some kinds of gestation, such as sailing, and travelling in an easy carriage on smooth roads, have often proved a remedy. When the cough is very troublesome, it is absolutely necessary to exhibit frequently a small dose of an opiate. Dr Dickson also informs us, that the nitre joined with spermaceti, or pulv. & traga-canthis comp., has produced equally good effects with the electuary above mentioned; in the composition of which he at first considered the conserve only as a vehicle for the nitre, though he means not to insinuate that the former is totally destitute of efficacy.

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

**PHTHISIS.**

**PULMONARY CONSUMPTION.**

*Phthisis, Sauv. gen. 276. Lin. 208. Vog. 319.* *Sag. 101. Junck. 33.* *Phthisis pulmonis, Boerh. 1196.* *Affectio phthisica, sive tabes pulmonalis, Hoffm. II. 284.*

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

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

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

*Phthisis confirmata auctorum.* *Phthisis humida, Sauv. sp. 2.*

Sometimes, notwithstanding all the care that can be taken, the haemoptysis will degenerate into a phthisis pulmonalis, or consumption of the lungs; and sometimes haemoptysis will be the consequence of this dangerous disorder. It has indeed been supposed, that an ulceration of the lungs, or phthisis, was the natural and almost necessary consequence of haemoptysis: but according to Dr Cullen, this is in general a mistake; for there are many instances of 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 phthisis, therefore, Dr Cullen reduces to five heads. 1. A haemoptysis. 2. A suppuration of the lungs in consequence of a pneumonia. 3. A catarrh. 4. An asthma; and, 5. Tubercles.

1. When a phthisis arises from a haemoptysis, it is probable that it is occasioned by particular circumstances; and what these circumstances are, may not always be easily known. It is possible, that merely the degree of rupture, or frequently repeated rupture, preventing the wound from healing, may occasion an ulcer; or it is possible, that red blood effused, and not brought up entirely by coughing, may, by stagnating in the 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 bronchiæ that it properly constitutes the phthisis pulmonalis. In the case of empyema, the chief circumstances of a phthisis are indeed also present: but we shall here consider only that case in which the abscess of the lungs gives occasion to purulent expectoration.

An abscess of the lungs, in consequence of pneumonia, is not always followed by a phthisis: for sometimes a hectic fever is not formed; the matter poured into the bronchie is a proper and benign pus, which frequently is coughed up very readily, and spit out; and though this purulent expectoration should continue for some time, if it be without hectic fever, the ulcer soon heals, and every morbid symptom disappears. This has so frequently happened, that we may conclude, that neither the access of the air, nor the constant motion of the lungs, will prevent an ulcer of these parts from healing, if the matter of it be well-conditioned. An abscess of the lungs, therefore, does not necessarily produce phthisis pulmonalis; and if it be followed by such a disease, it must be in consequence of particular circumstances which corrupt the purulent purulent matter; produced, render it unsuitable to the healing of the ulcer, and at the same time make it afford an acrimony, which, absorbed, produces a hectic fever and its consequences.

The corruption of the matter of such abscesses may be owing to several causes; as, 1. That the matter effused during the inflammation had not been a pure serum fit to be converted into a laudable pus, but had been joined with other matters which prevented that, and gave a considerable acrimony to the whole. Or, 2. That the matter effused and converted into pus, merely by long stagnation in a vomica, or by its connexion with an empyema, had been so corrupted as to become unfit for the purpose of pus in the healing of the ulcer. These seem to be possible causes of the corruption of matter in abscesses, so as to make it the occasion of a phthisis in persons otherwise sound; but it is probable that a pneumonic abscess especially produces phthisis when it happens to persons previously disposed to that disease, and therefore only as concurring with some other causes of it.

3. The third cause supposed to produce a phthisis is a catarrh; which, in many cases, seems in length of time to have the expectoration of mucus proper to it gradually changed to an expectoration of pus; and at the same time, by the addition of a hectic fever, the disease, which was at first a pure catarrh, is changed into a phthisis. But this supposition is, 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 supposed to do so, the ulcer produced might readily heal up, as it does in the case of a cynanche tonsillaris; and therefore should not produce a phthisis.

Farther, The catarrh, as purely the effect of cold, is generally a mild disease as well as of short duration; and, according to Dr Cullen, there are at most but very few of the numerous cases of it, which can be said to have ended in a phthisis. In all these cases in which this seems to have happened, he thinks it probable that the persons affected were peculiarly predisposed to phthisis; and the beginning of phthisis so often resembles a catarrh, that it may have been mistaken for such a disease. It often happens also, to increase the fallacy, that the application of cold, which is the most frequent cause of catarrh, is also frequently the exciting cause of the cough, which proves to be the beginning of a phthisis.

Many physicians have supposed that an acrimony of the fluids eroding some of the vessels of the lungs is a frequent cause of ulceration and phthisis; but this appears to Dr Cullen to be a mere supposition. He acknowledges, that in many cases in acrimony subsisting in some part of the fluids is the cause of the disease; but observes that it is at the same time probable, that this acrimony operates by producing tubercles, rather than by any direct erosion.

But, notwithstanding these objections, experience affords numerous examples of cases in which a disease long subsisting under the form of catarrh has at last degenerated into phthisis, and proved fatal from supervening hectic fever. It must, however, at the same time be allowed, that catarrh, degenerating into a phthisis chronic state after 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 absent. He has likewise seen them in subjects of different ages, who had been troubled with no symptoms of an affection of the breast during their lifetime. In these, however, they were small, and few in number. This proves that they may exist without inconvenience till they begin to disturb the functions of the lungs by their size and number; or till some degree of inflammation be excited, either by accidental causes, or by certain changes that take place within their substance; for as yet we know but little of their true nature. These little tumours vary in their consistence; in some they are composed of a pulpy substance, and in others approach more to the nature of scirrhus. They are most commonly formed in consequence of a certain constitutional predisposition; but whatever is capable of occasioning a morbid irritability of the lungs seems 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 scrophula. Tubercles may likewise sometimes be owing to the sudden repulsion of cutaneous eruptions, or of the matter of exanthemata, &c. or to other causes.

The persons who are most liable to consumption are those of a fair complexion, fine and soft skin, florid cheeks, and a slender make; with high cheek-bones, hollow temples, long neck, shoulders standing out like wings, narrow chest, and a remarkable prominence of the processes of the os sacrum. To these marks we may add, that of sound teeth, which, as the disease advances, vances, usually become of a milky white colour, and more or less transparent. Of those who are carried off by this disease, Dr Simmons asserts, the greater number will be found never to have had a carious tooth. This circumstance, however, does not seem to us to hold so generally as Dr Simmons is disposed to imagine: and instances not unfrequently occur of patients dying of phthisis, although they have had many teeth subjected to caries; and some of these beginning even at an early period of life.

Persons of the above description often remain for a long time without feeling any other inconvenience than some oppression at the breast in moist weather, or in hot apartments. Their breathing is easily hurried, sometimes by the slightest motion; and they become languid, paler, and thinner. All this time, however, they feel no heat or painful sensation in the breast. As the evil increases, the patient begins to be attacked with a slight, frequent, and dry cough, which is most troublesome in the night time. But this, by proper care, is often relieved; and the patient remains in this state for a considerable time, and even for many years, if he be sensible of his danger, and careful to guard against it by a suitable manner of living. More commonly, however, we find the cough increasing, and sometimes accompanied with more or less catarrh. This is usually ascribed to cold; and but too generally neglected, till the disease 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 saltish mucus irritating the membrane of the trachea, all judicious practitioners agree in recommending an attention to regimen, the free use of diluting liquors, bland emulsions, small doses of nitre, the taking away a few ounces of blood if there be much inflammation, the inhaling the steams of warm water by means of the machine contrived for that purpose, and the occasional use of such a dose of elixir paregoricum as will be sufficient to allay the irritation of the bronchia, and to promote a general 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 socks and a flannel under-waistcoat. The use of flannel has been condemned by several medical writers as increasing the insensible perspiration; but in the present case, to say nothing of some others in which it may be useful, it will in general be found to have the best effects. It will prevent a too great determination to the lungs, and should not be left off till the approach of summer. In some few instances in which flannel was found to have a disagreeable effect, a piece of dimity worn over the breast next the skin, will prevent the return of colds and coughs in persons of a delicate habit, who had before been liable to them on the slightest occasions. Shirts made of cotton cloth are much more effectual than linen in preserving an equable temperature of the surface, and guarding against the action of external cold; while at the same time they are much more pleasant to most people than even the finest flannel. In these cases, circumstances that are seemingly of the most trifling nature become of importance.

Sometimes the cough is occasioned by an immediate inflammation of some part of the lungs, from some of the usual causes of inflammation; and when this happens, no time is to be lost in removing it. To do this will perhaps require more than one bleeding, together with a strict attention to a cooling plan of diet, diluting drinks, the inhalation of warm steams, and if convenient, the use of the warm bath; but, above all, the speedy application of a large blister as near as may be to the supposed seat of the inflammation. The cough, in this case, will often remain after the original complaint is abated. A prudent use of opiates at bedtime, either by themselves or combined with gummy and mucilaginous medicines, will then generally be useful as a sedative and 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 bringing up the patient: but this never fails to increase the cough, and of course to do great and very irreparable mischief.

And here it will not be foreign to our subject to observe, that a symptomatic cough, which has its rise not from catarrh, or from an immediate inflammation of the lungs, but from their sympathy with the stomach, has sometimes laid the foundation of phthisis, from its having been mistaken, and of course improperly treated. It seems to be owing to a redundancy or vitiated state of the bile, or to some affection of the stomach, which it is perhaps not easy to define. It is sometimes a concomitant of other bilious symptoms; and when this happens to be the case, it cannot easily be mistaken; but we sometimes find it occurring singly, and in general attacking persons of a sedentary life. Dr Stoll of Vienna, who has noticed this cough, has very properly given it the name of tussis stomacchica. 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 have failed, both of which circumstances but too frequently happen, the patient begins to complain of a soreness, and of slight lancinating pains shooting through the breast, sometimes in the direction of the mediastinum, and sometimes confined chiefly to one side. The soreness is pretty constant, and much increased by the cough. The pain in the side often prevents the patient from lying on the side affected; and this inability of lying except on one side, frequently occurs even when no such pain is felt. In this stage of the disease, flushing heats are felt on the palms of the hands and soles of the feet: the breathing is short and laborious; and it is not long before the patient begins to expectorate a thin and frothy phlegm, at first in small quantities, coughed up with difficulty, and some pain of the breast, and now and then streaked with blood: this may be considered as the inflammatory period of the disease, to which succeeds the suppurative stage. In the latter, the expectoration becomes more copious and purulent, the breath proportionably offensive, and the exacerbations of the hectic fever more considerable: an increased quickness of the pulse comes on about the middle of the day; but the most considerable paroxysm of the fever is at night, and at first continues till towards morning, commonly till three or four o'clock, when it terminates in a sweat, which usually begins upon the breast. As the disease advances, these sweats become more profuse, and sometimes come on almost as soon as the pulse begins to quicken, but without affording any relief to the patient. During the exacerbations, we observe a circumscribed redness of the cheeks, while the rest of the face is pale, and appears as if it were not clean washed. The costiveness that commonly accompanies the beginning of the disease is usually succeeded by a diarrhoea; the spitting lessens, and all the purulent matter seems to be carried downwards. The wasting of the fat and the loss of nourishment occasion the nails to curve inwards, the hair to fall off, and the eyes to sink in their sockets. In the mean time, the legs commonly swell; till at length death closes a scene which is melancholy to all but the patient himself, who in general continues sensible to the last moment, and even then indulges a vain hope of prolonging a miserable existence. In some cases, and that not unfrequently, a delirium comes on towards the close of the disease.

The hectic fever that attends this and some other chronic diseases, is evidently the effect of acrimony, and most commonly of pus absorbed and carried into the circulation. The nature of this acrimony, and the different irritability of different patients, are probably the sources of the variety we observe in fevers of this denomination; a variety which is doubtless much greater than we are aware of. Thus we find that the matter of the smallpox excites a fever of this kind; but this secondary fever, as it is called, differs from the hectic attendant on consumptions; nor does the latter correspond with that which sometimes accompanies the suppuration of a cancerous ulcer. In the pulmonary consumption, or at least in the third stage of it, the fever induced often appears to be of the putrid kind, and has been denominated febris hectica putrida by the judicious Morton, who considers it as being combined with a peri-pneumonic or inflammatory fever, which recurs as often as fresh tubercles begin to inflame. For although we have named one period of the disease the inflammatory, and another the suppurative period, yet we are not to suppose that the latter is exempt from inflammation. While matter is poured into the bronchiae, or absorbed and carried into the system from one part of the lungs, other parts are in a crude state of inflammation, or advancing towards suppuration; so that, on examining the lungs of persons who die consumptive, we find some tubercles that are small and just formed, some that are large and full of matter, and others that are in a state of ulceration. This easily accounts for the occasional combination of inflammatory symptoms with those of the putrid hectic. When the matter absorbed is a laudable pus, as in the case of the psoas abscess, we find the form of the hectic fever differing from either of those we have mentioned.

Cure. In these different periods of the disease, the curative indications are sufficiently obvious. To prevent the formation of fresh tubercles; to obviate the inflammation of those already formed; to promote their resolution; to allay morbid irritability, the cough, and other troublesome symptoms; and, above all, to check the tendency to the hectic state, are the views that every rational physician proposes to himself in the treatment of the genuine consumption. We know of no medicines that can exert their specific effects upon the lungs by dissolving tuberculous concretions; nor is it probable, from what we know of the animal economy, that any such will ever be discovered. Yet medicines that operate in a general manner upon the system, may, by promoting absorption, and diminishing the determination to the lungs, tend to disperse tubercles, or to prevent their formation. There are not wanting instances of wonderful recoveries, in cases where the evil was supposed to be beyond the power of physic; and in some, where nature was left to herself; so that a physician who has observed the various and powerful resources nature has within herself, will be very cautious how he asserts, that a disease is incurable.

The most formidable effects of ulcerated lungs are the absorption and consequent hectic. It seems evident, that, in many cases, death is brought on by this, rather than by the lungs themselves being rendered unfit for the purposes of respiration. So that if we can obviate the effects of the absorption, diminish the preternatural determination to the lungs, and fulfil the other general indications just now mentioned, we may very often enable nature to recover herself. It may be alleged, indeed, that the physicians art has hitherto proved very unsuccessful in these cases; but may not this be owing to the remedies that are employed being very often such as are inimical to the cure?

The cinchona is, perhaps, the most commonly employed of any, and often confided in as an ultimate resource in these cases. But besides this, the sulphuric acid, the balsams, and frequent bleeding, have each had their partizans. The use of blisters and issues, opiates, a milk and vegetable diet, exercise, and change of air, are pretty generally recommended by all. Concerning cinchona, Dessault long ago observed, that it had been productive... productive of great mischief in consumptive cases; and Dr Fothergill, in a paper lately published by him on this subject, very judiciously remarks, that it is so far from curing the hectic fever arising from 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 peri-pneumonic fevers; but that it stops this discharge, changes slight wandering pains into such as are fixed, and increases them with all their consequences, in a variety of cases.

The elixir of vitriol, or the sulphuric acid properly diluted, though in many instances a highly useful remedy, is often exhibited in consumptive cases with no less impropriety than cinchona. This medicine, from its astringency, is obviously improper in the inflammatory state of the disease. But in the latter stage, when a general tendency to putrefaction takes place, it is serviceable in resisting the effect; it restrains the colliquative sweats; and if the lungs be not injured past reparation, 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 stypticity, and perhaps the air it contains may also have an antiseptic quality. On the whole, it appears to be an efficacious medicine, and is often found of remarkable benefit to consumptive patients.

Change of air, particularly from bad to good, is of great consequence to all chronic diseases of the lungs. In consumptive cases, the air of all large cities is found to be particularly injurious.

A sea voyage has been much recommended in the cure of this disease. The benefit of exercise has also been strongly urged by many writers; but, however salutary when properly used, it certainly ought to be regulated with discretion. Dr Dickson declares himself of opinion, that riding on horseback in consumptive cases is most commonly hurtful, without such regulations as in general have been little regarded. For instance, he has known a person who, by a ride of an hour or two in the morning, was very much recruited, and who, at another time, in the afternoon and evening, without undergoing more bodily motion, has returned faint and languid, and apparently worse. This observation on the same person has been so frequently made, as to point out clearly the times when this exercise shall not do hurt in consumptive cases. In this disease, the pulse, however calm in the morning, becomes more frequent in the afternoon and night, attended with heat and other feverish symptoms. Exercise therefore, at this time, can only add to the mischief of the fever. For this reason he prudently recommends to all hectic persons, especially those who shall travel to distant places on account of a better air, or the benefit expected from any particular water, that their travelling should be slow, confined to a very few hours, and only in the morning.

Exercise on horseback seems to be chiefly beneficial in those cases where consumption is a secondary disease. For example, in the nervous atrophy; in the hypochondriacal consumption; or when it is the effect of long-continued intermittents, or of congestions in any of the abdominal viscera; or, in a word, whenever the consumption is not attended with an inflamed or ulcerated state of the lungs, long journeys on horseback will be beneficial. Such a practice may likewise be highly useful in obviating an attack of phthisis, or in carrying off a dry husky cough in a person of a consumptive habit, when there is reason to suppose that no tubercles are as yet formed. On the other hand, in the confirmed phthisis, when the lungs are inflamed or ulcerated, much or violent exercise will be improper; and there have been instances where the death of the patient was evidently accelerated by it. The exercise therefore should be gentle, proportioned to the strength of the patient, and employed only in the morning. In fine weather, an easy open carriage is perhaps the most eligible, not only on account of its being open to the air, but because it affords that kind of agitation which is most wanted in these cases. For if we consider the different modes of exercise, we shall find that walking, though the best exercise in health, as it employs the most muscles, is the worst for the sickly, who should have the benefit of exercise without fatigue. Riding on horseback agitates the viscera more than walking, and is therefore preferable to it in many chronic diseases; but when a premature determination to the lungs has taken place, it will be liable to increase the evil, and may likewise be hurtful by the fatigue that attends it. For these reasons it will be prudent to begin with a carriage; and if the patient gain strength, and the disease abates, recourse may afterwards be had to horse-exercise.

The gentle motion of a coach has been often found of great utility in pulmonary complaints. Its efficacy seems to depend chiefly on its increasing the determination to the surface of the body. The nausea which this motion excites in some persons is an effect of this increased determination. It has therefore been found beneficial in haemoptysis; and Dr Simmons mentions the case of a lady, who, after trying various remedies to no purpose, was cured of this complaint by travelling several hundred miles through different parts of England in her own coach. At first, whenever she remained three or four days in any place, the disorder began to return again; but at length by persevering in her journeys, it gradually went off. Dessault, who practised at Bordeaux about 40 years ago, tells us, he sent several consumptive patients to Bareges, and with good success; but that in these cases his reliance was not so much upon the Bareges waters, as upon the motion of the carriage and the change of air in a journey of more than 100 leagues.

It is now pretty generally acknowledged, that the good effects of sea voyages in consumptive cases depend more upon the constant and uniform motion of the ship, than upon any particular impregnation of the sea air; although this from its coolness and purity may likewise be of great use, especially in the hot months, when sea voyages are generally undertaken by consumptive patients. The ancients were no strangers to this remedy; and amongst the Romans it was no unusual thing for consumptive persons to sail to Egypt. Pliny observes, that this was not done for the sake of the climate, but merely on account of the length of the voyage.

Many of our English physicians have recommended a voyage to Lisbon in these cases. When this is done, the proper season of the year should be carefully attended to. Dr Simmons knew a gentleman who went thither with symptoms of incipient phthisis, and who experienced some relief during the course of the voyage; but happening to arrive at Lisbon at the beginning of the rainy season, the disease was soon greatly increased, and terminated fatally.

Another species of motion has of late been extolled as highly useful in consumptive cases. Dr James 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 cases has fully confirmed; and he recommends it as a mode of cure which may be employed with advantage in every stage of phthisis. While, however, the reasoning of Dr Smyth on this subject seems to be liable to many objections, we are sorry to add, that his observations in practice have by no means been confirmed by those of others, who have had recourse to this mode of cure.

The best adapted diet in consumptive cases is milk; the milk of asses, both as an article of diet and as a medicine, has in particular been highly extolled. It may however be remarked, that there are constitutions in which this salutary nutriment seems to disagree. A propensity to generate bile, or too strong a disposition to ascendency from a weakness of the digestive organs, both merit attention. Whey, either from cows or goats milk, appears to be more suitable in the former case; and for correcting acidity, lime water may be added to the milk. The method of adding rum or brandy to asses or cows milk, should be used with great caution: for when added beyond a certain quantity, as is often the case, they not only coagulate the milk, but heat the body; by which means the 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 sity; when there is much pain in the breast; and when venesection is followed by an abatement of every symptom. In these cases, bleeding is certainly proper, and ought to be repeated so long as it seems to be attended with advantage. In very delicate constitutions, however, even where the pulse is quick, with some degree of fulness, and the blood last drawn considerably sity, 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 menses, 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 colliquative sweats.

In these cases, when an emetic has been administered twice a week, and the cough is mitigated, the expectoration facilitated, and the other symptoms relieved, both the patient and the physician will be encouraged to proceed, and to repeat the vomit every second day, or even every day, for several days together, as Dr Simmons has sometimes done when the good effects of it were obvious.

The choice of emetics to be employed in these cases is by no means a matter of indifference. Carduus tea, chamomile tea, warm water, and others that act by their bulk, and by exciting nausea, relax the tone of the stomach when they are frequently repeated, and of course will be improper. More active emetics are therefore to be preferred; and here some of the preparations of antimony might naturally be thought of. But the operation of these is not confined to the stomach. They produce evacuations by stool, and a disposition to sweat; and are therefore improper in the pulmonary hectic. The mildness and excellence of ipecacuanha as an emetic, are well known; but in these cases, Dr Simmons has often employed the sulphate of copper, concerning the effects of which we meet with some groundless assertions in several medical books. Its operation is confined to the stomach; it acts almost instantaneously; and its 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 dissolved in a cupful of water. The dose of it must be adapted to the age and other circumstances of the patient, and may be varied from two grains to ten, fifteen, or twenty. As some persons are much more easily puked than others, it will be prudent to begin with a small dose: not that any dangerous effects will be produced by a large one, for the whole of the medicine is instantly rejected; but if the nausea be violent, and of long continuance, the patient may perhaps be discouraged from repeating it. In general, the moment the emetic has reached the stomach it is thrown up again. The patient must then swallow another half pint of water, which is likewise speedily rejected; and this is commonly sufficient to remove the nausea.

Dr Marryat, in his New Practice of Physic, prescribes with great freedom what he calls the dry vomit, from its being directed to be taken without drinking. This medicine consists of sulphate of copper and tartrite 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-myrrh. 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 Boerhaave, tells us, from the information of a person of credit, that in some parts of Spain they have a method of curing the phthisis pulmonalis by the use of this remedy; and he quotes the celebrated Solano de Linque in confirmation of this practice. Solano speaks of the banos de tierra, or earth-baths, as a very old and common remedy in Granada and some parts of Andalusia, in cases of hectic fever and consumptions; and relates several instances of their good effects in his own practice. The method he adopted on these occasions was as follows: He chose a spot of ground on which no plants had been sown, and there he made a hole large and deep enough to admit the patient up to the chin. The interstices of the pit were then carefully filled up with the fresh mould, so that the earth might everywhere come in contact with the patient's body. In this situation the patient was suffered to remain till he began to shiver or felt himself uneasy; and during the whole process, Solano occasionally administered food or some cordial medicine. The patient was then taken out, and, after being wrapped in a linen cloth, was placed upon a mattress, and two hours afterwards his whole body was rubbed with an ointment, composed of the leaves of the 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 colliquiative 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 sca-scurvy. Dr Priestley observes, that the Indians, he has been told, have a custom of burying their patients labouring under putrid diseases up to the chin in fresh mould, which is also known to take off the 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 setons, 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 setons act chiefly in the latter of these two ways; and in this respect their effects, though less sudden and less powerful at first, are more durable from the continuance of the discharge they occasion. It is perhaps hardly necessary to remark, that, if much service is to be expected from either of these remedies, they should be applied early in the disease. The ingenious Dr Mudge, who experienced the good effects of a large scapular issue on his own person, very properly observes, that the discharge in these cases ought to be considerable enough to be felt. But it is seldom possible for us to prevail on the delicate persons, who are most frequently the victims of this disease, to submit to the application of a caustic between the shoulders. The discharge produced by a seton 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 seton 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.

Hæmorrhois, Sauv. gen. 217. Lin. 192. Sag. gen. 182.

Sp. I. External Piles.

Var. A. Bloody Piles.

Hæmorrhois moderata, Sauv. sp. 1. Hæmorrhoides ordinatæ, Junck. 11. Hæmorrhoides nimæ, Junck. 11. Hæmorrhois immodica, Sauv. sp. 2. Hæmorrhoides excedentes, Alberti de hæmorrhoid. p. 179. Hæmorrhois polyposa, Sauv. sp. 3.

Var. B. Mucous Piles.

Hæmorrhoides decoloratæ, albeæ, et mucidæ, Junck. 13. Alberti, p. 248.

Sp. II. The Piles from a Providentia Ani.

Hæmorrhois ab exanis, Sauv. sp. 4.

Sp. III. The Running Piles.

Sp. IV. The Blind Piles.

Hæmorrhoides cœcæ, Junck. 12. Alberti, p. 274.

