ltr.;f:55ii:L' '■"■"-. -"Hi- ^.^!aJtS ".^.■;;u.vaa «jtff ■ -:r"".r?^g :.:,rafekr^ lu^r-aj: ,,, ,I.,k» -t-...!*,. ,..T....-i.£.................£.-,.-., • Ti»tK,':rr'..';v;,f:;v;:.:;rr:^.:' t7::: \ &3^£'i3'^H'-■*•>£'-'"!:: "'i- .,«•»*■ M -,.,-V. ••• ", .-. , .»':' ; tt: I.I...WH. .AJI7,...........-.,«....»:,....... P^?* !r!:;:ii^:^ ij'ifiv;;: ^:/;:l:;'!rf: )•• •■'.' )'.■:.;' :iir.v<- '•:&:?• ...Crr^- r,^"rf,^-.*-'."A-.."V-,:.^:>-- v::. i'4rt.wr?.c:.,;-;,.,::.:.".vy.",--:t>.,.,7ti. ,.;,'■ 'HWJ4t;.;.n.";'-. ;'■ '£.' '-•" • ■ .'•■' ?->► "y^Sr^l - - ■ ' ;5t3£?k»'iJ•'^■«'<•<•■|»'",.-'•••'•■•■'■" ■';::':"'""' '" !.»ri»»£iUi'^»M>>t»;';;;,,"'>' '..;.; ,.;; ,,: .....', . >5Cn^ir..'*f"f,**t*"" t L iri.,.. ' . ....... :r^S'X^.-R--- <•-■ ,■'•■' - ' -.' f %. ^DBO^ SM x. / |—\^X THJE x / STUDY OF MEDICINE. with a IPSIfSE©^©®!!®^ S^SfflS! NOSOLOGY. JOHN MASON GOOD, M.D. F.R.S. MEM. AM. PHIL. SOC. AND F.L.S. OF PHILADELPHIA, IN FIVE VOLUMES VOL. II. y^S^ V~rv. SECOND AMERICAN EDITIQN. Puiatelpfua: • BENNETT & WALTON, A. SMALL, TJKIAH HUNT, MABOT & WALTBB, J. GKIGG, E. PARKEB, AND T. DESIEVEB. AND COLLIN'S & HANNAY, COLLINS & Co. BLISS & WHITE, AND J. V. SEAMAN, NEW-YORK. 1S24. we Glo^S }C:L. ?- /f$ 2 <*•*•>"> t g(jilatitlp!)ia. Printed by William Brow*. CLASS III. t CLASS III. HiEMATICA. DISEASES OF THE SANGUINEOUS FUNCTION. ORDER I. PYRECTICA. FEVERS. II. PHLOGOTICA. INFLAMMATIONS. III. EXANTHEMATICA. . ERUPTIVE FEVERS. Vf. DYSTHETICA. CACHEXIES. » T^'efACOLfYC}^ CLASS III. PHYSIOLOGICAL PROEM. On treating of the very important and extensive range of diseases included under the present class, let us first take a brief survey of the sanguineous function which is the immediate theatre of their operation, and the means and instruments by which it is maintained. This comprehensive subject may be most conveniently discussed under the three following divisions:— I. THE MACHINERY OF THE SANGUINEOUS SYSTEM. II. Its moving powers. III. The nature of the fluid conveyed. I. The importance of the blood to the general health of the ani- mal system, and its existence in every part of almost every organ, have been known in every country in which medicine has been studied from the first dawn of its cultivation. It is not necessary to retrace the wild and idle hypotheses that were started in ancient times to account for the means by which this universal fluid travels from one part to another, and appears in every quarter. It is enough to observe, that till the great and transcendant doctrine of the circulation of the blood was completely established, the acutest physiologists wandered about in darkness and uncertainty, seldom satisfying themselves, and still more rarely the world around them: insomuch that I am not acquainted with a single conjecture that was ever vented upon the subject that is in the least degree worthy of repetition. The opinion, indeed, of a circulation of the blood through the system was loosely started by various writers even of very early times; but under every modification it was found to be accompanied with so many difficulties as always to be dropped almost as soon as it was revived, and rarely till the middle of the seventeenth century, to show itself to any effective purpose. Hippocrates guess- ed at it, Aristotle assented 10 it, Serveto, who was burnt as a here- tic in 1553, imperfectly taught it by pointing out the smaller circu- lation, or that through the lungs; and our own illustrious country- man, Harvey, about a century afterwards, gave a finish to the 6 PHYSIOLOGICAL PROEM. CL. III. inquiry, by establishing the larger circulation, or that over the whole frame. The principal proofs of a circulation of the blood offered by Har- vey, and those, indeed, on which we chiefly rely in the present day, are deduced from the disposition of the valves of the heart; the range of the arteries and the veins, and from what occurs when either the arteries or veins are opened, compressed, tied, or injected, Thus, if we open an artery, the blood that jets from the puncture flows in a direction from the heart; and in a direction to the heart, if we open a vein. A compression or ligature upon an artery, puts a stop to the blood that flows from above the ligature; but the same upon a vein puts a stop to the blood from below it, in which di- rection the vein immediately becomes distended. In like man- ner, an acid liquor injected into the veins coagulates the blood in the direction towards the heart, proving that the venous blood is every where travelling in this course. While an examination by the microscope of the half-transparent vessels of frogs and other cold-blooded animals confirms the view laid open by these pheno- mena, and shows to us a continual flow of th© blood from the heart into the arteries, thence into the veins, and thence to the heart again; thus completing the circular career. The arteries, therefore, generally speaking, terminate in veins; but by no means the whole of them, for many are exhalent or se- cretory, and terminate in minute orifices on the surface of mem- branes and other organs; which no microscope, however, has yet discovered, but whose existence we have every reason to believe, as we perceive a perpetual oozing of fluids, whose flow we cannot otherwise account for, into all the cavities of the body; which keeps their surfaces moist, and makes motion easy. While, accord- ing to M. Magendie, whose experiments, however, seem to want confirmation, other minute arteries terminate in lymphatics, which he makes as much a part of the sanguiferous system as the veins ; the lymphatics conveying the more attenuate part of the arterial blood, slightly tinged of an opaline or rose coloured hue, though sometimes of a madder-red; such as the fluid which oozes upon puncturing the lymphatics, or the thoracic duct after a long fast. It is not necessary to examine into the correctness of this hy- pothesis in the present place, as we shall have occasion to notice it more at large when treating of the excernent system, which will be found to embrace both the absorbent and secretory vessels. It should, however, be remarked, that in M. Magendie's hypothesis the veins, and not the lymphatics, are the absorbents of the body.* Omitting then for the present the consideration of the lymphatics, the machinery by which the circulation of the blood is principally effected, consists of the heart itself, the arteries and the veins. The heart, in the more perfect classes of animals, as mammals, birds, and most, though not all, amphibials, is a very compound or- gan ; for in all these the blood, when received from the veins, is * Precis Elementaire de Physiologie, Tom. II. CL. HI.] PHYSIOLOGICAL PROEM. 7 first sent from this central organ to the lungs to be duly aerated, or, according to Mr. Ellis's hypothesis, to be unloaded of its excess of carbone, and is afterwards returned from the lungs to the same or- gan before its general circulation over the system commences. These classes, therefore, are said to possess a double circulation. And as the heart itself consists of four cavities, a pair, composing what is called an auricle and a ventricle, belonging to each of the two circulations; and as each of these pairs is divided from the other by a strong membrane, these classes are also said to have not only a double circulation, but a double heart; a pulmonary and cor- poreal circulation, and a pulmonary and corporeal heart. The heart is well known to be situated in the chest between the lungs, above the diaphragm, and to be influenced by all the motions of the diaphragm. It is loosely surrounded by a dense and fibrous membrane, named, from its situation,pericardium, possessing little sensibility, closely connected with the substance of the diaphragm, and reflected over the heart and its large vessels. Its use is to con- fine the heart in its proper post; and to lubricate it, in its state of unceasing activity, with a peculiar fluid, denominated liquor pericar- dii, supposed to be secreted by peculiar glands, but more probably exhaled from the capillary arteries of the internal surface. In a state of health this fluid is small in quantity and of a reddish hue, some portion of the red parts of the blood being intermixed with it; but, in a morbid state of the membrane, it is apt to accumu- late, change its properties, and lay a foundation for various com- plaints. The power possessed by the pericardium of restraining the heart to its proper post, is obvious from the following fact. If, after detaching the sternum and opening the chest, an incision be made into the pericardium of a living animal wide enough for the pur- pose, the heart will often be found to leap out of its sac through this aperture, and to fall on the right or the left side of the thorax. And hence the common and colloquial expression derived from common feeling, of the leaping of the heart for joy—and it might as well be said for grief or terror—is founded on actual fact. The heart, which is loosely confined by its vessels, often leaps as far as its surrounding sac will allow it. And hence again one cause of the violent palpitations to which this organ is subject, as we shall here- after have to explain more at large. The general structure of the arteries and veins has, till of late years, been considered as alike, both being supposed to consist of two separate tunics, an elastic or outer, and a muscular or inner, independently of the soft and common covering which lines them within. Yet nothing can differ more widely than the relative spis- situde and power ascribed to these tunics compared with each other in different parts of the circulating course. As the heart is the salient point of the circulation, and pours forth about two ounces of blood at every jet, the greatest force is exerted against the arteries that immediately issue from the heart. Here, there- 8 PHYSIOLOGICAL PROEM. [CL. HI fore, we find the greatest resisting power; for in the aorta and pul- monary artery, the elastic tunic is stronger than the muscular, by which contrivance the arterial canal is never too much dilated in either by the action of the heart in its contraction, or, as the Greeks call it, systole. In like manner this tunic becomes stronger at the- bendingof the joints, and continues so through the whole length of the curve; and the same provision takes place at the sharp angles made by a trunk and its branch, or at an angle formed by the divi- sion of one trunk into two. As the arteries, however, recede from the heart, the blood, resisted at every step by the elastic tunic of the canal it flows through,progressively loses its impetus, and a less elastic power becomes necessary and is actually provided. At a considerable distance, therefore, from the heart, in whatever direc- tion the arteries ramify, their muscular tunic soon balances their elastic, and gradually becomes superior; till at length, in the capil- lary arteries, it is nearly, if not altogether, the only tunic of which the canal consists; whence the ease with which these vessels col- lapse on some occasions, as loss of blood, or the exercise of terror, or any other depressing passion; and the equal facility with which they open in other cases, as in the sudden blush of shame or mo- desty. In the veins, the elastic and muscular tunics are considerably weak- er than in the arteries; they have, nevertheless, a more difficult task to perform than arteries; for,with a few exceptions, they have uniformly to force the current of blood upwards to the heart against the power of gravitation. They are hence far more numerously furnished with valves than the arteries, by which the ascending columns of blood are prevented from retrograding; and have by many physiologists been supposed to possess some degree of con- tractile, and consequently of propulsive power by the joint pressure of the sides of the arteries or muscles chat accompany them, and that of the external atmosphere; to which subject, however, we shall have occasion to return presently. I have thus far adverted to the commonly received opinion, and that taught by the most celebrated physiologists of our own country, and especially by Mr. John Hunter. Nevertheless it has long been a disputed point, whether, not merely the veins, but even the arte- ries, possess muscular fibres. The physiological arguments of Bi- chat, and the chemical researches of Berzelius, militate so strongly against the affirmative to this proposition, that the existence of such fibres in both classes of vessels has of late been doubted by many, and the contractility of the arteries been ascribed to their elasticity of texture alone; while the veins are conjectured to be altogether passive in the change of diameter they sustain. Yet whatever doubts may be entertained upon this subject in veins and arteries, the existence of muscular fibres cannot be questioned in the minute vessels termed capillaries. I have observed, that the force with which the blood is at first projected from the heart is progressively diminished by the resist- fiL. III.] PHYSIOLOGICAL PROEM. 9 ance it encounters in the thick and powerfully elastic tunic of the trunks or large arteries into which it is immediately propelled. There are two other causes which co-operate in producing a pro- gressively diminishing force. The first is the short angle's against which the blood has to strike at the origin of all the different branches : and the next, and most important, is the larger diameter of the general mass of the arteries, compared with that of the heart or the arteries from which they immediately proceed; the range of the diameter augmenting in proportion to the increase of the rami- fications. From experiments, indeed, made by Mr. JohnHunteron the carotids of camels and swans,* the very same arteries appear gradually to widen from the upper end or that nearest the heart to the lower, or that most remote. From all which he concludes that the aggregate diameter of the arterial system forms a cone whose apex is the heart. And he concludes, also, and most correctly, that this conic proportion is most obvious, increases most rapidly, and spreads with its broadest base in infants, or rather in the foetus ; for here the main trunks of the arteries are extremely short, while the capillaries are very large, and, from the obliteration of many vessels in subsequent life, more numerous than at any other period. It is highly probable indeed that while the aorta in childhood is not a fourth part of the size of the same vessel in an adult, the aggre- gate of the capillaries of the former possesses a diameter more than four times as large as the aorta in the latter. We may hence, in some degree, account for the difference in the quickness of the' pulse at different periods of life. In early infancy it beats as much as 140 strokes in a minute; towards the end of the second year it is reduced to 100; at puberty it is only 80; about virility 75; and after sixty years of age seldom more than 60 in a minute; for reasons connected with the preceding, it is more fre- quent in persons of short stature, those of strong passions of mind, those of great muscular exertion, and in females. From the in- creasing diameter of the blood-vessels as they diverge from the heart, the blood has a greater space for moving forward, and is able to move with more freedom : and hence one reason for the empty state in which the arteries are found immediately after death: a second reason is, that the tunics of the veins possessing little or no elasticity, readily dilate to the distensive power of the blood as it moves forward : a third, and indeed the principal reason, as suffi- ciently proved by Dr. Carson of Liverpool, is, the natural elasticity or resilience of the lungs, which, by keeping them after death in a state of dilation, allows the blood to accumulate here as in a vacuum. And hence, again, the reason of the accumulation of blood which is usually found in the chest after death, as well as the empty state of the vessels. This vacuity of the arteries upon death, was one of the objections urged very forcibly by the ancients against the circulation of the * On Blood, inflammation, &c. Part I. Sect, viii, p. 170. VOL. II.—-2 10 • PHYSIOLOGICAL PROEM. [CL. in. blood, or even its following at all the course of the arteries ; and which Dr. Harvey very unsatisfactorily replied to, by asserting, contrary indeed to farh that the heart continues to contract for some time after death, and even after it has received blood:—for the heart is generally found loaded with blood.* And it is this objec- tion, together with some others, that has induced Mr. Ker of Aber- deen once more to revive the doctrine of the ancients, and deny that of a circulating system altogether, assigning to the arteries the uses the ancients allotted to them. It still, however, remains to be ascertained by what means the ultimate branches of the arteries terminate in those of the veins, and how this communication is conducted. The pulmonary artery, which receives from the heart the blood returned into it from the veins, bears a very close proportion to the diameter of the aorta,t which sends the blood from the heart over the whole of the large circulation. The aorta possesses more strength, but their elasticity is nearly equal, and the measure of each, on being slit, is about 3| inches: and hence there can be little doubt that the quantity of blood sent back to the heart, is on an exact balance with that which flows from it. It is not, however, at any time the identical blood which is thus returned to the heart; for every organ takes from the general current, as it visits them, such parts and such principles as it stands in need of to support the wear and tear of its own action ; while another considerable portion is thrown off as we have already observed in the form of secretions or exhalations from various emunctories that open externally, or into internal cavities. But the drain which is hereby produced on the arterial blood is compensated by the various fluids collected from every part of the absorbent vessels, and by the flow of the chyle from the digestive organs; both which are poured into the thoracic duct, and finally intermixed with the returning current of venous blood a short time before it reaches the heart; and in this manner the balance of arterial and venous blood is maintained. With respect to the actual quantity of blood contained in the entire system, our means of determination are so imprecise, and consequently the calculations, or rather the conjectures that have been offered upon the subject, are so strikingly discrepant, that it is not easy to reach a satisfactory conclusion. It is only necessary to state a few of the different opinions that have been offered to show the sbsurdity of several of them. Muller and Abeildgaard estimate the weight even in an adult at very little more than eight pounds;!: Borelli at 20; Planch at 28; Haller at 30; Dr. Young at 40 § Hamberger at 80; and Keil at 100. Blumenbach states the proportion in an adult healthy man to be as 1 to 5 of the entire • See Dr. Carson "On the Vacuity of the Arteries after Death." Medico- Chir. Trans. Vol. XL Part 1. f See Hunter on Blood, p. 133. i Blumenb. Elem. Phys. p. 4. § 6 § Phil, Trans. 1809, p. 5, gl. ni.] PHYSIOLOGICAL PROEM. 11 weight of the body. Yet little reliance can he placed on this last mode of determination, on account of the great diversity in point of bulk and weight of adults, whose aggregate quantity of blood is in all probability nearly alike. The mean numbers, as those of Baron Haller and Dr. Young, making the amount from 30lb. to 40lb. appear most reasonable; and perhaps fall not far short of the sum intended by Professor Blumenbach. The subject requires further examination, and a nicer estimate. II. There is another question which has also, in all ages, greatly occupied the attention of physiologists, but upon which we still remain in a very considerable degree of indecision : and that is, the moving powers employed in the circulation ; or, in other words, the projectile force by which the blood is sent forward. The heart forms the salient point of motion, and with its systole or contraction the circulation commences. But what is it that ex- cites the heart to contract? One of the most common answers to this question in the writings of physiologists is the flow of the blood into the ventricles. But this is merely to argue in a circle; for the question still returns, what is it that makes the blood flow into the ventricles ? Others have referred the cause to an immediate impulse from the brain. Now, in contractions of the voluntary muscles, there is no doubt of the existence of such an impulse, for we are conscious of it, and assent to it; but we are neither conscious of nor assent to any thing of the kind in respect to the contraction of the heart; and are perfectly sure that no such power of the will takes place during sleep. It is a mere assumption; and an assump- tion which can only apply to a part of the great animal kingdom even during wakefulness; for, as it is only in the mammals and birds that the nerves can be thus influenced in their passage to the heart, the postulate does not account for the contraction or dilatation of the heart in other classes of animals.* m Mr. John Hunter ascribes this action of the heart, or rather the whole career of the circulation, of which he regards the action of the heart as a single and ordinary link in the general chain, to what he calls a stimulus of necessity; by which he seems to mean an instinctive power dependant on the general sympathy of the system which in every part is craving or demanding such an alternation; or, in other terms, is uneasy without it. His words are as follows; u The alternate contraction and relaxation of the heart constitutes a part of the circulation ; and the whole takes place in consequence of anecessity, the constitution demanding it, and becoming the stimulus. It is rather, therefore, the.want of repletion, which makes a nega- tive impression on the constitution, which becomes the stimulus, than the immediate impression of something applied to the heart. This we see to be the case, wherever a constant supply or some kind of aid is wanted in consequence of some action. We have as regularly the stimulus for respiration, the moment one is finished an • Hunter on blood, p. 148. • \% PHYSIOLOGICAL PROEM. [CL. 111. immediate demand taking place; and if prevented, as this action is under the influence of the will, the stimulus of want is increased. We have the stimulus of want of food which takes place regularly in health, and so it is with the circulation. The heart, we find, can rest one stroke, but the constitution feels it; even the mind and the heart is thereby stimulated to action. The constant want in the constitution of this action in the heart, is as much as the constant action of the spring of a clock is to its pendulum, all hanging or depending on each other."* Mr. Hunter's " Treatise on the Blood," is a work of such sterling merit, so rich in its facts, and so valuable in its remarks, that, notwithstanding a few nice-spun and chimerical speculations that occasionally bewilder it, there is no book on physiology which a Student ought to study more assiduously. Yet I am much afraid that the language now read has no great deal of meaning in it; and that it does little more than tell us that the heart contracts because it contracts, or, rather, that the circulation takes place be- cause it takes place. Few physiologists indeed seem to have adopted this opinion : and hence a far more plausible and intelligible hypothesis has been since offered. This consist* in supposing the heart to be stimulated by the oxygene of the blood introduced into it at the lungs by the process of respiration. Such was the favourite opinion of Dr. Darwin: and such appears to have been the opinion of Professor Blumenbach, who was so fully persuaded of the oxygenized state of the blood when first received by the heart and poured into the arteries, that he expresses a desire of changing the terms arterial and venous blood for oxygenized and carbonized. That oxygene, if introduced into the blood, would stimulate the heart, there can be no doubt, from numerous experiments which prove that a very smgll quantity of any foreign body whatever, even an ounce or two of solution of gum Arabic, infused into the blood by opening a vein, will not only stimulate the heart, but the stomach, intestinal canal, and other organs with which the heart readily sympathizes.f But, unfortunately for Dr. Darwin's hypo- thesis, Mr. Ellis, as we observed at some length in the proem to the preceding class, has advanced a variety of arguments so stubborn anci cogent, to prove that no oxygene whatever is introduced into the blood into its transit through the lungs, that, till these arguments are disposed of, the present hypothesis, beautifully simple as it is, is entitled to the claim of ingenuity, and nothing more. But passing by, till this question is settled, the doctrine of the priroum mobile, or first moving power of the blood from the heart —by what means is the motion, thus mysteriously commenced, maintained afterwards through the whole circulatory course? • On Blood, p. 149. + De Chirurgia Infusiroa renovanda. Aut. J. M. Regnaudot. 