Description. The discharge of blood from small tumors on the verge of the anus constitutes what is called the hemorrhoids or piles. They are distinguished into the external and internal, according to the situation of the tumors, either without or within the anus. Sometimes, however, these tumors appear without discharging any blood; and in this case they are called the hæmorrhoides cœcæ, or blind piles. Sometimes the disease appears without the verge of the anus in distinct separate tumors; but frequently only one tumid ring appears, seeming as it were the anus pushed without the body. Sometimes these tumors appear without any previous disorder of the body; but more frequently, before the blood begins to flow, and sometimes even before the tumors are formed, various affections are perceived in different parts of the body; as headache, vertigo, stupor, difficulty of breathing, sickness, colic pains, pain of the back and loins, and frequently a considerable degree of pyrexia; while along with these symptoms there is a sense of fulness, heat, itching, and pain, in and about the anus. Sometimes the disease is preceded by a serious discharge from the anus; and sometimes this serious discharge, accompanied with swelling, seems to come in place of the discharge of blood, and to relieve the above-mentioned disorders of the system. This serious discharge hath therefore been named the hæmorrhois alba.

In this disease the quantity of blood discharged is different upon different occasions. Sometimes it flows only when the person goes to stool, and commonly follows the discharge of faeces. In other cases it flows without any discharge of faeces; and then generally in consequence of the disorders above mentioned, when it is also commonly in larger quantity. This is often very considerable; and, by the repetition, so great, that we could hardly suppose the body to bear it but with the 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 leucoplegnatia or dropsy 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 varicose dilatations have appeared on 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 haemorrhoidal 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 costive. From the same causes, the disease happens frequently to those who are subject to a Ham 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 the blood from it, occasions a considerable swelling, and the formation of a tumid ring round the anus.

Upon the sphincter's being a little relaxed, as it is immediately after its strong contraction, the portion of the gut which had fallen out is commonly taken into the body again; but by the frequent repetition of the accident, the size and fulness of the ring formed by the prolapsed intestine is much increased. It is therefore more slowly and difficulty replaced; and in this 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 haemorrhoids or piles.

From considering that the pressure of the faeces, and other causes interrupting the return of venous blood from the lower extremity of the rectum, may operate a good deal higher up than that extremity, we may understand how tumors may be formed within the anus; and probably it also happens, that some of the tumors formed without the anus may continue when taken within the body, and even be increased by the causes just mentioned. Thus may the production of internal piles be explained, which, on account of their situation and bulk, are not protruded on the person's going to stool, and are therefore more painful.

The production of piles is particularly illustrated by this, that pregnant women are frequently affected with the disease. This is to be accounted for, partly from the pressure of the uterus upon the rectum, and partly from the costive habit to which pregnant women are liable. Dr Cullen has known many instances of piles happening for the first time during the state of pregnancy; and there are few women who have born children, that are afterwards entirely free from piles.

Purgatives also, especially those of the more acid kind, and particularly 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 haemorrhoids 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 the renewal of the causes which occasioned it. It happens also to persons much exposed to a congestion in the haemorrhoidal 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 connection with the stomach; so that certain affections of the stomach excite the haemorrhoidal disease, and certain states of this disease excite the disorders of the stomach.

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

Cure. The general intention of cure in cases of haemorrhoids are much varied, according to the circumstances of the affection at the time. When haemorrhoids exist in the state of tumor, the principal objects are to counteract inflammation, and to promote a discharge of blood from the part. When it is in the state of evacuation, the chief intentions of cure are, to diminish the impetus of blood at the part affected, and to increase the resistance to the passage of blood through the ruptured vessels. And finally, when the disease exists in the state of suppression, the aims of the practitioner must chiefly be, to obviate the particular affections which are induced in consequence of the suppression; to restore the discharge, as a means of mitigating these and preventing others; or, when the discharge cannot with propriety or advantage be restored, to compensate the want of it by various 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 costiveness; 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 haemorrhoids to be especially attended to is the prolapsus ani, which is apt to happen on a person's having a stool. If this shall occur to any considerable degree, and be not at the same time easily and immediately replaced, it most certainly produces piles, or increases them when otherwise produced. Persons therefore who are liable to this prolapsus, should, after having been at stool, take great pains to have the intestine immediately replaced, by lying down in a horizontal posture, and pressing gently upon the anus, till the reduction shall be completely obtained. When this prolapsus is occasioned only by the voiding of hard and bulky faeces, it is to be removed by obviating the costiveness which occasions it. But in some persons it is owing to a laxity of the rectum; and in those it is often most considerable on occasion of a loose stool. In these cases, it is to be treated by astringents, and proper artifices are to be employed to keep the gut in its place.

When the disease has frequently recurred from neglect, and is thus in some measure established, the methods above mentioned are no less proper; but in this case some other measures must also be used. It is especially proper to guard against a plethoric state of the body; and therefore to avoid a sedentary life, full diet, and intemperance in the use of strong liquor, which in all cases of hemorrhage is of the most pernicious consequence.

Exercise of all kinds is of great service in obviating and removing a plethoric state of the body; but upon occasion of the haemorrhoidal flux, when this is immediately to come on, both walking and riding, as increasing the determination of the blood into the haemorrhoidal vessels, are to be avoided. At other times, when no such determination is already formed, these modes of exercise may be very properly employed.

Another method of removing plethora is by cold bathing; but this must be employed with caution. When the haemorrhoidal flux is approaching, it may be dangerous to divert it; but during the intervals of the disease, cold bathing may be employed with safety and advantage; and in those who are liable to a prolapsus ani, the frequent washing of the anus with cold water may be useful.

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

When the flux has actually come on, we are to moderate it as much as possible, by causing the patient lie in a horizontal posture on a hard bed; by avoiding exercise in an erect posture, using a cool diet, and avoiding external heat. But with respect to the further cure of this disease, we must observe, that there are only two cases in which it is common for haemorrhoidal persons to call for medical assistance. The one is, when the affection is accompanied with much pain; and the other, when the piles are accompanied with excessive bleeding. In the first case, we must consider whether the piles be external or internal. The pain of the external piles happens especially when a considerable protrusion of the rectum has taken place; and while it remains unreduced, it is strangled by the constriction of the sphincter; and at the same time no bleeding happens to take off the swelling of the pro-

Vol. XIII. Part I. truded portion of the intestine; and sometimes an inflammation supervenes, which greatly aggravates the pain. In this case, emollient fomentations and poultices are sometimes of service, but the application of leeches is generally to be preferred.

In 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 haemorrhoids seems perfectly safe and proper. It is only when the disease arises from a plethoric habit, and from a stagnation of blood in the hypochondriac region, or when, though originally topical, it has by frequent repetition become habitual, and has thereby acquired a connection with the system, that any doubt can arise about curing it entirely. In any of these cases, however, Dr Cullen is of opinion, that it will be proper to moderate the bleeding, lest, by its continuance or repetition, the plethoric state of the body, and the particular determination of the blood into the haemorrhoidal vessels, be increased, and the return of the disease be too much favoured. Dr Stahl is of opinion, that the haemorrhoidal flux is never to be accounted excessive, excepting when it occasions great debility or leucoplegmatia: 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 haemorrhage, and by degrees to suppress it altogether; while at the same time measures are to be taken for the removing the necessity of its recurrence.

GENUS XXXIX. MENORRHAGIA.

Immoderate Flow of the Menses.

Menorrhagia, Sauv. 244. Lin. 202. Vog. 96. Menorrhagia, Sag. gen. 179. Uteri hemorrhagia, Hoffm. II. 224. Haemorrhagia uterina, Junck. 14. Leucorrhoea, Sauv. gen. 267. Lin. 201. Vog. 119. Sag. gen. 202. Cachexia uterina, sive 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. Convulsio uteri, sive abortus, Hoffm. III. 176.

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

Menorrhagia rubra, Cul. Menorrhagia immodica, Sauv. sp. 3. Menorrhagia stillatitia, Sauv. sp. 2.

Description. The quantity of the menstrual flux is different in different women, and likewise in the same woman at different times. An unusual quantity therefore is not always to be considered as morbid: but when a large flow of the menses has been preceded by headache, giddiness, or dyspnoea; has been ushered in by a cold stage; and is attended with much pain of the back and loins, with a frequent pulse, heat, and thirst, it may then be considered as preternaturally morbid. On the other hand, when the face becomes pale, the pulse weak, an unusual debility is felt in exercise, and the breathing is hurried by little labour; when the back becomes pained from any continuance in an erect posture, when the extremities become frequently cold, and when at night the feet appear affected with 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 surprise. A large flow of the menses attended with barrenness in married women, may generally be considered as preternatural and morbid. Generally, also, that flow of the menses may be considered as immoderate, which is preceded and followed by a leucorrhoea.

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 strainings 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 restraining the discharge when present, or of preventing the return of an excessive discharge at the succeeding period. The first is chiefly to be accomplished by employing such practices as diminish the force occasioning the discharge of blood, or as augment the resistance to its passage through the vessels by which it is to be discharged. The last is in some degree to be obtained by avoiding causes which either increase the general impetus of the blood, or the impetus at the uterus in particular; but princi- In all cases, the first attention ought to be given to avoiding the remote causes, whenever they can be done; and by such attention the disease may be often entirely cured. When the remote causes cannot be avoided, or when the avoiding them has been neglected, and a copious menstruation has come on, it should be moderated as much as possible, by abstaining from all exercise at the coming on or during the continuance of the menstruation; by avoiding even an erect posture as much as possible; by shunning external heat, and of course warm chambers and soft beds; by using a light and cool diet; by taking cold drinks, at least as far as former habits will allow; by avoiding venery; by obviating costiveness, or removing it by laxatives which give little stimulus. The sex are commonly negligent, either in avoiding the remote causes, or in moderating the first beginnings of this disease. It is by such neglect that it so frequently becomes violent and of difficult cure; and the frequent repetition of a copious menstruation may be considered as a cause of great laxity in the extreme vessels of the uterus.

When the coming on of the menstruation has been preceded by some disorder in other parts of the body, and is accompanied with pains of the back, somewhat like parturient pains, with febrile symptoms, and when at the same time the flow seems to be copious, a bleeding at the arm may be proper, but is not often necessary; and it will in most cases be sufficient to employ, with great attention and diligence, those means already mentioned for moderating the discharge.

When the immoderate flow of the menses shall seem to be owing to a laxity of the vessels of the uterus, as may be concluded from the general debility and laxity of the person's habit; from the remote causes that have occasioned the disease; from the absence of the symptoms which denote increased action in the vessels of the uterus; from the frequent recurrence of the disease; and particularly from this, that the female in the intervals of menstruation is liable to a leucorrhoea: in such a case, the disease is to be treated, not only by employing all the means above mentioned for moderating the haemorrhage, 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 ealybeates. 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 subsemestris. c, Abortus octimestris. 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 vitoriun, Cul. Menorrhagia ex hysteroptosi, Sauv. sp. 5. Menorrhagia ulcerosa, Sauv. sp. 9.

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

Menorrhagia alba, Cul. Leucorrhoea, Sauv. gen. 267. Menorrhagia decolor, Sauv. sp. 7. Leucorrhoea Americana, Sauv. sp. 5. Leucorrhoea Indica, Sauv. sp. 6. Leucorrhoea Nabothi, Sauv. sp. 9. Leucorrhoea gravidarum, Sauv. sp. 8.

Description. The fluor albus, female weakness, or whites, as it is commonly called, is a disease of the womb and its contiguous parts; from which a pale-coloured, greenish, or yellow fluid is discharged, attended with loss of strength, pain in the loins, bad digestion, and a wan sickly aspect.

Causes, &c. The quantity, colour, and consistence of the discharge chiefly depend upon the time of its duration, the patient's habit of body, and the nature of the cause by which it was produced. Taking cold, strong liquor, immoderate heat and moisture, or violent exercise, are all observed to produce a bad effect, as to its quantity and quality.

Weakly women of lax solids, who have had many children, and long laboured under ill health, are of all the most subject to this disagreeable disease; from which they unfortunately suffer more severe penance than others, as the nicest sensations are often connected with such a delicacy of bodily frame as subjects them to it.

In Holland it is very frequent, and in a manner peculiar to the place, from the dampness of its situation; the surrounding air being so overcharged with moisture as to relax the body, stop perspiration, and throw it upon the bowels or womb; producing in the first a diarrhoea or flux, in the last the fluor albus or female weakness.

The discharge often proceeds from the vessels subservient to menstruation; because, in delicate habits, where those vessels are weak, and consequently remain too... long uncontracted, the fluor albus sometimes immediately follows the menses, and goes off by degrees as they gradually close. It also comes from the mucous glands of the womb, as is particularly evident in very young females of eight and ten years old; in whom, though very rarely, it has been observed, and where it must then necessarily have escaped from those parts, as the uterine vessels are not sufficiently enlarged for its passage at so early a period.

Sometimes, as in women with child, it proceeds from the passage to the womb, and not from the womb itself; which, during pregnancy, is closely sealed up, so that nothing can pass from thence till the time of labour. The application of those instruments called 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 vessels 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 supernatural 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 unstrung; or partial, where the womb only is thus affected, in consequence of hard labour, frequent miscarriages, a suppression or immoderate quantity of the menses, or a sprain of the back or loins.

In the first case, the discharge being generally mild, may be safely taken away. In the second, it may proceed from a vitiated or impure blood, where the body, from thence, is loaded with 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, dropsy, 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 smith's forge water, may be used with a womb-syringe 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 those cannot conveniently be had, the alkaline aerated water, impregnated with iron, will make an excellent substitute. If it should render her costive, and occasion headache, she may desist, and drink a solution of crystals of tartar, or a little senna tea sweated 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 dropsy, or consumption; it were to be wished that women, on such occasions, would be more attentive to their own safety, by using all possible means, in due time, to prevent those disorders.

Dr Leake says he has attended more patients labouring under the fluor albus in the autumn than at any other season. 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 cinehona with aromatics. He observed, that several about this time who escaped the disorder, were visited with bad colds, a dcluxion 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 melbis 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 six ounces of water, was taken to the extent of half an ounce, four times a day; nay, in some cases, the tincture was exhibited to the extent of half an ounce in a day, without any inconvenience, and with the best effects. As examples of the power of this remedy, Mr Robertson has given a detail of six cases, selected from a number which have been under his care. In three cases, as being the most invertebrate, the effects of the cantharides were most evident. And we shall only observe, that if this remedy be found by other practitioners to be equally successful in the cure of leucorrhoea, it will be a very valuable acquisition in the practice of medicine, especially if it shall be found by others, as well as by Mr Robertson, that not only the general symptoms of leucorrhoea are removed, but that the tone and functions of the uterine system are completely restored by the use of cantharides.

As women are sometimes connected with those who do not conscientiously regard their safety, it is a circumstance of the utmost consequence to distinguish a fresh venereal infection from the fluor albus or whites: for if the first be mistaken for the last, and be either neglected or improperly treated, the worst consequences may arise.

The following signs will best inform the patient whether there be occasion for her doubts or not.

A fresh infection, called gonorrhoea, is malignant and inflammatory; the fluor albus most commonly arises from relaxation and bodily weakness: and therefore the remedies proper in the first disorder would render the last more violent, by locking up and confining the infectious matter.

In the gonorrhoea, the discharge chiefly proceeds from the parts contiguous to the urinary passage, and continues whilst the menses flow; but in the fluor albus it is supplied from the cavity of the womb and its passage, and then the menses are seldom regular.

In the gonorrhoea, an itching, inflammation, and heat of urine, are the forerunners of the discharge; the orifice of the urinary passage is prominent and painful, Catarrhus, and the patient is affected with a frequent irritation to make water. In the fluor albus, pains in the loins, and loss of strength, attend the discharge; and if any inflammation or heat of urine follow, they happen in a less degree, and only after a long continuance of the discharge, which, becoming sharp and acrimonious, excoriates the surrounding parts.

In the gonorrhoea, the discharge suddenly appears without any evident cause; but in the fluor albus, it comes on more slowly, and is often produced by irregularities of the menses, frequent abortion, 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 haemorrhage enumerated by medical writers, are by Dr Cullen reckoned to be symptomatic.

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

Species: Scorbutica, Purulenta, &c.

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

Species: Plethorica, Catamenialis, Scorbutica, &c.

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

Species: Purulenta, Calcnosa, Hemorrhoidalis, &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. Tussis, Sauv. gen. 142. Lin. 155. Vog. 205. Sag. gen. 245, 255. Junck. 30. Tussis catarrhalis et rheumatica, Hoffm. III. 109.

Sp. I. Catarrh from Cold.

Catarrhus à frigore, Cul.

Catarrhus benignus, Sauv. sp. 1. Catarrhus pectoreus, Sauv. sp. 6. Coryza catarrhalis, Sauv. sp. 1. Coryza phlegmatorrhagia, Sauv. sp. 2. Salmuth. Obs. cent. 1, 37. Junck. 28. Morgagni de sed. xiv. 21. Coryza fabricosa, Sauv. sp. 6. Tussis catarrhalis, Sauv. sp. 1. N. Rosen. Diss. apud Haller, Disput. Pract. tom. ii. Rheuma catarrhale, Sauv. sp. 1. Amphimerina catarrhalis, Sauv. sp. 2. Amphimerina tussiculosa, Sauv. sp. 13. Cephalalgia catarrhalis, Sauv. sp. 10. Sp. II. Catarrh from Contagion.

Catarrhus à contagio, Cul. Catarrhus epidemicus, Sauv. sp. 3. Rheuma epidemicum, Sauv. sp. 2. Synochia catarrhalis, Sauv. sp. 5.

There are several symptomatic species: as, Catarrhus Rubeolosus; Tussis Variolosa, Verminosa, Calculosa, Phthisica, Hysterica, à dentitione, Gravidarum, Metallicolarum, &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 attends the chief form of catarrh, that is, the increased excretion from the bronchia; 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 catarrh mucus; which is at first thin, but gradually becoming thicker, is brought up with less frequent and less laborious coughing. The hoarseness and soreness of the trachea are also relieved or removed; and the febrile symptoms abating, the expectoration becomes again less considerable, and the cough less frequent, till at length they cease altogether.

Such is generally the course of this disease, neither tedious nor dangerous; but it is sometimes in both respects otherwise. The body subjected to catarrh seems to be more than usually liable to be affected by cold air; and upon exposure of the body to fresh cold, the disease, which seemed to be yielding, is often brought back with greater violence than before, and is rendered not only more tedious than otherwise it would be, but also more dangerous by the supervening of other diseases. Some degree of the cynanche tonsillaris often accompanies the catarrh; and when this is aggravated by a fresh application of cold, the cynanche also becomes more violent and dangerous from the cough which is present at the same time. When a catarrh has been occasioned by a violent cause, when it has been aggravated by improper management, and especially when it has been rendered more violent by fresh and repeated applications of cold, it often passes into a pneumonic inflammation, attended with the utmost danger.

Unless, however, such accidents as these happen, a catarrh, in sound persons not far advanced in life, is always a slight and safe disease; but in persons of a phthisical disposition, a catarrh may readily produce a haemoptysis, or perhaps form tubercles, in the lungs; and still more readily in persons who have tubercles already formed in the lungs, an accidental catarrh may occasion the inflammation of these tubercles, and in consequence produce a phthisis pulmonalis.

In elderly persons, a catarrh sometimes proves a dangerous disease. Many persons, as they advance in life, and especially after they have arrived at old age, have the natural mucus of the lungs poured out in greater quantity, and requiring a frequent expectoration. If, therefore, a catarrh happen to such persons, and increase the influx of fluids to the lungs, with some degree of inflammation, it may produce the peripneumonia notha, or more properly chronic catarrh, a disease continuing often for many years, or at least returning regularly every winter; which in such cases is very often fatal.

Causes, &c. The proximate cause of catarrh seems to be an increased influx of fluids to the mucous membrane of the nose, fauces, and bronchia, along with some degree of inflammation affecting the same. The latter circumstance is confirmed by this, that, in the case of catarrh, the blood drawn from a vein commonly exhibits the same inflammatory crust which appears in the case of phlegmasia. The remote cause of catarrh is most commonly cold applied to the body. This application of cold producing catarrh is generally evident; and 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 going off, they are renewed by any fresh application of catarrhus cold.

**Prognosis.** Considering the number of persons who are affected with catarrhus, of either the one species or the other, and escape from it quickly without any hurt, it may be allowed to be a disease commonly free from danger; but it is not always to be treated as such; for in some persons it is accompanied with pneumonic inflammation. In the phthisically disposed, it often accelerates the coming on of phthisis; and in elderly persons it often proves fatal in the manner we have explained above, viz. by degenerating into its chronic state. But though chronic catarrhus 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 catarrhus from contagion. This species of catarrhus, 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.

**Care.** The cure of catarrhus 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. Proluvia macopoea, 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 discussing 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 he 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 bronchiae 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 soreness of the respiratory organs, or the petulance of the cough, show the cold which has been contracted to have been very severe, the inhaler, without the opiate, should be again repeated for the same time the next morning.

"Secondly, If the use of the inhaler, &c. be delayed till the second night, it will be always right to repeat it again the next morning without the opiate, but with it if the seizure has been violent.

"And, lastly, If the cough be of some days standing, it will be always necessary to employ both parts of the process at night and the succeeding morning, as the first simple inflammatory mischief is now most probably aggravated by an additional one of a chronic tendency.

"But if, through the want of a timely application, or a total neglect of this or any other remedy, the cough should continue to harass the patient, it is, particularly in delicate and tender constitutions, of the utmost consequence to attempt the removal of it as soon as possible, before any floating acrimony in the constitution (from the perpetual irritation) receives an habitual determination to an organ so essential to life as the lungs.

"If the patient expectorate with ease and freedom a thick and well-digested inoffensive phlegm, there is generally but little doubt of his spitting off the disorder, with common care, in a few days; and till that be accomplished, a proper dose of elixir paregoricum for a few successive nights will be found very useful in suppressing the fatiguing irritation and inefficacious cough, occasioned by a matter which, dripping in the early state of the disease into the bronchiae during the night, is commonly at that time too thin to be discharged by these convulsive efforts.

"If, however, notwithstanding a free and copious expectoration, the cough should still continue, and the discharge, discharge, instead of removing the complaint, should itself, by becoming a disease, be a greater expense than the constitution can well support, it is possible that a tender patient may spit off his life through a weak relaxed pair of lungs, without the least appearance of purulence, or any suspicion of suppuration. In those circumstances, besides, as was mentioned before, increasing the general perspiration by the salutary friction of a flannel waistcoat, change of situation, and more especially long journeys on horseback, conducted as much as possible through a thin, sharp, dry air, will seldom fail of removing the complaint.

"But, on the contrary, if the cough should, at the same time that it is peludant 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 5ss or 3ij of bals. sulph. 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 salutary revolution made from the lungs by the simple application of a large plaster, about five or six inches diameter, of Burgundy pitch, between the shoulders; for the perspirable matter, which is locked up under it, becomes so sharp and acid, that in a few days it seldom fails to produce a very considerable itching, some little tendency to inflammation, and very frequently a great number of boils. This application should be continued (the plaster being occasionally changed), for three weeks or a month, or longer, if the complaint be not so soon removed.

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

"If, however, notwithstanding these and other means, the cough, continuing dry or unattended with a proper expectoration, should persevere in harassing the patient; if, at last, it should produce, together with a soreness, 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 issue, assisted by a diet of asses milk and vegetables."

GENUS XLI. DYSENTERIA.

The Dysentery.

Dysenteria, Sauv. gen. 248. Lin. 191. Vog. 107. Sag. 183. Hoffm. III. 151. Junck. 76.

Description. The dysentery is a disease in which the patient has frequent stools, accompanied with much griping, and followed by a tenesmus. The stools, though frequent, are generally in small quantity; and the matter voided is chiefly mucus, sometimes mixed with blood. At the same time, the natural faeces seldom appear: and when they do, it is generally in a compact and hardened form, often under the form of small hardened substances known by the name of seybala. 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 costive, with an unusual flatulence in the bowels. Sometimes, though more rarely, some degree of diarrhoea is the first appearance.—In most cases, the disease begins with griping, and a frequent inclination to go to stool. In indulging this, little is voided, but some tenesmus attends it. By degrees the stools become more frequent, the griping more severe, and the tenesmus more considerable.—With these symptoms there is a loss of appetite, and frequently sickness, nausea, and vomiting, also affecting the patient. At the same time there is always more or less of pyrexia present. It is sometimes of the remittent kind, and observes a tertian period.—Sometimes the pyrexia is manifestly inflammatory, and very often of a putrid kind. These febrile states continue to accompany the disease during its whole course, especially when it terminates soon in a fatal manner. In other cases, the febrile state almost entirely disappears, while the proper dysenteric symptoms remain for a long time after. In the course of the disease, whether for a shorter or a longer time, the matter voided by stool is very various. Sometimes it is merely a mucous matter, without any blood, exhibiting that disease which is named by some the morbus mucosus, and by others the dysenteria alba. For the most part, however, the mucus discharged is more or less mixed with blood. This sometimes appears only in streaks among the mucus; but at other times is more copious, giving a 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 sanics, proceeding from gangrenous parts. There are very often mixed with the liquid matter some films of a membranous appearance, and frequently some small masses of a seemingly sebaceous matter. While the stools voiding these various matters, are, in many instances, exceedingly frequent, 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 scyphata, 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 enteric 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 connection the disease has with the state of the bile.