8vo. Lued fcat.1779. b CL. ID.] PHYSIOLOGICAL PROEM. 13 Harvey replied to this question by asserting, that it is maintained by the action of the heart alone, winch propels the blood equally through the entire length of the arteries and veins, both which he regarded as tubes alike inert, and in no respect contributing to the propulsive energy. This dictum was at first received with universal assent; and the mechanical physiologists immediately set to work in order to calcu- late the force with which the heart acts at every contraction, in the same manner as they had endeavoured 10 calculate the force of the stomach in the process of digestion. It is not necessary to enter into the details of these estimates. It is sufficient to observe, that from Michelot to Sauvages or Cheseldcn, they all differed from each other as widely as the calculations of the quantity of blood in the system; and that while Keil estimated the projectile power of the heart at eight ounces, Borelli fixed it at not leas than one hundred and eighty thousand pounds. There are various facts, however, which sufficiently prove that the heart cannot be the sole propulsive power through the entire range of the circulation; the chief of which are: Firstly, that the pulse, if the systole of the heart were the only projectile force, must take place, not synchronously all over the system, as it is well known to do, except in a few morbid cases in which local causes interfere, but subsequently to the contraction of the heart, and soncEssivKLY through the whole line of the arterial tubes, in propor- tion as they lie more remote from the salient point. And, secondly, that whatever may be the projectile power of the heart, it must altogether cease with the arteries, and cannot reach the veins. And hence arose another hypothesis, which ascribed the propul- sive power to a progressive vis a tergo, or a force communicated from the ventricles of the heart to the commencement of the arteries producing a vibration or alternate dilatation and contraction of their tunics, through their whole length to the veins; and thus acting in conjunction with the projectile force of the heart itself. In proof of this auxiliary power afforded by the coats of the arteries, the phenomenon of pulsation was triumphantly appealed to; which, it was maintained, gave a direct and incontrovertible evi- dence that an alternate dilatation and contraction, or enlargement and diminution in the diameter of the arteries, is constantly taking place. This, by Bichat, is attributed solely to the loco-motion of the arterial tubes, propagated to their terminal ramifications, and thence continued to the veins; but by most modern physiologists, to a joint power compounded of the action of the heart and the arteries. M. Bichat's doctrine has of late been incontrovertibly refuted by one or two very simple experiments of M. Magendie.* Besides which, however, it is now a well-ascertained fact, and one that has * Precis Elementaire de Physiologic Tom. II. p. 320.* 14 PHYSIOLOGICAL PROEM. [CL. III. been thoroughly elucidated by Dr. Parry of Bath, that no increase of size, or indeed change of bulk of any kind takes place in arteries during either the systole or diastole of the heart's ventricles in a state of health.* The arteries of animals, to ascertain this point, have been exposed in different parts, and to considerable lengths, without evincing the least apparent increase of size. And hence it is the pressure of the finger, or of some other substance, against the side of an artery that alone occasions pulsation, in consequence of the resistance hereby made to the regular flow of the blood; the alternating beat being produced by the greater momentum with which the current strikes against the finger or other cause of ob- struction, during the systole than during the diastole of the heart. It may be still further observed, that m a state of inflammation, the pulse of the inflamed part, in consequence of local excitement, is much more frequent than that of the heart or of any other organ. Thus in a whitlow, the radial artery may give to the finger a hun- dred pulsations in a minute, while not more than seventy strokes may be exhibited in any other part of the system. The rapidity of the pulse is in this case usually in proportion to the degree of the inflammatory action; and hence, if the system should labour at the same time under ten different inflammations in different parts or organs of a different structure, as glands, muscles, and membranes, it is possible that it may have so many different scats of pulsation taking place at such different parts at one and the same lime, while all of them are at variance with the pulsation of the heart. The hypothesis, therefore, of a vis a tergo, whether dependant upon the heart alone, upon the arteries alone, or upon a combina- tion of the two, has by no means proved sufficiently satisfactory, or been sufficiently supported by evidence in respect to the entire cir- culation. Under no modification does it account for the flow of the blood through the veins. And in regard to the whole of the views which have been thus far examined, Mr. John Hunter, as I have already observed, was so extremely discontented, that he placed no more stress upon one part or organ of the sanguiferous system than upon another; upon the heart than upon the arteries; or upon the arteries than upon the veins ; regarding the whole economy as the result of a sort of instinct, to which, as just noticed, he gave the name of a stimulus of necessity: and which opinion he supported by making an appeal to insects which have no proper heart; to worms, most of which have no heart whatever; and to monsters which have been born without a heart; whilst at the same time he contended that veins, at least the larger, exhibit, under certain cir- cumstances, an expansile and contractile power as well as arteries. " I think it probable," says he, " that where there is an universal action of the vascular system, the action of the arteries and veins * Experimental Inquiry into the Nature, Cause, and Varieties of the Arterial Pulse, &c. «y C. H. Parry, M. D. F. R. S, &c. Bath, 1816, CL. in.] PHYSIOLOGICAL PROEM. 15 is alternate: that where.the arteries contract, as in many fevers, the veins rather dilate, more especially the larger."* Upon the whole we may conclude with Haller, that the heart exerts a very considerable degree of force in the general economy of the circulation, although it is impossible to estimate its power with mathematical precision. And we may reasonably refer the first, or arterial half of the general circuit of the blood to this force, if not alone, in conjunction with the aid contributed by the elastic and contractile tunics of the arteries themselves, whether pulsa- tion be a result of these powers alternately exercised, or of mere local pressure. It yet remains, however, to account for the second half, or that which consists in the passage of the blood through the veins; and upon this subject there is one most important and elucidating fact, which, till of late, has never been in any degree brought forward in the course of the inquiry. It is this; that when the heart by the contraction of its ventricles has exhausted itself of the.blood contained within it, a comparative vacuum must follow, and the blood from the venae cavae, or venous system at Large, be sucked up into the right auricle. This ingenious remark seems first to have been thrown out by Dr. Wilson Philip: and Dr. Carson of Liver- pool, taking advantage of it, has constructed a simple and beautiful theory of the projectile powers employed in the circulation, the general principle of which may be expressed in a few words. The heart is supposed to act at one and the same time in a two-fold capacity. By the contraction of the ventricles, it propels the blood through the arteries; and by the dilatation of the auricles, it draws it up from the veins. It is at once, therefore, a forcing and a suc- tion pump. The contraction of the heart, and consequently its comparative vacuum, are supposed to be considerably assisted by the elasticity of the lungs, and the play of the diaphragm, which we had occasion to notice at some length in our physiological proem to the preceding class, and the great resistance which they jointly afford to the atmospheric pressure; whilst this very pres- sure, applied on every part of the exterior of the animal frame, contributes in an equal degree to the ascen: of the blood in the veins; for, as the column of venous blood is perpetually girt on all sides and cannot fall back because of the numerous valves with which the veins are furnished, it must necessarily take an opposite or ascending direction. There are, nevertheless, numerous difficulties that yet remain to be explained; such as the proportion of projectile power fur- nished by the conducting pipes themselves; by what means the want of a diaphragm is compensated in birds and reptiles which have no such organ; and what constitutes the projectile power in animals that have no heart, and consequently no double pump to work with. *Oqblgod,p. W 16 PHYSIOLOGICAL PROEM. [CL, III. There is also another curious fact which physiology has pointed out, but has never hitherto been able to explain: and that is, a direct communication between remote or unconnected organs, ap- parently, by some other channel than the circulation of the blood. Something of this kind seems to exist between the spleen ami the stomach, the former of which has been proved by Sir Everard 'Hon.e to receive fluids from the cardiac portion of the iailer, though we can trace no intercourse of vessels: but the most extra- ordinary example of this kind which at present we seem to possess, is the communication which exists between the stomach and the bladder. For the experiments of Sir Everard Home,* and the still more decisive ones of Dr. Wollaston and Dr. Marcet,f seem to have established beyond a controversy, that certain substances introduc- ed into the stomach, as rhubarb or prussiate of pot-ash, may pass into the bladder without taking the course of the blood-vessels, and consequently by some other channel; a channel, indeed, of which we know nothing. This is a subject well worth studying: for if two organs so remotely situated as the stomach and the bladder be thus capable of maintaining a peculiar intercourse; so other organs may possess a like intercommunion; and by such means lay a foun- dation for those numerous sympathies between distant parts which so often strike and astonish us. M. Magendie's hypothesis, that veins are absorbents, will explain the facts in Sir Everard Home's experiments, but has no bearing upon that of Dr. Wollaston and Dr. Marcet. The discovery of the circulation of the blood has given a great importance to the doctrine of pulsation; for by the strength or weakness, the slowness or frequency, the hardness or softness, the freedom or oppression, the regularity or irregularity of the beat of the artery against the pressure of the finger, we are now able to de- termine many momentous facts, relative, not merely to the state of the heart, but of the general system; and, in many cases, to prognos- ticate upon grounds which were altogether unknown to the earlier cultivators of medicine. And on this account it is that the Greek physicians took but little notice of the pulse, which, even in the days of Celsus, was regarded as a res fallacissima. The pulse is influenced indirectly by the general state of the body, but directly by that of the heart, or the arteries, or of both, or of the quantity of blood which the vessels have to contain. In an adult male of good health, and not too corpulent, the com- mon standard of the pulse may be fixed at seventy strokes in a minute: but it varies in different individuals from sixty to eighty, being greatly affected by the temperament, and partly by the habit of life. In the man of a high sanguine character it rarely sinks below eighty, and is often at ninety; and in the melancholic it sel- dom rises above sixty, and sometimes sinks to forty. In idiosyn- * Phil. Trans. 1811, p. 163. t Ibid, p. 96. CL.m.] PHYSIOLOGICAL PROEM. 17 crasies the discrepancy is so considerable, and complicated with other changes than those of frequency and tardiness, that there is no reducing them to any rule. Lizzari tells us of a person whose pulse was not more than ten beats in a minute.* Dr. Heberden says, he once saw a person whose pulse, as he was told, did not number in the beginning of his illness above twelve or sixteen in a minute; though he sus- pects in this and all other instances, where it is below forty, that the artery beats oftener than it can be felt; because such slow pulses are usually unequal in their strength, and some of the heats are so faint as but just to be perceived; so that others, probably still fainter, are too weak to make a sensible impression on the finger. He had attended two patients, who, in the best health, had always very unequal pulses, as well in their strength as in the spaces between them, but which constantly became regular as the patient grew ill, and gave a never-failing sign in recovery in their once more returning to a state of irregularity.! In women the pulse is, generally speaking, six or eight strokes in a minute quicker than in men, and hence, many women of firm health and a lively disposition have a standard pulse of eighty-five. In a weakly frame the pulse is usually rapid; for debility is al- most always accompanied with irritability, and the heart partakes of the general infirmity. In this case, also, from the feebleness with which the heart contracts, the ventricle is but imperfectly emptied, and consequently soon filled again, and sooner stimulated to contraction. Hence, in infancy the pulse is peculiarly quick, and gradually becomes slower as the child increases in strength. Dr. Heberden, who paid particular attention to this subject, estimates the pulse on the day of his birth, and while asleep, from a hundred and thirty to a hundred and forty; and fixes it at little less than the same rate, or that of a hundred and twenty strokes, for the first month. During the first year he calculates it at from a hundred and twenty to a hundred and eight: during the second, at from a hundred to ninety: during the third,from a hundred and eigh; to eighty, at which it continues for the three ensuing years. In the seventh year it is frequently reduced to seventy-two; and in the twelfth, to seventy.\ In advanced age, from the small quantity of sensorial power secreted, and the general inertness of the organs^ the pulse sinks often considerably below sixty strokes in a minute. " I knew one," says Dr. Heberden, " whose chief distemper was the age of four score, in whom, for the last two years of his life, I only once counted so many as forty-two pulsations ; but they were seldom above thirty, and sometimes not more than twenty-six. And though he seemed heavy and torpid, yet he could go out in a car- * Raccolta d'Opusculi Scientifici, p. 265. f Medic. Trans. Vol.11. Art. II. p. 29. * Med. Trans. Vol. II. Art. II. p, 29. VOL II.—3 18 PHYSIOLOGICAL PROEM. [CL. HI riage, and walk about his garden, receive company, and eat with a tolerable appetite." The pulse may be counted with great accuracy up to a hundred and forty or a hundred and fifty in a minute; and if the stroke be equal, and the wrist slender, so that we can take in more than half the artery by the pressure of two fingers, we can reach a hundred and eighty: but beyond this there is great confusion and uncertain- ty : and it is difficult, therefore, to understand by what nice mode of measurement Dr. Wendt could distinguish, as he tells us he has done, a pulse of two hundred and forty-three strokes in a minute.* The pulse is quickened by very slight excitements both external and internal. The stimulus of the air, of the light, and of sounds, is sufficient to make that of an infant awake, fifteen or twenty strokes more frequent than when it is asleep, and beyond their con- trol. The pulse of an adult is usually quickened eight or ten strokes during the digestion of a meal; and running, or any sudden and rapturous emotion of the mind will double the ordinary scale. The depressing passions, on the contrary, check it, and have, some- times, put a total stop to the heart's motion, with a deadly shock, and killed the patient in a moment. There are many drugs that have a like tendency, of which all the simple narcotic poisons af- ford examples. The digitalis and hyoscyamus are expressly used on account of this property: the prussic acid, and the plants that contain it, as bitter almonds and the leaves of the prunus lauro- cerasus, when given in free doses, destroy the irritability, and ex- tinguish the pulse instantly: and this so effectually that the heart, when immediately examined, has been insensible, not only to puncture, but to concentrated acids. As the excitement of the stomach during the natural process of digestion is capable of accelerating the pulse eight or ten strokes in a minute, there can be no difficulty in conceiving that it may be still more accelerated by a morbid excitement of any other large organ, and particularly where the primary seat of excitement is in the sanguiferous system itself. And as, generally speaking, the frequency of the beat is in proportion to the degree of excitement, the pulse becomes a sort of nosometer, or measurer of the violence and danger of the disease: and it measures it equally, whether the return of the beat be below the standard of health or above it. How far, in either case, the pulse may vary from its natural num- ber without great danger, depends upon a multitude of collateral circumstances, as the age of the patient, his idiosyncrasy, the pecu- liar disease he is labouring under, and the strength or weakness of the system. And hence, in addition to the number of the pulse, we should also attend to its degree of fulness, softness, firmness free- dom, and regularity; a critical knowledge of which can only be learnt by experience and a nice discrimination. It has been highly injurious, however, to the study of medicine, * De Mutatione quadam pulsus insigni. Erlang. 1778. V. liuld. Syll. v. CL. HI.] PHYSIOLOGICAL PROEM. 10 that this subject has been often too finely elaborated, and the varia- tions of the pulse been ramified into so many divisions and subdivi- sions, and nice unnecessary distinctions, as to puzzle the young and be of no use to the old. And hence, some of the best pathologists of modern times have been too much disposed to shake off nearly the whole of the incumbrance, and pay no attention whatever to the pulse except in regard to its frequency. Amongst this number was Dr. Heberden: " Such minute distinctions of the several pulses," says he, " exist chiefly in the imagination of the makers, or, at least, have little place in the knowledge and cure of diseases. Time, indeed, has so fully set them aside, that most of these names of pulses are now as unheard of in practice as if they had never been given."* And in forming, therefore, his prognostic of a dis- ease, while he appeals to the pulse merely in respect to its number, he draws his other grounds of decision from the nature of the ma- lady, and the violence of its specific signs. But this is to limit the subject to too strict a boundary; and to exclude ourselves from what, in many instances, are clear and even leading diagnostics. There are some practitioners, and of very high merit too, whose fingers are no more capable of catching the finer distinctions of the pulse than the ears of other persons are the niceties of musical sounds. I suspect this was the case with Dr. Heberden, as it was also with the late Dr. Hunter; of whom Mr. John Hunter observes, that, " though he was extremely accurate in most things, he could never feel that nice distinction in the pulse that many others did, and was ready to suspect more nicety of dis- crimination than can really be found. Frequency of pulsation in a given time is measurable by instruments; smartness or quickness in the stroke, with a pause, is measurable by the touch, but the nicer peculiarities in the pulse are only sensations in the mind. I think," continues this distinguished physiologist, " I have been certain of the pulse having a disagreeable jar in it when others did not per- ceive it, when they were only sensible of its frequency and strength: and it is, perhaps, this jar that is the specific distinction between constitutional disease or irritation and health. Frequency of pulsa- tion may often arise from stimulus, but the stroke will then be soft; yet softness is not to be depended on as a mark of health, it is often a sign of dissolution; but then there must be other attending symp- toms, "f Dr. Fordyce's table of the pulse is, perhaps, unnecessarily compli- cated ; but the strength or weakness, fulness or smallness, hardness or softness, regularity or irregularity of the pulse, are indications nearly as clear as its frequency or slowness, and, in many cases, quite as diagnostic of the general nature of the disease. Frequency and slowness of the pulse taken by themselves, indicate little more than the degree of irritability of the heart, or the force of the sti- • Med. Trans. Vol. n. p. 20. t On Blood, Part. II. Ch. iii. p. 318. g0 PHYSIOLOGICAL PROEM. tCL-HL mulus that is operating upon it. The strength and regularity,^or weakness and irregularity of the pulse are as palpable to the finger as the nrecedine signs, and show, in characters nearly as decisive, thedeeree^ofvfgour 01 debility of the heart; and hereby, except where Uns organ is labouring under some local affection, the vigour or debility of the system, which a mere variation in the state of the freouency ot the pulse will not tell us. A full and a small pulse may be distinguished with almost as much ease as any other property it possesses; this Mr. John Hunter ascribes to the state of the arteries: but, if 1 mistake not, it gives us rather a measure of the quantity ot blood circulating through the system, than of the muscular strength of the arteries, or of the heart itself; which is often a very impor- tant indication, and especially when combined with the preceding signs; as it will then be our best guide in cases where we have determined upon emptying the vessels as far as we can do it with- out danger. Hardness and softness of the pulse, together with that vibratory thrill which has been called wireness, are not quite so easily learnt as its fullness and smallness, but a nice finger will readily discriminate them, and practice will point out the difference to every one. These characters Dr. Fordyce makes dependent, and I think with great reason, on the state of the arteries rather than on that of the heart, or on the quantity of the circulating fluid; and Mr. John Hunter concurs in the same view. They measure the degree of vascular tone, or power of resistance ; and when the same effect, whether above or below the natural standard, takes place in the capillary arteries, it produces that change in the pulse which he distinguished by the names of obstruction and freedom, but which it is not always easy to discriminate from several of the preceding qua- lities; nor is it of* great importance, as we have in such cases other symptoms that more strikingly manifest the same fact. Thus far, perhaps, the doctrine of pulsation may be studied to advantage ; but when, beyond this, we come to a distinction between the free and dilated pulse, as proposed also by Dr. Fordyce; the quick and the frequent, as proposed by Stahl ;* and the dicrotic, coturnizing, and inciduous, proposed by Solano,t as mere sub-varie- ties of the rebounding, or redoubling, itself a variety of the irregu- lar pulse, we perplex pathology with a labyrinth in which the stu- dent is lost, and the master wanders to no purpose. De Bordeu acquired great reputation in the middle of the last cen- tury, fbr ayplying the doctrine of pulsation as an index to the dis- eases of every distinct drgan of the body; whence he not only adopted most of the subdivisions of Solano, but added others, and subdivided them still further. He started it as a new hypothesis, which he endeavoured to support by facts and arguments, that every separate organ possesses a principle of life in some measure peculiar to itself, and independent of the rest of the frame; that each is endowed with a proper function, and susceptible of proper * De Differenti1 Pulsus celeris et frequentis. jNov Observai.ones circa crisium praedictiones ex pulsfl. Wejscb, Medi- cine ex pulsu. Vind. 1770. Vienn. 1753» CL. III.] PHYSIOLOGICAL PROEM. 21 sensations and movements ; and that, by the agreement and co-ope- ration of all these distinctive powers, the life and health of the en- tire system are built up and maintained. These principles are developed and defended in his thesis " De Sensu gerenice conside- rato," published at Montpellier in 1742. Though arrogating the merit of originality, they are, however, little more than a revival of the ancient doctrine of harmony invented by Aristoxenus, and at one time very popular in Greece, as we learn from Lucretius : — Multa quidem sapientum turba putarunt Sensum animi certa non esse in parte locatum; Verum habitum quemdam vitalem corporis esse, 'apmonian Graiei quam dicunt.