It has been observed, that the effluvia from very putrid animal substances ready 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 putrescent tendency in the human body. This, however, does not at all explain 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 faeces are seldom voided; and when they are, it is in a form which gives reason to suppose they have been long retained in the cells of the colon, and consequently that the colon had been affected with a preternatural constriction. This is confirmed by almost all the dissections which have been made of the bodies of dysenteric patients; in which, when gangrene had not entirely destroyed the texture and form of the parts, 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 constriction of the colon, occasioning, at the same time, those spasmodic efforts which are felt in severe gripings, and which efforts, propagated downwards to the rectum, occasion there the frequent mucous stools and tenesmus. But whether this explanation shall be admitted or not, it will still remain certain, that hardened faeces, retained in the colon, are the cause of the gripings, frequent stools, and tenesmus; for the evacuation of these faeces, whether by nature or by art, gives relief from the symptoms mentioned; and it will be more fully and usefully confirmed by this, that the most immediate and successful cure of dysentery is obtained by an early and constant attention to the preventing the constriction, and the frequent stagnation of faeces in the colon.

Cure. 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 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 more safe, more especially as an inflammatory state so frequently accompanies the disease. Whatever laxatives produce an evacuation of natural faeces, and a consequent remission of the symptoms, will be sufficient to effectuate the cure. But if the gentle laxatives shall not produce the evacuation now mentioned, somewhat more powerful must be employed; and Dr Cullen has found nothing more proper or convenient than tartar emetic, given in small doses, and at such intervals as may determine its operation to be chiefly by stool. To the tartrate of antimony, however, employed as a purgative, the great sickness which it is apt to occasion, and the tendency which it has, notwithstanding every precaution, to operate as an emetic, are certainly objections. Another antimonial, at one time considered as an almost infallible remedy for this disease, the vitrum antimonii ceratum, is no less exceptionable, from the uncertainty and violence of its operation; and perhaps the safest and best purgatives are the different neutral salts, particularly those containing fossil alkali, such as the soda vitriolata tartarisata or phosphorata. Rhubarb, so frequently employed, is, Dr Cullen thinks, in several respects, amongst the most unfit purgatives; and indeed from its astringent quality, it is exceptionable at the commencement of the affection, unless it be conjoined with something to render its operation more brisk, such as mild muriated mercury, or calomel as it is commonly called.

Vomiting has been held a principal remedy in this disease; and may be usefully employed in the beginning, with a view both to the state of the stomach and of the fever: but it is not necessary to repeat it often; and, unless the emetics employed operate also by stool, they are of little service. Ipecacuanha is by no means a specific; and it proves only useful when so managed as to operate chiefly by stool.

For relieving the constriction of the colon, and evacuating the retained faeces, clysters may sometimes be useful; but they are seldom so effectual as laxatives given by the mouth; and acrid clysters, if they be not effectual in evacuating the colon, may prove hurtful by stimulating the rectum too much.

The frequent and severe griping attending this disease, leads almost necessarily to the use of opiates; and they are very effectual for the purpose of relieving from the gripes: but, by occasioning an interruption of the action of the small intestines, they favour the constriction of the colon, and thereby aggravate the disease; and if, at the same time, the use of them supersedes 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 semicupium, or by fomentation of the abdomen continued for some time. In the same case, the pains may be relieved, and the constriction of the colon may be taken off, by blisters applied to the lower belly.

At the beginning of this disease, when the fever is any way considerable, bloodletting, in patients of tolerable vigour, may be proper and necessary; and, when the pulse is full and hard, with other symptoms of an inflammatory disposition, bloodletting ought to be repeated. But as the fever attending dysentery is often of the typhoid kind, or does, in the course of the disease, become soon of that nature, bloodletting must be cautiously employed.

From our account of the nature of this disease, it will be sufficiently obvious, that the use of astringents in the beginning of it must be very pernicious. But although astringents may be hurtful at early periods of this affection, yet it cannot be denied, that where frequent loose stools remain after the febrile symptoms have subsided, they are often of great service for diminishing morbid sensibility, and restoring due vigour to the intestinal canal. Accordingly, on this ground a variety of articles have been highly celebrated in this affection; among others we may mention the quassia, radix indica lopeziana, 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 aerid 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 aerid 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 acescent. 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 acescents. At the beginning of the disease, absorbents seem to be superfluous; and, by their astringent and septic powers, they may be hurtful; but in after periods they are often of advantage.

When this disease is complicated with an intermit- Comata, 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.* Class VI. Ord. II. *Sag.* Class IX. Order V.

*Soporosi, Lin.* Class VI. Ord. II.

*Adynamiae, Vog.* Class 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. *Wepfer.* Hist. apoplecticorum.

*Carus, Sauv.* gen. 181. *Lin.* 100. *Vog.* 231. *Boerh.* 1045. *Sag.* gen. 287.

*Cataphora, Sauv.* gen. 180. *Lin.* 99. *Vog.* 232. *Boerh.* 1045. *Sag.* gen. 286.

*Coma, Vog.* 232. *Boerh.* 1048.

*Hæmorrhagia cerebri, Hoffm.* II. 240.

To this genus also Dr Cullen reckons the following diseases to belong:

*Catalepsis, Sauv.* gen. 176. *Lin.* 129. *Vog.* 230. *Sag.* gen. 281. *Boerh.* 1036. *Junck.* 44.

*Affectus cerebri spasmodico-ecstaticus, Hoffm.* III. 44.

*Ecstasis, Sauv.* gen. 177. *Vog.* 333. *Sag.* gen. 283.

The following he reckons symptomatic:

*Typhomania, Sauv.* gen. 178. *Lin.* 97. *Vog.* 23. *Sag.* gen. 284.

*Lethargus, Sauv.* gen. 179. *Lin.* 98. *Vog.* 22. *Sag.* gen. 285.

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

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

*Description.* In this disease the patients fall suddenly down, and are deprived of all sense and voluntary motion, but without convulsions. A giddiness of the head, noise in the ears, 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 anything be swallowed without shutting the nostrils; and even when this is done, the person is in the utmost danger of suffocation. Sometimes apoplectic patients will open their eyes after having taken a large dose of 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, apoplexy of the speech. Dissections sometimes show a rupture of some vessels of the meninges, or even vessels of the brain itself; though sometimes, if we may believe Dr Willis, no defect is to be observed either in the cerebrum or cerebellum.

*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 connection 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 scrofulous apoplexy, after mentioned. The body is to be kept in a somewhat erect posture, and the head supported in that situation.

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

*Apoplexia pituitosa, Sauv.* sp. 7. *Apoplexia serosa, Preysinger,* sp. 4. *Morg.* de causis, &c. IV. LX.

*Carus à hydrophalo, Sauv.* sp. 16.

*Cataphora hydrocephalica, Sauv.* sp. 6.

*Cataphora somnolenta, Sauv.* sp. 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 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 prognosis of the sanguineous, may also be said of that of the serous apoplexy.

**Cure.** In this species venesection can scarcely be admitted; aerid purgatives, emetics, and stimulating elixirs, are recommended to carry off the superabundant serum; but in bodies already debilitated, they may perhaps be liable to the same exceptions with venesection itself. Volatile salts, cephalic elixirs, and cordials, are also prescribed; and in case of a hemiplegia supervening, the cure is to be attempted by aperient potions, 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.

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

Hydrocephalus interior, Sauv. sp. i. Hydrocephalus internus, Whytt's works, page 725. London Med. Obs. vol. iv. art. 3, 6, and 25. Gaudelius de hydrocephalo, apud Sandifort The-saur. vol. ii. Hydrocephalus acutus, Quin. Diss. de hydrocephalo, 1779. Asthenia à hydrocephalo, Sauv. sp. 3.

**History and description.** This disease has been accurately treated within these few years by several eminent physicians, particularly the late Dr Whytt, Dr Fothergill, and Dr Watson; who concur in opinion, with respect to the seat of the complaint, the most of its symptoms, and its general fatality. Out of twenty patients that had fallen under Dr Whytt's observation, he candidly owns that he had been so 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 dropsy of the ventricles of the brain; and this opinion is fully established by dissections. It is observed to happen more commonly to healthy, active, lively children, than to those of a different disposition.

Dr Whytt supposes that the commencement of this disease is obscure; that it is generally some months in forming; and that, after some obvious urgent symptoms rendering assistance necessary, it continues some weeks before its fatal termination. This, in general, differs from what has hitherto been observed by Dr Fothergill; the latter informing us, that he has seen children, who, from all appearance, were healthy and active, seized with this distemper, and carried off in about 14 days. He has seldom been able to trace the commencement of it above three weeks.

Though the hydrocephalus be most incident to children, it has been sometimes observed in adults; as appears from a case related by Dr Huck, and from some others.

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

Those who are seized with this distemper usually complain first of a pain in some part below the head; most commonly about the nape of the neck and shoulders; often in the legs; and sometimes, but more rarely, in the arms. The pain is not uniformly acute, nor always fixed to one place; and sometimes does not affect the limbs. In the latter case, the head and stomach have been found to be most disordered; so that when the pain occupied the limbs, the sickness or headache was less considerable; and when the head became the seat of the complaint, the pain in the limbs was seldom or never mentioned. Some had very violent sicknesses and violent headaches alternately. From being perfectly well and sportive, some were in a few hours seized with those pains in the limbs, or with sickness, or headache, in a slight degree, commonly after dinner; but some were observed to droop a few days before they complained of any local indisposition. In this manner they continued three, four, or five days, more or less, as the children were healthy and vigorous. They then commonly complain of an acute deep-seated pain in the head, extending across the forehead from temple to temple; of which, and a sickness, they alternately complain in short and affecting exclamations; dosing 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 a very great degree of strabismus. The patients are unwilling to be disturbed for any purpose, and can bear no posture but that of lying horizontally. One or both hands are most commonly about their heads. The urine and stools come away insensibly. At length the eyelids become paralytic, great heat accompanied with sweat overspreads the whole body; respiration is rendered totally suspitious, the pulse increases in its trembling undulations beyond the possibility of counting, till the vital motions entirely cease; and sometimes convulsions conclude the scene.

Many of the symptoms above enumerated are so common to worm cases, teething, and other irritating causes, that it is difficult to fix upon any which particularly characterize this disease at its commencement. The most peculiar seem to be the pains in the limbs, with sickness and incessant headache; which, though frequent in other diseases of children, are neither so uniformly nor so constantly attendant as in this. Another circumstance observed to be familiar, if not peculiar to this distemper, is, that the patients are not only costive, but it is likewise with the greatest difficulty that stools can be procured. These are generally of a very dark greenish colour with an oiliness or a glassy bile, rather than the slime which accompanies worms; and they are, for the most part, extremely offensive. No positive conclusion can be drawn from the appearance of the urine; it being various, in different subjects, both in its colour and contents, according to the quantity of liquor they drank, and the time between the discharges of the urine. From their unwillingness to be moved, they often retain their water 12 or 15 hours, and sometimes longer. In complaints arising from worms, and in dentition, convulsions are more frequent than in this disorder. Children subject to fits are sometimes seized with them a few days before they die. Sometimes these continue 24 hours incessantly, and till they expire.

Causes. The causes of internal hydrocephalus are very much unknown. Some suppose it to proceed from a rupture of some of the lymphatic vessels of the brain. But this supposition is so far from being confirmed by any anatomical observation, that even the existence of such vessels in the brain is not clearly demonstrated. That lymphatics, however, do exist in the brain, cannot be doubted; and one of the most probable causes giving rise to an accumulation of water in the brain is a diminished action of these. Here, however, as well as in other places, accumulation may also be the consequence of augmented effusion; and in this way, an inflammatory 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 strabismus, intolerance of light, or dilatation of the pupil. And in cases where these symptoms have taken place to a remarkable degree, while upon dissection after death but a very small collection of water was found in the ventricles, it has been observed, that a peculiar tumid appearance was discovered about the optic nerves, which upon examination was found to arise from water in the cellular texture. This may have given compression producing a state of insensibility; but it may have been preceded, or it may even have originated from some inflammatory affection of these parts, producing the intolerance of light.

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

Of late the digitalis purpurea has been thought, in some cases of hydrocephalus, as well as in other obstinate dropsies, 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 atrabiliaris, Sauv. sp. 12. Preysinger. sp. 6.

This takes place in the last stage of the diffusion of bile through the system, i.e. of the black jaundice; and in some cases the brain has been found quite tinged brown. It cannot be thought to admit of any cure.

Sp. V. Apoplexy from External Violence.

Apoplexia traumatica, Sauv. sp. 2. Carus traumaticus, Sauv. sp. 5.

The treatment of this disease, as it arises from some external injury, properly falls under the article Surgery.

Sp. VI. Apoplexy from Poisons.

Apoplexia temulenta, Sauv. sp. 3. Carus à narcoticis, Sauv. sp. 14. Lethargus à narcoticis, Sauv. sp. 3. Carus à plumbagine, Sauv. sp. 10. Apoplexia mephitica, Sauv. sp. 14. Asphyxia à mephitide, Sauv. sp. 9. Asphyxia à musto, Sauv. sp. 3. Catalepsia à fumo, Sauv. sp. 3. Asphyxia à fumis, Sauv. sp. 2. Asphyxia à carbone, Sauv. sp. 16. Asphyxia foricariorum, Sauv. sp. 11. Asphyxia sideratorum, Sauv. sp. 10. Carus ab insolatione, Sauv. sp. 12. The poisons which bring on an apoplexy when taken internally may be either of the stimulant or sedative kind, as spirituous liquors, opium, and the more virulent kinds of vegetable poisons. The vapours of mercury, or of lead, in great quantity, will sometimes produce a similar effect; though commonly they produce rather a paralysis, and operate slowly. The vapours of charcoal, or fixed air, in any form, breathed in great quantity, also produce an apoplexy, or a state very similar to it; and even cold itself produces a fatal sleep, though without the apoplectic stertor. To enumerate all the different symptoms which affect the unhappy persons who have swallowed opium, or any of the stronger vegetable narcotics, is impossible, as they are scarcely to be found the same in any two patients. The state induced by them seems to differ somewhat from that of a true apoplexy; as it is commonly attended with convulsions, but has the particular distinguishing sign of apoplexy, namely, a very difficult breathing or snorting, more or less violent according to the quantity of poisonous matter swallowed.

Of the poisonous effects of fixed air, Dr Percival gives the following account. "All these noxious vapours, whether arising from burning charcoal, the fermenting grape, the Grotti di Cani, or the cavern of Pyrmont, operate nearly in the same manner. When accumulated and confined, their effects are often instantaneous: they immediately destroy the action of the brain and nerves, and in a moment arrest the vital motions. When more diffused, their effects are slower, but still evidently mark out a direct affection of the nervous system.

"Those who are exposed to the vapours of the fermenting grape, are as instantly destroyed as they would be by the strongest electrical shock. A state of insensibility is the immediate effect upon those animals which are thrust into the Grotti di Cani, or the cavern of Pyrmont: the animal is deprived of motion, lies as if dead; and if not quickly returned into the fresh air, is irrecoverable. And if we attend to the histories of those who have suffered from the vapours of burning charcoal, we shall in like manner find, that the brain and moving powers are the parts primarily affected.

"A cook who had been accustomed to make use of lighted charcoal more than his business required, and to stand with his head over these fires, complained for a year of very acute pain in the head; and after this was seized with a paralytic affection of the lower limbs, and a slow fever.

"A person was left reading in bed with a pan of charcoal in a corner of the room. On being visited early the next morning, he was found with his eyes shut, his book open and laid on one side, his candle extinguished, and to appearance like one in a deep sleep. Stimulants and cupping-glasses gave no relief: but he was soon recovered by the free access of fresh air.

"Four prisoners, in order to make their escape, attempted to destroy the iron-work of their windows, by the means of burning charcoal. As soon as they commenced their operation, 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.

"Cælius Aurelianus says, that those who are injured by the fumes of charcoal become cataleptic. And Hoffman enumerates a train of symptoms, which in no respect correspond with his idea of suffocation. Those who suffer from the fumes of burning charcoal, says he, have severe pains in the head, great debility, faintness, stupor, and lethargy.

"It appears from the above histories and observations, that these vapours exert their noxious effects on the brain and nerves. Sometimes they occasion sudden death: at other times, the various symptoms of a debilitated nervous system, according as the poison is more or less concentrated. The olfactory nerves are first and principally affected, and the brain and nervous system by sympathy or consent of parts. It is well known, that there is a strong and ready consent between the olfactory nerves and many other parts of the nervous system. The effluvia of flowers and perfumes, in delicate or irritable habits, produce a train of symptoms, which, though transient, are analogous to those which are produced by the vapours of charcoal; viz. vertigo, sickness, faintness, and sometimes a total insensibility. The female malefactor, whom Dr Mead inoculated by putting into the nostrils dossils of cotton impregnated with various matter, was immediately on the introduction, afflicted with an excruciating headache, and had a constant fever till after the eruption.

"The vapours of burning charcoal, and other poisonous effluvia, frequently produce their prejudicial, and even fatal effects, without being either offensive to the smell or oppressive to the lungs. It is a matter of importance, therefore, that the common opinion should be more agreeable to truth; for where suffocation is supposed to be the effect, there will be little apprehension of danger, so long as the breast keeps free from pain or oppression.

"It may be well to remember, that the poison itself is distinct from that gross matter which is offensive to the smell; and that this is frequently in its most active state when undistinguished by the sense." the following cautions generally attended to, they might in some instances be the happy means of preserving life. Never to be confined with burning charcoal in a small room, or where there is not a free draught of air by a chimney or some other way. Never to venture into any place in which air has been long pent up, or which from other circumstances ought to be suspected; unless such suspected place be either previously well ventilated, or put to the test of the lighted candle: for it is a singular and well-known fact, that the life of flame is in some circumstances sooner affected and more expeditiously extinguished by noxious vapours than animal-life; a proof of which I remember to have received from a very intelligent clergyman, who was present at a musical entertainment in the theatre at Oxford. The theatre was crowded; and during the entertainment the candles were observed to burn dim, and some of them went out. The audience complained only of faintness and languor; but had the animal effluvia been still further accumulated or longer confined, they would have been extinguished as well as the candles.

"The most obvious, effectual, and expeditious means of relief to those who have unhappily suffered from this cause, are such as will dislodge and wash away the poison, restore the energy of the brain and nerves, and renew the vital motions. Let the patient therefore be immediately carried into the open air, and let the air be fanned backwards and forwards to assist its action; let cold water be thrown on the face; let the face, mouth, and nostrils, be repeatedly washed; and as soon as practicable, get the patient to drink some cold water. But if the case be too far gone to be thus relieved, let a healthy person breathe into the mouth of the patient; and gently force air into the mouth, throat, and nostrils. Frictions, cupping, bleeding, and blisters, are likewise indicated. And if, after the instant danger is removed, a fever be excited, the method of cure must be adapted to the nature and prevailing symptoms of the fever."

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

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

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 solids, as well as increasing the motion of the fluids, is found to answer better than any other thing as a preservative: but when the pernicious effects have already begun to discover themselves, nothing but increasing by some means or other the heat of the body can possibly be depended upon: and even this must be attempted with great care; for as, in such cases, there is generally a tendency to mortification in some of the extremities, the sudden application of heat will certainly increase this tendency to such a degree as to destroy the parts. But for the external treatment of such mortifications, see the article Surgery.

Sp. VII. Apoplexy from Passions of the Mind.

Carus à pathemate, Sauv. sp. ii. Asphyxia à pathemate, Sauv. sp. 7. Ecstasis catoche, Sauv. sp. i. Ecstasis resoluta, Sauv. sp. 2. Apoplexies from violent passions may be either sanguineous or serous, 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 immersorum, 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, exanthemata, hysteria, epilepsy, gout, worms, ischuria, 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. Paralysis, Sauv. gen. 169. Lin. 104. Vog. 226. Junck. 115. Atonia, Lin. 120.

Sp. I. The Partial Palsy.

Paralysis, Sauv. gen. 169. Lin. 104. Vog. 226. Junck. 115. Paralysis plethorica, Sauv. sp. 1. Paralysis serosa, Sauv. sp. 12. Paralysis nerva, Sauv. sp. 11. Mutitas a glossolysi, Sauv. sp. 1. Aphonia paralytica, Sauv. sp. 8.

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

Hemiplegia, Sauv. gen. 170. Lin. 103. Vog. 228. Sag. gen. 276. Hemiplegia ex apoplexia, Sauv. sp. 7. Hemiplegia spasmodica, Sauv. sp. 2. Hemiplegia serosa, 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 a spina 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 slighter degrees of the disease, it only affects a particular muscle, as the sphincter of the anus or bladder, thus occasioning an involuntary discharge of excrements or of urine; of the muscles of the tongue, which occasions stammering, or loss of speech; of the muscles of the larynx, by which the patient becomes unable to swallow solids, and sometimes even liquids also.—In the higher degrees of the disease, the paralytic affection is diffused over a whole limb, as the foot, leg, hand, or arm; and sometimes it affects a whole side of the body, in which case it is called hemiplegia; and sometimes, which is the most violent case, it affects all the parts below the waist, or even below the head, though this last be exceedingly rare. In these violent cases, the speech is either very much impeded, or totally lost. Convulsions often take place in the sound side, with the cynic spasm or involuntary laughter, and other distortions of the face. Sometimes the whole paralytic part of the body becomes livid, or even mortifies before the patient’s death; and sometimes the paralytic parts gradually decay and shrivel up, so as to become much less than before. Whether the disease be more or less extended, many different varieties may be observed in its form. Sometimes there occurs a total loss of sense while motion is entire; in others a total loss of motion with very slight or even no affection of sense; and in some cases, while a total loss of motion takes place in one side, a total loss of sense has been observed on the other. This depends entirely on the particular nerves or branches of nerves in which the affection is situated; loss of sense depending on an affection of the subcutaneous nerves; and loss of motion on an affection of those leading to the muscles.

Causes, &c. Palsies 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 Poictou, and the apoplexy. The hemiplegia especially often follows the last-mentioned disease. Aged people, and those who are by any other means debilitated, are subject to palsy; which will sometimes also affect even infants, from the repulsion of exanthemata of various kinds. Palsies are also the infallible consequences of injuries to the large nerves. Prognosis. Except in the slighter 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 itchiness in the affected parts; and if a fever should arise, it bids fair to cure the palsy. When the sense of feeling remains, there is much more room to hope for a cure than where it is gone, as well as the power of motion. But when we observe the flesh to waste, and the skin to appear withered and dry, we may look upon the disease to be incurable. Convulsions supervening on a palsy are a fatal sign.

Cure. Many remedies have been recommended in palsies: but it must be confessed, that, except in the slighter cases, medicines seldom prove effectual; and before any 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 issues.

The natural hot baths are often found useful in paralytic cases; and where the patients cannot avail themselves of these, an artificial bath may be tried by dissolving salt of steel in water, and impregnating the water with fixed air. Frictions of the parts, and scourging them with nettles, have also been recommended, and may do service, as well as volatile and stimulating medicines taken inwardly. 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 M. Fresnoi; and Dr Alderson of Hull, in a late dissertation on this plant, has published several cases, even of very obstinate palsy, in which its use was attended with wonderful success. In some cases also at Edinburgh, it has been used with apparent advantage, but in a much greater number without any benefit.

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

Sp. IV. The Palsy from Poisons.

Paralysis metallariorum, Sauv. 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 pictonum, 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, asthenia, or convulsions; and therefore need not be treated of by itself.

ORDER II. ADYNAMIÆ.

Adynamia, Vog. Class VI. Defectivi, Lin. Class VI. Order I. Leiopopsychiae, Sauv. Class VI. Order IV. Sag. Class IX. Order IV.

GENUS XLIV. SYNCOPE.

Fainting.

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

Sp. I. The Cardiac Syncope.

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

Sp. II. Occasional Syncope.

Leiopathymia à pathemate, Sauv. sp. 1. Senac. p. 544. Syncope pathetica, Sauv. sp. 21. Asphyxia 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. 544. Syncope à sphacelo, 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.

Asphyxia 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 leipothymia, the patient does not entirely lose his senses, but turns cold and pale; and the pulse continues to beat, though weakly; the heart also seems to tremble rather than beat; and the respiration is just perceptible. But in the true syncope or full asphyxia, not the smallest sign of life can be perceived; the face has a death-like 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 haemorrhages 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 constriction, and restore freedom to the circulation; by bleeding, if the habit be at all inclined to fulness; and by giving a mixture, with equal parts of the vinum antimoniale and tinctura opii camphorata, in some agreeable vehicle, which will bring on sleep and encourage perspiration. It was formerly mentioned, that convulsions, or even an epilepsy, may be brought on by frights; which should make people cautious of playing foolish tricks in this way.

When a surfeit, or any species of saburra, occasions 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 dipt 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 haemorrhagies, it will be a safer practice to abstain from all heating and stimulant things; as life, in these cases, is preserved by the coagulation of the blood in the extremities of the open vessels; which might be prevented by the pouring in hot wine or volatile alkaline spirits.

When a syncope is the consequence of the too violent operation of either an emetic or cathartic, the tinctura thebaica, mixed with spiced wine, is the most efficacious remedy; but the opiate must be given gradually, and in very small doses.

A syncope, or even asphyxia, wherein the patient shall lie for several hours, is frequent in hysteric constitutions; and during the fit requires fetid antispasmodics, together with acid stimulants: to prevent returns, nothing answers better than the cinchona joined with chalybeates.

Genus XLV. Dyspepsia.

Depraved Digestion.

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

The idiopathic species are,

Anorexia pituitosa, Sauv. sp. 2. Anorexia à saburra, Sauv. sp. 9. Anorexia exhaustorum, Sauv. sp. 8. Anorexia paralytica, Sauv. sp. 1. Nausea ex cacochylia, Sauv. sp. 11. Vomitus pituitosus, Sauv. sp. 26. Vomitus ruminatio, Sauv. sp. 6. Vomitus à saburra, 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 nidrosa, Sauv. sp. 2. Cardialgia bradypepta, Sauv. sp. 9. Cardialgia à saburra, Sauv. sp. 2. Cardialgia lactantium, Sauv. sp. 11. Cardialgia flatulenta, Sauv. sp. 3. Cardialgia paralytica, Sauv. sp. 7. Gastrodynia saburralis, Sauv. sp. 1. Gastrodynia flatulenta, Sauv. sp. 2. Gastrodynia periodyans, Sauv. sp. 7. Gastrodynia astringens, Sauv. sp. 9. Gastrodynia attrens, 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 distemper called dyspepsia, when considered as an original disease, as there are very few maladies which some way or other do not show themselves by an affection of the stomach; and much more difficult still must it be to enumerate all its symptoms. The most remarkable, however, and the most common, are the following: Want of appetite; distention of the stomach when no food has been taken for some time before; slight dejection of spirits; a gradual decay of the muscular strength; languor, and aversion from motion; the food which is taken without appetite is not well digested; the stomach and intestines are much distended with flatus, whence the patients are tormented with spasms, gripes, and sickness; frequently a limpid water, having an acid or putrid taste, is brought up; sometimes the food itself is thrown up by mouthfuls; and sometimes, though rarely, the same is swallowed again, after the manner of ruminating animals. While matters are in this situation, the heart sometimes palpitates, and the breath is quick, and drawn with difficulty; the head aches and is giddy; and sometimes both these symptoms are continual, and very violent, insomuch that the patient is not only tormented with pain, but staggers as if he was drunk. From the too great accesity 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 costiveness, 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 last stagnates in them, so that the face becomes livid, swelled and has an unusual appearance; and at the same time that the circulation and nervous power are in this languid state, the perspiration becomes less copious; the skin becomes dry and corrugated; the natural heat, especially of the extremities, is much diminished; the tongue is white; and an universal laxity takes place, insomuch that the uvula and velum pendulum palati are sometimes enlarged to such a degree as to become extremely troublesome. The patient is either deprived of rest, or wakes suddenly out of his sleep, and is disturbed by frightful dreams; at the same time that the mind seems to be affected as well as the body, and 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 anasarca or ascites.

Causes, &c. The causes of dyspepsia may be anything which debilitates the system in general, but in a particular manner affects the stomach. Such are, opium taken in immoderate quantities, which hurts by its sedative and relaxing powers; spirituous liquors drunk to excess; tobacco, tea, coffee, or any warm relaxing liquor, taken in too great quantity; acid, unripe fruits; vomits or purges too frequently taken; an indolent sedentary life, &c. &c. All these act chiefly upon people of a weak and delicate habit; for the robust and hardy seldom labour under a dyspepsia, or at most a very slight one.

Prognosis. When a dyspepsia first occurs, it is frequently removed without great difficulty; when it is symptomatic, we must endeavour to cure the primary disease; and without this we cannot expect a complete removal of the affection; but when it frequently returns, with symptoms of great debility, hectic fever, or dropsy, we have great reason to dread the event.

Cure. A radical cure of dyspepsia is only to be expected by removing from the stomach and system that debility on which the disease depends. On this ground, the objects chiefly to be aimed at in the cure are, 1st, The avoiding whatever will tend to diminish the vigour of the stomach; 2d, The employing such remedies as have influence in increasing that vigour; and, in the third place, The obviating urgent symptoms, particularly those which tend to increase and support the affection. Of the avoiding causes, which tend to diminish the vigour of the stomach, after what has already been said of the causes inducing the disease, it is unnecessary to make any farther observations: and indeed every dyspeptic patient will be taught by experience what is to be done with this intention. The medicines chiefly employed with the view of increasing vigour are those of the tonic kind: but, previous to their use, it will be necessary to evacuate the contents of the alimentary canal by vomits or purgatives. If there be a tendency to putrescence, 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 testaceous powders, as being purgative when dissolved in an acid, while the others are rather astrin- gent. In the third volume of the Medical Observations, we have an account of two cases of dyspepsia attended with a very uncommon degree of cardialgia, in which magnesia was so successful, that we can hardly doubt of its efficacy in slighter degrees of the disorder. But although acidity may often be successfully obviated in this manner, yet the best way of counteracting this symptom, as well as of obviating costiveness, 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.

Hypocondriasis, Sauv. gen. 220. Lin. 76. Vog. 218. Sag. 332. Morbus hypochondriacus, Boerh. 1098. 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, gripping, and tormenting pains under the ribs, and chiefly in the left side; which sometimes are exasperated, and become pungent, burning, or lancinating. Frequently there is an inflation of the left hypochondrium, which sometimes becomes stationary, and by Hippocrates was taken for a symptom of an enlarged spleen. When these symptoms take place in the right hypochondrium, they are commonly attended with colic pains, uncertain flying heats, especially in the head, with a transient redness of the face, and very frequently an oedematous swelling of the feet succeeds. To these are superadded almost all the affections of the stomach occurring in dyspepsia, besides a variety of other symptoms, such as palpitations, sleepless nights, and the like. But besides these, there occurs also a particular depression of spirit and apprehension of danger, which may be considered as one of the great characteristic symptoms of the disease.

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

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

GENUS XLVII. CHLOROSIS.

GREEN SICKNESS.

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

Of this genus also Dr Cullen thinks there is but one idiopathic species: viz. what some distinguish by the title of chlorosis virginea, others of chlorosis amatoria.

Description. This disease usually attacks girls a little after the time of puberty, and first shows itself by symptoms of dyspepsia. But a distinguishing symptom is, that the appetite is entirely vitiated, and the patient will eat lime, chalk, ashes, salt, &c. very greedily; while at the same time there is not only a total inappetence to proper food, but it will even excite nausea and vomiting. In the beginning of the disease, the urine is pale, and afterwards turbid; the face becomes pale, and then assumes a greenish colour; sometimes it becomes livid or yellow; the eyes are sunk, and have a livid circle round them; the lips lose their fine red colour; the pulse is quick, weak, and low, though the heat is little short of a fever, but the veins are scarcely filled; the feet are frequently cold, swell at night, and the whole body seems covered with a soft swelling; the breathing is difficult: nor is the mind free from affection more than the body; it becomes irritated by the slightest causes; and sometimes the patients love solitude, become sad and thoughtful. There is a retention of the menses throughout the whole course of the disorder; and at last all the bad symptoms increasing, a leucophlegmasia, anasarca, atrophy, and death succeed.

Causes. The cause of chlorosis is thought to be an atony of the muscular fibres of the alimentary canal, especially of the stomach, joined with a similar atony of the perspiratory vessels over the whole surface of the body, and the whole depending on an atony of those small arteries which pour out the menstrual blood: This atony may be occasioned by the same causes which bring on dyspepsia and hypochondriasis, but very frequently arises from love and other passions of the mind.

Prognosis. The chlorosis in all cases is tedious, though it does not generally prove fatal; but we can never promise a certain cure unless the menscs 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 Spasmi, lating also the vessels of the uterus; and for this reason indulgence in venery has sometimes been said to produce a cure, particularly with love-sick maids. The cold bath is also extremely proper.

Order III. SPASMI.

Spasmi, Sauv. Class IV. Vog. Class V. Sag. Class VIII. Motorii, Lin. Class VII. Morbi spasmodici et convulsivi, Hoffm. III. 9. Spasmi et convulsiones, Junck. 45, 54. Epilepsia, Boerh. 1071, 1088.

Genus XLVIII. TETANUS.

Tetanus, Sauv. gen. 122. Lin. 127. Vog. 180. Sag. gen. 228. Catochus, Sauv. gen. 123. Lin. 128. Vog. 183. Sag. gen. 229. Opisthotonos, Vog. 181. Episthotonos, 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 opisthotonos 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 opisthotonos 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 opisthotonos he gives three remarkable cases in lib. v. § vii. de Morb. vulg. and repeats them in another place: but the few symptoms he recounts do not show themselves with us. Galen, 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 class of spasmodic diseases, there are three which distinguish themselves in a very particular manner, on which the names of emprosthotonos, opisthotonos, 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 emprosthotonos. When the posterior muscles are similarly affected, so that the head is drawn towards the spine, and the spine itself is recurved, it has then the name of opisthotonos; although in fact, in this, all those muscles which act in deglutition, bend the head forwards, or turn it to either side, are equally contracted with those which raise the head and spine. The tetanus differs from, or rather is compounded of, both the others; for in this the patient is found rigid and inflexible, being as it were braced between the opposite contractions of the anterior and posterior muscles; yet even here the head is much retracted.

I never saw the emprosthotonos; and shall only speak of the opisthotonos and tetanus, the first being by far the most common, and in the last stage of which the tetanus frequently intervenes. Let it be observed, that the following description by no means respects such symptomatic contractions as often happen immediately before death, both in acute and chronic diseases; neither will it agree with that spurious opisthotonos 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 opisthotonos, contrary to what Bontius asserts, often comes on gradually and by slight 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 lassitude. These increase, and become so troublesome when he attempts to turn his head, or to bend it forward, as to oblige him to walk very erect; for he can by no means look downward, nor to either side, without turning his whole body. He cannot open his jaws without pain; and has some difficulty in swallowing, which discourages him from attempting to eat. At times he feels a sudden and painful traction under the cartilago ensiformis, which strikes through to the back, and instantly increases the rigidity about the neck and shoulders, draws the head backward a little, and shuts the jaws closer. The pain under the sternum returns more frequently and with greater violence; 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 opisthotonus, 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 less acute, few are lost after the ninth or eleventh: which number of days it would not be possible for them to complete, unless the violence of the disease was in a good measure subdued; although I had one who recovered, after having been subject to its tyrannical attacks daily for six weeks. In this stage the pulse is slow, and very hard, and the belly is bound; blood taken away seems not to be altered from the natural state, so that no indication can be deduced therefrom, and it only varies with regard to laxity or compaction, according to the age of the person and season of the year.

"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 are that moment snapped together, and cannot afterwards be opened so wide as to receive the end of one's little finger; an attempt to do which, by way of experiment, almost constantly hurries on the spasm. The mastoid, coraco-hyoid and sterno-hyoid muscles, as well as all the others concerned in deglutition, and the deltoid and pectorals, are most violently contracted, so that the shoulders are strongly raised forward, and the arms are stretched out or drawn across the body; but the wrists and fingers seem not to be affected.

"Such is the condition of the patient in the time of the spasm, which ceases in a few seconds: after which the shoulders and arms recline, and the inferior extremities relax; yet not so entirely, but that such a degree of rigidity for the most part remains as will not permit them to bend when this is attempted by another person; for as to the sick himself, he cannot at all move them. The muscles on the sides and forepart of the neck continue still contracted, although not so strongly; but their action is overcome by the number and strength of the posterior ones; so that the retraction of the head constantly remains. The patient breathes quick for some minutes, as if he had been excessively exercised; and the pulse is small, fluttering, and irregular, but both become more calm and slow. The face is sometimes pale in the intervals, but oftener flushed; and the whole countenance expresses strong appearances of the most melancholy distress, as well 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 sustained. The tongue is stiff and torpid; but so far as it can be seen, is not foul. The belly is always bound, and cannot easily be loosened. 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 distended 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 upwards with such a spring, that the head is struck with great force against whatever happens to be in the way, the thighs and legs being in this case no less rigid than the other parts. The tongue is spasmodically darted out, and is often miserably torn, as the teeth are that moment snapped together; so that it is necessary to prevent this by keeping the handle of a spoon, wrapped round with soft rags, between the teeth, when this can be done. At the time that the tongue is thus thrust out, the muscular flesh, which lies between the arch of the lower jaw and head of the trachea, seems to be drawn upwards within the throat. The countenance is very much contracted, and he is in a foam of sweat, the heat being very great; and the pulse between the spasms is exceedingly quick, small, and irregular, although the heart throbs so strongly, that its motions may be plainly seen, and a palpitating subsultory 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 subsist 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 opisthotonus, 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 opisthotonus, 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 spasms 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 opisthotonus. 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 any thing 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 be put to bed wrapt in the softest blankets; and while they remain there, the belly ought either to be stuped, 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 polychores, 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 spasmodic affections to leave behind them extreme weakness and relaxation of the muscular fibres. In order to perfect the recovery, a course of the cinchona and the Peruvian balsam is to be tried; and the spine may be rubbed with spirituous liniments, or with a mixture of rum and Barbadoes tar: but those 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 excrements; 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 convulsed backwards or drawn into a rigid straight line, strongly extended and immovable like a statue, and will so remain immovable out of either of those postures for a considerable time, a minute or two; and when the disease is arrived at this degree, Dr Hillary thinks... 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 prima via.

To answer these intentions, the following method, with variations pro re nota et pro ratione statis, as the cause is different, has been found to answer the desired effect best: R. Seri lactis 3ij. Sapon. Venet. 3j. Mannee Calab. 3ij. vel iii. Ol. amygd. dul. 3ss. Ol. ficinuli dul. gut. ij. Bals. Peruvi gut. v. Misc. Fi enema quam primum 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: R. Ag. sem. ficinuli 3ij. Magnes. albae 3ss. Ocul. cancer. prop. 3j. Syr. e cicchor. cum rheo. Rosar. solut. ana 3ij. Misc. Or, R. Ag. sem. ficinuli 3ij. Sapon. amygdal. 3ss. Magnes. albae 3ss. Syr. e cicchor. cum rheo. Mannee opt. ana 3ij. Ol. amygd. dul. 3ij. Misc.: Exhibe cochl. parv. vel duo pro ratione statis, omni semihora, vel omni hora, donec respond. alvus.

Two or three stools being obtained by these, the following is exhibited in order to abate the convulsive twitchings, and prevent the tetanus from coming on: R. Ag. sem. ficinuli 3ij. Magnes. albae 3ss. Ocul. cancer. prop. 3j. Moschi orient. gr. iiij. Spir. C. C. gut. xv. Syr. e mecon. 3ss. Misc.: Exhibe cochl. parv. (a child's spoonful) ter quatuor de die, vel septem, 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 babes. R. Ag. ficinuli. 3ij. Moschi orient. gr. j. Tinct. thebaica gut. iiij. Syr. e mecon. 5ij. Misc. pro duobus dos. de quibus exhibe unam quam primum, et alteram si convul. spasmi. reducent.

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 dosing 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 seized 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 assistance of the medical art is most wanted, it most generally fails. We have been assured by a gentleman who practised for some time in the warm parts of America, that out of 30 cases of the tetanus he had seen, not one of the patients recovered, though he had given opium to the quantity of 20 grains thrice a-day; and others, he was assured, had taken 30 grains thrice a-day. In the beginning of the disease, the medicine produced a violent headache; but towards the end, it had no manner of effect whatever. In two patients, the disease came on from the slightest causes imaginable. The one accidentally fell in attempting to avoid a loaded cart, and put the heel of his shoe upon one of his thumbs in rising; the other, in avoiding the same cart, slightly ruffled the skin of his nose. Both were seized with the tetanus; and both died, notwithstanding all possible assistance was given. The former had his thumb amputated without effect.

In the Edinburgh Physical and Literary Essays vol. iii. Dr Donald Monro describes a new method of cure, communicated to him by a gentleman who was formerly a practitioner in Jamaica. While this gentleman practised in that island, he had under his care a great number of cases of tetanus attended with the locked jaw. At first, he used to give very freely of opium, musk, and other medicines of this class; to bleed, and make other evacuations; while he used baths, fomentations, embrocations, and other external applications, but all without the least success; and, as he had lost a great many patients without being so lucky as to make one cure, he began to believe that this disorder always proved fatal, and was not to be cured by medicine, notwithstanding what some practitioners Spasmi. titioners had alleged. However, having received an unexpected hint concerning the good effects of the mercurial ointment in such cases, he resolved to try it; and ordered the first patient that offered to be put into a warm room, and to be rubbed two or three times a day with the ointment, till such time as a salivation was raised; when he with pleasure observed, that, as soon as the mercury began to affect the mouth, the convulsions of the muscles of the jaws, as well as all the other spasms and convulsions, ceased, and the patient was freed of all his complaints. After this, he treated every case of this kind, which came under his care in the same manner, and cured twelve, which were all who applied to him for advice so early in the disorder that there was time to bring the mercury to the mouth before the fatal period was expected. A few died, in whom the disease was so far advanced before he saw them that there was no time to raise a salivation. None of the cases which were under this gentleman's care in the West Indies were the consequences of wounds or capital operations; nor has he had any opportunity of trying it since in cases of the locked jaw, which sometimes follows capital operations, owing to his having given over practice: but he thinks, that from the similarity of the complaint, there is no doubt that the mercurial frictions would be equally efficacious in such cases, as when the disorder comes from catching cold or other such causes.

In the second volume of the Medical Transactions, we have an account of a cure performed by Dr William Carter of Canterbury, by means very different from any of those above related.—On the 17th of May 1767, the doctor was called to a strong healthy man, in the 21st year of his age, and who had been confined to his bed for three weeks. What gave rise to his present disorder was an wound on the inner ankle of the right leg, which he had received six weeks before from a joiner's chisel. At that time his mouth was so far closed, as to admit only the most liquid nourishment, which he constantly sucked through his teeth: but his legs and jaw, and the whole length of the spina dorsi, were quite immoveable, being as stiff and rigid as those of a person long dead; his head was drawn backward, and he was frequently strongly convulsed. The motion indeed of both his arms was but 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 the patient; a detail of which had been given before the doctor set out on his journey, which he undertook with a determined resolution to make use of the method recommended by Dr Silvester, in the first volume of Medical Observations and Inquiries, published in the year 1757; (and which has been related from Dr Chalmers and Dr Hillary.) But, on his arrival at the house, he found great quantities of the extractum thebaicum dissolved had been already given him; and that, for the five last days, he had taken no less than 28 grains of that medicine, with 50 grains of musk, in the space of 24 hours, without any sensible effect, except the bringing Tetanus on a confused sleep, out of which he frequently awoke in great hurries, attended with a violent pain in the head, which almost deprived him of his senses. The doctor was afraid to extend the dose; and soon determined to take some other method, though at a loss what method to pursue, as, during a course of almost 30 years practice, nothing of the same kind had ever fallen under his cognizance before. Reflecting, however, that this disorder had always been deemed of the spasmodic kind, and that the good effects produced by the extractum thebaicum must probably be owing to the relaxing and resolving faculty of that medicine, he directed a blister to be applied between the shoulders, the whole length of the spine; the jaw to be anointed with the oleum latertium; and a purge consisting of the tinctura sacra, tinctura jalape, and the syrupus de rhanno cathartico, to be given him. This was repeated three several times afterwards, at the distance of three or four days between each dose. On the intermediate days, he was ordered the oleum succinii, the fetid gum, and the oleum amygdalimum. Of the first he took 30 drops, of the gum 20 grains, and of the last four ounces, in 24 hours. By these means, and these only, the convulsions soon ceased; and he grew daily better and better, till at the end of a fortnight he was able to walk about his room, and in less than three weeks became in all respects well, some small 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 elysters 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. cinehona 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 Coehrane'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 sixth 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 Rush, 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 Rush, 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 the oil of turpentine. How far this practice will be confirmed by more extensive experience, we cannot take upon us to determine. We may only observe, that a very contrary practice has been recommended as highly successful by some practitioners in Spain, where tetanic affections are a very frequent occurrence in consequence of slight accidents. There gentle emollients are strongly recommended, particularly immersing the wounded part in tepid oil for the space of an hour or so at a time, and repeating this application at short intervals. By this mode many cases, after very alarming appearances had taken place, are said to have been completely and speedily removed. While the practice is very simple, it appears at the same time in many respects very rational, and may perhaps be considered as well deserving a trial in the first instance.

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

**GENUS XLIX. TRISMUS.**

The Locked Jaw.

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

**Sp. I. Trismus Nascentium.**

Locked Jaw in children under two months old.

Trismus nascentium, Sauv. sp. 1. Heister Comp. Med. Pract. cap. xv. § 10. Cleghorn on the Diseases of Minorca, Introd. p. 33. Hofer. in Act. Helvet. tom. i. p. 65.

This distemper is so closely connected with the tetanus, that it ought rather to be accounted a symptom of the tetanus than a primary disease. And nothing need now be added to what has been said respecting tetanus.

**Sp. II. The Trismus from Wounds or Cold.**

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

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

Convulsio à nervi punctura, Sauv. sp. 2.

Trismus catarrhalis, Sauv. sp. 15. Hillary's Barbadoes, 221. Lond. Med. Obs. vol. iv. 7.

The internal remedies proper in all cases of the locked jaw, from whatever cause it may proceed, have been already mentioned under Tetanus: the external treatment of wounded parts which may give occasion to it belongs to the article Surgery. But of this also we have offered some observations under the head of Tetanus; and, indeed, trismus may be considered as being merely an incipient tetanus, or rather a slight degree of that disease.

**GENUS L. CONVULSIO.**

**CONVULSIONS.**

Convulsio, Sauv. gen. 128. Lin. 142. Vog. 191.

Sag. gen. 235.

Convulsio universalis, Sauv. sp. 11.

Hieranosos, Lin. 144. Vog. 190.

Convulsio habitualis, sp. 12.

Convulsio intermittens, Sauv. sp. 16.

Convulsio hemitotonos, Sauv. sp. 15.

Convulsio abdominis, Sauv. sp. 10.

Convulsio ab inanitione, Sauv. sp. 1.

Convulsio ab onanism, Sauv. sp. 13.

Scelotyrbe festimans, Sauv. sp. 2.

**Description.** When convulsions attack only particular parts of the body, they are generally attended with some kind of paralysis at the same time, by which means the affected parts are alternately convulsed and relaxed; a permanent convulsion, or unnatural contraction of particular muscles, is called a 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 menses; and boys have likewise a chance of being relieved as they advance in life: but in grown-up people, unless the cause be very evident, a cure is hardly to be expected, especially after the disease has been of long continuance.

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

GENUS LI. CHOREA,

ST VITUS'S DANCE.

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

Description. This disease shows itself first by a kind 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 desirous of drinking, they use a number of odd gesticulations before they can bring the cup to their mouths, because their arms are drawn this way and that by the convulsions which affect them.

Causes, &c. The general cause of St Vitus's dance is a debility of the system; and hence we find it attacks only weakly boys, and more especially girls, when under the age of puberty. But the particular causes determining the muscles to be affected in such and such a manner are entirely unknown.

Prognosis. As this disorder scarce ever attacks any persons but such as are under the age of puberty, there is almost a certain prospect of its being then cured, though generally the disorder is easily removed before that time.

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

Cure. It has hitherto been almost universally the common practice to treat this disease with antispasmodics and tonics, particularly opium, hyoscyamus, valerian, cinchona, preparations of iron, zinc, and copper, and cold bathing; and under the use of these the disease has, in general, been removed. But Dr James Hamilton, senior physician to the Royal Infirmary of Edinburgh, in a treatise which he has lately published on the use of purgative medicines, has recommended a very different practice in this disease, the use, viz. of brisk cathartics: these he advises to be repeated daily for some time. The great object, however, which he has in view, is not to evacuate from the system, but to produce a thorough and complete evacuation of the intestinal canal. He finds, that by the first doses, large quantities of black-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.

RAPHANIA.

Raphania, Lin. 155. Vog. 143. Lin. Amoen. Acad. vol. vi. Convolvus raphanii, Sauv. sp. 7. Eclampsia typhodes, Sauv. sp. 1. Sennert. de febr. l. iv. cap. 16. Gregor. Horst. Oper. tom. ii. l. viii. obs. 22. Brunner in Ephem. Germ. D. iii. A. ii. obs. 224. Willisch. ibid. cent. vii. obs. 13. Weffer. de Affect. Capitis, obs. 129. Breslauer Sammlung 1717, Julio, Septembri, et Decembr. ibid. 1723, Januar. A. N. C. vol. vii. obs. 41. Bruckmann. Comb. Norimb. 1743, p. 50.

Description. According to Sauvages, this distemper begins with a lassitude 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 hiccup, fever, delirium, stupor, constriction 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 passing of worms, thirst, and in young people an unnatural hunger. It continues from ten days to three months. About the eleventh or twentieth day, some are relieved by copious sweats, or purple exanthemata: while others fall into a tabes, with stupor, or stiffness of the joints.

Causes, &c. This disease is frequently epidemic in Swabia and other parts of Germany; where it is said to be produced by seeds of radishes, which are often mixed with rye in that country; and from this supposed cause 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.

EPILEPSIA.

FALLING-SICKNESS.

Epilepsia, Sauv. gen. 134. Lin. 143. Vog. 188. Sag. gen. 24. Boerh. 1071. Hoffm. III. 9. Junck. 54. Eclampsia, Sauv. sp. 133. 182. 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 SYMPATHICA, or Sympathetic Epilepsy, with a sensation of something rising from a certain part of the body towards the head.

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

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

Epilepsia traumatica, Sauv. sp. 13. Eclampsia traumatica, Sauv. sp. 9. Epilepsia à dolore, Sauv. sp. 10. Epilepsia rachialgica, Sauv. sp. 14. Eclampsia à doloribus, Sauv. sp. 4. a, Rachialgica. b, Ab otalgia. c, A dentitione. Eclampsia parturientium, Sauv. sp. 3. Eclampsia verminosa, Sauv. sp. 2. Eclampsia ab atrope, Sauv. sp. 11. Eclampsia ab cantho, 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 saburra, Sauv. sp. 5. Epilepsia à pathemine, Sauv. sp. 7. Eclampsia ab inanitione, Sauv. sp. 8. Epilepsia neophytorum, Sauv. sp. 15.