* M. de Bordeu, in adopting this hypothesis, supposed farther, that an affection of any particular organ will occasion a peculiar varia- tion in the pulse from its natural state; and, by a careful attention to these changes, he conceived himself capable of ascertaining the seat of the disease, and the channel through which nature was aim- ing at a crisis. He describes, in consequence, an overwhelming multiplicity of organic pulses ; but his general division is into supe- rior and inferior pulses : and this he founds on an observation that the actions of the parts seated above the diaphragm, and of those below, excite very different impressions on the circulatory system. These views are chiefly given in the most famous of all his publi- cations, entitled," Recherches sur le Pouls par rapport aux crises."f This hypothesis became extremely popular in France and Germany, and excited a considerable degree of attention at Edinburgh. It is now, however, little heard of, and is by no means worth reviving. In effect, a voluminous and complicated classification of pulse is rather a proof of an active fancy than of a sound judgment: and though Dr. Heberden and Dr. Hunter may have thought too lightly of this branch of pathognomy, it is better to adopt their simplicity than the puerile conceits of many more elaborate pulse-makers. The Chinese have a more operose system of pulsations than any that have appeared in Europe ; but nothing can be more whimsical than their divisions. Avicenna treated of the pulse musically ; and Hoffenuffer, persuing his principles, drew up, in 1641, a musical scale of the pulse, dividing it into musical time, and marking the different beats by semibreves, minims, and crotchets, semiquavers, and demisemiquavers; thus reducing his patient to a harpsichord, and his profession to a chapter on thorough-bass. III. To speak minutely of the constituent principles of the blood, would carry us too far into the regions of animal chemistry; and I shall hence limit myself to a very brief analysis of those that are fixed or confinable, having already paid some attention to the gasses in the physiological proem to the preceding class. * De Rer. Nat. Lib. III. 98 Seethe author's examination of this hypothesis, and its resemblance to others oflater date, in the notes of his Translation of Lucretius. Book V. 100 and 104. f Paris 1756, 8vo. 22 PHYSIOLOGICAL PROEM [CL. ffl. For the first judicious account of these principles, we are indebted to an elaborate memoir of MM. Parmentier and Deyeux, who ar- ranged them under the following heads:—I. A peculiar aroma, or odour, of which every one must be sensible who has been present at a slaughter-house, on cutting up the fresh bodies of oxen. 2. Fi- brin, or fibrous matter. 3. Gelatine. 4. Albumen. 5. Red colour- ing matter. 6. Iron. 7. Sulphur. 8. Soda. 9. Water. Still minuter and more exact experiments have since been made upon particular portions or the whole of the blood, especially by Dr. Marcet,* Dr. Bostock,t and Professor Berzelius,! which confirm the greater part of the preceding results, but have detected a few errors which it is necessary to notice. Neither the blood of man nor of quadrupeds, so far as they have been examined, contain any gelatine. " The mistake," says M. Berzelius, " arises from the gelatinous appearance of the albu- men ; I have never been able to detect a particle of gelatine in blood, and, as far as my researches extend, I have found gelatine to be a substance altogether unknown to the economy of the living body, and to be produced by the action of boiling water on cartilage, skin, and cellular membrane; substances which are totally distinct from fibrin and albumen." It follows, therefore, that wherever ge- latine is found in the animal frame, it is produced by a decomposi- tion and recombination of the particles of the blood by the action of the secernents. The sulphur detected in the blood by Parmentier and Deyeux does not exist in a free state, but is a component part of its albu- men, as is also its carbone and hydrogene, which, in consequence* have as strong a claim to be considered as constituent principles as sulphur. It is by means of its constituent sulphur that the albumen of blood or of an egg, becomes capable of blackening a silver instru- ment employed to stir it. And as it is the albumen that is now known to dissolve the oxydes of mercury introduced into the blood in the cure of syphilis, it is probably owing to the sulphur of the albumen that this effect is produced; or that the oxydes of any me- tals introduced as medicines into the blood are dissolved ; since the albumen of the serum is also discovered to be a powerful menstruum in dissolving iron, copper, and other metallic preparations. The iron traced in the blood is, in like manner, a constituent principle of the red colouring matter, and exists in so intimate an union with it that it cannot be detected by the best re-agents we possess, till the composition of the colouring matter is totally de- stroyed by heat, or some other means. With these explanations we are now able to proceed to a clear comprehension of the following brief analyses of the blood, as cor- rected by the latter experiments of M. Berzelius, supported by those I have just adverted to, of Dr. Marcet and Dr. Bostock. • Trans. Medico-Chirurg. Soc. Vol. II. p. 370. f Id. Vol. I. * Id. Vol. in. CL. 111.] PHYSIOLOGICAL PROEM. 23 Blood is composed of two parts, one homogeneous and liquid, and one only suspended in the liquor, and spontaneously separating from it when at rest. The homogeneous and liquid part consists of much albumen and a little fibrin, both combined with soda, and all dissolved in water. It also contains a small portion of a few other saline and animal sub- stances. The suspended part consists of the colouring matter. It differs from albumen chiefly in its colour and its insolubility in serum. Iron enters as a constituent ingredient into this material, in the pro- portion of ■yi.-ff of its weight. It seems to be the colouring princi- ple; but cannot be separated from it as long as it continues to be colouring matter. This separation can only be effected by combus- tion, or by the concentrated acids, both of which agents entirely de- compose the substance with which the metal is combined. The iron exists in the form of oxyde, with a small proportion of sub- phosphate of the same. But the colouring matter cannot be arti- ficially produced by uniting albumen with red subphosphate of iron. Fibrin, albumen, and colouring matter, resemble each other so closely, that they may be considered as modifications of one and the same substance. Each of these three substances yields, when de- composed, but does not contain, earthy phosphates and carbonate of lime; for the entire blood holds in solution no earthy phosphate, ex- cept, perhaps, in too small a quantity to be detected. From these earths it is clear fhat the bones derive their earthy supply; which, however, it is also clear they can only do, as in the case of the formation of gelatine, in consequence of a decomposition of the blood as it arrives at the secernents of the bones. Vauquelin endeavoured to separate the colouring matter from the blood by means of sulphuric acid ; but this material is not wanted, and does not very well answer the purpose. A method proposed by M. Berzelius in another communication is much simpler as well as more effective.* It consists in placing the clot or coagulum of blood «pon blotting paper, to get rid of the serum as completely as possible. The clot is then to be put into water, in which the co- louring matter dissolves, while the fibrin remains unaffected; when the water being evaporated, the colouring matter is obtained in a separate state. On reducing this matter to ashes, about5£5 of iron can always be separated. It is difficult to determine by what means the iron, or the sul- phur, or the elementary principles of calcareous earth, obtain an existence in the blood. If these materials were equally diffused throughout the surface of the earth, we might easily conceive that they are introduced through the medium of food. But as this is not the case ; as some regions, like New South Wales, at least on this side the Blue mountains, contain no lime-stone whatever, and others • Ann de Chim. et de Phys. V. 42. 24 PHYSIOLOGICAL PROEM. fCL. Ill no iron or sulphur, while all these are capable of being obtained apparently as freely from the blood of the inhabitants of such re- gions, as from that of those who live in quarters where such mate- rials enter largely into the natural products of the soil; it is per- haps most reasonable to conclude that they are generated in the laboratory of the animal system itself, by the all-controlling influ- ence of the living principle. What may be the aggregate quantity of any of these minerals in the mass of blood belonging to an adult, has not been determined with accuracy. The amount of the iron has been calculated by Parmentier and Deyeux, upon grounds furnished them by Menghini, at seventy scruples, or very nearly three ounces, estimating the average of blood in the vessels of an adult at twenty-four pounds, which is most probably something short of the mark. Whether iron exists in any other part of the animal frame than the colouring matter of the blood, is in some degree doubtful. Vauquelin seems to have traced it in egg-shells and oyster-shells ; and Mr. Brande thinks he has done the same in the chyle and in the serum, and this as largely as in the colouring matter of the blood, which, after all, he thinks contains only a very minute quantity.* But these experiments are too indefinite, and by no means coincide with those of Berzelius, since confirmed by other chemists. If the experiments of Menghini may be relied upon, human blood contains a larger proportion of iron than that of quadrupeds ; quadrupeds have more than fishes, and fishes more than birds. But though there can be no longer any question of the existence of iron as a constituent principle in the blood, we are in total igno- rance of the part it is intended to perform. It is, perhaps, the co- louring material, though, as I have already observed in the physio- logical proem to the preceding class, even here we are still very much in the dark, and are overwhelmed with contending hypo- theses. It is probable that the red particles of the blood contribute to the strength of animals to whom they are natural, as conjectured by Mr. J. Hunter, and that the strength of such animals is in pro- portion, or nearly so, to their number. Yet such particles are never found in the blood of several classes of animals, as insects and worms : and in those in which they are found, they have often no existence in the commencement of life; for they are not disco- verable in the egg of the chick, when the heart first begins to pul- sate ; nor are they, in any animals, pushed into the extreme ar- teries, where we must suppose the serum reaches. And hence, whatever their value, they cannot be regarded as the most impor- tant part of the blood, or as chiefly contributing to the growth and repair of the system.f Various attempts have at different times been made, to determine the form and measure the diameter of the corpuscles of the blood, but even this does not even seem to have been accompanied with very great success. Delia Torre, by applying his microscope, detected * Phil. Trans. 1812, p. 112. f On Blood, p. 46.48. CL. III.] PHYSIOLOGICAL PROEM. 25 them, as he thought, to be flat circles or rings with a perforation in the centre ; and Mr. Hewson ascribed to them the same shape, but represented them as hollow or vesicular, with a dot of red colour- ing matter in the centre instead of a perforation; so that, if his de- scription could have been substantiated, they might literally have been regarded as the wheels of life moving on iron axles. Mr. Hewson's hypothesis, however, extended much farther; for, by a variety of plausible experiments, he persuaded himself, and many others also, that it is the office of the thymus and lymphatic glands to secrete and elaborate these vesicles which are then carried by the lymphatics and thoracic duct to the arteries, and from the arte- ries to the spleen which furnishes them with their coloured axles. These physiological and microscopic fancies, however, have been long overturned ; and the general shape of the corpuscles has been sufficiently proved to be globular, the diameter of which, as mea- sured by the microscopical experiments of M. Bauer, is t^^ part of an inch; a dimension, however, which has since been reduced by Captain Kater to j^o part of an inch.* M. Bauer has also as- certained, as he thinks, that it is not the centre of the globule that is dotted, but its outline that is surrounded with colouring matter; so that, instead of being annular wheels with iron axles, they are sphe- rular wheels with iron tiers. It does not seem that the microscope has added much that can be depended upon to our knowledge upon this subject. We have also still much to learn, not merely in respect to the real difference between human blood and that of quadrupeds, but the real difference between that of any one species of animal and any other. M. Berzelius observes, that " the great agreement in the composition of human and ox blood is remarkable, and explains to us the possibility of the phenomena observed in the experiments in transfusion." But we have a clear proof that the blood of one species of animals differs so much from that of another, either in its principles or their modification, that no benefit can result from transfusion, unless from like, kinds to like kinds. Thus, according to several interesting experiments of Dr. Blundell, a dog, asphyxi- ated by hemorrhage, may easily be recovered by a transfusion of blood from another dog, but is little or not at all relieved if the blood be taken from man.f Upon the whole, however, we cannot but regard the blood as in many respects the most important fluid of the animal machine: from it all the solids are derived and nourished, and all the other fluids are secreted; and it is hence the basis or common pabulum of every part. And as it is the source of general health, so it is al- so of general disease. In inflammation it takes a considerable share, and evinces a peculiar appearance. The miasms of fevers and ex- anthems, are harmless to every other part of the system, and only become mischievous when they reach the blood: and emetic tartar, * Phil. Trans. 1818, p. 173, 187. t Trans. Medico-Chir. Soc. Vol. IX. p. 86. vol. ii.—4 26 PHYSIOLOGICAL PROEM. [CL. m. when introduced into the jugular vein, will vomit in one or two minutes, although it might require, perhaps, half an hour if thrown into the stomach, and in fact does not vomit till it has reached the circulation. And the same is true of opium, jalap, and most of the poisons, animal, mineral, and vegetable. If imperfectly elaborated, or with a disproportion of some of its constituent principles to the rest, the whole system partakes of the evil, and a dysthesis or mor- bid habit is the certain consequence; whence tabes, atrophy, scur- vy, and various species of gangrene. And if it become once im- pregnated with a peculiar taint, it is wonderful to remark the te- nacity with which it retains it, though often in a state of dormancy and inactivity, for years or even entire generations. For as every germ and fibre of every other part is formed and regenerated from the blood, there is no other part of the system that we can so well look to as the seat of such taints, or the predisposing cause of the disor- ders I am now alluding to; often corporeal, as gout, struma, phthisis; sometimes mental, as madness, and occasionally both, as cretinism. It is hence the blood has been supposed to be alive: a belief of very high antiquity, and which has been warmly embraced by Dr. Harvey and many others of the first physiologists of modern times. It was a favourite opinion of Mr. John Hunter, and runs through the whole of his doctrines. " That the blood," says he " has life, is an opinion I have started above thirty years, and have taught it for near twenty of that time in my lectures. It does not, therefore, come out at present as a new doctrine; but has bad time to meet with considerable opposition, and acquire its advocates. To con- ceive that blood is endowed with life, while circulating, is, perhaps, carrying the imagination as far as it well can go; but the difficulty arises merely from its being a fluid, the mind not being accustomed to the idea of a living fluid."* The experiments and train of reasoning he urges in favour of this opinion are highly ingenious and peculiarly strong. And, though they may not be demonstrative of a vital and energetic essence separate from the blood itself, but inherent in its substance, and con- trolling its motions, they seem very clearly to show that the blood is endowed with peculiar powers; and that, as matter at large is subject to the laws of gravitation, so the matter of the blood is sub- ject to the laws of instinct. We may here add, in favour of Mr. Hunter's opinion, the following two corollaries of Dr. Philip, de- duced from a large field of experiments. " The power of the blood- vessels, like that of the heart, is independent of the nervous system. —The blood-vessels can support the motion of the blood after the heart is removed."t Admitting these deductions to be established, the power here re- ferred to, and capable of influencing the blood or the blood-vessels, separately from that of the heart, and of the nervous system, must be the power of simple life, or of instinct, which is simple life ope- rating by the exercise of its own laws. • On Blood, p. 77. f Phil. Trans. 1815, p. 445. CLASS III. HiEMATICA. ORDER I. PYRECTICA. HEA*r AND NUMBER Of THE PULSE PRETERNATURALLY AUGMENTED i USUALLY PRECEDED BY RIGOR, AND FOLLOWED BY PERSPIRATION J DURING THE RIGOR, PAINS FIXED OR WANDERING : LASSITUDE : DE* BILITY OF MIND, AND VOLUNTARY MUSCLES. There is no complaint so common as fever; none in which mankind, whether professional or laical, are so little likely to be mistaken, and yet none so difficult to be defined. In reality no writer seems to have been fully satisfied with his own definition: and it is not extraordinary, therefore, that he should seldom have given satisfac- tion to others. The difficulty proceeds from the complexity of the symptoms that enter into the character of a fever ; the contrariety of many of them to each other in different stages of it; and the oc- casional absence of some that, in other instances, appear to consti- tute its leading features. There are also two other difficulties of considerable magnitude that the nosologist has to contend with in laying down a clear and perspicuous survey of fevers; and that is, their division or colloca- tion, and their generic names. But as I have already pointed out these difficulties, and the means by which they are attempted to be remedied under the present arrangement and nomenclature, in the running commentary to the order before us in the volume of Noso- logy, I shall beg to refer the reader to the observations there laid down, and shall subjoin only one or two additional remarks upon the same subject. Although the number of the pulse as well as the heat is preter- naturally augmented in almost every case of fever, an extraordinary instance is sometimes to be met with that opposes the general law, for the most part dependent, I believe, on a great and sudden op- pression of the brain; an explanation which withdraws the anomaly, and accounts for the ordinary increase of pulsation as soon as such 28 HAEMATIC A. [CL. III.—OR. i oppresion is removed. Thus, in the yellow fever of Antigua in 1816, the pulse, as Dr. Musgrave informs us, was, in one instance, under forty-four. " We almost fancied," says he, " this unusual softness might be constitutional: but, on opening a vein, it greatly increased in frequency: and, after the loss of a considerable quantity of blood, it numbered eighty, with nearly complete relief from every uneasy sensation."* In such cases the heat of the system usually exhibits as little fe- brile pugmentation as the pulse : for as the former is the result of increased action, till such increased action takes place, the heat, as in the first stage of the paroxysm, may continue even below the natural standard. There is a still more curious variation from the general law, which is sometimes, though very rarely, found to take place, of which Schenck gives a single example that occurred in his own practice ; I mean, a reversed order of the symptoms of the febrile paroxysm, and an appearance of the sweating stage before the shivering and hot fit.} To provide for these extraordinary and anomalous incidents by any definition whatever, is beyond the power of language. They must be left to themselves, and will rather confirm than disturb the definition now offered, agreeably to the maxim of the schools— exceptio probat regulam. In dividing fevers into distinct genera, I have taken the line of demarcation from the character of their duration, as limited to a single paroxysm; as composed of numerous paroxysms, with inter- vals of intermission or perfect apyrexy ; as composed of numerous exacerbations, with intervals of remission, or imperfect apyrexy; and as composed of a single series of increase and decrease, with a mere tendency to intervals of remission, without perfect apyrexy at any time. Other nosologists have drawn their generic distinctions from other circumstances; as their disposition or indisposition to putridity; their inclination to a sporadic or an epidemic character; the vigour and violence, or weakness and debility of their action ; or, in the language of Dr. Darwin, the nature of their influence on the sensitive or irritative fibres of the animal frame. The most obvious mark, however, and that which has been most generally approved, is the character of duration assumed in the arrangement before us. To all the rest there are greater or less objections, which, as I have already examined them in the comment just refer- red to, need not be repeated in the present place. Regulated, therefore, by the principle before us, fever admits of the four following genera:— I. EPHEMERA. diary fever. II. ANETUS. INTERMITTENT FEVER. III. EPANETUS. REMITTENT FEVER. IV. ENECIA. CONTINUED FEVER. ■■ —i— , __________________________________________________________ .,, * Trans. Med. Chir. Soc. Vol. IX. p, 133. f Lib. VI, Obs. 34. CL. HI__OR. I. SANGUINEOUS FUNCTION. 29 To each of these belong several species, and to most of the spe- cies several varieties, as will be noticed in their respective order. Some slight deviation from the ordinary nomenclature may be observed in the generic names above: but the reader can have no difficulty upon this head, as he will find the changes that have hereby been occasioned are in every instance founded upon a' principle of correctness and simplification ; and consequently calculated to dis- entangle rather than to add to his incumbrances, and to facilitate his progress in the labyrinth before him. The term Ephemera, is, indeed, well known to every one. Anetus and Epanetus are Greek terms, importing intermittent and remittent, from xvwfit and eirxvtyfM. Enecia, from the same tongue, denotes continued action, and is a derivation from yver-w. Before, however, we enter upon the practical part of this subject, it appears necessary to make a few remarks upon one or two other questions that have very largely occupied the attention of many pathologists, and especially concerning the proximate and remote causes of fever; and the tendency which fever has been supposed to evince of terminating suddenly, either favourably or unfavourably, at fixed periods of its progress. Proximate and remote causes are rather terms of recent than of ancient writers. In early times the causes of diseases chiefly con- templated where its proegumenal or predisponent, and its proca- tarctic or occasional. Thus, an hereditary taint, or habitual indul- gence in high living, may be regarded as a proegumenal cause of gout; and catching cold, or an unusual exertion of muscular exercise, may form its procatarctic cause: both of which are absolutely neces- sary ; for it is clear that the latter, without the former, would not produce the disease; and it is just as clear that the former might remain harmless in the constitution for years, were it not to meet with the co-operation of the latter, which is often, on this account, denominated an exciting cause. Generally speaking, the first was regarded as an internal, and the second as an external cause ; and in the instance selected they are so ; but they are not so always. To be acquainted with causes of this kind is always useful; and, in guarding against the approach of diseases, it is often of the utmost importance : but they give us very little information upon the real nature of diseases, and the mode of managing them when present. And hence another set of causes have been adverted to, and have of late been chiefly studied, and particularly in the case of fever. " That only," says Gaubius, " deserves the name of a physical cause which so constitutes the disease, that, when present, the disease exists ; while it continues, the disease continues; when changed or removed, the disease is altered or destroyed." It is this which con- stitutes the proximate cause, and is, in fact, the essence of the dis- ease, the actual source of all its effects. The remote cause is that which directly produces the proximate; as a specific virus in sy- philis, or a specific miasm in influenza, or epidemic catarrh. In fever we can often trace the remote causes; though we are 30 1LEMATICA. [CL. III.