Description. The epilepsy often attacks suddenly, and without giving any warning; but more frequently is preceded by a pain in the head, lassitude, some disturbance of the senses, unquiet sleep, unusual dread, dimness of sight, a noise in the ears, palpitation of the heart, coldness of the joints; and in some there is a sensation of formication, or a cold air, &c., ascending from the lower extremities towards the head. In the fit, the persons fall suddenly to the ground (whence the name of the falling-sickness), frequently with a violent cry. The thumbs are shut up close in the palms of the hands, and are with difficulty taken out; the eyes are distorted, so that nothing but the whites are to be seen; all sensation is suspended, insomuch, that by no smell, noise, or otherwise, nor even by pinching the body, can they be brought to themselves; they 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 lassitude 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 cartily concretions within the skull; besides many others which are recorded by Bonetus, Morgagni, and Liecutaud. But often the causes are impossible to be discovered; for even in those who have died of the disease, the brain and all other parts of the nervous system have been apparently sound. The disease will attack strong as well as weak people; and in those who are subject to it, any considerable excess in drinking, a surfeit, violent passion, or venery, &c. will certainly bring on a fit. Some have epileptic paroxysms returning periodically after considerable intervals; and the disease 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... Spasms 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. Numberless specifics have been recommended, but all of them have failed of answering the expectation. When the cause can be discovered, that must be removed. In other cases, the cold bath, valerian root, castor, musk, opium, the fetid gums, cinchona, with the whole tribe of nervous and antispasmodic medicines, have been recommended: but none of those, or indeed any combination of them, have been found generally useful; though the slighter, or symptomatic cases, may often be removed by them.

Of late the calx or oxide, improperly called the flowers, of zinc, have obtained such reputation in convulsive disorders as to be received into the Edinburgh Pharmacopoeia under the title of oxidum zinci. They were proposed by Dr Gaubius as an antispasmodic, in his Adversaria; and their efficacy has since been confirmed by various observations. In an inaugural dissertation published by Dr Hart at Leyden, the medical virtues of the flowers of zinc are considered. He observes, that they have long been used externally, chiefly for inflammations of the eyes from acrid lymph. Glauber first proposed the internal use of them; and Gaubius discovered them to be the remedy of a celebrated empiric Luddemannus, which he styled his luna fixata. After this he exhibited them with success in convulsive and spasmodic diseases. Dr Hart supposes, that they act either as absorbents, or as possessing a specific virtue: but is a strong advocate for their efficacy, on whatever principles they may operate; and, in favour of his opinion, relates seven cases in which they proved successful. A girl of 17 years of age was seized with a slight chorea from a fright; and when the disease had continued six days, she began to take the flowers of zinc, by which her disorder was removed in less than three weeks. Her cure required only 16 grains of the zinc. In a few months the complaints returned, from the same cause; and were removed by four grains of the medicine divided into 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 venesection and the use of some other remedies; but returned again in two weeks, when it was finally removed by the zinc. The two last cases are related from Dr Gaubius, who affirms that he has used the flowers of zinc in cases of the chincough, hysteric hiccough, and spasmus 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 Pereval 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 re-assume their white colour on being allowed to cool. The latter gives a case of hieranosos, or strange convulsions of almost all the muscles of the body, cured by zinc, after a number of other remedies had failed. But, although from these and other respectable authorities, there can be no doubt that zinc has often been successful in epilepsy; yet it is equally certain, that in many others it has had a fair trial, without producing any benefit.

In Dr Home's clinical experiments and histories, also, oxide of zinc is mentioned as having been found serviceable upon trial in the Royal Infirmary of Edinburgh. Of the other principal remedies which have been recommended for the epilepsy and other convulsive disorders allied to it, we have the following account by the same author.

1. The cold-bath was tried in one who had a convulsive disorder of one side, but the symptoms were rendered much worse by it.

2. Venesection. Not to be depended on in convulsions.

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

4. Epispastics. 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. Castor seems to be unworthy of the confidence formerly put in it. It is indeed possessed of a sedative power, and therefore may be useful in spasmodic feverish cases.

8. Asafoetida 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 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. Pongy 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. Extractum hyoscyami was given to an epileptic patient, to one afflicted with the hemitotonos, and to one who laboured under the hysteric affection, without the least good effect.

13. Folia aurantiacum were exhibited with the like bad success. Five drams of the powdered leaves were taken at once without any sensible effect.

14. Cardamine pratensis, in three epileptic cases, was not attended with any success.

15. Opium did no good.

16. Ammoniaretum cupri made no cure in four cases of epilepsy in which it was tried.

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

Genus LIV. PALPITATIO.

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 viscus, or from plethora, fear, or spasmodic affections of the nervous system. When it proceeds from diseases of the heart or large vessels, it is absolutely incurable. In spasmodic cases, the remedies above related may be used. If the patient be plethoric, bleeding will probably remove the disorder, at least for the present.

Genus LV. ASTHMA.

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

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

Asthma spasticum, Junck. tab. 51.

Sp. I. Spontaneous Asthma.

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

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

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

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

Orthopnea spasmodica, Sauv. sp. 3.

Orthopnea hysterica, Sauv. sp. 4.

Sp. II. The Exanthematic Asthma.

Asthma exanthematicum, Sauv. sp. 11.

Asthma eaelecticum, Sauv. sp. 13.

Sp. III. The Plethoric Asthma.

Asthma plethorium, 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 supervenes a fit of the asthma. As the paroxysm wears off, and the breathing becomes free, there is more or less of an expectoration of mucus; and the urine, from being pale and limpid, becomes high coloured, and lets fall a copious sediment.

In order to obtain relief in the fit, we must sometimes bleed, unless extreme weakness or old age should forbid, and repeat it according to the degrees of strength and fulness: a purging clyster, with a solution of asafoetida, must be immediately injected; and if the violence of the symptoms should not speedily abate, it will be proper to 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 Mocca, newly burnt, and made very strong immediately after grinding it. He commonly ordered an ounce for one dish; which is to be repeated fresh after the interval of a quarter or half an hour; and which is to be taken without milk or sugar. The medicine in general is mentioned by Musgrave in his treatise de Arthritide anomala; but he first heard of it from a physician in Litchfield, who had been informed 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 oxymel scillitum and vinum antimoniale, with a view to promote expectoration; or the gum ammoniac, and others of similar virtues, may be formed into pills, and combined with soap, as mentioned for the dyspnea pituitosa; or a mass 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, horse-radish 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 elixir with honey or syrup of garlic; and if, notwithstanding the use of these things, a costive habit should prevail, it will be necessary, from time to time, to give a few grains of pills of aloes and myrrh, soap and aloes, or a mass of equal parts of rhubarb, scammony, and soap.

The dry or spasmodic asthma, during the extreme violence of the fit, is best relieved by opiates; and sometimes very large doses are required. But in order to obtain permanent relief, nothing is found to answer better than ipecacuanha in small doses. Three, five, eight, or ten grains, according to the strength and constitution of the patient, given every other day, have been productive of the happiest effects; acting sometimes as an evacuant, pumping up the viscid phlegm; at others, as an antispasmodic or sedative. Issues are generally recommended in both species, and will often be found useful.

Changes of weather are usually felt very sensibly by asthmatic people, who in general cannot live with tolerable ease in the atmosphere of large cities; though we shall sometimes meet with patients who agree better with this air, which is so replete with gross effluvia of various kinds, than with the purest that can be found in country situations. And some are found who breathe with the most ease in a crowded room, with a fire and candles.

A light diet of meats that are easy of digestion, and not flatulent, is requisite for asthmatic people; and the exercise of riding is 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, simpisms 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 febriculoseum, and invades at regular intervals, we must have recourse to the Peruvian bark. The asthma exanthematicum will require blisters or issues, to give vent to the acrid matters which were repelled from the surface of the body; and courses of sulphureous waters, goats whey, and sweetening diet drinks, or perhaps mercurial alternatives, in order to correct the sharpness of the juices.

**Genus LVI. DYSPNOEA:**

*Habitual Difficulty of Breathing.*

Dyspnea, 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.

Dyspnea à tuberculis, à hydatibus, &c. Sauv. sp. 2, 4, 5, 20.

Orthopnea à lipomate, Sauv. sp. 18.

This is generally accompanied with a phthisis pulmonalis; but Sauvages mentions one species of phthisis to which the dry dyspnea seems more particularly to belong. The patients fall away by degrees, and have a great difficulty of breathing, continual thirst, and little or no spitting. When opened after death, their lungs are found not to be ulcerated, but shrivelled and contracted as if they had been smoke-dried. Goldsmiths and chemists are said to be subject to this disease, by reason of the vapours they draw in with their breath. Sauvages doth not mention any particular remedy. Shortness of breath arising from tubercles, as they are termed, or a seirrhus enlargement of the lymphatic glands which are dispersed through the lungs, is com- 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 gypseous matter.

Sp. V. The Watery Dyspnoea.

Dyspnoea pituitosa, Sauv. sp. 1. Orthopnoea ab hydropneumonia, 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 vessels, or swellings of the abdomen, &c.

Genus LVII. Pertussis.

Chincough.

Pertussis, Sydenham, Ed. Leid. p. 200, 311, 312. Huxham de aere, ad ann. 1732. Tussis convulsiva, sive ferina, Hoffm. III. III. Tussis ferina, Sauv. sp. 10. Sag. sp. 10. Tussis convulsiva, Sauv. sp. 11. Sag. sp. 11. Amphimerina tussiculosa, Sauv. sp. 13.

Description. This disease comes on at first like a common cold; but is from the beginning attended with a greater degree of dyspnoea than is common in catarrh; and there is a remarkable affection of the eyes, as if they were swelled, and a little pushed out of their sockets. By degrees the fits of coughing become longer and more violent, till at last they are plainly convulsive, so that for a considerable time the patient cannot respire, and when at last he recovers his breath, inspiration is performed with a shrill kind of noise like the crowing of a cock. This kind of inspiration serves only as an introduction to another convulsive fit of coughing, which is in like manner followed by another inspiration of the same kind; and thus it continues for some time, very often till the patient vomit, which puts an end to the paroxysm at that time. These paroxysms are attended with a violent determination of the blood towards the head, so that the vessels become extremely turgid, and blood not unfrequently flows from the mouth and nose. The disease is tedious, and often continues for many months. It is not commonly attended with fever, 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 attack, or at least suffer Spasmi. most from them. In general it has been concluded, that whatever weakens the solids, or tends to bring on a dissolution 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 neurulation 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 Butter, in a dissertation expressly on the subject, relates 20 cases of it cured by the extract of hemlock. He directs half a grain daily for a child under six months old; one grain for a child from six months to two years; afterwards allowing half a grain for every year of the patient's age till he be 20: beyond that period, he directs ten grains to be given for the first day's consumption, gradually increasing the dose according to the effect. If the patient have not two stools daily, he advises magnesia, or the sulphur potassae cum sulphure, to be added to the hemlock mixture. By this method he says the peculiar symptoms of the disease are removed in the space of a week; nothing but a slight cough remaining. The use of hemlock, however, has by no means become universal in consequence of this publication, nor indeed has this remedy been found equally successful with others who have given it a fair trial.

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

Genus LVIII. PYROSIS.

The Heart-Burn.

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

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

Genus LIX. COLICA.

The Colic.

Colica, Sauv. gen. 204. Lin. 50. Vog. 160. Sag. 162. Junck. 156. Colica spasmodica et flatulenta, Hoffm. II. 284. Rachialgia, Sauv. gen. 211. Sag. 163. Ileus, Sauv. gen. 252. Vog. 162. Sag. gen. 187. Iliaca, Lin. 185. Dolor et spasmus iliacus, Hoffm. II. 263. Passio iliaca, Junck. 107.

Sp. I. The Spasmodic Colic.

Colica flatulenta, pituitosa, 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, twisting, boring, a ligature drawn very tight, &c. The belly is generally costive, though sometimes there is a violent evacuation of bilious matters upwards and downwards. In these cases the disease is sometimes accompanied from the beginning with a weak and intermittent pulse, cold sweats, and fainting. In some the disease comes on gradually, beginning with an habitual costiveness; 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 clsters will be vomited; which constitutes that disease commonly called the iliac passion.

Causes, &c. Colics may arise from any sudden check given to perspiration, as by violent cold applied to any part of the body, especially to the lower extremities and abdomen. Very frequently they are occasioned by austere, acid, or indigestible aliments taken into the stomach. By any of these, a violent colic, or indeed an iliac passion, may be occasioned; for Dr Cullen justly observes, that this last, though commonly accounted a different species of disease, differs from colic in no other way than in being in every respect in a much higher degree. In those who have died of this disease and been dissected, the intestines have sometimes been found twisted; but more commonly there hath been an intrasusception of the intestine, that is, one part of the gut seems to have entered within the other. In the Edinburgh Medeal 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 constriction 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 intrasusception he explains by quoting a passage from Peyerus, who made the following experiment on a frog. Having irritated the intestine of the animal in several different places, he observed it to contract at those places most violently, and to protrude its contents upwards and downwards wherever the relaxed state of the part would permit; by which means the contents were heaped together in different parts. Hence some parts of the intestine being dilated much more than enough, by reason of the great quantity of matter thrown into them, formed a kind of sack which readily received the constricted part into it. If this happen in the human body, there is the greatest danger of a mortification; because the part which is constricted, and at any rate disposed to inflammation, has that disposition very much increased by its confinement within the other, and by the pressure of the contents of the alimentary canal from the stomach downwards upon it. An iliae 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 Medeal 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 gastrotony, or opening the abdomen of the patient, in order to remove the cause of the disorder. The patient, a woman of about 28 years of age, died after suffering extreme torture for six days. The body being opened, some quantity of a dirty coloured fluid was found in the cavity of the abdomen. The jejunum and ileum were greatly distended with air. A portion of the omentum adhered to the mesentery, near that part where the ileum terminates in the cecum. From this adhesion, which was close to the spine, there ran a ligamentous cord or process about two inches and a half long, unequally thick, in some places not thicker than a packthread; which by its other extremity adhered to the coats of the ileum, about two inches above the cecum. This cord formed a circle with the mesentery, large enough to admit a hen's egg to pass through it. The cord had formed a noose (in a manner difficult to be explained), which included a doubling of about two inches of the lower end of the ileum, and was drawn so tight, that it not only put a stop to the passage of every thing 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 clsters evacuated by the mouth, there is much more hope of a cure, than when the belly is obstinately costive, and there is some fixed obstruction which seems to bid defiance to all remedies.

Cure. 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 intussusception. 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 spasmodic 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 pressure, would tend to fix the intussusception 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 hydrargyrus, 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, basins of cold water are to be dashed on his feet, legs, and thighs; and this must be continued for an hour or longer, if a stool 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 stopped neither by anodynes nor any other medicines, the sharpest glysters being returned unaltered, and all kinds of purgatives thrown up soon after they were swallowed; but by the above-mentioned method, a stool was procured in 35 minutes, and the patient recovered. In some others the 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-attested instances of their success. In some obstinate cases, however, benefit has certainly been derived from tobacco-smoke injections, and likewise from injections of tepid water to the extent of several pounds. For putting in practice these modes of cure, a particular apparatus has been contrived; and in cases even apparently desperate, neither should be neglected. The cold water gives a general and very considerable shock to the system, checks the perspiration, and thus drives the humours inward upon the intestines, by which they receive a much more effectual stimulus than can be supposed to arise from any kind of 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 asafoetida, 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 Citesii.

Another cause to which violent colics are frequently to be ascribed, and which often gives occasion to them where it is very little suspected, is lead, or some solution or fume of it, received into the body. To this cause is evidently owing the colics to which plumbers, lead-miners, and smelters of lead are subject. To the same cause, though not so apparent at first sight, are we to ascribe the Devonshire colic, where lead is received into the body dissolved in cider, the common drink of the inhabitants of that country. This has been proved by experiment; for lead has been extracted from cider in quantity sufficient to produce pernicious effects on the human body. The colic of 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 gripping pains to the bowels. Soon after there is a distention, 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 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 seybada, and are in small quantity. There is, however, usually an obstinate costiveness; the urine is discharged in small quantity, frequently with pain and much difficulty. The pulse is generally low, though sometimes a little quickened by the violence of the pain; but inflammatory symptoms very seldom occur. The extremities are often cold, and sometimes the violence of the pain causes cold clammy sweats and fainting. The mind is generally much affected, and the spirits are sunk. The disease is often tedious, especially if improperly treated, insomuch that the patients will continue in this miserable state for twenty or thirty days successively; nay, instances have been known of its continuing for six months. In this case the pains at last become almost intolerable: the patient's breath acquires a strong fetid smell like excrements, from a retention of the feces, and an absorption of the putrid effluvia from them by the lacteals. At last, when the pain in the bowels begins to abate, a pain comes on in the shoulder-joints and adjoining muscles, with an unusual sensation and tingling along the spinal marrow. This soon extends itself from thence to the nerves of the arms and legs, which become weak; and that weakness increases till the extreme parts become paralytic, with a total loss of motion, though a benumbed sensation often remains. Sometimes, by a sudden metastasis, the brain becomes affected, a stupor and delirium come on, and the nervous system is irritated to such a degree as to produce general convulsions, which are frequently followed by death. At other times, the 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 costiveness 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 aeruginous bile both ways; but the exertions of this humour lessen by degrees; and before the course be ended, it has little other effect than to cause some degree of squeamishness, or promote a few bilious stools, or perhaps may not move the patient at all. At the time of using this medicine the patients should live upon broth made of lean meat, gruel, or panada: but about the seventh or eighth day, they may be allowed bread and boiled chicken. Here the copper seems to do service by its tonic power; and for the same reason alum, recommended by Dr Percival, most probably cures the disease. He says he has found this very efficacious in obstinate affections of the bowels, and that it generally proves a cure in the slighter cases of the colica pectorum. It was given to the quantity of fifteen grains every fourth, fifth, or sixth hour; and the third dose never failed to mitigate the pain, and sometimes entirely removed it. Among purgative medicines the oleum recini 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 Costiveness.

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 sicca aurigina, à fungis venenatis, ejusd. sp. 2.

When colics arise from acrid poisonous matter taken into the stomach, the only cure is either to evacuate the poison itself by vomiting, or to swallow some other substance which may decompose it, and thus render it inactive. The most common and dangerous substances of this kind are corrosive mercury and arsenic. The former is easily decomposed by alkaline salts; and therefore a solution of lixivial salt, if swallowed before the poison has time to induce a mortification of the bowels, will prove a certain cure. Much more uncertain, however, is the case when arsenic is swallowed, because there is no certain and speedy solvent of that substance yet known. Milk has been recommended as efficacious; and lately a solution of hepar sulphuris. The latter may possibly do service; as arsenic unites readily with sulphur, and has its pernicious qualities more obfuscated by that than by any other known substance: but indeed, even the solvent powers of this medicine are so weak, that its effects as well as those of others must be very uncertain.

Some kinds of fungi, when swallowed, are apt to produce colics attended with stupor, delirium, and convulsions; and the same sometimes happens from eating a large large quantity of the shell-fish known by the name of muscles (the *Mytilus*). Some of the fungi, doubtless, may have an inherent poisonous quality; but generally they as well as the muscles act on a different principle. Their pernicious effects happen most commonly when they are taken on an empty stomach; and are then supposed to be occasioned by their adhering so close to its coats, that it cannot exert its powers, and the whole system is thrown into the utmost disorder. The malady may therefore be very easily prevented; but when once it has taken place, it cannot be removed till either vomiting be excited, or the stomach has recovered itself in such a manner as to throw off the adhering matter.

**Sp. V. Colic of New-born Infants, from a Retention of the Meconium. (*Sauv.* sp. 19.)**

This disorder would be prevented were children allowed immediately to suck their mothers, whose milk at first is purgative. But as this is not commonly done, the child is frequently troubled with colics. These, however, may be removed by a few grains of ippecacuanha, or a drop or two of antimonial wine. By these means the stomach is cleansed by vomiting, and the belly is generally loosened; but if this last effect does not happen, some gentle purge will be necessary.

**Sp. IV. Colic from a Callosity of the Colon.**

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

**Sp. VII. The Colic from Intestinal Calculi. (*Sauv.* sp. 10. 15.)**

When certain indigestible bodies, such as cherry-stones, plum-stones, small pieces of bones, &c., are swallowed, they frequently prove the basis of calculi, formed by an accretion of some kind of earthly 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.* 253. *Lin.* 186. *Vog.* 110. *Sag.* 183. *Hoffm.* II. 165. *Diarrhoea cholérica,* *Junck.* 112.

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

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

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

Cholera erapulosa, *Sauv.* sp. 11. Cholera à venenis, *Sauv.* sp. 4, 5.

The cholera shows itself by excessive vomiting and purging of bilious matters, with violent pain, inflation and distention of the belly. Sometimes the patients fall into universal convulsions; and sometimes they are affected with violent spasms in particular parts of the body. There is a great thirst, a small and unequal pulse, cold sweats, fainting, coldness of the extremities, and hiccup; and death frequently ensues in 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 restrain that increased secretion of bile, by which a fresh deposition in the alimentary canal would otherwise be soon produced. And, in the last place, measures must often be employed to restore a sound condition to the alimentary canal, which is frequently much weakened by the violence of the disease.

On these grounds, the cure of this distemper is effected by giving the patient a large quantity of warm water, or very weak broth, in order to cleanse the stomach of the irritating matter which occasions the disease, and injecting the same by way of clyster, till the pains begin to abate a little. After this, a large dose of laudanum is to be given in some convenient vehicle, and repeated as there is occasion. But if the vomiting and purging have continued for a long time before the physician be called, immediate recourse must be had to the laudanum, because the patient will be too much exhausted to bear any further evacuations. Sometimes the propensity to vomit is so strong, that nothing will be retained, and the laudanum itself thrown up as soon as swallowed. To settle the stomach in these cases, Dr Douglas, in the Medical Essays, recommends a decoction of oat-bread toasted as brown as coffee; and the decoction itself ought to be of the colour of weak coffee. He says he does not remember that this decoction was ever vomited by any of his patients. An infusion of mint leaves, or good simple mint-water is also said to be very efficacious in the same case.

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

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

**Genus**

DIARRHOEA.

Looseness.

Diarrhoea, Sauv. gen. 253. Liu. 187. Vog. 105. Sag. gen. 189. Junck. 112. Hepatirrhoea, Sauv. gen. 246. Cholerica, Liu. 190. Coeliaca, Sauv. gen. 255. Liu. 189. Vog. 109. Sag. gen. 199. Lienteria, Sauv. gen. 256. Liu. 188. Sag. gen. 191. Vog. 108. Pituitaria, et leucorrhoeis, Vog. 111. 112.

Sp. I. The Feculent Diarrhoea.

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

This is occasioned by too great a quantity of matter thrown into the alimentary canal; and what is discharged has not the appearance of excrements, but is much whiter, and of a thinner consistence. Voracious people who do not sufficiently chew their food, gormandizers, and even those who stammer in their speech, are said to be liable to this disease. In slighter cases it is removed without any medicine, or by a dose of rhubarb; but where the matters have acquired a putrid taint, the disorder may be much protracted and become dangerous. In this case lenient and 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 locat of the bowels, thirst, bitterness and dryness of the mouth, yellowness of the tongue, and frequently follows an intermitting or bilious fever. When the fever is gone, the diarrhoea is to be removed by acidulated and cooling drinks, with small doses of nitre.

Sp. III. The Mucous Diarrhoea.

Diarrhoea lactentium, Sauv. sp. 19. Dysenteria Parisiaca, Sauv. sp. 3. Diarrhoea ab hypercatarsi, Sauv. sp. 16. Dysenteria a catharticis, Sauv. sp. 12. Pituitaria, Vog. 111. Leucorrhoeis, Vog. 112. Diarrhoea pituitosa, Sauv. sp. 4. Coeliaca mucosa, Sauv. sp. 3. Diarrhoea serosa, Sauv. sp. 10. a. Diarrhoea urinosa.

This kind of diarrhoea, besides the matters usually excreted, is attended with a copious dejection of the mucus of the intestines with great pain; while the patient daily pines away, but without any fever.—Persons of all ages are liable to it, and it comes on usually in the winter-time; but is so obstinate, that it will sometimes continue for years. In obstinate loosenesses of this kind, vomits frequently repeated are of the greatest service. It is also very beneficial to keep the body warm, and rub the belly with stimulating ointments; at the same time that astringent clysters, rhubarb, and stomachic medicines, are to be exhibited. Starch clysters are very often efficacious.—Some kinds of looseness are contagious; and Sir John Pringle mentions a soldier who laboured under an obstinate diarrhoea, who infected all those that used the same privy with himself. In the looseness which frequently followed a dysentery, the same author tells us that he began the cure with giving a vomit of ipecacuanha, after which he put the patients on a course of astringents. He used a mixture of three drachms of extract of logwood, dissolved in an ounce and a half of spirit of cinnamon, to which was added seven ounces of common water, and two drachms of tincture of catechu. Of this the patient took two spoonfuls once in four or five hours, and sometimes also an opiate at bedtime. He recommends the same medicine in obstinate diarrhoeas of all kinds. A decoction of simarauba bark was also found effectual, when the dysenteric symptoms had gone off. Dr Huck, who used this article in North America, also recommends it in diarrhoeas. Two or three ounces of the simarauba 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.

Coeliaca chylosa, Sauv. sp. 1. Coeliaca lactea, Sauv. sp. 4.

There are very great differences among physicians concerning the nature of this disease. Sauvages says, from Arctetus, 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 Arctetus, 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 celiac 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 Areteus that the whiteness is only occasioned by the want of bile. He endeavours to prove at length, that the celiac 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 celiac 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, antiscptics, and tonics, as in other species of diarrhoea.

Sp. V. The Lientery.

Lienteria spontanea, Sauv. sp. 2.

The lientery, according to Sauvages, differs from the celiac passion only in being a slighter species of the disease. The aliment passes very quickly through the intestines, with scarce any alteration. The patients do not complain of pain, but are sometimes affected with an intolerable hunger. The cure is to be attempted by stomachics and tonics, especially the Peruvian bark. 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 diarrhoea is by Sauvages described as a flux of bloody serous matter like the washings of flesh, which percolates through the coats of the intestines by means of the anastomosing vessels. It is the celiac passion of Trillianus; 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.

DIABETES.

A profuse Discharge of Urine.

Diabetes, Sauv. gen. 263. Lin. 197. Vog. 115. Sag. gen. 199. Junck. 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., Eiusdem Monita Med. cap. ix. sect. 2. Dobson in Lond. Med. Observ. vol. v. art. 27. Myers Diss. inaug. de Diabete, Edinb. 1779. Diabetes febricosus, 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. Areteus de Morb. diurnum. lib. ii. cap. 2. Diabetes ex vino, Sauv. sp. 5. Ephem. Germ. D. I. A. II. Observ. 122.

Description. The diabetes first shows itself by a dryness of the mouth and thirst, white frothy spittle, and the urine in somewhat larger quantity than usual. A heat begins to be perceived in the bowels, which at first is a little pungent, and gradually increases. The thirst continues to augment by degrees, and the patient gradually loses the power of retaining his urine for any length of time. It is remarkable, that though the patients drink much, the quantity of urine always exceeds what is drank. In Dr Home's Clinical Experiments we have an account of two patients labouring under this disease: one of them drank between 10 and 12 English pints a-day without being satisfied. The quantity was greater in the forenoon than in the afternoon. In the other 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 scarce distinguishable from that obtained from the sugar-cane. This discovery was first made by Dr Dobson of Liverpool, who made some experiments on the urine of a person labouring under a diabetes, who discharged 28 pints of urine every day, taking during the same time from 12 to 14 pounds of solid and liquid food. Some of this urine being set aside, fell into a spontaneous effervescence, changed first into a vinous liquor, and afterwards into an acetous one, before it became putrid and offensive. Eight ounces of blood taken from the same patient, separated into crassamentum and serum; the latter being sweet to the taste, but less so than the urine. Two quarts of the urine, evaporated to dryness, left a white cake weighing four ounces two 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 supernatural sweetness; in one of them the crassamentum was was covered with a thick inflammatory crust. In one of these patients the urine yielded an ounce and a half, and in the other an ounce, of saccharine matter from each pound. It had, however, an urinous smell, and a saline taste mixed with the sweet one; and the urine of one fermented with yeast, we are told, into "tolerable small-beer." Both these patients had a voracious appetite, and perpetual gnawing sense of hunger; as had also Dr Dobson's patient. The insipid urine of those affected with diabetes has not been examined by physicians with sufficient accuracy to enable us to speak with confidence of its contents.

Causes. These are exceedingly obscure and uncertain; spasms of the nervous system, debility, and everything 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.—Dissections have only shown that the kidneys were in an enlarged and lax state. In one of Dr Home's patients who died, they smelled sour; which showed that the urine peculiar to diabetes came from the kidneys, and was not sent directly from the intestines by a retrograde motion of the lymphatics, as some imagine.

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

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

On these grounds the principal hopes of a cure in this distemper are from astringent and strengthening medicines. Dr Dobson's patient was relieved by the following remedies; which, however, were frequently varied, as none of them produced their good effects for any length of time: Cinchona in substance, with small doses of rhubarb; decoction of the bark, with the acid elixir of vitriol; the cold infusion of the bark, of which he drank from a quart to two quarts daily; Dover's powder; alum-whey; lime-water; antimonials combined with tinctura thebaica. The warm bath was used occasionally when the skin was remarkably hot and dry, and the patient complained of restlessness and anxiety. The tincture of cantharides was likewise tried; but he could never take more than 25 drops for a dose, without exciting great uneasiness in his bowels. The body was kept constantly open, either with rhubarb or the infusion of senna joined with rhubarb. His common drinks were rice-water, barley-water, lime-water, and milk; lime-water alone; sage, balm, or mint tea; small beer, simple water, and water acidulated with the sulphuric acid. In seven months, these remedies, Diabetes, 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; insomuch that he uses this remarkable expression: "Thus, these two patients have exhausted all that experience had ever recommended, and almost all that theory could suggest; yet in both cases, the disease has resisted all the means of cure used." It is remarkable, that though septic were given to both, in such quantity as evidently to produce a putrescency in the prime via, the urine remained unaltered both in quantity and quality.

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

But of all the modes of cure lately proposed, that which has been most celebrated, is the treatment recommended by Dr Rollo of the Royal Artillery. In a valuable work lately published, entitled Cases of the Diabetes Mellitus, he has recorded two remarkable examples of the good effects of a peculiar regimen in this disease. He considers diabetes as being a disease not of the kidney but of the alimentary canal, and as arising from the formation of an uncommon quantity of sugar. He therefore strictly forbids the use of every article of diet which can furnish sugar, even of bread; and by a diet consisting entirely of animal and alkalescent 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.

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. Convulsiv. cap. 5. 10. 11. Sydenham Diss. Epist. ad G. Cole, Whytt on Nervous Disorders.

Description. The hysteria is a convulsive disease, which comes on at uncertain intervals, sometimes longer and sometimes shorter, but at no stated time. The paroxysms commonly begin with a languor and debility of the whole body; yawning, stretching, and restlessness. A sense of coldness also in the extremities, almost always precedes, and for the most part remains during the whole time of the paroxysm. To this 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 convulsed; the umbilicus is drawn inwards; and there are frequently such spasms of the intestines, that neither clysters can be injected, nor even flatus pass downwards. Sometimes the paroxysm remits after these symptoms have continued for a certain time, but more frequently the patients fall into fainting fits; sometimes they lie without motion, as if they were in a deep sleep; sometimes they beat their breasts violently and continually with their hands, and sometimes they are seized with general convulsions, and the disease puts on the appearance of an epilepsy. In some patients the extremities become cold and stiff, and the body has the appearance of one in a catalepsy. Sometimes a most violent beating pain takes place in some part of the head, as if a nail was driven into it, and all visible objects seem to turn round; grievous pains attacks the loins, back, and bladder, and the patients discharge a surprising quantity of urine as limpid as water; which last is one of the surest signs of the disease. The mind is very much affected as well as the body. Sometimes the patients are tormented with vain fears: sometimes they will laugh, at other times cry immoderately; and sometimes their temper becomes so peevish and fretful, that they cannot enjoy a moment's quiet. The appearances which take place in this affection are indeed so much varied, that they can hardly be enumerated: they may, however, with propriety, be divided into hysteric fits, which very much resemble those of epilepsy, excepting that they are not attended with an abolition of the internal senses; and hysteric symptoms, such as the globus hystericus, clavus hystericus, and the like, which are chiefly known to constitute a part of this disease from being observed to alternate with fits.

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

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

Cure. The 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 hysteric 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 venesecesis, though this remedy has been generally condemned in hysterical cases. Asafoetida 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 hysteric fit; but its effects are of short duration; and if it do not effect a cure soon after its exhibition, no service is to be expected either by perseverance in the use of it or by increasing the dose; and with some constitutions it disagrees to such a degree as to occasion convulsions. If the patient be seized with a violent fit, so that she can swallow nothing, which is frequently the case, it will be proper to apply some strong volatile alkali to her nose; or if that be not at hand, the vapors 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 hysteric symptoms. A plaster of galbanum and asafoetida will also prove serviceable: but it must be remembered, that none of these things will prevent the return of the disease; and therefore a radical cure is to be attempted by exercise, cinchona, chalybeates, mineral waters, and other tonics; but particularly, where the state of the patient is such as to be able to bear it, by the use of the cold bath, which, where it does not disagree with the constitution, is often of the greatest service in preventing returns of this affection.

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

HYDROPHOBIA.

The Dread of Water

Hydrophobia, Sauv. gen. 231. Lin. 86. Veg. 30. Sag. gen. 343. Boerh. 1138. Junck. 124. Mead on Poisons. Dessault sur la rage. Sauv. diss. sur Sp. I. Hydrophobia Rabiosa, or Hydrophobia consequent on the Bite of a Mad Animal.

Hydrophobia vulgaris, Sauv. sp. i.

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

Description. This disease commonly does not make its attack till a considerable time after the bite. In some few instances it has commenced in seven or eight days from the accident; but generally the patient continues in health for 20, 30, or 40 days, or even much longer. The bite, if not prevented, will in general be healed long before that time, frequently with the greatest ease; though sometimes it resists all kinds of healing applications, and forms a running ulcer which discharges a quantity of matter for many days. It has been said, that the nearer the wounded place is to the salivary glands, the sooner the symptoms of hydrophobia appear. The approach of the disease is known by the cicatrix of the wound becoming high, hard, and elevated, and by a peculiar sense of prickling at the part; pains shoot from it towards the throat; sometimes it is surrounded with livid or red streaks, and seems to be in a state of inflammation; though frequently there is nothing remarkable to be observed about it. The patient becomes melancholy, loves solitude, and has sickness at stomach. Sometimes the peculiar symptom of the disease, the dread of water, comes on all at once. We have an instance of one who, having taken a vomit of ipecacuanha for the sickness he felt at his stomach, was seized with the hydrophobia in the time he was drinking the warm water. Sometimes the disease begins like a common sore throat; and the soreness daily increasing, the hydrophobic symptoms show themselves like a convulsive spasm of the muscles of the fauces. In others, the mind seems to be primarily affected, and they are subject to despondency and melancholy for some time prior to any dread of water. And when that dread commences, it is with an evident mental affection. Dr James, in his Treatise on Canine Madness, mentions a boy sent out to fill two bottles with water, who was so terrified by the noise of the liquid running into them, that he fled into the house crying out that he was bewitched. He mentions also the case of a farmer, who, going to draw some ale from a cask, was terrified to such a degree at its running into the vessel, that he ran out in a great haste with the spigot in his hand. But in whatever manner this symptom comes on, it is certain that the most painful sensations accompany every attempt to swallow liquids. Nay, the bare sight of water, of a looking-glass, of any thing clear or pellucid, will give the utmost uneasiness, or even throws the patient into convulsions.

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

In this disease there seems to be an extreme sensibility and irritability of the nervous system. The eyes cannot bear the light, or the sight of any thing white; the least touch or motion offends them, and they want to be kept as quiet and in as dark a place as possible. Some complain of the coldness of the air, frequently when it is really warm. Others complain of violent heat; and have a great desire for cold air, which yet never fails to increase the symptoms. In all there is a great flow of viscid saliva into the mouth; which is exceedingly troublesome to the patients, as it has the same effect upon their fauces that other liquids have. This therefore they perpetually blow off with violence, which in a patient of Dr Fothergill's occasioned a noise not unlike the hollow barking of a dog, and which he conjectures might have given rise to the common notion that hydrophobous patients bark like dogs. They have an insatiable thirst; but are unable to get down any drink, except with the utmost difficulty; though sometimes they can swallow bread soaked in liquids, slices of oranges, or other fruits. There is a pain under the serobiculus 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... Spasm. 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 returns 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, sighing, spitting a frothy saliva, screeching, sometimes belching, retching, but rarely vomiting. Every member is convulsed by fits, but most violently from the navel up to the breast and oesophagus. The fit comes on every quarter of an hour; the fauces are not red, nor the tongue dry. The pulse is not at all feverish; and when the fit is over nearly like a sound pulse. The face grows pale, then brown, and during the fit almost black; the lips livid; the head is drowsy, and the ears tingling; the urine limpid. At last they grow weary; the fits are less violent, and cease towards the end; the pulse becomes weak, intermittent, and not very quick; they sweat, and at last the whole body becomes cold. They compose themselves quietly as if to get sleep, and so they expire. The blood drawn a few hours before death appears good in every respect. A general observation was, that the lint and dressings of the wounds, even when dry, were always black, and that when the pus was very good in colour and appearance." In one of Dr Wolf's patients who recovered, the blood stunk intolerably as it was drawn from a vein; and one of Mr Vaughan's patients complained of an intolerable fetid smell proceeding from the wounded part, though nobody but himself could perceive it. In general, the violent convulsions cease a short time before death; and even the hydrophobia goes off, so that the patients can drink freely. But this does not always happen; for Mr Vaughan mentions the case of a patient, in whom, "when he had in appearance ceased to breathe, the spasms cynicus was observable, with an odd convulsive motion in the muscles of the face; and the strange contrariety which took place in the action of these produced the most horrid assemblage of features that can well be conceived. Of this patient also it was remarkable, that in the last hours of his life he ceased to cry 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 pursued and struck. One symptom indeed, if it could be Hydro 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 sound dog. If the latter eats it, it is a sign the dog was not mad; but if the other rejects it with a kind of howling noise, it is certain that he was. Dr James tells us, that among dogs the disease is infectious by staying in the same place; and that after a kennel has been once infected, the dogs put into it will be for a considerable time afterwards in danger of going mad also. A remedy for this, he says, is, to keep geese for some time in the kennel. He rejects as false the opinion that dogs when going mad will not bark; though he owns that there is a very considerable change in their bark, which becomes hoarse and hollow.

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

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

With regard to the immediate cause among mankind, there is not the least doubt that the hydrophobia is occasioned by the saliva of the mad animal being mixed with the blood. It does not appear that this can operate through the cuticle; but, when that is rubbed off, the smallest quantity is sufficient to communicate communicate the disease, and a slight scratch with the teeth of a mad animal has been found as pernicious as a large wound. It is certain also, that the infection has been communicated by the bites of dogs, cats, wolves, foxes, weasels, swine, and even cocks and hens, when in a state of madness. But it does not appear that the distemper is communicable from one hydrophobic person to another, by means of the bite, or any other way. Dr Vaughan inoculated a dog with the saliva of a hydrophobic child, but the animal continued free from disease for two months: 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 kissed this child during the time of his disorder, but no bad consequence ensued.

When we attempt to investigate the nature of the cause of the hydrophobia by dissections, our inquiries are commonly disappointed. In two bodies opened by Dr Vaughan, there was not the least morbid appearance; in the very fauces, where we might have expected that the disease would have shown itself most evidently, there was not the least appearance even of inflammation. The stomach, intestines, diaphragm, esophagus, &c. were all in a natural state: neither do we find in authors of credit any certain accounts of morbid appearances in the bodies of hydrophobous persons after death. Dr Vaughan therefore concludes, that the poison acts upon the nervous system; and is so wholly confined to it, that it may be doubted whether the qualities of the blood are altered by it or not; and that it acts upon the nerves by impairing and disturbing their functions to such a degree as speedily to end in a total extinction of the vital principle. As to the difficulty in swallowing generally believed to accompany the dread of water, he treats it as a misrepresentation, as well as that the esophagus 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 esophagus, 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 scrobiculus cordis; to which the sufferer applies his hand. From this last circumstance, therefore, from the presence of the risus sardonicus, from the muscles of the abdomen being forcibly contracted, and from the sense of suffocation which seems to threaten the patient with immediate death, Dr Vaughan has been led to think that in the hydrophobia a new sympathy was established between the 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 had been applied, is unquestionably the most to be depended upon. This practice, therefore, should be had recourse to as soon as possible. The sooner it can be accomplished the better. But it has been observed, that as a peculiar sensation at the part affected always precedes the accession of the disease, even when it takes place at a late period after the bite, there is good ground for believing that the removal of the part may be of advantage even after a considerable interval. But besides removal of the contagious matter, by cutting away the part to which it is attached, this should also be attempted by careful and long-continued washing. This may be done, in most instances, before a proper opportunity can be had of having recourse to the knife. Cold water should particularly be poured upon the wound from a considerable height, that the matter may be washed away with some force. Even after removal by the knife, careful washing is still a necessary and proper precaution. And after both these, to prevent as far as can be the possibility of any contagious matter lurking about the wounded part, it should not be allowed to heal, but a discharge of matter should be supported for the space of several weeks, by ointment with cantharides, or similar applications. By these means there is at least the best chance of removing the matter at a sufficiently early period. And this mode of prevention seems to be of more consequence than all others put together which have hitherto been discovered. But besides removal, prevention may also be obtained by the destruction of the contagious matter at the part; and where there is the least reason to think that a complete removal has not been obtained, this should always be had recourse to. With this intention the actual 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 inefficacious. But although no greater confidence is perhaps to be put in specifics of modern date, it will be proper that these should be mentioned.

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

There is a famous East India medicine, composed of 24 grains of native and as much factitious cinnabar, made into a powder with 16 grains of musk. This is called the Tonguin medicine, and must be taken in a tea cupful of arrac 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, sage, polypody, wormwood, mint, mugwort, balm, betony, St John's wort, and lesser centaury. These herbs must be gathered in their prime, dried separately in the shade, and then powdered. The dose is a dram, or a dram and 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 turbitb mineral, in order if possible to raise a slight salivation, on which the efficacy was thought to depend. Besides this, venesection, opium, cinchona, and camphor, have been tried in very large quantities; the warm bath; and, in short, every thing which human invention could suggest; but with how little success, can be judged from many well authenticated cases.

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

The following case by Dr Raymond of Marseilles shows the inefficacy of mercury even as a preventive.—On the 19th of July 1765, Mr Boyer, aged 25, of a bloated cachectic habit, was bit by a mad dog in the inferior part of the leg: the wound extended half way round, bled freely, and was like a great scratch. The patient's legs had been swelled for a considerable time before the accident; and there were also two ulcers in the other leg. Some hours after the accident, the actual cautery was applied to the wound. The doctor was not present at this operation; but the part around the bite was rubbed with mercurial ointment immediately after, and the eschar was dressed with the same ointment. The eschar was separated on the first day, but the dressing was continued till the wound was cicatrised. The second day a bolus of four grains of turbitb and eight grains of camphor was exhibited. This procured a considerable evacuation both by vomit and stool, and a spitting also came on. The third day the bitten leg was rubbed with mercurial ointment: in the space of a month the frictions were repeated five times on both legs, three drams of mercurial ointment being used in each friction. During the same time the bolus was five times repeated; and this treatment kept up a slight salivation to the 40th day. The evening of the third day he took the Tonguin medicine, called also Sir George Cobb's powder, in a bolus; which vomited him briskly. This powder was repeated seven or eight times in the month, generally with the same effect. During the first seven or eight days he got four times, in the morning, a dram of the anguallis flore puniceo, fresh gathered and powdered. The 41st day, the turbitb 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 distemper; and died on the 76th, seemingly suffocated or strangled, his mouth covered with slaver, and his his face bloated. He lost his senses not above half a quarter of an hour before his death. The pulse was quiet the whole time.

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

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

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

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

"Take half an ounce of chalk, three drams of Armenian bole, 10 grains of alum, one dram of 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 preservative against the hydrophobia: however, there is a possibility that there may be some unknown ingredient in the genuine powder: for it is difficult to analyse powders after the ingredients are thoroughly mixed together. The efficacy of the medicine therefore must depend on the virtues of that unknown ingredient, if any such there be. The following cases, however, too well determine that it is not infallible, as was at first pretended. In all probability, as well as many others, its reputation also is solely rested on its being exhibited in many cases where no contagion was communicated to the person bit, and while of course no disease could take place.

On the 14th of February 1774, Mr Bellamy of Holborn, aged 40, was bit by a cat affected with rabies, which was killed the same morning. The following day he took the celebrated Ormskirk medicine, sold by Hill and Berry in Hill-Street, Berkeley-Square, and conformed in every respect to the directions given by the vender. A servant maid, who was bitten in the leg before her master was bitten, likewise took the same remedy. About the middle of April Mr Bellamy complained of a pain in his right knee, which he supposed to be rheumatic, and which continued and increased till the 7th of June, when he got some pills of calomel, ipsecacuanha, and pil sapon, from an apothecary, with Huxham's tincture of the bark in small doses. In six days more he had a titillation in the urethra, a contraction of the scrotum and penis to a degree of pain, and an emission of semen after making water, to which he had frequent calls. The medicines were discontinued; and on the 16th of that month the hydrophobia came on, and Dr Fothergill was called. Six ounces of blood were taken from his arm, and a bolus of a scruple of native cinnamon and half a scruple of musk was given every four hours. The distemper manifestly increased through the day. In the evening a clyster was injected, and several times repeated during the night; he had been put into the warm bath, and two drams of strong mercurial ointment rubbed into his legs and thighs by himself. He was greatly relieved by the warm bath while he continued in it, but the symptoms returned with increased violence in the night. The next day being greatly worse, he was bled to as great a quantity as he could bear, had the warm bath and clysters repeated, and half an ounce of mercurial ointment rubbed into his thighs and legs. Pills of opium were prescribed, but he did not take them. He died... Spasm, the same night, at half an hour after 12. This patient was a man of great resolution, and could in part conquer his aversion at water. He seemed to have totally forgot the accident of the bite; and casually said, that he thought this disorder resembled the hydrophobia, without supposing that he was afflicted with that distemper at the time.—The bite on the girl’s leg refused to heal, baffled the art of a young surgeon who attempted to cure it, and continued a running ulcer for a long time. She did not fall into the hydrophobia. Hence Dr Fothergill thinks it probable, that keeping the wounds made by the teeth of mad animals open for a long time, would probably be of service as a preventive; but in some of Dr Wolf’s patients these artificial drains appear not to have been attended with success.

On the 16th of November 1773, Thomas Nourse, a strong healthy boy of 14, was admitted into the Leicester infirmary; having been that day 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 Ormskirk medicine was also administered with all due care. It was bought of the person in Leicester who is deputed by the proprietor to sell it for him. A common adhesive plaster was applied to the part after sea-bathing; and in the course of a month, without any further trouble, the wound was healed; excepting a small portion, somewhat more than an inch in length, and in breadth about one-tenth. This yielded no discharge, and was quite in a cicatrizing state. Five days before his admission into the infirmary, he began to complain of a tightness over his temples, and a pain in his head: in two days the hydrophobia began to appear; and at its commencement he complained of a 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 plaster of three drams of powdered camphor, half an ounce of opium, and six 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 six ounces of mutton-broth was injected into the intestines, but to no purpose. A larger dose of opium was then given, but with as little effect as the former, and he died the same night.

In the month of September 1774, a farmer, aged 25, was bit by a mad dog, whose teeth made a slight wound in the fore finger of the left hand. He was dipped, as usual, in the sea; and drank the sea-water for some time on the spot, which operated briskly as a purge. He continued well till the 6th of June following, when he first felt a pain in that hand and arm; for which he bathed in a river that evening, supposing that it had been a rheumatic complaint. The next day he was sick; and in the evening was seized with a violent vomiting, which continued all that night and till the middle of the next day, when it was succeeded by the hydrophobia. He was treated with the warm bath; had a purgative elyser 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 cataplasmata cyniwo, to which was added an ounce of opium. An embrocation was applied to the region of the stomach with continued friction, consisting of half an ounce of spirit of sal ammoniac, ten drams of olive oil, six drams of oil of amber, and ten drams of laudanum. Two ounces of strong mercurial ointment were rubbed upon the shoulders and back; and as a further means of inducing a ptyalism speedily, he received the smoke of cinnabar into the mouth by throwing a dram of that substance now and then upon a hot iron: he was also directed to take every four hours a bolus of 15 grains of musk, three grains of 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 inefficacy of this pretended specific: which will, it is hoped, create a due degree of caution in those to whom they who are so unfortunate as to be bit by a mad animal may commit themselves. Another remedy may also be mentioned as having had the reputation of being sometimes successful in this disease; which is chiefly employed in different parts of India, particularly in the territory of Tanjore. The medicine to which we now allude contains indeed several articles which are altogether unknown in our materia medica: but it contains at least one very powerful substance well known to us, viz. arsenic. This medicine, known by the name of the Snake Pills, as being principally employed against the bite of the most venomous snakes, is directed to be prepared in the following manner:

Take white arsenic, of the roots of nelli navi, of nevi visham, of the kernels of the ner 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 East India practitioners, it cannot be said that we have authentic evidence of its want of success, it can as little be pretended that there is indubitable evidence of its efficacy in any instance; and it is by no means improbable, that it will be found equally inefficacious with others at one time considered as infallible.

Of the great variety of remedies which have had their day of reputation, there is not one which has not possessed the credit, some time or other, of preventing the noxious effects arising from the bite of a mad dog. A more adequate experience has with all of them discovered the deception. It was above observed, that rabies is by no means the infallible consequence of being bit by a mad animal; and that of between 22 and 30 persons who were bit by the dog which gave the fatal wound to one of Dr Vaughan's patients, not one felt the least ill effect but himself. "In the above number (says the doctor) were some who took the Ormskirk medicine; others went to the salt water; and part of them used no remedy, who yet fared equally well with the most attentive to their injury. The same thing has often happened before; and much merit, I doubt not, has been attributed to the medicine taken, from that celebrated one of Sir George Cobb down to the infallible one which my good Lady Bountiful's receipt-book furnishes."

From all that has been said, the reader will judge how far the hydrophobia is capable of being subdued by any of the medicinal powers which have yet been tried. Some eminent physicians assert that it is totally incurable; and allege that the instances recorded by different authors of its cure have not been the genuine kind, but that which comes on spontaneously, and which is by no means so dangerous. Indeed two of Dr Wolf's patients recovered, where the disease seems to have been perfectly genuine: but in these the poison seemed to vent itself partly on some other place besides the nervous system. In one the blood was evidently infected, as it had an abominable odor; and the other had a violent pain and swelling in the belly. In all the others, it seemed to have attacked only the nervous system; which perhaps 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 crassamentum. He affirms, however, that the duodenum appears to be one of the parts first and principally affected; and as it is not inflamed, it would seem that the affection it sustains must arise from the vitiated state of its juices.