—OR. I. still too little acquainted with the nature of several of them to be able to restrict them to a specific mode of action ; of the proximate cause, we know but very little at present, and it will probably be long before we shall know much more. Let us, however, begin with the proximate cause as that which has most excited the attention of physicians in all ages. Upon this subject, indeed, a great deal of learned dust has beed raised, and a great deal of valuable time consumed. Ancient speculations, for they are not entitled to the name of theories, have been overthrown ; and modern speculations, in vast abundance, erected upon their ruins; which, in rapid succession, have also had their day and ex- pired. It is an inquiry, therefore, not likely to prove very pro- ductive ; yet, as forming a part of medical science of which no stu- dent should be altogether ignorant, it seems necessary to extend it to a brief survey of the most popular doctrines which have been advanced upon the subject in different ages. Fevers then, in respect to their proximate cause, have been con- jectured to originate from a morbid change, either in the composi- tion of the blood, or in the tone or power of the living fibre. The first view has given rise to various hypotheses, that rank under the common division of the humoral pathology. The second has given rise to other hypotheses appertaining to the common division of the fibrous or nervous pathology. The hypotheses derived from the one or the other of these sources, that are chiefly entitled to attention, are the following : of which the first two belong to the former division, and the remainder to the latter. I. That of the Greek schools, founded on the doctrine of a con- coction and critical evacuation of morbific matter. II. That of Boerhaave, founded on the doctrine of a peculiar vis- cosity, or lentor of the blood. III. That of Stahl, Hoffman, and Cullen, founded on the doctrine of a spasm on the extremities of the solidum vivum, or living fibre. IV. That of Brown and Darwin, founded on the doctrine of accu- mulated and exhausted excitability, or sensorial power. V. To which we may add that fevers have, by some physiologists, as Dr. Clutterbuck, and Professor Marcus, been identified with in- flammation ; and their proximate cause been ascribed to increased action in some particular organ. I. It was the opinion of Hippocrates that fever is an effort of na- ture to expel something hurtful from the body, either ingenerated, or introduced from without. Beholding a violent commotion in the system, followed by an evacuation from the skin and kidneys, with which the paroxysm terminated, he ascribed the commotion to a fermentation, concoction, or ebullition, by which the noxious matter was separated from the sound humours ; and the evacuation to a despumation or scum which such separation produced, or rather to the discharge of this morbid scum from the emunctories that open externally. Galen supported this view with all the medical learn- CL. III.—OB. I.] SANGUINEOUS FUNCTION. 3 J ing of his day; and it is the only explanation of fever to be met with in medical writings, through the long course of three thousand years ; in fact, till the time of Sydenham, who still adhered to it, and whose pages are full of the language to which it naturally gave birth. It blended itself almost insensibly with the language of the che- mists of the day, notwithstanding the professed hatred of Paracelsus, and Van Helmont towards the whole range of Galenic doctrines, and the solemn pomp with which the former had condemned and burnt the entire works of Hippocrates and Galen. And hence, under the influence of chemistry, at this time assuming a soberer aspect, the supposed animal despumation was contemplated as possessed according to different circumstances, of different chemi- cal qualities and characters; and particularly as being acid, alkaline, effervescent, or charged with some other acrimonious principle, too highly exalted, or in too great a proportion. This doctrine, considered merely hypothetically, is not only inno- cent, but highly ingenious and plausible. It js in unison with seve- ral of the phaenomena of pyrectic diseases;" and derives a strong collateral support from the general history of exanthems or eruptive fevers, in which we actually see a peccant matter, producing gene- ral commotion, multiplying itself as a ferment, and at length sepa- rated and thrown off at the surface by a direct depuration of the system. So far therefore as relates to exanthems, the opinion is sufficiently correct. But the moment it is brought forward as the proximate cause of fever properly so called, in which there is no specific eruption, it completely fails. For, first, no explanation is here given as to the means by which any such concoction or fermentation, or multiplication of morbific matter in any way takes place. Next# there are many fevers pro- duced evidently by cold, fear, and other excitements, as well mental as corporeal, in which most certainly there is no morbific matter introduced, and wherein we have no reason to conceive there is any generated internally ; while the disease, limited perhaps to a single paroxysm, closes nevertheless with an evacuation from the skin or the kidneys. And, thirdly, we sometimes behold fevers suddenly cured, as Dr. Cullen has observed, by a hemorrhage so moderate, as for example a few drops of blood from the nose, as to be incapable of carrying out any considerable portion of a matter diffused over the whole mass of the blood; while we are equally incapable of con- ceiving how such diffused morbific matter could collect itself at a focal point, or pass off at a single outlet: or of tracing in the dis- charge, after the minutest examination, any properties different from those of blood in a state of full health. I have observed that this hypothesis is, however, harmless enough when merely brought forward as a speculation. But it has not al- ways been limited to this point; for it has occasionally been advan- ced as a practical and efficient principle ; and the febrile commotion? 32 HJEMAT1CA. ICL'1IL"" and particularly the hot fit, has, in treating the disease, been pur- posely increased, with a view of assisting nature in her curious but unknown process of expelling the peccant material; and the most dangerous consequences have followed. li. The acute and penetrating mind of Boerhaave, who was born in 1668, was sufficiently sensible of this danger; and the discoveries which were now taking place in chemistry and physiology, led him progressively to the construction of a new theory, which in a tew years became so popular as to obtain a complete triumph over that of the Greek Schools. . _ . Leeuwenhoeck, by a delicate and indefatigable application ot the microscope to animals of a transparent skin, had endeavoured to es- tablish it as a fact, that the constituent principles of the blood con- sist of globular corpuscles ; but that these corpuscles differ in size in a regular descending series according to the constituent principles themselves; and that each set of principles has its peculiar blood- vessels, possessing a diameter just large enough to admit the glo- bules that belong to it, and consequently incapable, without force, of allowing an entrance of those of a larger magnitude; and hence that the blood-vessels possess a descending series as well as the par- ticles of the blood. It was upon this supposed fact, that Boerhaave built his hypothe- sis. He conceived that almost all diseases may be resolved into an introduction of any given series of particles of blood into a series of vessels to which they do not properly belong; and he distinguished such introduction by the name of error loci. He conceived still far- ther, that this heterogeneous admixture is very frequently taking place; and that its chief cause consists in a disproportion of one or more sets of the sanguineous principles to the rest, by which their globular form is occasionally broken down and destroyed, and ren- dered either too thin and serous, or too gross and viscid. The vis- cidity of the blood he distinguished by the name of lentor ; and to a prevalence of this lentor, or viscidity, he ascribed the existence of fever; maintaining that the general disturbance which constitutes fever proceeds from an error loci of the viscid blood, whose gross- er corpuscles, from their undue momentum as well as superabun- dance, press forcibly into improper series of vessels, and stagnate in the extremities of the capillaries whence the origin of the cold stage, and consequently of the stages that succeed it, to which the cold stage gives rise ;* and hence those medicines which were supposed capable of dissolving that tenacity, or breaking down the coales- cence of such a state of the blood, were denominated diluents, hu- mectants, and attenuants, whilst those of an opposite character were called inspissants : terms which have descended to our own day, and are still retained even by those who pay little attention to the hypothesis that gave them birth. The system of Boerhaave, therefore, consisted of an elegant and * Aph. 756. Comment Van Swiet. Tom. II. p. 528. Edit.Lugd. Bat. 40.1745. CL. III.—OR. I.] SANGUINEOUS FUNCTION. 3$ artful combination of both the earlier and later doctrines of corpus- cular physiology. Without deserting the humoral temperaments of Galen, or the constituent elements and elective attractions of the al- chemists, he availed himself of the favourite notions of the corpus- cular pathologists, their points or stimuli, their frictions, angles and spherules, derived from the Cartesian philosophy, which were now exercising as triumphant a sway over the animal, as over the material system; and interwove the whole into an eclectic scheme, so plau- * sible and conciliatory to all parties, that all parties insensibly felt themselves at home upon it, and adopted it with a ready assent. In the emphatical language of M. Quesnay, it was " la medicine col- lective." The most triumphant fact in favour of the Boerhaavian hypothe- sis is that the crust on the blood in inflammations, and cauma, or inflammatory fever, is often found peculiarly dense. But as fevers (and certainly the greater number) are found without any such crust; and as a similar crust, though perhaps, not quite so dense, exists under other and very different states of body, as in pregnancy and scurvy (porphyra), even this leading appeal has long lost its power of conviction : whilst the abruptness with which fevers make their as- sault, from sudden occasional causes and in constitutions of every diversity, forbid the supposition that in such cases a lentor or sizy crasis of the blood, and especially a glutinosum sfiontaneum can have time to be produced, however it may exist occasionally, and be perhaps the source of other disorders. III. To this period of time, in the production of fever, and indeed of all other diseases, the human body was regarded as almost en- tirely passsive, a mere organic machine, operated indeed upon by some autocrateia, as nature, or a vis medicatiux, but in the same manner as other machines, and mostly by similar laws. Its mus- cles were contemplated as mechanical levers, and its vessels as hy- draulic tubes, whose powers were calculated upon the common principles of mechanics and hydronamics; and were only supposed to be interfered with by the internal changes perpetually taking place in the fluids they had to convey. A new era, however, at length began to dawn upon the world: a more comprehensive spirit to pervade medical study: the animal frame was allowed to exhibit pretensions superior to the inanimate, and not only to be governed by powers of its own, but by powers which are continual- ly and systematically from a given point operating to a preservation of health where it exists, and to a restoration of health where it has been lost or injured. Stahl, who was contemporary with Boerhaave, and in the university of Halle in 1694, first started this loftier and more luminous idea,—more luminous, though the light was still struggling with darkness; made the mind the controlling principle, and the solidum vivum, or nervous system, the means by which it acted. Fever, on*his hypothesis, consisted in a constric- tive or tonic spasm, in his own language spasmus tonicus, produced by a torpor or inertness of the brain, at the extremity of the nerves, vol. n.—5 34 H.EMATICA. [CL. III.—OR. I. and counteracted by the remedial exertions of the mind, the vires medicatrices of his hypothesis, labouring to throw off the assailing power; whence the general struggle and commotion by which the febrile paroxysm is characterized. Hoffman, who was a colleague of Stahl, took advantage of this new view; followed up the crude and primary ideas of Stahl with much patient and laborious investi- gation ; and soon presented to the world a more correct system, in a more attractive style; but apparently with a disingenuous con- cealment of the source from which he had borrowed his first hints. He omitted the metaphysical part of the Stahlian hypothesis, took from the mind the conservative and remedial power over the dif- ferent organs with which Stahl had so absurdly endowed it; seated this power as a law of life in the general organization; separated the nervous from the muscular fibres, the latter of which were re- garded as only the extremities of the former by Stahl; allowed a wider range and longer term to the constrictive spasm of fever; and changed its name from spasmus tonicus to spasmus peripherics :* giving also to the moving power of the muscular or irritable fibres the name of vis insita, as that of the nervous fibre was called vis nervea. It is highly to the credit of Boerhaave, that his mind, in the lat- ter part of his life, was so fully open to the merits of this hypothe- sis, that he admitted the agency of the nervous power, though a doctrine that struck at the root of his own system, of which we have a clear proof in the change which occurs in the fourth edition of his Aphorisms, and particularly aphorism 755, where he lays down the proximate cause of intermitting fevers. Hitherto it had run thus " unde post accuratum examen totius historian intermittentium causa proxima constituitur viscositas liquid! arteriosi." But to this, in the edition before us, is added the following: "forte et nervosi (liquidi) tain cerebri, quam cerebelli cordi destinati, inertia."t It is also equally creditable to the learned Gaubius, that, though strongly attached to the Boerhaavian school, in which he was edu- cated, and a zealous contender for many of its doctrines, his under- standing was alike open to the clearer and simpler views of the chemists of the day, upon various points not yet generally adopted, and allowed him to become a more thorough convert to their philo- sophy. The reader may judge of this change in his mind by the followingfpassage: " An et naturae humanae facultas inest, moleculas, acris detritas aut intropressasangulis, in sphaerulas tornando, blandi- tium creandi? Non satis constat speciosam ideam aequaliter in flui- dam solidamque acrimoniam quadrare.—Credibilius profecto mix- tione chemica magis quam mechanica rotundatione, id opus per- fici."$ In effect, there not only was at this time, but had been for many years antecedently, a general feeling among the cultivators * Med. Nat. Systemat. Tom. HI. § i. cap. 4. .Bochmer, Dis. de Spasrai Peri- pheric! signo in febribus continentibus. Hal. . 765. + De Motu Tonico. Theoria Medica vera. Halle 1734. ♦ Pathol. §298-300. CL. III.—OR. I.] SANGUINEOUS FUNCTION. 35 of medicine, that neither the laws of animal chemistry nor of the living fibre had been sufficiently studied for the purposes of a cor- rect pathology : in proof of which it may be sufficient to refer to various articles on both subjects, inserted in the Ephemerides Na- turae Curiosorum, published at Frankfort, in 1684 ; and the writings of Baglivi,* and Dr. Willis ;t and still more particularly to Dr. Gil- christ's elaborate treatise on nervous fevers, inserted in the Edin- burgh Medical Transactions ;{ in which last the author, following up the hint thrown out by Boerhaave in the aphorism just quoted, endeavours to show how well the two ideas of lentor and spasm are disposed to amalgamate in forming the proximate cause of fever; the spasm consisting of an universal muscular tension, and the len- tor being united according to the nature of the case with inflamma- tion, acrimony, or both; and hence often producing what he deno- minates an alternate nisus and re-ntsus. • The materials, however, were now becoming too unwieldy ; and the wheels of the machine were clogged by the very forces that were designed to increase its motion. Dr. Cullen was well aware of this, and boldly ventured upon a new attempt for the purpose of simpli- fying and facilitating its progress. As his basis he took the hypo- thesis of Stahl as modified and improved by Hoffman: and on this basis erected his stately and elaborate structure, so well known to the medical world, full of ingenuity and daring genius, and which, if it be at this moment crumbling into decay, certainly is not falling prostrate before any fabric of more substantial materials or more elegant achitecture. Dr. Cullen has been accused of the same want of ingenuousness towards Hoffman, as Hoffman is chargeable with towards Stahl; and of having introduced his system to the public with little or no acknowledgment of the sources from which he has drawn. But surely no one can bring forward such an accusation, who has read with any degree of attention the preface to his Prac- tice of Physic, in which he gives a full account of Dr. Hoffman's system in his own words, and pays complete homage to his merits. According to the more elaborated principles of the Cullenian system, the human body is a congeries of organs regulated by the laws not of inanimate matter, but of life, and superintended by a mobile and conservative power of energy, seated in the brain, but distinct from the mind or soul; acting wisely but necessarily, for the general health; correcting deviations, and supplying defects, not from a knowledge and choice of the means, but by a pre-establish- ed relation between the changes produced, and the motions requir- ed for the restoration of health ; and operating therefore, through the medium of the moving fibres, upon whose healthy or unhealthy state depends the health or unhealthiness of the general frame; which fibres, he regarded with Stahl, as simple nerves, the muscu- • Specimen de fibra motrici et morboso. f Pathologia Celebri et Norvorum. * Vol. IV. Art. XXIII. and Vol. V. Part. II. Art. XLVIII. 3G HAEMATIC A. [CL. 1II.-0R. I. lar filaments being nothing more than their extremities, and by no means possessed of an independent vis insita. The brain therefore, upon this hypothesis, is the primum mobile, but it closely associates in its action with the heart, the stomach, and the extreme vessels. Th» force of the heart gives extension to the arteries, and the growth of the body depends upon such ex- tension in conjunction with the nutricious fluid furnished by the brain, and deposited by the nerves in the interstices of their own fibres; the matter of which fibres is a solid of a peculiar kind, whose parts are united by chemical attraction. All nervous power com- mences in the encephalon; it " consists in a motion beginning in the brain and propagated from thence into the moving fibres, in which a contraction is to be produced. The power by which this motion is propagated, we name," says Dr. Cullen, " the Energy of the brain ; and we therefore consider every modification of the mo- tions produced, as modifications of that energy."* He further lays it down as a law of the economy, that the energy of the brain is alternately excited and collapsed, since every fibrous contraction is succeeded by a relaxation: whence spasms and convulsions are motus abnormes, and consist in an irregularity of such alternation. But we must distinguish in this system between the energy of the brain and the vital fluid it sends forth by the nerves; for while the former rises and sinks alternately, the latter remains permanently the same. It is not a secretion, but an inherent principle, never ex- hausted, and that never needs renewal.t This hypothesis, in its various ramifications, influenced every part of his theory of medicine, and consequently laid a foundation for his doctrine of fever. The proximate cause of fever was, in his opinion, a collapse or declination of the energy of the brain pro- duced by the application of certain sedative powers, as contagion, miasm, cold, and fear, which constitute the remote causes. This diminished energy extends its influence over the whole system, and occasions an universal debility; but chiefly over the extreme ves- sels, on which it induces a spasm ; and in this spasm the cold fit is supposed to consist. " Such, however," to adopt the words of Dr. Cullen himself, "is the nature of the animal economy, that this debility proves an in- direct stimulus to the sanguiferous system; whence by the inter- vention of the cold stage, and spasms connected with it, the action of the heart and larger arteries is increased, and continues so till it has had the effect of restoring the energy of the brain, of extend- ing this energy to the extreme vessels, of restoring therefore their action, and thereby especially overcoming the spasm affecting them; upon the removing of which, the excretion of sweat, and other marks of the relaxation of the excretories, take place."! * Mat. Med. Part. II. Chap. VIII. 349. f Id. Part. II. Chap. VI. p. 223. tPract. ofPhy. § XLVI CL. m.—OR. I.] SANGUINEOUS FUNCTION. 37 This relaxed or perspiratory section of the paroxysm, however, is not regarded by Dr. Cullen as a part of the disease, but as the prelude to returning health. Yet the fit still consists of three stages; the first of debility or diminished energy, the second of spasm, and the third of heat. And though Dr. Cullen had some doubts whether the remote causes of fever might not produce the spasm as well as the atony of the nervous system, yet he inclined to ascribe the second stage to the operation of the first, as he did most decidedly the third to that of the second: and thus to regard the whole as a regular series of actions, employed by the vis medicatrix naturae for the recovery of health. That fever in its commencement or earliest stage is characterized by debility of the living fibre, or, more closely in the words of Dr. Cullen, by diminished energy of the brain, extending directly or indirectly to the voluntary muscles and capillaries, cannot for a moment be doubted by any one who accurately watches its phaeno- mena. And thus far the Cullenian hypothesis is unquestionably correct; as it appears to be also in supposing the cold stage to be the foundation of the hot, and of the excretion of sweat by which the hot stage is succeeded. But it fails in the two following import- ant points, without noticing a few others of smaller consequence. The spasm on the minute vessels produced by debility takes the lead in the general assault; and though it forms only a link in the remedial process, is the most formidable enemy to be subdued; and hence all that follows in the paroxysm is an effort of the system to overcome this spasm. The effort at length proves successful: the debility yields to returning strength ; the spasm is conquered, and the war should seem to be over. But this is not the fact: the war continues notwithstanding; there is nothing more than a hollow truce ; debility and spasm take the field again, and other battles re- main to be fought. There is nothing in this hypothesis to account for a return of debility and spasm, after they have been subdued; nor to show why spasm should ever in the first instance be a result of debility. " In this system," says Dr. Parr, "the production of spasm by debility, is an isolated fact without a support; and the in- troduction of the vires medicatrices naturae, is the interposition of a divinity in an epic, when no probable resource is at hand." The next striking defect that must occur to the attentive reader is, that debility is here made a cause of strength; the weakened action of the first stage giving rise to the increased action and re- excited energy that restore the system to a balance of health : and here again we stand in need of the interposition of some present divinity to accomplish such an effort by such means. IV. It is not, therefore, to be wondered at that this system, with all its ingenuity and masterly combination, should not have proved satisfactory to every one. In reality, it did not for many years prove satisfactory to every one in the celebrated school in which it was first propounded. And hence, under the plastic hands of Dr. Brown arose another hypothesis, of which I shall proceed to give a 38 HiEMATICA. [CL. III.-OR. I. very brief outline, together with the modification it received under the finishing strokes of Dr. Darwin. Dr. Brown, who was at first a teacher of the classics at Edinburgh, and a translatorof inaugural theses into Latin, commenced the study of medicine about the middle of life, by a permission to attend the medical schools gratuitously. He was at first strongly attached to Dr. Cuflen and Dr. Cullen's system; but an altercation ensued, and he felt an equal animosity towards both. A new and opposite sys- tem, if so it may be called, was in consequence manufactured and publicly propounded in a variety of ways. It had great simplicity of principle, and some plausibility of feature ; it attracted the curi- ous by its novelty, the indolent by its facility, and every one by the boldness of its speculations. It circulated widely, and soon acquired popularity abroad as well as at home. Man, according to Dr. Brown, is an organized machine, endowed with a principle of excitability, or predisposition to excitement, by means of a great variety of stimuli both external and internal, some of which are perpetually acting upon the machine ; and hence the excitement which constitutes the life of the machine is main- tained. Excitability, therefore, is the nervous energy of Dr. Cul- len ; and, like that, is constantly varying in its accumulation and exhaustion ; yet like the nervous energy of Dr. Cullen, under the direction and guidance of a vis conservatrix et medicatrix naturae distinct from the matter of the organization itself, but pas- sively exposed to the effect of such stimuli as it may chance to meet with, and necessarily yielding to their influence. Upon this hypothesis, excitement is the vital flame, excitability the portion of fuel allotted to every man at his birth, and which, vary- ing in every individual, is to serve him without any addition for the whole of his existence : while the stimuli by which we are surround- ed, arc the different kinds of blasts by which the flame is kept up. If the fuel or excitability be made the most of, by a due tempera- ture or mean rate of blasts or stimuli, the flame or excitement may be maintained for sixty or seventy years. But its power of support- ing a protracted flame may be weakened by having the blast either too high or too low. If too high, the fuel or excitability will, from the violence of the Game, be destroyed rapidly, and its power of prolonging the flame be weakened directly; and to this state of the machine Dr. Brown gave the name of indirect debility, or exhaust- ed excitability. If the blasts or stimuli be below the mean rate, the fuel, indeed, will be but little expended, but it will become drier and more inflammable ; and its power of prolonging the flame will be still more curtailed than in the former case; for half the blast that would be required to excite rapid destruction antecedently, will be sufficient to excite the same effect now. This state of the machine, therefore, the author of the hypothesis contra-distinguish- ed by the name of direct debility, or accumulated excitability. Upon these principles he founded the character and mode of treat- ment of all diseases. They consist but of two families, to which he gave the name of sthenic and asthenic ; the former produced by ac- CL. III.—OR. I. SANGUINEOUS EUNCTION. 39 cumulated excitability, and marked by direct debility; the latter occasioned by exhausted excitability, and marked by indirect debi- lity. The remedial plan is as simple as the arrangement. Bleed- ing, low diet, and purging, cure the sthenic diseases; and stimulants ot various kinds and degrees, the asthenic. Fever, therefore, under this hypothesis, like other diseases, are either sthenic or asthenic ; they result from accumulated or exhaust- ed excitability. Synocha, or inflammatory fever (cauma, under the present arrangement), belongs to the first division, and tvphus to the second. Let us try the system by these examples. The first symptoms of inflammatory fever, like those of all others evince, as I have already observed, debility or languid action in every organ,—let the debility be distinguished by whatever epithet it may. The vital flame is weak, and scarcely capable of being supported; and yet the fuel is more inflammable than in a state of health, the excitability is accumulated. This scheme therefore, completely fails in accounting for the origin or first stage of inflam- matory, or, in Dr. Brown's own language, sthenic fever. Typhus pestilens, or jail-fever, is arranged by Dr. Brown as an astenic disease; and, as such, we have reason to expect debility as characteristic of its entire progress. Yet what is it that produces this debility ? The blast or stimulus is here contagion; and the ex- citability is exhausted by the violence of this blast or stimulus ; but there is no means of its becoming exhausted without increasing the excitement: the fuel can only be lessened by augmenting the flame that consumes it. Yet in typhus, according to this hypothesis, the fuel is expended, not in proportion as the flame is active and vio- lent, but in proportion as it is weak and efficient. The excitability is exhausted, and the debility increases in proportion as the excite- ment forbears to draw upon it for a supply. The blast blows hard but without raising the fire, and yet the fuel consumes rapidly. This scheme, therefore, completely fails, in accounting for any stage of low or asthenic fevers of every description. Dr. Brown, however, was not a man of much practice; his wri- tings show that he was but little versed in the symptoms of diseases; his descriptions are meagre and confused: and hence, when he comes to assort diseases into the only two niches he allots for their reception, he makes sad work; and maladies of the most opposite characters, and demanding the most opposite mode of treatment, are huddled together to be treated in the same manner, in many cases with no small risk to the patient. Thus, among the sthenic diseases are associated rheumatism, erysipelas, scarlet and inflammatory fe- ver; and among the asthenic, gout, typhus, apoplexy, and dropsy. The Brunonian hypothesis, nevertheless, offers one principle that is unquestionably founded on fact, and is peculiarly worthy of atten- tion ; I mean, that of accumulated excitability from an absence or defect of stimuli; in colloquial language, an increase of energy by rest. And it is this principle which forms the hinge on which turns the more finished system of Dr. Darwin. Sensible of the objection that weighs equally against that part of 40 HJEMATICA. [CL. IH.—OR. I- the system of Dr. Cullen snd Dr. Brown, which represents the energy or excitability of the living frame as capable of recruiting itself after collapse or exhaustion, without a recruiting material to feed on; he directly allows the existence of such a material; regards it as a peculiar secretion, and the brain as the organ that elaborates and pours it forth. The brain, therefore, in the system of Dr. Darwin, is the common fountain from which every other organ is supplied with sensorial fluid, and is itself supplied from the blood as the blood is from the food of the stomach. All this is intelligible; but when beyond this he endows his sensorial fluid with a mental as well as a corporeal faculty, makes it the vehicle of ideas as well as of sensation, and tells us that ideas are the actual " contractions, or motions, or configurations, of the fibres which constitute the immediate organ of sense,"* he wanders very unnecessarily from his subject, and clogs it with all the errors of materialism. He supposes the sensorial power, thus secreted, to be capable of exhaustion in four different ways, or through four different faculties of which it is possessed : the faculty of irritability, exhausted by external stimuli affecting simple irritable fibres : that of sensibility, exhausted by stimuli affecting the fibres of the organs of sense: that of voluntarity, exhausted by stimuli affecting the fibres of the voluntary organs acting in obedience to the command of the will: and that of associability, exhausted by stimuli affecting organs asso- ciated in their actions by sympathy or long habit. By all or any of these means, the sensorial power becomes evacuated, as by food and rest it becomes replenished, often, indeed, with an accumulation or surplus stock of power. In applying this doctrine to fever, he considers its occasional causes, whatever they may be, as inducing a quiescence or torpor of the extreme arteries, and the subsequent heat as an inordinate exer- tion of the sensorial power hereby accumulated to excess; and, consequently, the fever of Dr. Darwin commences a stage lower than that of Dr. Cullen, or in the cold fit instead of in a collapse of the nervous energy lodged in the brain. Now, allowing this explanation to account for the cold and hot stages of a single paroxysm of fever, like the spasm of Dr. Cullen, it will apply no farther. For when the sensorium has exhausted itself of its accumulated irritability, the disease should cease. It may, perhaps be said, that a second torpor will be produced by this very exhaustion, and a second paroxysm must necessarily ensue. Admitting this, however, for a moment, it must be obvious that the first or torpid stage only can ensue; for the system being now quite exhausted, the quiescence that lakes place during the torpor can only be supposed to recruit the common supply necessary for health; we have no reason to conceive, nor is any held out to us, that this quantity can again rise to a surplus. Yet it must be farther remark- ed, that in continued fevers we have often no return of torpor or ' Zoronom. Vol. I. Sect. II. ii. 7. CL. ill.—OK. I.] SANGUINEOUS FUNCTION. 41 quietude whatever, and, consequently, no means of re-accumulating irritability ; but one continued train of preternatural action and ex- haustion, till the system is completely worn out. And to this ob- jection the Darwinian hypothesis seems to be altogether without a reply. It is not necessary to pursue this subject further. Other conjec- tures more or less discrepant from those now examined have been offered, but they have not acquired sufficient notice, or evinced suf- ficient ingenuity to be worthy of examination. V. There are other pathologists who have referred the proxi- mate cause of fever to a morbid affection of some particular organ, or set of organs associated in a common function. Thus, Baron Haller alludes to several in his day, who ascribed it to a diseased state of the vena cava :* Bianchi pitched upon the liver,f Swalve on the pancreas,}: Rahn on the digestive organization generally,§ and Dr. Clutterbuck has still more lately, in our own country, and with far more reason and learning, brought forward the brain ; to an inflammation of which organ he ascribes fevers of every kind, regarding them merely as so many varieties of one specific disease, originating from this one common cause.|| But this is to confound fever with local inflammation, the idiopathic with the symptomatic affection. In treating of inflammation under the ensuing Order, we shall have sufficient opportunities of seeing that an inflamed state of almost any organ, and especially of membranous organs or the membranous parts of organs, is sufficient to excite some degree of fever or other, and not unfrequently fever of the highest degree of danger from its duration or violence. And hence, the liver, the lungs, the stomach, the intestines, the peritoneum, and the brain, have an equal claim to be regarded as furnishing a proximate cause of fever when in a state of inflammation. A very striking objection to Dr. Clutterbuck's hypothesis, is his limiting himself to a single organ as the cause of an effect which is equally common to all of them. And on this ground it is that Professor Marcus of Bavaria, who has contended with similar strenuousness for the identity of fever and inflammation, has regard- ed all inflamed organs as equal causes; and is hereby enabled to account, which Dr. Clutterbuck's more restricted view does not so well allow of, for the different kinds of fever that are perpetually springing before us, one organ giving rise to one, and another to another. Thus, inflammation of the brain, according to Dr. Marcus, is the proximate cause of typhus; inflammation of the lungs, of * Bibl. Med. Pr. I. p. 112. f Hist. Hepat. p. 112. i Pancreas, &c. p. 141. § Briefwechsel, Band. I. p. 150, II Treatise on Fever, 8vo. VOL. II.—6 42 HEMATIC A. [CL.—IU. OR. I hectic fever; that of the peritoneum, of puerperal fever; and that of the mucous membrane of the trachea, of catarrhal fever. , The general answer, however, to pathologists of every descrip- tion who thus confound or identify fever with inflammation, whether of a single organ or of all organs equally, is, that though fever is commonly a symptom or sequel of inflammation, inflammation is not uncommonly a symptom or sequel of fevers. And hence, though post-obit examinations, in the case of those who have died of fever, should show inflammation in the brain, the liver, or any other organ, it is by no means a proof that the disease originated there, since the same appearance may take place equally as an effect, and as a cause. Whilst a single example of fever terminating fatally without a trace of inflammation in any organ whatever, and such examples are perpetually occurring, is sufficient to establish the existence of fever as an idiopathic malady, and to separate the febrile from the phlogotic divisions of diseases. "A fever, therefore," to adopt the language of Dr. Fordyce, " is a disease that affects the whole system; it affects the head, the trunk of the body, and the extremities ; it affects the circulation, the absorption, and the nervous system; it affects the skin, the muscular fibres, and the membranes; it affects the body, and affects likewise the mind. It is, therefore, a disease of the whole system in every kind of sense. It does not, however, affect the various parts of the system uniformly and equally; but, on the contrary, sometimes one part is much affected in proportion to the affection of another part."* The result of the whole, as observed at the outset of this intro- duction, is that we know little or nothing of the proximate cause of fever, or the means by which its phaenomena are immediately produced. In the language of Lieutaud applied to the subject be- fore us, they are too often atra. caligine mersae ; nor have any of the systems hitherto invented to explain this recondite inquiry, however ingenious or elaborate, answered the purpose for which they were contrived. From the proximate cause of fever let us next proceed to a few remarks upon its remote causes. Dr. Cullen, who has striven so strongly and so ingeniously to simplify the former, has made a similar attempt in respect to the, latter. He first resolves all remote causes into debilitating or sedative powers, instead of being stimulant as they were formerly very generally considered, and as they are still regarded by many pathologists, and especially by those who contemplate fever and inflammation as identic. Whether this position of Dr. Cullen be correct or not, it was necessary for him to lay it down and to main- tain it, or he must have abandoned his system of fever altogether, which supposes it to commence in, and be primarily dependant upon debility. These sedative or debilitating causes he reduces to two: marsh * On Fever, Dissert. I. p. 28. CL. III.—OR. 1.] SANGUINEOUS FUNCTION. 43 and human effluvia. To the former of which he limits the term miasmata, and the power of producing intermittent fevers, which, with him, include remittent; while to the latter he confines the term contagions, and the power of producing continued fevers. It is true he has found himself compelled to take notice of a few other powers, as cold, fear, intemperance in venery or drinking; but these he is disposed to regard as little or nothing more than sub-agents, or co-agents, scarcely capable of producing fever by themselves. " Whether fear or excess be alone," says he, " the remote cause of fever, or if they only operate either as concurring with the operation of marsh or human effluvia, or on giving an opportunity to the operation of cold, are questions not to be positively answered : they may possibly of themselves produce fever; but most frequently they operate as concurring in one or other of the ways above mentioned."* To cold, however, he attributes a power of engen- dering fever more freely than to the rest; " yet even this," says he, " is commonly only an exciting cause concurring with the operation of human or marsh effiuvia."t We shall find, as we proceed, that these supplemental causes may admit of addition ; as we shall also that they more frequently exist as independent agents than Dr. Cullen is disposed to allow. Yet there can be little doubt that the chief and most extensive causes of fever are human and marsh effluvia. No great benefit, however, has resulted from endeavouring to draw a line of distinction between these two terms, and hence it is a distinction which has been very little attended to of late years. Miasm is a Greek word, importing pollution, corruption, or defile- ment generally ; and contagion, a Latin word, importing the applica- tion of such miasm or corruption to the body by the medium of touch. There is, hence, therefore, neither parallelism nor antago- nism, in their respective significations : there is nothing that neces- sarily connects them either disjunctively or conjunctively. Both equally apply to the animal and the vegetable worlds—or to any source whatever of defilement and touch ; and either may be predi- cated of the other ; for we may speak correctly of the miasm of contagion, or of contagion produced by miasm. And hence it is that the latter term is equally applied by Sauvages to both kinds of effluvia : " Miasmata, turn sponte in sanguine enata, turn extus ex aere, in massam sanguineam delata."!; It is a question of more importance whether we have yet the means of realizing the distinction between human and marsh mias- mata, which Dr. Cullen has here laid down, and which has been generally adopted from the weight of his authority. All specific miasmata may be regarded as morbid ferments, capable of suspen- * Pract. of Phys. Book I. Ch. IV. Sect. XCVII. fid. Sect. XC1I. * Nosol. Method. CI. II. Feb. Theor. Sect. 79. 44 HiEMATICA. [CL. III.—OR. I. sion in the atmosphere, but varying very considerably in their degree of volatility, from that of the plague, which rarely quits the person except by immediate contact, to that of the spasmodic cho- lera of India, which, as observed when treating of it,* works its way, if it be really from a specific poison, in the teeth of the most powerful monsoons, despising equally all temperatures of the atmos- phere and all salubrities of district, and travelling with the rapidity of the fleetest epidemy. They are of various kinds, and appear to issue from various sources, but we can only discriminate them by their specific effects. These are most clearly exemplified in the order of exanthems : in which for some thousands of years they have proved themselves to be of a determined character in all parts of the world where they have been the subject of observation, dif- fering only in circumstances that may be imputed to season, climate, and other external causes, or to the peculiar constitutions of the individuals affected. Thus, the miasm of smalNpox has uniformly continued true to small-pox, and that of measles, to measles ; and neither of them has, in a single instance, ran into the other disease, or produced any other malady than its own. But can we say the same of the supposed two distinct miasms of marsh and human effluvia ? Is it equally true that the former have never produced any other than intermittent fever, or the latter any other than continued ? And is it also equally true that each of these maladies adheres as strictly to its own character in every age, and every part of the world, as small-pox and measles; and that they have unifonnly shown as strong an indisposition to run into each other? Dr. Cullen's system is built upon an affirmative to these questions. For it, in fact, allows but two kinds of fever, each as distinctly proceeding from its own specific miasm as any of the exanthems. But this is to suppose what is contradicted by the occurrences of every day: which compel us to confess that, while we cannot draw a line of distinction between marsh and human effluvia from their specific effects, we have no other mode of distinguishing them. Some writers, indeed, have denied that intermittents, or rather the intermittents of marsh-lands, are produced by a miasm of any kind; for they deny that any kind of miasm is generated there ; and contend that the only cause of intermittents, in such situa- tions, is air vitiated by being deprived of its proper proportion of oxygene in consequence of vegetable and animal putrefaction, com- bined with the debilitating heat of the autumnal day, and the seda- tive cold and damp of the autumnal night.t But this opinion is too loosely supported to be worthy of much attention. It is sufficient- ly disproved by the intermittent described by Sir George Baker, as existing in the more elevated situations of Lincolnshire, while • Class I. Ord. I. Gen. IX. Spec. HI. f Currie. Trans. Amer. Phil. Soc. CL. III.—OR. I.] SANGUINEOUS FUNCTION. 45 the adjoining fens were quite free from it.* We have as much reason to suppose a febrile miasm in intermittents as in typhus ; and in some instances they have been found as decidedly conta- gious. " That intermittent fevers," says Dr. Fordyce, " produce this matter, or, in other words, are infectious, the author (meaning himself) knows from his own observation, as well as from that of others."! And notwithstanding that it becomes us to speak with diffidence upon a subject respecting which we are so much in want of in- formation, I may venture to anticipate that the evidence to be advanced in the ensuing pages upon the general nature and diver- sities of fever, will show that there is more reason for believing that the febrile principle produced by marsh and human effluvia is a common miasm, only varying in its effects by accidental modi- fications, and equally productive of contagion, than that it consists of two distinct poisons, giving rise to two distinct fevers, the one essentially contagious, and the other essentially uncontagious, as contended for by Dr. Cullen. In effect, we shall, I think, perceive this mysterious subject is capable of being, in some degree, more clearly elucidated and still farther simplified than it has been by preceding pathologists. In the decomposition of all organized matter, whether vegetable or animal, when suddenly effected by the aid of heat and moisture, an effluvium is thrown forth that is at all times highly injurious to the health, and, in a closely concentrated state, fatal to life itself. Thus, we are told by Fourcroy, that in some of the burial grounds in France, whose graves are dug up sooner than they ought to be, the effluvium from an abdomen suddenly opened by a stroke of the mattock, strikes so forcibly upon the grave-digger as to throw him into a state of asphyxy, if close at hand; and if at a little dis- tance, to oppress him with vertigo, fainting, nausea, loss of appe- tite, and tremours for many hours : whilst numbers of those who live in the neighbourhood of such cemeteries labour under de- jected spirits, sallow countenances, and febrile emaciation.| This effluvium is from the decomposition of animal matter alone; but the foul and stinking harmattan, when it rushes from the south-east upon the Guinea coast, loaded with vegetable exhalations alone, with which it impregnates itself while sweeping over the immense uninhabitable swamps and oozy mangrove thickets of the sultry regions of Benin, triumphs in a still more rapid and wasteful de- struction ; insomuch that Dr. Lind informs us, that the mortality produced by this pestilential vapour in the year 1754 or 1755 was so general, that in several negro towns the living were not suffi- cient to bury the dead ; and that the gates of Cape Coast Castle * Medic. Trans. Vol. HI. Art. Xln. f On Fever, Diss. I. p. 117. * Elemens de Chimie, Art. Putrefaction de Substances Animal, torn. iv. 46 HiEMATICA. [CL. HI.