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

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

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

But whatever plan may be pursued in the hopes of curing this dreadful malady after any of the symptoms have made their appearance, we ought, in every instance, to direct our immediate care to prevention, as being perhaps the only real ground of hope: And the most certain and efficacious way of preventing the ill consequences, is instantly (if it can be done) to cut out the piece that happens to be bitten. Dr James, indeed, says, that he would have little opinion of cutting or cauterizing, if ten minutes were suffered to elapse from the receiving of the bite before the operation was performed. But in an inaugural dissertation lately published at Edinburgh by Dr Parry, the author is of opinion that excision will be of use a considerable time after the bite is received. He adopts this opinion from what happens in the smallpox, where the blood does not seem to receive the infection till some days after inoculation has been performed. A second inflammation, he tells us, then takes place, and the infection is conveyed into the blood. In like manner, when the hydrophobic infection is about to be conveyed into the blood, according to him, the wound, or its cicatrix, begins again to be inflamed; and it is this second inflammation which does all the mischief. Excision, or the cautery, will therefore be effectual any time between the bite and the second inflammation of the wound. Without implicitly trusting to this doctrine, however, or considering it as in any degree ascertained in what manner the poison diffuses itself, by what marks its progress may be known, or how soon the system may be irremediably 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. sp. 2.

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

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

ORDER IV. VESANIAE.

Paranoiae, Vog. Class IX. Deliria, Sauv. Class VIII. Ord. III. Sag. Class XI. Ord. III. Ideales, Lin. Class V. Ord. I.

AMENTIA.

Folly, or Idiotism.

Amentia, Sauv. gen. 233. Vog. 337. Sag. 346. Morosis, Lin. 106. Stupiditas, Morosis, Fatuitas, Vog. 336. Amnesia, Sauv. gen. 237. Sag. 347. Oblivio, Lin. 107. Vog. 338. Memoriae debilitas, Junck. 120.

MELANCHOLIA.

Melancholy Madness.

Melancholia, Sauv. gen. 234. Lin. 71. Vog. 332. Sag. 347. Boerh. 1089. Junck. 121. Demonomania, Sauv. gen. 236. Sag. 348. Demonia, Lin. 69. Vesania, Lin. 70. Paraphobia, Lin. 75. Athymia, Vog. 329. Delirium melancholicum, Hoffm. III. 251. Frotomania, Lin. 82. Nostalgia, Sauv. gen. 226. Lin. 83. Sag. 338. Junck. 125. Melancholia nervea, Cl. Lorry de melancholia, P. I.

MANIA.

Raving or Furious Madness.

Mania, Sauv. gen. 235. Lin. 68. Vog. 331. Sag. 349. Boerh. 1118. Junck. 122. Battie on Madness. Paraphrosyne, Lin. 66. Amentia, 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 Battie, is a false perception; and under this general character may be comprehended all kinds of what is called madness, from the most silly stupidity and idiotism to the most furious lunacy. Frequently the different kinds of madness are changed into each other by the casual excitement of some passion: thus, an idiot may become furiously mad, by being put in a violent passion; though this does not so often happen as the change of melancholy into the raving madness, and vice versa.

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

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

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

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

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

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

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

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

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

Dr Monro assures us, that the evacuation by vomiting is infinitely preferable to any other: the prodigious quantity of phlegm with which the patients in this disease abound, he says, is not to be overcome but by repeated emetics; and he observes, that the purges have not their right effect, or do not operate to so good purpose, until the phlegm be broken and attenuated by frequent emetics. He mentions the case of a gentleman who had laboured under a melancholy for three years, from which he was relieved entirely by the use of vomits and a proper regimen. Increasing the discharge by urine, is also of the greatest moment, especially when any degree of fever is present. The cutaneous discharges are also to be promoted; for which purpose the hot bath is of the highest service in maniacal cases. Hoffman asserts, that he has seen numerous instances, both of inveterate melancholy and raging madness, happily cured by means of warm bathing; bleeding and nitrous medicines having been premised. Camphor has also been highly commended; but, if we can believe Dr Locker of Vienna, not very deservedly. Having found very good effects from a solution of this medicine in vinegar, he took it for granted that all the success was owing to the camphor; therefore, in order to give it a fair trial, he selected seven patients, and gave it in large doses of half a dram twice a-day. This was continued for two months, and the doctor was surprised to find that only one of his patients received any benefit. He then returned the other six back to the camphorated julep made with vinegar, and in a few weeks four of them recovered the use of their reason. This inclined him to think that the virtue depended solely on the vinegar, and accordingly he began to make the trial. Common vinegar was first given; but after a little while he fixed on that which had been distilled, and gave about an ounce and a half of it every day; the patients having been previously prepared by bleeding and purging, which was repeated according as it was found necessary. He gives a list of eight patients who were cured by this method; some in six weeks, others in two months, and none of them took up more than three months in perfecting the cure. He does not indeed give the ages of the patients, nor mention the circumstances of the cases; he only mentions the day on which the use of the vinegar was begun and the day on which they were discharged; and he adds, that they all continued well at the time of his writing.

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

Both reason and experience show the necessity of confining such as are deprived of their senses; and no small share of the management consists in preventing them from hurting either themselves or others. It has sometimes been usual to chain and to beat them; but this is both cruel and absurd; since the contrivance called the strait waistcoat answers every purpose of restraining 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 anything that is required. The physician, however, should never deceive them in any thing, but more especially with regard to their distemper: for as they are generally conscious of it themselves, they acquire a kind of reverence for those who know it; and by letting them see that he is thoroughly acquainted with their complaint, he may very often gain such an ascendant over them that they will readily follow his directions.

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

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

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

**Genus LXVIII. ONEIRODYNIUM.**

**Uneasiness in Sleep.**

*Somnium, Vog. 339.* *Sommambulismus, Sauv. gen. 221.* *Lin. 77.* *Sag. 333.* *Hypnobataxis, Vog. 340.*

*Noctambulatio,* Noctambulatio, Junck. 124. Ephialtes, Sauv. gen. 138. Lin. 163. Sag. 245. Incubus, Vog. 221. Junck. 50.

The greatest uneasiness which people feel in sleep is that commonly called the incubus or night-mare. Those seized with it seem to have a weight on their breasts and about their precordia. Sometimes they imagine they see spectres of various kinds which oppress or threaten them with suffocation. Neither does this uneasiness continue only while they are asleep; for it is some time after they awake before they can turn themselves in their beds or speak; nay, sometimes, though rarely, the distemper has proved mortal.—The incubus rarely seizes people except when the stomach is oppressed with aliment 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. Class X. and Class VIII. Sag. Class III. Deformes, Lin. Class X.

Order I. Marcores.

Macies, Sauv. Class X. Order I. Sag. Class III. Order I. Emaciantes, Lin. Class 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.

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

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

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

Order II. Intumescentiae.

Intumescentiae, Sauv. Class X. Ord. II. Sag. Class III. Ord. II. Tumidosi, Lin. Class X. Ord. II.

Genus LXXI. Polysarcia.

Corpulency.

Polysarcia, Sauv. gen. 279. Lin. 213. Vog. 540. Sag. 160. Scatiles, Vog. 390.

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

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

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

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

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

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

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

But Dr Fothergill observes, that a strict adherence to vegetable diet reduces exuberant fat more certainly than any other means that he knows; and gives two cases in which this regimen succeeded remarkably well. The famous Dr Cheyne brought himself down in this way, from a most unwieldy bulk to a reasonable degree of weight; as he himself informs us. It deserves, however, to be remarked, that every practice for the removal or prevention of fatness must be used with great caution and prudence; for not a few, anxious to prevent this affection, have had recourse to a regimen and to medicine which have proved fatal. This has particularly arisen from the excessive use of acids, probably operating by entirely destroying the action of the chylopoietic viscera.

Genus LXXII. PNEUMATOSIS.

Emphysema, or Windy Swelling.

Pneumatosis, Sauv. gen. 280. Vog. 391. Sag. 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 insinuates 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. Sag. 118. Boerh. 226. Junck. 87. Affectio tympanitica, Hoffm. III. 339. Meteorismus, Sauv. gen. 292.

This is an inflation of the abdomen, and is of two kinds: 1. That in which the flatus is contained in the intestines, in which the patient has frequent explosions of wind, with a swelling of the belly commonly unequal. 2. When the flatus is contained in the cavity of the abdomen; in which case the swelling is more equal, and the belly sounds when struck, without any considerable emission of flatus. Of these two, however, the former disease is by much the most common; 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 stomach and intestines. It happens frequently to women after abortion; to both sexes after the suppression of the hemorrhoids; and sometimes from tedious febrile disorders injudiciously treated.

Prognosis. This disease is generally very obstinate, and for the most part proves fatal by degenerating in to an ascites. Sometimes, if the patient be healthy and strong, the disease may terminate favourably, and that the more readily if it has followed from some disorder. A hectic consumption, dry cough, and emaciated countenance in a tympany, with a swelling of the feet, denote approaching death in a very short time.

Cure. With a view to the prevention of this affection, it is necessary, in the first place, to avoid, as far as it can be done, causes giving rise to an uncommon extrication of air; by preserving the proper tone of the alimentary canal. After the affection has taken place, the indications are, first, to expel the air already extricated and confined in different cavities; and, secondly, to prevent further accumulation. On these grounds different remedies are employed. The cure, however, is principally attempted by carminative, resolvent, and stomachic medicines, gentle laxatives, and at last tonics, especially chalybates. In the Edinburgh Medical Essays, vol. i. we have a very remarkable history of a tympany by Dr Monro senior. The patient was a young woman of 22 years of age, who fell into the distemper after a tertian ague, in which she was badly treated. She became a patient in the Edinburgh Infirmary the 24th of March 1730; took several purgatives, and some doses of calomel; used the warm bath; and had an 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 strained; 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 distended, 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 costive, had her menses at irregular periods, but no oedematous swellings appeared in the feet or anywhere else. In this situation she continued from the time of her admission till the 21st of June, during which interval she had only menstruated twice. Throughout the 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 medicines of the strongest kinds, such as asafoetida, oleum corn. cerv. &c. mixed with soap, were given in large doses, accompanied with the hotter antiscorbutics as they are called, as horseradish and ginger-root infused in strong-ale with steel. The patient was ordered to use frequent and strong frictions to all the trunk of her body and extremities, and to use moderate exercise. Immediately before the menses began to flow, Physomelsters of the same kind of medicines were injected. The menses were in sufficient quantity; but as soon as they ceased, her belly increased in its circumference four inches and a half, but soon subsided. She then complained of pains, which a gentle sweat carried off. Borborygmus were for the first time observed on the same day, June 25th; and having taken some tinctura sacra at night, she passed a small quantity of blood next day by stool. This was the first appearance of the return of the hemorrhoids, to which she had been formerly subject.

The two following days her saponaceous, 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.

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

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

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 Dropsy. Millman Animadversiones de hydropoe 1779. Phlegmatia, Sauv. gen. 282. Angina aquosa, Boerh. 791.

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

The remedies employed with these intentions are much the same with what are employed against the more more important genus of ascites. Only it may be here noticed, that in anaesthesia it has by many been recommended to scarify the feet and legs. By this means the water is often discharged; but the operator must be cautious not to make the incisions too deep; they ought barely to penetrate through the skin; and 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 transversely; as they not only discharge better, but are also longer in healing, than when made longitudinally.

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

HYDROCEPHALUS.

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 Apoplexia Hydrocephalica, chiefly in the water being collected in the external parts of the head, whereas the former is entirely within the skull. In the fifth volume of the Medical Observations we have an account of a very extraordinary case of this kind. The patient was a child only of a few days old, and had a tumor on his head about the size of a common tea-cup, which had the appearance of a bladder distended with water; near the apex was a small opening, through which a bloody serum was discharged. In other respects the child was healthy. No application was used but a piece of linen dipt in brandy. The tumor continued to increase for many months; at the end of which time the membrane containing the water appeared equally thick with the other part of the scalp, except at one place about the size of a shilling, which continued thin, and at times appeared as if it would burst. He remained in this situation for about 17 months, when the circumference of the head was 20 inches, the base 16½, the middle 18½; and from the base to the apex near 8½. The water was then drawn off, and the child died in two days. Almost all other cases of this distemper have proved fatal; the sutures of the skull generally give way, and the whole external part of the head is equally enlarged; but in the instance just now given there was a deficiency of part of the bones. Although, however, in some instances, where the head is thus enlarged to an enormous size, the water is exterior to the brain, and therefore entitled to the appellation of hydrocephalus exterior, yet much more frequently in those instances where there is a manifest separation of the bones of the cranium at the sutures, the water is still contained within the ventricles; and accordingly the disease may be much more properly distinguished into the acute and chronic hydrocephalus, than as is commonly done into the internal and external. Although the latter be much slower in its progress, sometimes subsisting even for years, yet it is equally difficult of cure with the former, and very often it proves fatal in a few days if the water be drawn off by an artificial opening, which may be very easily performed by a mere puncture with a common lancet, without either pain or any immediate hazard from the operation itself, although the water be lodged in the ventricles; for these are distended to an enormous size, and the substance of the brain almost totally destroyed, so that hardly anything is to be punctured but membrane.

HYDRORACHITIS.

Spina Bifida.

Hydrorachitis, Sauv. gen. 287. Morgagni de sed. XII. 9. 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 vertebrae themselves, though generally considered as approaching to the nature of rachitis, is commonly referred to the article Surgery, which may be consulted with regard to this affection.

HYDROTHERAX.

Dropsy of the Breast.

Hydrotorax, Sauv. gen. 350. 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 stooping somewhat forwards. The pulse is very irregular, and has often remarkable intermissions. But the disease has been thought to be principally characterized by a sudden starting from sleep, in consequence of an almost inexpressible uneasy sensation referred to the breast, and attended with strong palpitation, which may probably arise from an affection either of circulation or of respiration.

That these symptoms are common attendants of this disease, is undeniable; and they are certainly the best characteristics of this affection with which we are yet acquainted: but it must be allowed that they are present in some cases where there is no water in the breast; and that in other instances where the disease exists, they are either altogether wanting, or occur only to a very slight degree. Certain diagnostics, therefore, of this disease still remain to be discovered.

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

GENUS LXXIX. ASCITES.

DROPSY of the Abdomen.

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

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

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

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

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

But another and much more sufficient cause for the production of dropsy is an obstruction of the circulation; and this may take place from polypi in the heart or large vessels, and hard swellings in the abdomen. Instances have been observed of a dropsy arising from steatomatous tumors in the omentum, and many more from a scirrhou liver or spleen, and from an infarction. Intumescence and obstruction of the mesenteric glands, by which means the lymph coming from the extremities is prevented from arriving at the heart. Scirrhosity of the liver, the most common cause of ascites, probably operates by augmenting effusion, in consequence of its preventing the return of the venous blood, the greater part of the veins from the abdomen going to the formation of the vena portatium.

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

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

It is moreover evident from experiments, that, in a healthy state, not only water is not deposited in the cavities, but that if it is injected into them it will be absorbed, unless some laxity of the solids has already taken place. Dr Musgrave injected into the right side of the thorax of a dog four ounces of warm water; whence a difficulty of breathing and weakness immediately followed. But these symptoms continually lessened, and in the space of a week the animal seemed to be in as good health as before. Afterwards he injected 16 ounces of warm water into the left cavity of the thorax in the same dog; the same effects followed, together with great heat, and strong pulsation of the heart; but he again recovered in the space of a week. Lastly, He injected 18 ounces of water into one side of the thorax, and only six into the other: the same symptoms followed, but vanished in a much shorter time; for within five days the dog was restored to perfect health. During this time, however, he observed that the dog made a greater quantity of urine than usual.

The remote causes of dropsy are many and various. Whatever relaxes the solids in such a manner as to give an occasion of accumulation to the serous fluids, disposes to the dropsy. A lazy indolent life, rainy wet weather, a swampy or low soil, and every thing which conduces to vitiate the viscera, or insensibly to produce obstructions in them, paves the way for a dropsy. Hence those are ready to fall into the disease who use hard and 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 dropsy arises from a scirrhus of the liver or spleen, or any of the other viscera, the prognosis must always be unfavourable, and also when it arises from disorders of the lungs. Neither is the case more favourable to those in whom the small vessels are ruptured, and pour out their liquids into the cavity of the abdomen. Those certainly die who have polypi in the vessels, or tumors compressing the veins and vessels of the abdomen. A dropsy arising from obstructions in the mesenteric glands is likewise difficult to cure, whether such obstructions arise from a bad habit of body, or from any other cause; if we can, however, by any means remove the disease of the glands, the dropsy soon ceases. But in those who fall into dropsy without any disease preceding, it is not quite so dangerous; and even though a disease has preceded, if the patient's strength be not greatly weakened, if the respiration be free, and the person be not affected with any particular pain, we may entertain great hopes of a cure. But where a great loss of blood is followed by a fever, and that by a dropsy, the patients almost always die, and that in a short time: those, however, are very frequently cured who fall into this disease without any preceding 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 per- 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 dropsy consist in gently evacuating the waters by means of diuretics. But the efficacy of these is generally very doubtful. Dr Freind has long ago observed, that this part of medicine is of all others the most lame and imperfect; but a French physician, Mr Bacher, lately discovered, as he alleges, a method of making the diuretics much more successful. His reputation became at last so great, that the French king thought proper to purchase his secret for a great sum of money. The basis of his medicine was the black hellebore root, the malignant qualities of which he pretended to correct in the following manner: A quantity of the dried roots of black hellebore were pounded, and then put into a glazed earthen vessel, and afterwards sprinkled with spirit of wine. They were suffered to stand for twelve hours, stirring them about twice or thrice during that space of time. They were then sprinkled again, and at last good Rhenish wine was poured on till it stood six fingers above the roots. The mixture was frequently agitated with a wooden spatula; and as the wine was imbibed by the roots, more was poured on, so as to keep it always at the same height for 48 hours. The whole was then put on the fire and boiled for half an hour, after which the decoction was violently pressed out; the same quantity of wine was added as at first, and the mixture boiled as before. After the second expression the woody residuum was thrown away as useless. Both the strained liquors were then mixed together with two parts of boiling water to one of the decoction. The whole is afterwards evaporated in a silver vessel to the consistence of a syrup. One part of the extract is again mixed with two parts of boiling water, and the whole inspissated as before.—By this means, says he, the volatile nauseous 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 invasivating 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 Daigman 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 anasarca following intermittent fevers. The second class contained those who had an anasarca, together with some degree of ascites, arising from tedious febrile disorders. All these were cured; but these two classes consisted of such cases as are most easily removed. But the third contained six who were seized with a most violent anasarca and ascites, after being much weakened by tedious disorders, and of consequence in whom the disease was very difficult to be cured. Even of these, however, four were cured, and the other two died. The body of one of these being dissected, both sides of the cavity of the thorax were found to be full of a blackish-red water. The lungs were unsound; there was a polypous concretion in the right ventricle of the heart; the liver and spleen were hard, and of a preternatural bulk; and the glands of the mesentery were obstructed and infarcted. In the other, the liver and pancreas were scirrhous, and the spleen very hard.

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

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

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

If the patient be not very much debilitated, he is sometimes treated with the purging waters, and a dose of jalap and calomel alternately. On the intermediate days he gets a saline mixture, with 40 or 60 drops of acetum scillitium every sixth hour; drinking with the purgatives oat-gruel and some thin broths. That he might the better ascertain what share the liquids given along with the medicines had in producing a copious flow of urine, he sometimes gave the medicines in the beginning of the 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, lest, by following this course, the strength of the sick might be too much reduced, he then began his course of diuretic medicines, giving large quantities of barley water with a little sal diureticus; by which means, sometimes in the short space of 48 hours after the course was begun, the urine flowed out in very large quantity: but as saline drinks are very disagreeable to the taste, a drink was composed purposely for hydropic persons, of half an ounce of 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 hydropic cases. In the Acta Bono-niensia, 15 cases of hydropic patients are related who were cured only by taking half an ounce of cream of tartar daily. But it is remarkable, that by these very patients the cream of tartar was taken for 20, 30, nay 40 days, often without any perceptible effect; yet when dissolved in a large quantity of water, it showed its salutary effects frequently within as many hours, by producing a plentiful flow of urine. This liquor is now the common drink of hydropic patients in the hospital above mentioned, of which they drink at pleasure along with their medicines.

Among purgative medicines Sir Francis Milman recommends the radix senecae; but says the decoction of it, according to the Edinburgh Pharmacopoeia is too strong, as he always found it excite vomiting when prepared as there directed, and thus greatly to distress the patients: but when only half an ounce or six drams of the root are used to a pound of decoction, instead of a whole ounce as directed by the Edinburgh college, he finds it an excellent remedy; and though it may sometimes induce a little vomiting, and frequently a nausea, yet it seldom failed to procure nine or ten stools a day, and sometimes also proved diuretic. But we must take care not to be too free in the use of seneca, 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 dropsy 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 scirrhus liver; while, on the other hand, in one who had the mesenteric glands obstructed, along with a scirrhosity of the liver and vitiated state of the lungs, the most powerful diuretics proved ineffectual. In some cases Sir Francis Milman thinks the kidneys may be so pressed with the weight of the water, as to be unable to perform their office. With regard, however, to diuretics in general, it may be remarked, that the operation of none of them can be certainly depended upon. In particular constitutions, and at particular times, one will be observed to succeed, after another, though commonly much more powerful, has been tried in vain. Accordingly various articles of this kind are often used in succession. Recourse is particularly often had to the root of taraxacum, of colchicum, and of squills; the latter, especially when combined with calomel, is often found to be a very powerful diuretic. And indeed mercury in different forms, probably from acting as a deobstruent, is often of very great use in dropsical 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 cinehona, with some of the warm aromatics, and a due proportion of 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.

HYDROMETRA.

Dropsy of the Uterus.

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

HYDROCELE.

Dropsy of the Scrotum.

Oscheocoele, Sauv. gen. 41. Vog. 388. Oscheophyma, Sag. 44. Hydrops scroti, Vog. 389. Hydrops testium, Boerh. 1227.

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

PHYSCONIA.

Swelling of the Belly.

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

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

RACHITIS.

The Rickets.

Rachitis, Sauv. gen. 294. Lin. 212. Vog. 312. Sag. gen. 120. Boerh. 1480. Hoffm. 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 slowness, debility, and tottering in his motion, which soon brings on a constant desire of sitting, and afterwards of lying down; insomuch that nothing at last is moveable but the neck and head. As they grow older, the head is greatly enlarged, with ample sutures; the thorax is compressed on the sides, and the sternum rises up sharp, while the extremities of the ribs are knotty. The abdomen is protuberant, and the teeth black and carious. In such patients as have died of this disease, all the solids appear soft and flaccid, and the fluids dissolved and mucous.

Causes. The rickets may proceed from 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 farinaeuous 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 viscid 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 vertebre 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 shirt dipped in the oil is put upon the body of the patient: this brings on a more violent and sensible fever than any of the former unctions; and is continued till the cure be completed, which it commonly is in a short time.

A German physician, Dr Strack, has lately published a paper, in which he recommends the filings of iron as a certain remedy in the rickets. This disease, he observes, in general begins with children when they are about 16 months old. It is seldom observed with children before they be one year old, and seldom attacks them after they pass two; and it is very generally worse where it begins early than where it begins late. For effecting a cure, it is, he affirms, a matter of the utmost consequence to be able to distinguish very early, whether a child will be afflicted with rickets or not. And this, he assures us, may be determined by the following symptoms: Paleness and swelling of the countenance; and in that part of the cheeks which should naturally be red, a yellow colour approaching to that of sulphur. When that is the case, he directs that a medicine should be immediately had recourse to which will retard the further progress of the disease, and remove what has already taken place. For this purpose, he advises that five grains of the filings of iron, and as much rhubarb, should be rubbed up with ten grains of sugar, and given for a dose every morning fasting, and every evening an hour before supper. But if considerable looseness should be produced, it will be necessary, at first, to persist in the use of one dose only every day.

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

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

Mr Bonhome de 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. Class X. Ord. V. Sag. Class III. Ord. V.

SCROPHULA.

King's Evil.

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

Description. This disease shows itself by hard, scirrhouss, and often indolent tumors, which arise by degrees in the glands of the neck, under the chin, armpits, and different parts of the body, but most commonly in the neck, and behind the ears. In process of time, the cellular substance, ligaments of the joints, and even the bones themselves, are affected. In scrophula the swellings are much more moveable than those of the scirrhous kind; they are generally softer, and seldom attended with much pain; they are tedious in coming to suppuration; are very apt to disappear suddenly, and again to rise in some other part of the body. We may likewise mention as characteristic circumstances of this disease, a remarkable softness of the skin, a kind of fulness of the face, generally with large eyes, and a very delicate complexion.

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

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

Cure. It was long supposed that scrophula depended upon an acid acrimony of the fluids; and this, it is probable, gave rise to the use of burnt sponge, different kinds of soap, and other alkaline substances, as the best remedies for acidity. But although a sourness of the stomach and prima via 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 acescence 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 tumors, 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 rosacea in the face; a complaint which it is often difficult to remove, and which is extremely disagreeable to the fair sex.

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

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

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

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

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

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

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

But, after all, the best form under which the cicuta can, we think, be exhibited, is that of powder from the leaves. This, either under the form of powder or made into pills, may be given at first to the extent of four or five grains, and the dose gradually rising till it amount to 15 or 20 grains twice or thrice a day. Given to this extent, particularly when conjoined with cinchona, it has often been found of great service in 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 Gillsland, have been much recommended in scrofula, and sometimes productive of benefit. Recourse has sometimes also been had with advantage to zinc, iron, and barytes, particularly muriate of barytes. But as well as in rachitis, no remedy has been found more efficacious in scrofula than cold bathing, especially sea-bathing.

SIPHYLIS.**

*Lues Venerea,* or French Pox.

Siphyllis, Sauv. gen. 3086. Lin. 6. Vog. 319. Sag. 126.