—OR. I. were shut up for want of centinels to perform duty; blacks and whites falling promiscuously before this fatal scourge. In this case, as in the preceding, the vapour is always accompa- nied with an intolerable stench from the play of affinities between the different gasses that are let loose by the putrefactive decompo- sition ; and hence it is impossible to affirm that the mortality thus produced is the result of any single or specific miasm operating to this effect. But it shows us that the general effluvium from the decom- position of all dead organized matter, whether animal or vegetable, is equally deleterious to health and life. The decomposition, however, to which we are, on the present occasion, chiefly to direct our attention, is of a mixed kind; for the marsh and oozy soil of inhabited countries is necessarily a combi- nation of animal and vegetable matter. If this decomposition take place slowly, as in cold or dry wea- ther, and more particularly in a breezy atmosphere, not the slight- est evil is sustained during its entire process. And hence, in order to render it mischievous, and particularly in order to render it ca- pable of producing fever of any kind, it is necessary that it should be assisted by the co-operation of certain agents, many of which we do not seem to be acquainted with, but which, so far as we are ca- pable of tracing them, appear to be auxiliary to the general pro- cess of putrefaction, as warmth, moisture, air, and rest or stagnation. The simplest and slightest fever that is produced under the joint influence of these powers, is the intermittent: and we find these produced where their joint influence is but feeble, and where it exists, perhaps, in its lowest stage, as in the favourable climate of our own country ; where we are not often overloaded with equi- noxial rains, and have not often to complain of a sultry sky or a stagnant atmosphere. Even here, however, we perceive a change in the character of the intermittent at different seasons : for while in the spring it usually exhibits a tertian type, in the autumn we find it assume a quartan. And as these can only be contemplated as varying branches of the same disease, we have thus far, at least, reason to regard it as produced by a common febrile miasm, modi- fied in its operation by a variation in the relative proportion which its auxiliaries, known and unknown, bear to each other during the vernal and autumnal seasons ; coupled, perhaps, with some degree of change produced by the same seasons in the state of the human body. If from our own country we throw our eyes over the globe, we shall find in every part of it, where the same causes exist, that in proportion as they rise in potency they produce a fever of a severer kind, more violent in its symptoms, and more curtailed in its intervals, till we gradually meet, first with no distinct intervals, and at length with no intervals whatever; and hence perceive the remittent progressively converted into intermittent and continued fevers. And that here we have still the same miasm merely mo- dified in its operation by the varied action of its auxiliary powers CL. HI.—OB. I.] SANGUINEOUS FUNCTION. 47 on the constitution of the individuals it attacks, is as clear as in the former case: because, in many attacks, v*e see different individuals touched by the very same influence, exhibit all the varieties now alluded to, and intermittent, remittent, and continued fevers co-ex- isting m every diversity of violence; commencing with either of these forms ; keeping true to the form with which they commenc- ed ; or changing one form for another. Such more particularly was the fact in the highly malignant yellow-fever of Antigua in 1816, as fully and admirably described by Dr. Musgrave,* and to which we shall have occasion to refer more particularly in its pro- per place. v This disease first showed itself during sultry weather and a quiet atmosphere, in a swampy part of the island, among a ship's crew lately arrived, but from a healthy vessel, and themselves in good health at first landing. It soon spread widely, and at length indis- criminately in town and country, among all ranks and conditions, and situations, blacks as well as whites, the oldest settlers as well as the newest comers. The head was, in some cases, chiefly affect- ed ; in others the stomach, the liver, or a still different organ. Hic- cough and black vomit were common towards the close of the dis- ease, though many died without it; and recovery was no exemption from a second attack. Dr. Musgrave asserts farther, that, during the whole of this fatal epidemy, there was no instance of its being received by contagion The argument however, which he offers upon this subject is not quite convincing. Yet admitting the fact to be as he states it, we have an additional proof, if proof were wanting, firstly, that when the animal frame has been previously debilitated or relaxed, as in the caae of a ship's crew that has been long voyaging in high lati- tudes and living on salted provisions, it suffers sooner and more severely than where no such relaxation has taken place: and, secondly, that by a long and gradual exposure to the influence of febrile miasm, however produced, whether from the living human body or from dead organized matter, the animal frame becomes torpid to its action, as it does to the action of other irritants. Whence prisoners confined in jails with typhous miasm around them, as well as those who have long stood the climate in the West Indies, receive the contamination to which they are exposed far less rapidly than strangers. The argument, however, of Dr. Musgrave upon this point, we have said, is not quite satisfactory ; because he admits that those who were about the patients, and paid no attention to personal cleanliness, did not wholly escape; but then, says he, they escaped as generally and were not more frequently affected than those who never entered the doors of an infirmary. Now as all ranks and conditions, blacks and whites, even far off in the country, were af- fected indiscriminately, we have no reason to expect that those * Medico-Chirurg. Trans. Vol. IX. p. 92. 45 H.EMAT1CA. |CL. 111.—OIL I. whose habits had rendered them peculiarly torpid to the action of the febrile miasm should be more frequently affected than others. The very admission that they were as much so, seems to imply that the febrile miasm was attacking them in some new mode, against which they were not guarded by previous habit. Nor is it easy to conceive by what means the local disorder of the coast could be converted into so extensive an epidemy unless through the medium of contagion. I have dwelt the longer upon bis subject, because it is desirable to reconcile as much as possible the conflicting testimony of respec- table writers, who, having adopted different theories, are insensi- bly led to support them by inaccordant descriptions of the same dis- ease. In direct opposition to Dr. Musgrave, Dr. Bancroft,* and a host of distinguished writers who think with them, we are told by Mr. Pym, that the Bulam fever, admitted by Dr. Musgrave to be the same as the above, not only is contagious, but is never introduced into any fresh region but by contagion.f Wnile Dr. Rush, speak- ing of the yellow fever of Philadelphia of 1793, asserts, that " there were for several weeks two sources of infection, viz. exhalation and contagion. The exhalation," says he, " infected at the distance of three and four hundred yards, while the contagion infected only across the streets. After the 12th of September, the atmosphere of every street in the city was loaded with contagion." He adds, that a few caught the disease who had it before: thus taking a middle course between Dr. Musgrave, who tells us that recovery affords " no exemption from a second attack," and Mr. Pym, who affirms that the fever "attacks the human constitution but once." In the fever of Cadiz of the year 1800, Sir James Fellowes, who coincides in the view adopted by Mr. Pym, asserts, not only that it was contagious and propagated only by contagion, but that " the air from itsjstagnant state became so vitiated that its noxious quali- ties affected even animals: canary birds died with blood issuing from their bills, and in all the neighbouring towns, which were afterwards infected, no sparrow ever appeared."| I do not remember to have seen this last fact so directly affirm- ed by any modern writer ; but it is not contradicted in the course of the controversy, and is in perfect coincidence with the state of the air during the plague in most places,§ and particularly at Athens, as described by Thucydides: rex^tiptov JV rm ua rotovrm •fnimextXti'tyii rxQift eysvcrc xxt ovy, tupmro ovre xXXas, ovte vtpi toiovtm * Essay on the Disease called Yellow Fever. f Observations upon the Bulam Fever, which has of late years prevailed in the West Indies, on the coast of America, at Gibralter, Cadiz, and other parts of Spain, &c. in 8vo. 1815. + Report of the Pestilential Disorder of Andalusia, which appeared at Cadiz in the years 1800, 1809, 1810, and 1813, &c. 8vo. 1815. § Diemerbr. De Peste, Cap. IV. Van Swieten, ex prof. Sorbait, in sect. 1407. CL. III.—OR. I.] SANGUINEOUS FUNCTION. 49 »vacv. 0< 01 x.vves (utXXoi xterftjiriv 7rxpct%ov tov xttoGxivovtos, oix to Qvvfoxi- vx intemperament of the atmosphere itself. Why a corrupt state of the atmosphere should be necessary to the general action of the febrile miasm, is a question which still re- mains to be discussed. Dr. Hosack supposes that the latter " pro- duces its effects by some chemical combination with the peculiar virus secreted from the deceased body," and which is floating in the atmosphere: of the nature of which virus, however, he has not given us any information ; while Dr. Chisholm conceives that it is the impurity of the atmosphere itself which operates by " increas- ing the susceptibility of the system to the action of the poison in- troduced."* But to this explanation Dr. Hosack successfully re- joins, " that the predisposition of those who are most exposed to such impure air is less, while those who reside in the pure air of the country are most liable to be infected when exposed to the con- tagion." The true state of the case appears to me as follows. In a pure atmosphere, the miasmic materials easily become dissolved or de- composed; but slowly and with great difficulty, perhaps not at all, in a corrupt atmosphere, already saturated with foreign corpuscles. In a state thus crowded, moreover, they less readily disperse or ascend beyond their proper periphery of action; and perhaps by their tenacity adhere to bodies more ponderous than themselves, and thus loiter for a still longer period within the stratum of human intercourse. Upon this explanation it is not necessary to suppose that febrile miasm has a power either of concentrating its virulence, so as to render it more active; or of multiplying its own form, so as to in- crease its numerical strength; against both which views, there are weighty objections. Every distinct particle thus suspended, and withheld from dissolution, becomes an active individual in the field of battle, and is almost sure to grapple with its man. So that hereby alone we have a force equal to any degree of mortality that can be conceived. While then the remote causes of fever are of different kinds, its chief and most effective is febrile miasm; the origin and laws of which, so far as we are at present acquainted with it, may be ex- pressed in the following corollaries: 1. The decomposition of dead organized matter, under the influ- ence of certain agents, produces a miasm that proves a common cause of fever. 2. The whole of these agents have not yet been explored; but so far as we are acquainted with them, they seem to be the common auxiliaries of putrefaction, as warmth, moisture, air, and rest, or stagnation. * Letter to Hay garth. CL. III.—OR. L] SANGUINEOUS FUNCTION. 53 3. The nature of the fever depends, partly upon the state of the body at the time of attack; but chiefly upon some modification in the powers or qualities of the febrile miasm, by the varying pro- portions of these agents in relation to each other, in different places and seasons. And hence, the diversities of quotidians, tertians, and quartans; remittent and continued fevers, sometimes mild and some- times malignant. 4. The decomposition of the effluvium transmitted from the liv- ing human body, produces a miasm similar to that generated by a decomposition of dead organised matter, and hence, capable of becoming a cause of fever under the influence of like agents. 5. The fever thus excited, is varied or modified by many of the same incidents that modify the miasmic principle when issuing from dead organized matter; and hence, a like diversity of type and vehemence. 6. During the action of the fever thus produced, the effluvium from the living body is loaded with miasm of the same kind, com- pletely elaborated as it passes off, and standing in no need of a de- composition of the effluvium for its formation. Under this form it is commonly known by the name of febrile contagion. In many cases, all the secretions are alike contaminated ; and hence, febrile miasm of this kind is often absorbed, in dissection, by an accidental wound in the hand, and excites its specific influence on the body of the anatomist. 7. The miasm of human effluvium is chiefly distinguishable from that of dead organized matter, by being less volatile, and having a power of more directly exhausting or debilitating the sensorial energy, when once received into the system. Whence the fevers generated in jails or other confined and crowded scenes, contami- nate the atmosphere to a less distance than those from marshes and other swamps, but act with a greater degree of depression on the living fibre. 8. The more stagnant the atmosphere, the more accumulated the miasmic corpuscles from whatever source derived; and the more accumulated these corpuscles, the more general the disease. 9. The miasmic material becomes dissolved or decomposed in a free influx of atmospheric air ; and the purer the air the more readily the dissolution takes place: whence, e contrario, the fouler as well as more stagnant the air, the more readily it spreads its in- fection. 10. Under particular circumstances, and where the atmosphere is peculiarly loaded with contamination, the miasm that affects man, is capable also of affecting other animals. 11. By a long and gradual exposure to the influence of febrile miasm, however produced, the human frame becomes torpid to its action, as it does to the action of other irritants; whence the na- tives of swampy countries, and prisoners confined in jails with ty- phous contamination around them, are affected far less readily than strangers j and, in numerous instances, are not affected at all. 54 IIJEMATICA. [CL. in.—OR. I. 12. For the same reason, those who have once suffered from fever of whatever kind hereby produced, are less liable to be in- fluenced a second time: and, in some instances seem to obtain a complete emancipation. It only remains to offer a few remarks upon the doctrine of crises ; or that tendency which fevers are by many supposed to pos- sess, of undergoing a sudden change at particular periods of their progress. A sudden and considerable variation of any kind, whether favoura- ble or unfavourable, occurring in the course of the general disease, ,and producing an influence on its character, is still loosely express- ed by the name of crisis. The term is Greek, and pathologically imports a separation, secretion, or excretion of something from the body: which was in truth the meaning ascribed to it when first em- ployed, agreeably to the hypothesis of concoction which we have just considered. The original hypothesis is abandoned ; but the term is still continued in the sense now offered. That changes of this kind are perpetually occurring in the pro- gress of continued fevers, must, I think, be admitted by every con- siderate and experienced practitioner. Nothing is more common than to behold a patient suddenly and unexpectedly grow decidedly better or worse in the progress of a fever of almost any kind, and pass on rapidly towards a successful or an unsuccessful termination. But the important question is, whether there be any particular periods in the progress of a fever in which such changes may be expected ? Hippocrates conceived there were; he endeavoured to point out and distinguish them by the name of critical days. As- clepiades and Celsus denied the existence of such periods; and the same diversity of opinion has prevailed in modern times. It is not very easy to determine upon the subject in the present day, and especially in our own country. For, first, fever, like many other complaints, may have undergone some change in its progress from a like change in the nature of its remote causes, or in the constitution of man. And, next, it seems to be generally allowed, that sudden transitions, whether regular or irregular, are more apt to take place in almost all diseases in warm than in cold climates. On these grounds, it is probably a subject which will never become of great practical importance at home. Yet it is well worthy of atten- tion asa question of history, and which may yet be of great import- ance to many parts of the world. If we examine the phenomena of the animal economy, as they occur in a natural series, we shall find that they are in almost every instance governed by a periodical revolution. A man, in a state of health and regular habits, generally becomes exhausted of sensorial power within a given period of time, and requires a periodical suc- cession of rest: his appetite requires a periodical supply, and his intestines a periodical evacuation. This tendency equally accom- panies and even haunts him in disease ; he cannot disengage himself from it. Gout, rheumatism, mania, rapidly and pertinaciously estab- CL. HI.—OR. L] SANGUINEOUS FUNCTION. 55 lish to themselves periods of return. The hemorrhoidal discharge often does this; and the catamenia constantly. The same occurs in fevers, but especially in intermittents; for the quotidian, the ter- tian, the quartan, have, upon the whole, very exact revolutions. And, though accidental circumstances may occasionally produce a considerable influence on every one of these facts, whether morbid or natural, the tendency to a revolutionary course is clear and un- questionable. Now, although Hippocrates has not appealed to this reasoning, it forms a foundation for his observations : and when stript of the perplexities that encumber his writings upon this subject, partly produced by erroneous transcripts, and in a few instances perhaps by his own irresistible attachment to the Pythagorean hypothesis of numbers, he may be regarded as laying down the following as the critical days of continued fever : the 3d, 5th, 7th, 9th, 11th, 14th," 17th, 20th; beyond which it is not worth while to follow the series, for it is not often that they extend further. In other parts of his works, he regards also the 4th and 6th and even the 21st as critical days ; so that in the first week, every day, after the disease has fully established itself, evinces a disposition to a serious change ; in the second week, every other day; and in the third week, every third day. It is not easy to determine why the 21st day should be a critical day as well as the 20th. Various con- jectures have been offered upon the subject; by some, it has been regarded as a mistake in the Greek copy, and by others, as a piece of favouritism in Hippocrates for this number, in consequence of its being an imperfect one in the Pythagorean philosophy, as the commencement of a septenary. De Haen with rigid and patient assiduity has put Hippocrates to the test upon these data; for he has accurately analyzed Hippocra- tes's own journal of the numerous cases of fever he has most in- dustriously collected and recorded, and finds the positions, in most instances, to be strictly justified ; and that out of 168 terminations of fever, not less than 107, or more than two-thirds, happened on the days denominated critical, not reckoning the 4th, 6th, or 21st, and that the 4th and 6th were very frequently critical. There are a few anomalies ; but it is not necesary to notice them, because they are easily referable to accidental causes, similar to those that retard or accelerate the paroxysm of intermitting fevers. Now, admitting the Hippocratic table to be true, the continued fever, in its progress, is measured by the various types exhibited by intermittent fevers. Thus, the quotidian prevails through the first seven days ; there is on each day a slight excerbation, and no one day is more critical than any other. After this period the ter- tian type commences, and runs through the ensuing week ; the principal changes occur on the 9th and 11th days, and would occur on the 13th, but that the quartan type now assumes its prerogative ; and the principal transitions after the 11th, take place on the 14th, instead of on the 13th ; on the 17th ; and on the 20th. Dr. 56 HJEMATICA. [CL. m.—OR. I. Cullen who has examined this subject with great attention, and simplified it from many of its difficulties, directly asserts that his own experience coincides with the critical days of Hippocrates ; and Dr. Fordyce, who scarcely does justice to Culler upon other points, unites with him upon the present, and justly compliments him upon his ingenious examination and explanation of the Greek distribution of critical days. It is, nevertheless, addmitted on all hands, that the order of succession is far less distinct as well as less regular in cold than in warm climates; and that it requires a thoroughly attentive and practised eye to notice these changes in our own country, or indeed in any part of northern Europe. And hence, Craanen says, it is lost time to look for them ;* Stoll, that they are only to be found in inflammatory fevers ;t and Le Roy, that the supposed critical days have no influence and can lead to no prognosis or peculiarity of practice4 Why the first week of a fe- ver should incline to a quotidian type rather than to a tertain, or the second to a tertain rather than to a quartan, we know no more than we do why fevers should ever intermit, or at any time observe the distinctions of different types. We are in total ignorance upon all these subjects. We see, moreover, that intermitting fevers, whether quotidian, tertain, or quartan, have their paroxysms recur regularly in the day time ; the quotidian in the morning, the tertain at noon, and the quartan in the afternoon ; and that in no instance do the paroxysms take place at night: and we see also that in con- tinued fevers, the exacerbations uniformly took place later in the day, than the paroxysms of the latest intermittent; for these rarely occur earlier than between five and six o'clock in the evening, while the paroxysms of the quartan return commonly before five. Of these interesting and curious scenes we are spectators ; but we are nothing more ; for we are not admitted to the machinery be- hind the curtains. By some pathologists the source of these phaenomena is sought in the influences of the heavenly bodies, and especially in those of the sun and the moon. In ancient times these luminaries were supposed to produce an effect on all diseases, and especially on mania, epilepsy, catamenia, and pregnancy. And when the Newtonian philosophy first illumined mankind with the brilliant doctrine of universal at- traction, Dr. Mead stepped forth into the arena, and revived and supported the ancient doctrine with great learning and ingenuity. And as an ingenious conjecture and possible fact, of which no prac- tical use could be made, it was contemplated till towards the close of the last century : about which time Dr. Darwin, by interweaving it with his new hypothesis, once more endeavoured to raise it into popular notice, and gave it an air of serious importance. Dr. Bal- four, of British India, however, has still more lately brought it for- * De Homine. f Rat. Med. Part IV. p. 283. t Du Prognostic dans less Maladies Aigues, 8vo. Montpel. 1778. CL. UL—OR. I.] SANGUINEOUS FUNCTION. 57 ward as a doctrine capable of direct proof, and as peculiarly affect- ing the progress of fevers. His opinion, which he endeavours to support by weighty facts and arguments, is, that the influence of the sun and the moon, when in a slate of conjunction, which is named sol-lunar influence, produces paroxysms or exacerbations in conti- nued fever in all cases in which a paroxysmal diathesis (for such is his expression) exists; and as this influence declines, in consequence of the gradual separation of these luminaries from each other, and their getting into a state of opposition, a way is left open to the system for a critical and beneficial change, which is so sure to take place provided the critical disposition is at this time matured. In other words, paroxysms and exacerbations in fever may be expect- ed to take place (and do in fact take place) at spring-tides, and cri- •■ ses at neap-tides. This is a new view of the influence of the heavenly bodies upon the human frame ; and a view which, though feebly supported by facts, is advanced with all the dogmatism of an established science. There is, nevertheless, more in medical astrology than is, perhaps, generally supposed ; it is an important branch of meteorology, and, as such, is well worth studying. Nor can there, I think, be a question in any impartial mind, that, under certain circumstances, and especially in tropical climates, many diseases are influenced by lu- nation, as we are sure they are, in all climates, by insolation. The concurrent observations of a host of candid and attentive pathologists, who have been witnesses of what they relate, are sufficient to im- press us with this belief: but till we know more fully what these circumstances are, we cannot avail ourselves of their remarks, and can only treasure them up as so many isolated facts. And hence it is, that in no age or country whatever, has the study been turned to any practical advantage, expedited the cure of a disease, or ena- bled us to transform the type or interval of one kind of fever into that of another. Nor is it any exclusive reproach to the art of me- dicine that it should be so ; for of all the subdivisions of general phi- losophy, there is none so little entitled to the name of a science as meteorology itself. And till the naturalist has explained the varia- tions of the barometer, the physicians need not blush at being inca- pable of turning to account the supposed influence of the planets, or of unfolding the origin or tracing the capricious courses of epi- demies and pestilences. VOL. II.