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

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

The venereal infection, however, cannot, like the contagious miasmata of the smallpox and some other diseases, be carried through the air, and thus spread from place to place: for unless it is transmitted from the parents to the children, there is no other way of contracting the disease but from actual contact with the infectious matter. Thus, when a nurse happens to labour under the disease, the infant that she suckles will receive the infection; as, on the other hand, when the child is infected, the nurse is liable to receive it: and there have even been instances known of lying-in women being infected very violently, from having employed a person to draw their breasts who happened to have venereal ulcers in the throat. It may be caught by touching venereal sores, if the cuticle be abraded or torn: and in this way accoucheurs and midwives have sometimes been infected severely. Dr Macbride says, the most inveterate pox he ever saw was caught by a midwife, who happened to have a whitlow on one of her fingers when she delivered a woman ill of the lues venerea.

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

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

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

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

Another strong sign of the confirmed lues is often afforded from certain deep-seated nocturnal pains, particularly of the 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. Gummata in the fleshy parts, nodes in the periosteum, ganglia upon the tendons, tophi upon the ligaments, exostoses upon the bones, and fisti 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 siphilitic virus, they are very seldom painful, or tend to inflame and suppurate, whereas those that are venereal usually do, and if they lie upon a bone generally bring on a caries.

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

These then are the principal and most evident signs of the confirmed lues. There are others which are more equivocal, and which, unless we can fairly trace them back to some that are more certain, cannot be held as signs of the venereal disease: Such are, 1. Obstinate inflammations of the eyes, frequently returning, with great heat, itching, and ulceration of the eyelids. 2. A singing and hissing noise in the ears, with ulcers or caries in the bones of the meatus auditorius. 3. Obstinate headaches. 4. Obstinate cutaneous eruptions, of the itchy or 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 siphylis, it is often very difficult to say whether certain symptoms, remaining after the ordinary modes of cure have been employed, be siphilitic or not. Very frequently, as appears from the sequel, nocturnal pains, ulcerations, and the like, remaining after a long course of mercury has been employed, are in no degree of a venereal nature, but are in reality to be considered as consequences rather of the remedy than 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 ease is venereal, we are to consider, first of all, whether it be of a longer or shorter date; for the more recent it is, it will, ceteris paribus, be less difficult to remove. But there are other circumstances which will assist us in forming a prognostic as to the event. As,

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

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

3. The habit of body. Persons who have acid juices will be liable to suffer more from the venereal poison than such as have their blood in a milder state; hence, when people of a scorbutic 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 distemper, than in one of a sound and healthy constitution. For as the original disease is increased by the accession of the venereal poison, so the lues is aggravated by being joined to an old disorder. The more numerous the symptoms, and the more they affect the bones, the more difficult the cure. Of all combinations the union of syphilis with scrofula is perhaps the most difficult to overcome; but if the acrimony should seize on the nobler internal parts, such as the brain, the lungs or the liver, then the disease becomes incurable, and the patient will either go off suddenly in an apoplectic fit, or sink under a consumption.

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

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

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

Corrosive sublimate, or the murias hydrargyri corrosivus, is one of the most active of all the mercurial preparations, 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 Siph looking into Wiseman, that this is an old medicine, though seldom given by regular practitioners. How it came to be introduced into so remote a part of the world as Siberia, is not easily found out; but Dr Clerc, author of the Histoire Naturelle de l'Homme Malade, assures us, that the sublimate solution has been in use there time out of mind.

It appears to have been totally forgotten in other places, until of late years, when Baron Van Swieten brought it into vogue; so that at one period, if we may credit Dr Locker, they used no other mercurial preparation at Vienna. The number of patients cured by this remedy alone in the hospital of St Mark, which is under the care of this gentleman, from 1754 to 1767 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 these, by a remedy first recommended by Dr Plenck, and since improved by Dr Saunders; consisting of mercury united with mucilage of gum arabic, which is said to render its exhibition perfectly mild and safe. For particulars, we refer to Dr Saunders's treatise.

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

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 pitan; 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 Astrue, 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 submuriæs 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 obstinate ulcerations and severe pains, benefit has often been derived from the use of opium: but there is little reason to believe, as has been held by some, that of itself it 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 resisting the use of mercury, a complete cure has in many instances been obtained from the use of the root of the mezereon, the daphne mezereum of Linnæus. This article has been chiefly employed under the form of decoction; and it now appears that it is the basis of an article at one time highly celebrated in venereal complaints, under the title of Lisbon diet drink. But, upon the whole, these sequelæ 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 sequelæ, 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. Rouppe de Morbis Navigantium.

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

The symptoms of the scurvy, like those of every other disease, are somewhat different in different subjects, according to the various circumstances of constitution; and they do not always proceed in the same regular course in every patient. But what is very remarkable in this disease, notwithstanding the various and immense load of distress under which the patients labour, there is no sickness at the stomach, the appetite keeps up, and the senses remain entire almost to the very last: when lying at rest, scorbutic patients make no complaints, and feel little distress or pain; but the moment they attempt to rise or stir themselves, then the breathing becomes difficult, with a kind of straitness or catching, and great oppression, and sometimes they have been known to fall into a syncope. This catching of the breath upon motion, with the loss of strength, dejection of spirit, and rotten gums, are held as the essential or distinguishing symptoms of the disease. The skin is generally dry, except in the very last stage, when the patients become exceedingly subject to faintings, and then it grows clammy and moist: in some it has an anserine appearance; but much oftener it is smooth and shining; and, when examined, is found to be spread over with spots, not rising above the surface, of a reddish, bluish, livid or purple colour, with a sort of yellow rim round them. At first these spots are for the most part small, but in time they increase to large blotches. The legs and thighs are the places where they are principally seen: more rarely on the head and face. Many have a swelling of the legs, which is harder, and retains the impression of the finger longer than the common dropsical or truly oedematous swellings. The slightest wounds and bruises, in scorbutic habits, degenerate into foul and untoward ulcers; and the appearance of these ulcers is so singular and uniform, that they are easily distinguished from all others. Scorbutic ulcers afford no good digestion, but give out a thin and fetid ichor mixed with blood, which at length has the appearance of coagulated gore lying caked on the surface of the sore, not to be separated or wiped off without some difficulty. The flesh underneath these sloughs feels to the probe soft and spongy, and is very putrid. Neither detergents nor escharotics are here of any service; for though such sloughs be with great pains taken away, they are found again at the next dressing, where the same sanguineous putrid appearance always presents itself. Their edges are generally of a livid colour, and 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 distraction of the sensible fibres by the extravasated blood being forced into the interstices of the periosteum and of the tendinous and ligamentous parts; whose texture being so firm, the fibres are liable to higher degrees of tension, and consequently of pain.

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

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

Causes. The term scurvy has been indiscriminately applied, even by physicians, to almost all the different kinds of eutaneous foulness; owing to some writers of the last century, who comprehended such a variety of symptoms under this denomination, that there are few chronic distempers which may not be so called, according to their scheme: but the disease here meant is the true putrid scurvy, so often fatal to seamen, that with many it has got the name of sea-scurvy, though it be a disease frequently occurring on shore, as was experienced by the British garrisons of Boston, Minorca, and many other places. Indeed no disease is perhaps more frequent or more destructive to people 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 dissecting scorbutic subjects, sufficiently show that the scurvy may, with great propriety, be termed a disease of the blood.

Dr Lind has, in a postscript to the third edition of his treatise on the scurvy, given the result of his observations drawn from the dissection of a considerable number of victims to this fatal malady; from which it appears that the true scorbutic state, in an advanced stage of the distemper, consists in numerous effusions of blood into the cellular interstices of most parts of the body, superficial as well as internal; particularly the gums and the legs; the texture of the former being almost entirely cellular, and the generally dependent state of the latter, rendering these parts of all others in the whole body, the most apt to receive and retain the stagnant blood, when its crisis comes to be destroyed; and when it loses that glutinous quality which, during health, hinders it from escaping through the pores in the coats of the blood-vessels or through exhalant extremities.

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

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

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

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

Sir John Pringle, however, is of a very different opinion. He "is persuaded, after long reflection, and the opportunities he has had of conversing with those who to much sagacity had joined no small experience in nautical practice, that upon an examination of the several articles which have either been of old approved, or have of late been introduced into the navy, it will appear, that though these means may vary in form and in mode of operating, yet they all some way contribute towards preventing putrefaction; whether of the air in the closer parts of a ship, of the meats, of the water, of the clothes and bedding, or of the body itself."

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

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

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

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

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

Thus much being promised, 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 distempered 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 proposed. It must, however, be allowed, that Dr Lind is by no means the only writer who is disposed to consider this disease as not referable to the condition of the circulating fluids. In a late ingenious treatise on this subject by Sir F. Milman, he strenuously contends, that the primary morbid affection in this complaint is a debilitated state of the solids arising principally from want of aliment. But his arguments on this subject, as well as those of Dr Lind, are very ably answered by a still later writer on this subject, Dr Trotter, who has drawn his observations respecting it from very extensive experience, and who considers it as clearly established, by incontrovertible facts, that the proximate cause of scurvy depends on some peculiar state of the blood.—That this disease does not depend on a debilitated state of the solids, is demonstratively proved from numerous cases where every possible degree of debility occurs in the solids without the slightest appearance of scurvy. Dr Trotter, in the second edition of his Observations on the Scurvy, from the result of 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 causes. It is, therefore, a duty highly incumbent on officers commanding at sea, or in garrisons, to use every possible precaution; and, in the first place, to correct the coldness and moisture of the atmosphere by sufficient fires: in the next, to see that their men be lodged in dry, clean, and well ventilated births or apartments: thirdly, to promote cheerfulness, and enjoin frequent exercise, which alone is of infinite use in preventing the scurvy: fourthly, to take care that the clothing be proper, and cleanliness of person strictly observed: fifthly, to supply them with wholesome drink, either pure water or sound fermented liquors; and if spirits be allowed, to have them properly diluted with water and sweetened with 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 fleshy fibres retain any tolerable degree of firmness, the patient will recover; and that in a surprisingly short space of time, provided a pure air, comfortable lodgings, sufficient clothing, cleanliness, and exercise, lend their necessary aid.

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

It will now naturally occur to the reader, what those alimentary substances must be which bid the fairest faires 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 with jelly or mucilage, and which allow those nutritious parts to be easily developed; for though the viscera in scorbutic patients may be all perfectly sound, yet we cannot expect that either the digestive fluids or organs should possess the same degrees of power, which enable them, during health, to convert the crude dry farinacea, and the hard salted flesh of animals, into nourishment. We must therefore search for the antiscorbutic virtue in the tender sweet flesh of herbivorous animals; in new milk; and in the mucilaginous acid juices of recent vegetables, whether they be fruits, leaves, or roots.

The sour 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 supertartrite of potash, in order to abate the costiveness; 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 escharotics; but the dressing should consist of lint or soft rags, dipt 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. Be we 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 provisions: 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 1763; 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 sea antiscorbutic medicines yet found out; and if given in time, will, with proper attention to other things, I am persuaded, prevent the scurvy from making any great progress for a considerable time: but I am not altogether of opinion that it will cure it, in an advanced state, at sea."

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

The malt being thoroughly dried, and packed up in small casks, is carried to sea, where it will keep sound, in every variety of climate, for at least two years: when wanted for use, it is to be ground in a hand mill, and the infusion prepared from day to day, by pouring three measures of boiling water on one of the ground malt; the mixture being well 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 constiveness nevertheless prevails, gentle laxatives must be interposed from time to time, together with diaphoretics, and the topical assistants, fomentations and gargles, as in the common way of management.

Captain Cook was also provided with a large stock of sour kraut; (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 kraut, 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 kraut arrived. The scurvy at one period broke out among them with very alarming appearances; but by the seasonable arrival of a quantity of sour kraut, it was effectually overcome. Care, however, must be bestowed, that this article be properly prepared and properly kept. When due attention is paid to these particulars, it may be preserved in good condition for many months; and is considered both by sailors and soldiers as a very acceptable addition to their salt provisions. But when served out to them in a putrid state, it is not only highly disagreeable to the taste, but probably also pernicious in its effects.

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

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

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

Newly brewed spruce beer made from a decoction of the tops of the spruce fir and molasses, 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 scurvy, as a distinct species of disease from that which has been now described; but no writer has yet given a description so clear as to enable us to distinguish it from the various kinds of cutaneous foulness and eruption, which indeed are vulgarly termed scorbutic, but which are akin to the itch or leprosy, and for the most part require mercurials. These, however, are very different diseases from the true scorbutus, which, it is well known, may prevail in certain situations on land as well as at sea, and is in no degree to be attributed to sea air.

ELEPHANTIASIS.

Elephantiasis, Sauv. gen. 302. Vog. 321. Sag. 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 scirrhouss, 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 swollen 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 sordid 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 supercicies is covered with very thin scales, of a dull whitish colour, seemingly much finer, but not so white as those observed in the lepra Gracorum. The whole limb is overspread with tubercles, interspersed with deep fissures; sometimes the limb is covered with a thick moist scaly 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 oftenest endeavoured to be remedied by timely application; that by congestion, not being so conspicuous, is generally either neglected or attempted to be concealed, until perhaps it be too late to be cured, at least unless the patients would submit to a longer course of medicine and stricter regimen of diet than they are commonly inclined to do.

Several incipient disorders by fluxion have been known to yield to an antiphlogistic method, as bleeding, refrigerant salts in the saline draughts, and a solution of crystals of tartar in water, for common drink, (by this means endeavouring to precipitate part of the pectoral matter, perhaps too gross to pass the pores by the kidneys); and when once the fever is overcome, cinchona combined with sassafras, is the remedy principally to be relied on. The only topical medicine prescribed by Dr Heberden, was an attenuating embrocation of brandy and alkaline spirit. By the same method some confirmed cases have been palliated. But, excepting in one patient, Dr Heberden never saw or heard of a confirmed elephantiasis radically cured. He adds, however, that he never met with another patient possessed of prudence and perseverance enough to prosecute the cure as he ought. Genus 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 unadvisable, a cure may sometimes be effected by others. In particular cases, purging mineral waters, the decoction of cinchona, the infusion of the cenanthre 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 Framboesia 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 sloughs or sordes appear, under which is a small red fungus, growing out of the cutis, increasing gradually to very different magnitudes, some less than the smallest wood strawberry, some as big as a raspberry, and others exceeding in size even the largest mulberries; which berries they very much resemble, being knobbed as these are.” These protuberances, which give the name to the disease, appear on all parts of the body: but the greatest numbers, and the largest sized, are generally found in the groins, and about the pudenda or anus, in the armpits, and on the face: when the yaws are very large, they are few in number; and when remarkably numerous, they are less in size. The patients, in all other respects, enjoy good health, do not lose their appetite, and seem to have little other uneasiness than what the sores occasion.

M. Virgile describes the species of yaws that is common among the negroes of St Domingo, and which Sauvages has termed 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 muscles bare; these excoriations are sometimes moist with ichor and sometimes dry, but always painful, and consequently very distressing. They are mentioned also by the author of the article in the Medical Essays; and both he and M. Virgile observe, that there is always one excrescence, or yaw, of an uncommon size, which is longer in falling off than the others, and which is considered as the master-yaw, and so termed. An ingenious inaugural dissertation on the subject of the yaws was lately published at Edinburgh by Dr Jonathan Anderson Ludford, now physician in Jamaica. The author of that dissertation considers Dr Cullen as improperly referring 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 frambosia are rested not merely on the authority of Dr Ludford, but are supported also by the testimony of Dr William Wright, a physician of distinguished eminence, who, while he resided in Jamaica, had, in the course of extensive practice, many opportunities of observing this disease, and to whom Dr Ludford acknowledges great obligations for having communicated to him many important facts respecting it.

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

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

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

1. 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 theriaca. 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 ethiops and gum guaiacum. He may likewise use the decoction of guaiacum and sassafras fermented with molasses, for his constant drink while the electuary is taking, and a week or a fortnight after the electuary is finished.

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

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

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

In St Domingo they are salivated by unction; but it does not appear that success always followed this practice. It is also usual in that island to give the solution of corrosive sublimate along with a decoction of sarsaparilla. 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. TRICHOHA.

The Plica Polonica, or Plaited Hair.

Trichoma, Sauv. gen. 311. Sag. 137. Plica, Lin. 313. Plica sive Rhopalosis, Veg. 323.

This disorder is only met with in Poland and Lithuania, and consists of several blood-vessels running from the head into the ends of the hairs; which cleave together, and hang from the head in broad flat pieces, generally about an ell in length, but sometimes they are five or six yards long; one patient has more or less of these, up to 20, and sometimes 30. They are painful to the wearer, and odious to every spectator. At the approach of winter an eruptive fever happens to many in these countries: the eruptions principally infest the head, and when at the height an ichorous humour flows from them. In this state they are too tender to admit of being touched, and the matter running down the hairs mats them together; the skin by degrees, breaking, the ramifications of the capillary vessels following the course of the hair, or prolonged out of the skin, are increased to a vast length.

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

ICTERUS.

The Jaundice.

Icterus, Lin. 224. Vog. 306. Boerh. 918. Junck. 92. Aurigo, Sauv. gen. 306. Sag. 132. Cachexia icterica, Hoffm. III. 301.

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

In like manner, all the secretions are affected with the yellow colour of the bile, which in this disease is diffused throughout the whole mass of fluids. The saliva becomes yellowish and bitter; the urine excessively high coloured, in such a manner as to appear almost black; nay, the blood itself is sometimes said to appear of a yellow colour when drawn from a vein; yet Dr Heberden says, that he never saw the milk altered in its colour, even in cases of very deep jaundice. In process of time the blood begins to acquire a tendency to dissolution and putrefaction; which is known by the patient's colour changing from a deep yellow to a black or dark yellow. Hemorrhages ensue from various parts of the body, and the patients frequently die of an apoplexy; though in some the disease degenerates into an incurable dropsy; and there have not been wanting instances of some who have died of the dropsy after the jaundice itself had been totally removed.

Causes. As the jaundice consists in a diffusion of the bile throughout the whole system, it thence follows, that whatever may favour 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 scirrhus of the liver or other viscera pressing upon the biliary ducts, and obstructing the passage of the bile; from flatus distending the duodenum, and shutting up the entrance of the ductus communis choledochus into it; from the same orifice being plugged up by viscid bile, or other sordes; but by far the most frequent cause of jaundice is the formation of calculi, or more properly biliary concretions: for although they were long considered as being of a calcareous nature, yet more accurate experiments have now demonstrated, that they consist principally of a sabaceous matter; accordingly, while they are so light as to swim in water, they are also highly inflammable. These are found of almost all sizes, from that of a small pea to that of a walnut, or bigger: they are of different colours; and sometimes appear as if formed in the inward part by crystallization, but of lamellae on the outer part; though sometimes the outward part is covered with rough and shining crystals, while the inward part is lamellated. These enter into the biliary ducts, and obstruct them, causing a jaundice, with violent pain for some time; and which can be cured by no means till the concretion is either passed entirely through the ductus communis or returned into the gall-bladder. Sometimes, in the opinion of many celebrated physicians, the jaundice is occasioned by spasmodic constrictions 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 intestine forms as it were a species of valve that these concretions are retained.

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

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

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

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

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

When the jaundice arises from indurated swellings or 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 substances are by far too irritating to be given in sufficient quantity to affect a concretion in the biliary ducts. Boerhaave observes, that diseases of the liver are much more difficult to cure than those in any other part of the body; because of the difficulty there is in getting at the part affected, and the tedious and round-about passage the blood has to it. The juice of common 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 exercise are the principal medicines. The former are justly reckoned the most efficacious medicines, as they powerfully shake all the abdominal and thoracic viscera; and thus tend to dislodge any obstructing matter that may be contained in them. But if there be a tendency to inflammation, vomits must not be exhibited till bleeding has been premised. We must also proceed with caution if the pain be very sharp; for in all cases where the disease is attended with violent pain, it will be necessary to allay it by opiates before the exhibition of an emetic. There is also danger, that, by a continued use of vomits, a concretion which is too large to pass, may be so impacted in the ducts that it cannot even be returned into the gall-bladder, which would otherwise have happened. In all cases, therefore, if no relief follows the exhibition of the second or third emetic, it will be prudent to forbear their farther use for some time.

Of all kinds of exercise, that of riding on horseback is most to be depended upon in this disease. It operates in the same manner with vomits, namely, by the concussion it gives to the viscera; and therefore the cautions necessary to be observed in the use of vomits are also necessary to be observed in the use of riding. Cathartics also may be of service, by cleansing the prime viae, and soliciting a discharge of the bile into the intestines; but they must not be of too drastic a nature, else they may produce incurable obstructions, by bringing forward concretions that are too large to pass. Anodynes and the warm bath are serviceable by their relaxing quality; and there can be no doubt, that, from acting as powerful antispasmodics, they often give an opportunity for the discharge of concretions by very slight causes, when they would otherwise be firmly retained. Soap has been supposed to do service A catarract 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 catarract, 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 absorption of the opaque matter; and where this is possible, there is perhaps a better chance of its being effected by the agency of the electric fluid than by any other means. For this purpose electricity is chiefly applied under the form of the electric aura, as it has been called; but even this is very rarely successful.

GENUS XCIII. AMAUROSIS.

The Gutta Serena.

Amaurosis, Sauv. gen. 155. Lin. 115. Vog. 238. Sag. 261.

Anablyopia, Lin. 108. Vog. 236.

A gutta serena is an abolition of the sight without any apparent cause or fault in the eyes. In every case it depends on an affection of some part of the optic nerve. But the affections which may produce this disease are of different kinds. When it is owing to a decay or wasting of the optic nerve, it does not admit of a cure; but when it proceeds from a compression of the nerves by redundant humours, these may be in some measure drained off, and the patient relieved. For this purpose, the body must be kept open with the laxative mercurial pills. If the patient be young, and of a sanguine habit, he may be bled. Cupping with scarifications on the back part of the head will likewise be of use. A running at the nose may be promoted by volatile salts, stimulating powders, &c. But the most likely means of relieving the patient, are issues or blisters kept open for a long time on the back part of the head, behind the ears, or on the neck; which have been known to restore sight even after it had been for a considerable time lost.—Should these fail, recourse must be had to a mercurial salivation; or, what will perhaps answer the purpose better, 12 grains of the corrosive sublimate mercury may be dissolved in an English pint and a half of brandy, and a table spoonful of it taken twice a-day, drinking half a pint of the decoction of sarsaparilla 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 infected. This is a very essen-

CLASS IV. LOCALES.

Vitia, Sauv. Class I. Lin. Class XI. Vog. Class X. Sag. Class I.

Plaga, Sag. Class II.

Morbi organici Auctorum.

ORDER I. DYSAESTHESIAE.

Dysaesthesiae, Sauv. Class VI. Ord. I. Sag. Class IX. Ord. I.

CALIGO.

The CATARACT.

Caligo, Sauv. gen. 153. Vog. 288. Sag. gen. 259.

Cataracta, Lin. 109. 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 "those who cannot see by night," and others express by it "those who cannot see during the day, but during the night."—The difference in the account of this disorder, as to its appearing in the night or in the day, is reconciled by considering it as of the intermittent kind: the difference then will consist in the different times of its approach; so it may be called periodical blindness. Intermittents appearing in a variety of modes, and the success of cinchona in some instances of this sort of blindness, both favour the opinion of its being an intermittent disease of the eyes; and this view has accordingly been taken of it by some late writers, particularly in some papers in the London Medical Observations, and Medical Transactions.

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

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

This disorder may proceed from various causes both natural and accidental, some of which admit of no 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 contrivance is necessary. If it be owing to an albugo covering part of the pupil, or to a film rendering a portion of the cornea opaque, the remedies for these affections 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 diseased, and then the patient is said to be delirious. Sometimes, however, in these cases, it does not amount to delirium; but the person imagines he sees gnats or other insects flying before his eyes; or sometimes, that every thing he looks at 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 apoplexy or epilepsy. Sometimes, however, people have been affected in this manner during life without feeling any other inconvenience. Such a disorder can rarely if ever be cured.

Genus XCVI. DYSECOEA.

Deafness, or Difficulty of Hearing.

Genus XCVII. PARACUSIS.

Depravation of Hearing.

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

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

When deafness is the effect of wounds or ulcers of the ears, or of old age, it is not easily removed. When it proceeds from cold 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 effect of a fever, it generally goes off after the patient recovers. If it proceed from dry wax sticking in the ears, it may be softened by dropping oil into them; afterwards they must be syringed with warm milk and water.

eafness proceeds from dryness of the ears, which may Defect of Smelling.

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

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

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

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

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

Genus XCIX. AGEUSTIA.

Defect of Tasting.

Ageustia, Sauv. gen. 157. Sag. 263. Ageustia, Lin. 114. Apogeusis, Vog. 449.

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

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

Defect of the Sense of Feeling.

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

Causes, &c. This sense may be hurt by anything 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 stupor, or defect of touching, which arises from an obstruction of the cutaneous nerves, the patient must first be purged; afterwards such medicines as excite the action of the nerves, or stimulate the system, may be used. For this purpose, the spirit of hartshorn, either by itself or combined with essential oils, horse-radish, &c., may be taken inwardly; the disordered parts, at the same time, may be frequently rubbed with fresh nettles or spirit of sal ammoniac. 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.

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

Pathetici, Lin. Class. V. Order II.

Hyperæstheses, Vog. Class 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 aliments are thrown out too soon; and unless the person be indulged in his desire for eating, he frequently falls into fainting fits. Sometimes it is attended with such a state of the stomach, that the aliment is rejected by vomit almost immediately after being swallowed; after which the appetite for food returns as violent as ever. But there 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, opates, and in short every thing which in a sound person would be most apt to pall the appetite, may also be used as temporary expedients, but cannot be expected to perform a cure. In some, the pylorus has been found too large; in which case the disease must have been incurable.

Genus CII. Polydipsia.

Excessive Thirst.

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

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

Genus CIII. Pica.