—8 5$ HJEMATICA. ICL. III.—OR. I. GENUS I. EPHEMERA. 39farg iFefcer. ONE SERIES OF INCREASE AND DECREASE ; WITH A TENDENCY TO EXA- CERBATION AND REMISSION, FOR THE MOST PART APPEARING TWICE EVERY TWENTY-FOUR HOURS. This is the simplest form in which fever at any time makes its at- tack ; and hence Dr. Fordyce has distinguished it by the name of simple fever. For the purpose, however, of entering into the full character, not only of the present but of all the subsequent genera, and their respective species, it is necessary to bear in mind, that the ordinal definition forms a part of that character, and is essential- ly included in a less or greater degreee in all the subdivisions that appertain to it. I have said that the ephemera rarely exceeds a duration of twen- ty-four hours. Some practitioners, however, have called by this name a fever that has extended for three days; and Sauvages has arranged this mode of fever under his own genus of ephemera. But this is to confound different species under one generic name. Fordyce asserts, that he has often seen the ephemera commence its attack with all the essential appearances of fever, and terminate in eight, ten, or twelve hours.* And hence, in defining ephemera, the symptom of duration ought not to exceed the limit here allotted to it. In this simple shape of the disease, the pathognomic symptoms are few and striking ; for, however violent, it is confined to a single paroxysm of three distinct stages, shivering or languor, heat, and perspiration, each most probably dependent on the other, and ceasing, when true to itself, after having followed up the movements of the animal frame through a single diurnal revolution. The cold stage, however, is often scarcely perceptible, and sometimes altogether imperceptible, the general languor taking place without it. The genus exhibits two common and very distinct species; and if the ephemera sudatoria of Sauvages, the sweating sickness or English plague of other authors, be regarded as belonging to it, as unquestionably it ought, it will then afford us another after the manner following: 1. EPHEMERA MITIS. MILD DIARY FEVER. 2' --------- ACUTA. ACUTE DIARY FEVER. 3. --------- SUDATORIA. SWEATING-FEVER. • On Simple Fever, Diss. I. p. 33. t»E. I.—SP. I.} SANGUINEOUS FUNCTION. 59 SPECIES I. EPHEMERA MITIS. IfHtltt Marg iFcfcer. WITHOCT PRECEDING RIGOR; LASSITUDE AND DEBILITY INCONSIDER- ABLE ; PAINS OBTUSE, CHIEFLY ABOUT THE HEAD ; HEAT AND NUM- BER OF THE PULSE INCREASED SLIGHTLY : PERSPIRATION BREATH- ING AND PLEASANT. The common exciting causes are, excess of corporeal and especially of muscular exertion; long protracted study; violent passion j sup- pressed perspiration; sudden heat or cold. There are few persons who have not felt this species of diary fever at times, from one or other of the causes just enumerated. When a man has worked himself up into a violent and long conti- nued fit of wrath, whether there have been reason or no reason, and more especially in the latrer case; when he has taken a long and fatiguing journey on foot, walking with great speed, and suffer- ing beneath great heat and perspiration; or when he has devoted the whole of the day to a particular study, so profound and abstract- ing as to exhaust almost the entire stock of sensorial power that can be drawn from other parts of the system, at the single outlet of the attention;—and when, beyond this, he still urges his abstruse and protracted train of thought into a late hour of the night or the morning—there is a general irritation or undue excitement pro- duced, that simple rest cannot at once allay; his sleep is short, hurried, and interrrupted if he sleep at all; he yawns, stretches his limbs, turns himself again and again in his bed for an easy, perhaps for a cool place, for his skin is hot and dry; but for a long time he turns in vain. The morning strikes upon his eyes, but he has had little sleep and no refreshment: he is indisposed to leave his bed; and if he rise, he is still feverish, and unfit for business. He passes the day in disquiet, which perhaps increases towards evening; but at night he feels a moisture breaking forth over his skin, and com- fortably succeeding to the heat and dryness that have thus far dis- tressed him ; he recovers perhaps even while sitting up; but if, as he ought to do, he goes to an early bed, a quiet and refreshing sleep supervenes, and he wakes to the health he before possessed. It is not easy to explain why the febrile paroxysm should be more disposed to close its career sometimes towards the evening, but more generally later at night, except for the reason, whatever that reason may be, that all fevers are far more apt to commence their paroxysms in some part or other of the day-time, and espe- cially intermittents, and consequently to drop them as the day declines. Thus the quotidian makes its assault in the morning, the tertian at noon, and the quartan in the afternoon: as though the 60 HJEMATICA. [CL. IH.-OR. I. diurnal revolution were somewhat regularly divided between febrile attack and febrile cessation or truce. It* is possible indeed, that a fever of any kind may open its onset at any hour, but this is so contrary to the ordinary rule, that Dr. Fordyce affirms from his own observation that ten fevers commence in the day to one at night. The species before us forms scarcely a case for medicine: since nature or that instinctive power which is ever operating to the ge- neral welfare of the animal frame, will be usually found competent to its object. So that if any thing remedially is attempted, it should be confined perhaps to a slight increase of the peristalic action of the intestines by a dose of neutral salts, and to a removal of the dry heat of the skin by diluents and small doses of ipecacuan, which combines admirably with most aperients, and increases their pow- er, while its own diaphoretic quality continues at least undiminish- ed and is often improved. This is now well known, though not a discovery of recent date; for Gianella, Vater, and various writers of credit, strongly recommended the same from personal experience nearly a century ago.* Gamesters, after sitting up all night, and being worked up to madness by the chances and reverses of their ruinous stakes, are peculiarly subject to this species. A very told and wet towel tied round the temples seems to give some check to the violent excite- ment of the brain, and diminishes the morbid excess of sensorial power it is in the act of secreting; but in the long run I have gene- ally found persons who have adopted this practice become debilitat- ed and dropsical, and sink into an untimely grave, or creep on mis- erably through the fag end of a lingering life, that affords no retro- spective comfort, with a hospital of diseases about them. But whe- ther this proceed from the practice adverted to, or from the habitual exhaustion which necessarily accompanies a course of gambling, may admit of a doubt. Yet, the habit itself appears mischievous, however pleasant at the time, as having a strong tendency by fre- quent repetition to torpify the secretories of the brain by the rapid and violent change of action they are thus made to undergo. * Gianella, De admirabili Ipecacoanhze virtute in curandis febribus, &c. Patav. 1754.—Vater, Diss, de Ipecacoanha virtute febrifuga, &c.Witeb. 1732. GE. I.—SP. H.] SANGUINEOUS FUNCTION. 61 SPECIES II. EPHEMERA ACUTA. &cute Burri) iPefoer. severe rigor; great heat; pulse at first small and contract- ed, AFTERWARDS FULL AND STRONG; PERSPIRATION COPIOUS; GREAT LANGUOR. In a few instances the accession is slightly marked, and there is little chilliness or rigor. The heat that succeeds, however, are always considerable; the face is red and bloated ; and there are often pun- gent and throbbing pains in the head, corresponding with the pulsa- tions of the arteries ; though at times the pain in the head is dull and heavy. The high-coloured urine deposits a sediment with a tinge of orange-peel. We cannot always trace the remote causes of this species; but it is usually produced by some morbid affection of the stomach or of the collatitious viscera. f The most obvious and common cause is that of a surfeit, whether of eating or drinking.- And there is no great difficulty in inter- preting the means by which this cause operates. The stomach, in the language of Mr. John Hunter, and it is language confirmed by the experience of every day, is the great seat of general sympathy, and associates with almost every other organ in its action. The digestion of even an ordinary meal is a work of some labour to it, and especially in weakly constitutions; a greater degree of heat, as I took occasion to show in the proem to our second class, is regularly expended upon it during this process, and unquestionably also a greater degree of sensorial power ; both which, though taken directly from the brain, are taken indirectly from the system at large as from a common stock ; and the consequence is that, in infirm habits, a considerable degree of chill and debility are felt during this process, and other organs become torpid while the stomach is in a state of increased action. Hence infants and old persons sleep during digestion; delicate females feel a coldness shooting over their extremities; and those of irritable fibres become flushed in the face, and show other signs of irregular action. Now if this be the case in the digestion of ordinary meals, what disturbance may we not expect during the digestion of a meal that overloads the stomach, and with which the stomach is incapable of grappling ? what, more especially, when at the same time, by an immoderate use of wine or spirits, the brain becomes exhausted of its energy by the excess of stimulus applied to it ? The general chill over the surface, which, in the digestion of an ordinary meal, is only felt by the weak and delicate, is here often felt severely, and sometimes amounts to a horripilation. The 62 HjEMATICA. [CL.IU.—OR. I. first stage of fever is hence produced: and as the heat and perspira- tion are most probably a necessary result of the first, a foundation is hereby laid for the entire paroxysm. With the reaction that ensues a greater degree of sensorial power is again secreted; the general frame as well as the brain is roused to an increased energy; the diaphragm and its associate muscles, instinctively or remedially, contract, and the stomach disgorges its contents, or thrusts them forward half digested into the duodenum. The only and well known mode of cure consists, in the first place, in imitating this process: in unloading the stomach of its mischievous freight by a powerful emetic, and the alvine canal of whatever portion of the heating and crapulous mass has passed into it by a brisk cathartic. The fever hereby excited will often sub- side into a diurnal revolution ; and no tendency to a return of the paroxysm be produced. If the species before us, however generated, do not subside within this period of time, or a few hours beyond it, the disease becomes a cauma,or inflammatory fever of the continued kind, and consequent- ly belongs to the genus enecia. There are, however, a few exceptions to this rule: for Forcstus gives a case in whicl* the paroxysm led to fatal hectic :* and Borelli gives another of equal singularity, in which it kept true to a triennial revolution, returning punctually once every three years.t SPECIES III. EPHEMERA SUDATORIA. Stoeattnj^ifetev. tense pains in the neck and extremities j palpitation ; dysp- noea ; pulse rapid and irregular; heat intense ; intolerable thirst; drowsiness or delirium; excessive sweat. I have followed M. de Sauvages in introducing sweating-fever, the ephemera maligna of Borsieri,! or Burserius as he is more common- ly called, and the sudor Anglicus of most foreign writers, into the present place. Dr. Caius, who practised at the time of its appearance at Shrews- bury, and has written one of the best accounts of it extant, calls it " a contagious pestilential fever of one day." " It prevailed," says he " with a mighty slaughter, and the description of it is as tremen- * Lib. 1. Obs. 7. f Cent. II. Obs. 100. ± Institut. Med. Pract. 8vo. 4 Tom. Ven. 1782-5. GE. I.—SP. IH.] SANGUINEOUS FUNCTION. 63 dousasthatof the plague of Athens." And we are told by Dr. Wil- lis, " that its malignity was so extreme, that as soon as it entered a city it made a daily attack on five or six hundred persons, of whom scarcely one in a hundred recovered." It was certainly a malignant fever of a most debilitating character, but without any tendency to buboes or carbuncles, as in the plague. It ran its course in a single paroxysm; the cold fit and hot fit were equally fatal; but if the patient reached the sweating fit, he commonly escaped. Hence the cure consisted in exciting the sweating stage as quick- ly as possible, and in supporting the system with cordials throughout the whole of the short but vehement course of the fever. At Shrewsbury, it continued to rage for seven months, and during that period of time a thousand fell victims to its violence. But after the discovery of the benefit of the sweating-plan, it was certainly far less fatal. It made its first appearance in London in 1480 or 1483; Caius says in the latter year, first showing itself in the army of Henry VII. on his landing at Milford-Haven. In London, to which however it does not seem to have travelled till a year .or two afterward, it took up its abode with various intermissions of activity for nearly forty years. It then visited the continent, overran Holland, Germany, Belgium, Flanders, France, Denmark, and Norway; among which countries it continued its ravages from 1525 to 1530: it then return- ed to England, and was observed for the last time in 1551. It commenced its attack with a pain in the muscles of the neck, shoulders, legs, or arms, through which a warm aura seemed to creep in many instances; and after these symptoms, broke forth a profuse sweat. The internal organs grew gradually hot, and at length burning, the pungent heat extending to the extremities, an intolerable thirst, sickness, and jactitation followed speedily, occa- sionally with diarrhoea, and always with extreme prostration of strength, head-ache, delirium, or coma, and a wonderful wasting of the whole body. The sweat was tenacious, saburral, and of an offensive smell; the urine thick and pale; the pulse quick, often irregular; and the breathing laborious from the first. The modes of treatment were often puerile, and offer nothing instructive. A good constitution and exposure to free air seem to have been most successful in promoting a cure. Dr. Caius asserts, that a thick noisome fog preceded the distem- per, especially in Shropshire, and that a black cloud uniformly took the lead, and moved from place to place; the pestilence in a regular march following its direction. There may be some fancy in this: but it is an unquestionable fact, that the most fatal pestilences of ancient and modern times have been ushered in by stinking fogs or mists, or some other intemperament of the atmosphere, of which the reader will find various instances in the sequel of this work. The disease is generally, however, supposed to have been pro- duced by inclement harvests and vitiated grain, particularly wheat, which is less hardy than other grains and sooner infested with albi- 64 HiEMATICA. [CL. HI.—OR. I. go (mildew), ustilago (smut), and clavus (ergot or spur). And in proof that this last was the actual cause it is observed by Dr. Willan, that the contemporary inhabitants of Scotland and Wales, who fed on oaten or barley, instead of on wheaten bread, were not affected. Nevertheless, whatever was the primary cause, a peculiar miasm or contagion seems to have been generated by the disease itself, which chiefly contributed to its spread and continuance. For we are told concurrently by all the writers, that Englishmen who withdrew from their o\v,n country into France and Flanders with the hope of escaping the attack of the disease, fared no better than their coun- trymen at home. To which Dr. Friend adds, that, while English- men abroad were thus subject to the contagion, foreigners and even the Scotch in England were rarely or never seized with it ;* a fea- ture that has been copied by Dr. Armstrong in his very forcible description of the complaint, which is perhaps better adapted for poetry than for sober prose. Some, sad at home, and, in the desert, some Abjur'd the fatal commerce of mankind; In vain: where'er they fled, the fates pursued. Others, with hopes more specious, cross'd the main, To seek protection in far distant skies, But none they found. It seemed the general air, From pole to pole, From Atlas to the East, Was then at enmity with English blood: For, but the race of England, all were safe In foreign climes; nor did this fury taste The foreign blood which England then contained.! , Something may, perhaps, be set down to the score of a national diathesis; but without examining very closely into the accuracy of this wonderful part of its history, we may at least indulge a hope that this peculiar, most virulent and fatal contagion has long since worn itself out, and become decomposed; though it may be still only latent, and waiting for its proper auxiliaries once more to show itself in the field4 It is said, indeed, by Dr. Coste, the learned editor of Dr. Mead's works in French, that the disease continued to manifest itself occa- sionally as an epidemic in Picardy; but that, instead of terminating in a single day, it runs on to the third, fifth, and sometimes even to the seventh. It is hence sufficiently obvious that the two fevers, though possessing many points of resemblance, are not precisely the same. Yet M. Bellot, in his thesis " An febris putrida Picardii suete dicta, sudorifera ?" has maintained Dr. Coste's opinion. * Hist, of Physic. Vol. II. p. 533. f Art of preserving Health, B. HI. t Navier, Maladies Populaires, &c. GE. II.] SANGUINEOUS FUNCTION. 65 GENUS II. ANETUS. Xntrrmfttent iPetar. ague. PAROXYSM INTERMITTING, AND RETURNING DURING THE COURSE OF THE DISEASE : THE INTERMISSIONS GENERALLY PERFECT AND REGU- LAR. Under the preceding genus, the remote cause, whatever it consists in, lays a foundation for not m'ore than one paroxysm. In the genus before us, the cause introduces a tendency to a recurrence of tho paroxysm from the first; and, in most cases, with an interval that continues true to itself as long as the disease lasts. I say in most cases, because we shall see presently, that, when intermittent fever has raged very extensively, it has not unfrequently established a type of one kind in one person, and of another kind in another; whilst in the same patient quotidians have changed to tertians, ter- tians to quartans, quartans to quotidians, and all of them in a few in- stances to continued fever, in the most capricious and anomalous manner. Dr. Cullen unites intermittents and remittents into one section of fevers, merely distinguishing them as intermittents with an interpos- ed apyrexy, and intermittents with remission alone: and, as already observed, he makes it a part of the pathognomic character of both that they are derived from marsh-miasui—miasmate fialudum ortce— as though there were no other cause of their production, whence Dr. Young gives to intermittents and remittents the common name of paludal fever. The only ground then assumed for this union of intermittents, and remittents, is the supposition that the cause which generates them is single, common to the two, and never generates any other fever. Now, although the febrile miasm issuing from marsh-lands is by far the most common cause of intermittents, it is by no means the only cause; for we find intermittents, like all other species of fever, produced from various sources; existing in hot countries as well as in cold, in high lands as well as in low lands, sporadically as well as epide- mically ; sometimes excited by sympathy, someames by contagion. Even in tertians Dr. Cullen is obliged to admit of instances in which other agents are necessary; but then, says he, they are only co agents^ and would not operate alone. " Has potestates excitantes pro parte firincifiii hie admittimus, licet neutiquam excitassent, si miasma palu- dum non antea applicatum fuisset." But this is the vwy poin'. of controversy; for in many instances they produce the disease where marsn-miasm cannot be suspected. I have seen an isolated case uf a regular tertian on the highest part of Islington ; and another on the dry and gravelly coast of Gosport, a situation so healthy that all the VOL. II.—9 66 H.KMATICA. [CL. III.—OR I inhabitants escaped, when in the year 1765 a most fatal and epidem- ic fever, originating unquestionably from the miasm of swampy grounds, pervaded the whole island of Portsea, situate at not more than a mile distant on the other side of the water, and exhibiting, in different individuals, and often in the same person, all the diver- sities of the intermittent, remittent, and continued lype. Dr. For- dyce affirms, that he has seen an intermittent communicated by in- fection, meaning the miasm from human effluvium ; and where the yellow fever has long existed or become widely diffusive, this is com- mon. Where it arises from sympathy or organic aftcction, the case is still clearer. " Two children," says Mr. J. Hunter, " had an ague from worms, which was not in the least relieved by the bark; but by destroying the worms, they were cured." We have in like manner agues from many diseases of particular parts, more especial- ly of the liver and the spleen, and from an induration of the mesen- teric glands."* De Meza gives an instance of an intermittent pro- duced by a repelled herpes ;t and Baldertius, by suppressed lochia.! But one of the most singular and convincing proofs, that the de- composition of marsh-lands is not essential to the production of inter- mittent fever, is to be found in the epidemic intermittent of 1780, as described by Sir George Baker, and which we shall have occasion to advert to more particularly hereafter; for, during this, the inter- mittent harassed very extensively the elevated parts of Lincolnshire, While the inhabitants of the neighbouring fens were free from its ravages.§ And in like manner, the dry and healthy climate of Mi- norca, is sometimes attacked with remittent or intermittent fever, while Sardinia, proverbial for its insalubrity and febrile epidemics, escapes.|| To unite remittents, therefore, with intermittents, from an idea of their having a single and common origin, is to depart from the clear line of symptoms into a doubtful region of etiology. If inter- mittent ought to be separated (as unquestionably they ought) from continued fevers, so ought remittent to be separated from intermittent. To say that intermittents often run into remittents, is to say nothing, for remittents as often run into continued fever; and it is now an established doctrine that there is no continued fever whatever without occasional remissions. In effect, all fevers have a tendency to run into each other, and many causes are perhaps common to the whole. The difficulty is in drawing the line: yet a like difficulty is perpetually occurring to the physiologist in every part of nature; and equally calls for discrimination in zoology, botany, and mineralogy : and Dr. Parr has correctly observed, that " if a specific distinction can * On Blood, Part II. ch. IV. p. 411. f Act. Soc. Med. Hafn. Tom. I. N. 10. $ De Putridine, Urbin, 1608. § Med. Trans. Vol. III. Art. xiii. H Cleghorn, Diseases of Minorca. <*E. II.] SANGUINEOUS FUNCTION. 67 be established in any branch of natural history, it must be in the separation of remittents from intermittents." Vogel unites remit-* tent with continued fevers, to which Cullen, rightly enough, ob- jects ; but the former has as much reason on his side, as the latter has for uniting them with intermittent. Sauvages, Linneus, Sagar, and most modern writers, correctly distinguish each from the other. When an intermitting fever or ague is by the operation of marsh- miasm, or any other cause, once introduced into the system, and has once discovered its type, or given an interval of a particular measure between the close of the first and the commencement of the second paroxysm, it continues true, as a general rule, not merely to the same measure or extent of interval, but to the length and severity of paroxysm, through the whole course of the disease ; the character of the cold stage, determining that of the hot, and both together that of the sweating stage; and the paroxysm ceasing be- cause it has completed its career. But the first interval, like the first paroxysm, which regulates the rest, is of different duration in different cases: of the reason of this difference we know nothing; sometimes it seems to depend upon the season or the temperament of the atmosphere, operating upon the febrile miasm that is diffused through it, and ail who have agues in the same place or at the same time, have them of the same kind. Sometimes, on the con- trary, it seems chiefly to depend upon the time of life, the idiosyn- crasy, or the particular condition of the constitution, for, as already observed, different individuals even in the same place and under the same roof exhibit different types. But upon this subject we have no clear information. Nevertheless, whatever may be the cause of this difference, it lays a good foundation for dividing the intermittent genus into dis- tinct species, and the five following are sufficient to comprise all its principal diversities:— 1. ANETUS QUOTIDIANUS. QUOTIDIAN AGUE. 2. ------- TERTIANUS. TERTIAN AGUE. 3. ------- QUARTANUS. QUARTAN AGUE. 4.-------ERRATICUS. IRREGULAR AGUE. 5. -----— COMPLICATUS. COMPLICATED AGUE. As the connexion between all these is peculiarly close, and they occasionally run into each other's province ; and more particularly as the same mode of treatment is common to the whole, it will be most convenient to defer the general history and praxis, till we have taken a survey of these species in their respective definitions and the varieties they often exhibit. It may, however, considerably assist the student, and simplify his pursuit in acquiring a knowledge of their characters, to attend to the three following remarks :— Firstly, the shorter the intermission, the longer the paroxysm. Secondly, the longer the paroxysm, the earlier it commences in the day. 68 H.KMAT1CA. [CL. HI.—OR. I. Thirdly, the more durable the cold fit, the less durable the other stages. Thus, the quotidian has a longer paroxysm and a shorter inter- val than the tertian; and the tertian a longer paroxysm and a shorter interval than the quartan. And thus again, while the quo- tidian has the longest duration, it has the slightest cold stage ; and while the quartan has the shortest duration, it has.the longest cold stage. It is also the most obstinate to cure. Each of these species, however, admit of considerable variations: for sometimes we find the paroxysm protracted beyond its proper period ; sometimes anticipating, and sometimes delaying its proper period of return. In other cases, we find each of these species catenated with or giving rise to foreign symptoms or other dis- eases. And we also meet with a peculiar variety of the quotidian ague, in its being sometimes limited to a particular part or organ, in which case it is usually accompanied with very distressing pain. The most irregular of all the species is the fourth, for this is sometimes found to deviate from all the three rules I have just laid down; but particularly in the greater length of its interval, which is sometimes double or even treble that of the quartan, whose in- terval of seventy-two hours is the longest of the three more disci- plined species; it is hence found under the various forms of a five- day, a six-day, a seven, eight, nine, and even a ten-day ague ; and sometimes is so extremely vague as to bear no proportion whatever between the violence of its paroxysm, the duration of its stages, and the period of its return. The fifth species is distinguished from the rest by its peculiar complexity, consisting of double tertians, triple tertians, unequal tertians, duplicate tertians, together with as many varieties of the quartan type ; the nature and key of which will be more particularly noticed under the species itself. SPECIES I. ANETUS QUOTIDIANUS. ■* The disease sometimes terminates abruptly and with a critical sweat, or some other evacuation on the fourth or fifth day: but more usually increases in violence, though with occasional declina- tions, for a week longer; during which time, the pulse rises to a hundred or a hundred and ten strokes in a minute, but continues re- gular ; the nausea subsides, and the patient will take and retain whatever is offered to him of simple nutriment or medicine: the thirst is less violent, but the tongue is deeply furred, and the lips are parched. The disease is not often dangerous; and about the eleventh day gradually subsides, or yields to some critical discharge, which is usually that of a free and alleviating perspiration. The pulse soon sinks to eighty, and the chief symptom is weakness. During the course of the fever, every organ suffers from its mor 120 HJEMATICA. [CL. HI.—OR. I bid and increasing impetus ; but they do not suffer alike: for in some parts there is, occasionally, a greater spasticity or tetanic re- sistance in the blood-vessels, to the flow of the circulating fluid than in others, whence that acute pain which is often complained of in the head or the side; in the latter case, sometimes amounting to pleuralgia. And, not unfrequently, the vessels of one part will give way more readily than those of another, and there will be a sense of heaviness and oppression in the head, the heart, or the lungs; as though some effusion had taken place, which is perhaps actually the case in some instances. If the head be much affected, delirium is a frequent result, with raving and violence, rather than the low muttering incoherence of asthenic fevers. From the history already given of the malignant Causus, or ar- dent malignant remittent, it appears probable that inflammatory fever may sometimes be produced from febrile miasm, though it is commonly derived from other sources. Of these the stimulus of violent passions is, perhaps, one of the most common ; and especial- ly upon a vigorous and plethoric habit, which is the usual tempera- ment in which inflammatory fever makes its appearance. Undue muscular exercise, heating foods, or excesses of any kind in the same habit, are also frequent causes; while another may be found in the suppression of any accustomed discharge, as that of men- struation, epistaxis, or periodical blood-letting. Suddenly suppres- sed perspiration is, in like manner, a frequent, perhaps the most frequent cause of any; especially when the blood is very hot, and the change is effected by exposure to a temperature of great cold, applied externally or internally, as that of a current of cold air, a large draught of cold water, or plunging into a river. Some writers, as Sennert and Crichton, have supposed inflam- matory fever to be occasionally produced by an absorption of bile into the blood-vessels under the excitement of" a tropical sun, or of a torrid summer in milder regions; and they suppose that the bile is, in this case, possessed of a more than ordinary degree of acri- mony, and that the symptoms are varied by a more pungent heat and more intolerable thirst, with a more scanty secretion of urine, preternaturally acrid and high-coloured. That bile of this description is often forced back into the system under the circumstances here supposed, is unquestionable; as it is also that inflammatory fever is a frequent accompaniment of this morbid change. But notwithstanding the above authorities, such fever seems less attributable to the reflux of bile into the blood, than to the insolation or solar excitement; which, by unduly stimu- lating the liver, has been the cause of an overflow of the bilious secretion. How far a more irritant or exalted acrimony may be communicated to bile thus operated upon, or what may be its effect upon the system, admitting it to take place, it is difficult to deter- mine ; but there is much reason to doubt whether genuine bile in the sanguiferous system is ever a cause of fever, or stimulates the heart or arteries to increased action. For if this were the case, *>E. IV.—SP. I. SANGUINEOUS FUNCTION. 121 j aundice would always be accompanied with inflammatory fever. Instead of which, however, we find it accompanied with atony in- stead of entony, or diminished instead of increased power. Sauvages gives a case in which inflammatory fever was produced by a mechanical irritation o: the meninges of the braiu, by a lodg- ment of vermicles in the frontal sinus, of which seventy-two were discharged during a fit of vomiting and sneezing, from which time the patient began to recover. These vermicles were most probably the- larves of some species of the oestrus or gad-fly, which had crept up into the frontal sinus, after being hatched in the nostrils in which the parent insect had deposited her minute eggs. This is a very common affection in grazing quadrupeds, and especially in sheep, which are often pecu- liarly tormented, and sometimes driven almost mad by the violence of the irritation. Stoll gives a case in which the brain, on examination after death, was found deluged with serum diluvium serosum.* But such an ap- pearance is rather to be regarded as an effect than a cause of the disease ; as an instance of cephalitis fxrofunda, in consequence of the brain having suffered more than any other organ from the inflam- matory impetus. Hence the following varieties are noticeable under the present species: x Plethoricum. Produced in a plethoric habit Plethoric inflammatory fever. by great mental or muscular excitement, or heating foods; or by a sudden suppression of perspiration, or of other ac- customed discharges. (3 Biliosum. Accompanied with an excessive Bilious inflammatory fever. secretion of bile absorbed into the sunguineous system. y Pleuriticum. Accompanied with a violent Pleuritic imflammatory fever. stitch or pain in the side. £ Cephalalgicum. Accompanied with acute pain Cephalalgic inflammatory fever. in the head. As an inflammatory diathesis constitutes the essence of this fever, the cure must depend altogether upon a reduction of the vascular, and especially of the arterial entony: always bearing in mind the possibility that the disease may suddenly lose its inflammatory cha- racter, and rapidly pass into that of a typhus. Regulated by this view, we should generally commence with bleeding and cooling purgatives. There are a few cases, indeed, in which bleeding may be dispensed with, as when the habit is by no means plethoric, and the pulse obstructed rather than hard ; but these are cases that rare- ly occur. Diaphoretics, or relaxants as they are denominated by * Mat. Med. HI. p. 294. VOL. II.—16 122 HJEMATICA. [CL. HI.—OR I. Dr. Fordyce, may then be employed with advantage. Of these the tartarized antimony, the antimonial powder, or James's powder, are chiefly to be relied upon; and may be given alone, or, which is often belter, in saline draughts; and particularly those formed of the acetate of ammonia. And it may not be amiss to observe here, that the acetate of ammonia is sometimes prepared in the form of crystals, and sits more easily on the stomach in this than in any other shape. When given as a liquid, it is of importance that the solution should retain the carbonic acid gas of ammonia as largely as possible; and for this purpose the union should take place in a strong close vessel. According to Bergman, nearly half the weight of ammonia depends upon the quantity of this gas which it con- tains ; so that in a pint of the solution of the acetate of ammonia, comprising four drachms of the latter, there will be extricated, if made in the manner here recommended, little less than a hundred and sixty cubic inches of air. As the stomach is for the most part but little affected, emetics, if used at all, can only be employed for the purpose of determining to the surface; but as we can do this by the antimonial and other diaphoretics just referred to, as also by diluent drinks, it is hardly worth while to irritate the stomach in order to accomplish the same purpose. Perfect rest of body and mind, a reclined position, and a light liquid diet, destitute of all stimulants, are also indispensable toward recovery. The air should by all means be kept pure, by being constantly renewed, though without a sensible current, the temperature cool, and the clothing light and as often changed as may be necessary to maintain cleanliness. After all, however, it is not often that examples of pure inflam- matory fever are to be met with in the present day; and it is con- tended by very high authorities, and seems to be established by the medical records of earlier times compared with those of our own, that it is a disease far less common now than it was formerly; and that it is seldom, to adopt the words of Mr. J. Hunter, " that phy- sicians are obliged to have recourse to the lancet, at least to that excess which is described by authors in former times. They are, now, more obliged," continues the same writer, " to have recourse to cordials than evacuations; and, indeed, the diseases called the putrid fever and putrid sore throat are but of late date. I remem- ber when the last was called Fothergill's sore throat, because he first published upon it, and altered the mode of practice. I remem- ber when practitioners uniformly bled in putrid fevers; but signs of debility and want of success made them alter their practice. Whether the same difference takes place in inflammation, I do not know, but I suspect that it does in some degree; for I am inclined to believe that fever and inflammation are very nearly allied, and that we have much less occasion for evacuations in inflammation than there were formerly; the lancet, therefore, in inflammation, and also purgatives, are much more laid aside."* • On Blood, &c. Part II. p. 227. GE. IV— SP. I.] SANGUINEOUS FUNCTION. 123 It is not easy to account for this change in the national tempera- ment. It is common, indeed, to ascribe it to an alteration in our mode of life, which is asserted to be much fuller than that of our forefathers. " We may be said," says Mr. Hunter, " to live above par. At the full stretch of living, therefore, when disease attacks us, our powers cannot be excited further, and .we sink so as to re- quire being supported and kept up to that mode of life to which we have been accustomed." . If this be a correct view of the times in Mr. Hunter's day, they have greatly altered and improved within less than half a century : for there has never been a period, since wines and fermented liquors have been introduced among us, so temperate and sober as the present. Drunkenness, which was formerly common in our streets, is now rarely met with ; suppers are almost entirely relinquished ; and instead of its being disgraceful, as was the case in ' the olden time,' for the master of the house to let his guests leave him either sad or sober, nothing is now so disgraceful as intoxication. It is true, we are got back again to a very free use of the lancet in many instances ; which would seem to show that we had completed a revolution in our general temperament, as well as our general temperance ; but it is not a little singular, that while the lancet is still used with comparative caution in inflammatory fever, it is chiefly employed and often unsparingly in typhus, or putrid fever. And hence, there is more reason, I fear, for suspecting a revolution in the professional fashion than in national temperament; and that the bold and the timid plans have been alternately introduced, and alternately dropped, not so much from any radical change in the constitution, as from their being found to fail, because employed as popular means, or under the influence of some favourite hypothesis on all occasions, without a due degree of clinical discrimination, or attention to the habits or symptoms of individuals at their bed-side. SPECIES. II. TYPHUS. STSJrtws jFefcer. fULSE SMALL, WEAK, AND UNEQUAL; USUALLY FREQUENT; HEAT NEARLY NATURAL; GREAT SENSORIAL DEBILITY, AND DISTURBANCE OF THE MENTAL POWERS. The term is derived from Hippocrates, who uses it, however, in a sense not exactly parallel with its application in modern times. It is, nevertheless, admirably expressive of the general nature of ♦he fever to which it was applied at first, and which it designates at 124 HifcMATICA. [CL. HI.—OR. 1 present; which burns, not w ith open violence as the cauma, but with a sort of concealed and smothered flame;—for the Greek term rvf foul clothes or utensils in which it may be lodged ; and never infects a person in an adjoining street or house, or room in the same house; nor even, as Dr. Hay- garth has observed, in the patient's own chamber, if large, airy, and kept clean. It is also of great importance to know that typhus miasm, like the specific miasms of exanthems, does not render clean clothes of any kind contagious; or, in other words, does not adhere to or harbour in them. When, however, they are not clean, they may unquestionably be rendered contagious; and, hence, it is probable that the animal filth with which they are impregnated, while it is • Vol. II. CI. I. Ord. I. Sect. 9. p. 53. 126 HjEMATICA. [CL. III.—OR. I. a source of additional matter, becomes a fomes of that already formed, and separated from the patient's body. A susceptibility, however, to diseases of every kind varies very considerably in different individuals : and hence we find that many persons upon an equal exposure to typhus contagion with others, receive it far less readily, and in some cases seem to be almost favoured with a natural immunity. As we have already remarked that a particular state of body gives a peculiar tendency both to generate and receive typhus, we can easily conceive that where the body is in an opposite state it must be much less susceptible of its influence; and we are thus put in possession of a general cause of escape. But there seems to be something beyond this, dependent indeed, not upon the incidents of more vigorous health or higher animal spirits, but upon the nature of the idiosyncrasy itself. Dr. Haygarth has endeavoured to determine, from very ingenious and plausible data, the average proportion of those who in this manner remain exempt from contagion, while spreading on every side around them. And he limits the immunity to one in twenty- three : for he tells us, that when one hundred and eighty-eight men, women and children, were exposed fully to the typhous contagion for days and nights together, in small, close, and dirty rooms, all of them, except eight, were infected with this fever.* And he has farther endeavoured to show, that the miasmic poison, when received into the body, continues in a latent state for seven days, from the time of exposure to the contagion, before the fever commences, and may continue in the same state for seventy-two days, beyond which we have no instance of its producing any effect. And this deduction is in pretty close unison with the experience of Dr. Bancroft,! who in ninety-nine cases of orderlies and nurses that attended the English army on its arrival at Plymouth from Corunna in 1809, observed that they were rarely attacked with fever earlier than the thirteenth, and in no instance later than the sixty-eighth day. Man, however, is so much the creature of habit, that his constitu- tion is in a thousand instances brought bwdegrees to endure poisons of the most fatal power. This we see daily in the use of opium and ardent spirits; and we shaft" in due time have to notice something of the same kind, even in plague. This adaptation of the constitu- tion, however, to the circumstances by which it is surrounded, is in nothing more conspicuous than in the fever before us. Not, in- deed, in all persons—for all do not possess the same pliability of con- stitution—but in those who are endowed with it. And, hence, one reason why nurses and perhaps hospital-surgeons escape so often without injury; and especially why prisoners brought into a court for trial, remain themselves occasionally in perfect health, while their clothes are so impregnated with the contagious miasm as to * Letter to Dr. Percival, p. 31. f Essay on Yellow and Typhus Fevers, p. 515. GE. IV.—SP. H.] SANGUINEOUS FUNCTION. 127 infect a whole court, and communicate the disease to the judge or others who are at the greatest distance from them. There are other persons again, as Sir George Pringle has well observed, whose constitutions forming a middle line between those who readily receive, and who powerfully resist the contagious aura, are affected only in a modified degree. They bend to the assault, but are not cut down by it. They become feeble and irritable; the sleep is disturbed; the tongue white in the morning; the appetite impaired; the smallest exertion fatigues them, and accelerates the pulse; and in this state they remain for weeks together, and at length recover without any formal attack of fever. Wc have seen that the same influence of habit exists under yel- low fever; during which the natives of those climates, where its remote causes are in almost perpetual operation, suffer far less when it attacks them, and are far less susceptible of its attack. But though febrile miasm issuing from a decomposition of human effluvium has a peculiar tendency to generate typhus, we have seen that the same miasm issuing from a marsh effluvium or a decompo- sition of dead organized matter, under a peculiar state of modifi- cation, has produced remittents with a typhus character, and some- times specific typhus itself.* And, as in this case, the miasm is apt to spread more widely, typhus has by many writers been said to be occasionally epidemic. When, however, the disease issues from this source, it is far more generally in temperatures too low than too high and heated ; since, as already observed, cold, and especially cold and moisture, have a peculiar tendency to depress the living power: and hence this disease is said to be almost stationary at Carlscrone, or at least to have lingered there for four or five years on some occasions.f Typhus, therefore, originating from different causes, and all these causes modified in their action by collateral circumstances, may readi- ly be supposed to be accompanied with very different symptoms, and to appear under very different degrees of severity. The chief varieties, however, are the two following:— * Mitior, Nervous fever. S Gravior, Putrid fever. The first variety, or mild typhus, was called by Dr. Huxham/ This is sometimes produced by some accident, as that of a blow or severe pressure ; but more generally proceeds from a redundancy and consequently undue stimulus of milk, when first secreted after child-birth, so that the lacteal tubes have not time to enlarge suffi- ciently for its reception: in which last case it is usually called milk-abscess.—" In either case the suppuration commonly begins in many distinct portions of the inflamed part; so that it is not one large circumscribed abscess, but many separate sinuses, all of which generally communicate. Now it usually happens that only one of these points externally, which being either opened or allowed to break, the whole of the matter is to be discharged this way. But we sometimes find that the matter does not find a ready outlet by this opening, and then one or more of these different sinuses make distinct openings for themselves."§ In this case the complaint is usually protracted and tedious,though, where the constitution is good, and there is no lurking taint to inter- mix itself with the inflammation, the issue is always favourable. This sort of phlegmon was called by Dioscorides, sparganosis, from the Greek term e-x-xgyxa, " tumeo, distendo;" and after him it has still been so' denominated by various modern writers. Sparganosis, however, was employed by Dioscorides in a collective sense, to signify not only milk-abscess, but a variety of tumours, and other * Kalthchmied, Pr. de Tumore scirrhoso trium cum quadrante librarum glandulx Parotidis extirpata. Jen. 1752. ■J- Siebold, Parotidis scirrhosx feliciter extirpate Historia, Erf. 1791. $ Commerc. Lit. Nor. 1733-8. § Hunter, on Blood, p. 469. 188 H^MATICA. [CL. ni.—OR. U. diseases supposed to depend upon an overflow, suppression, misdi- rection, or depraved secretion of milk ; and especially those which have since been described under the general term galactirrhoea. Many of these have little or no connexion with each other; and particularly abscess of the breast, and that peculiar swelling of the lower limb which occasionally takes place soon after child-birth, to which the term is etymologically best applied, and to which there- fore it is restrained in the present system. SPECIES VI. PHLEGMONE BUBO. tfnfco. TUMOUR SEATED IN A CONGLOBATE GLAND ; REDDISH J HARD J DIF- FUSE; NOT EASILY SUPPURATING; OPENING WITH A CALLOUS EDGE. Bubo is a Greek term borrowed from the Hebrew verb yi or njn (bo or boa,) importing " to swell," and merely doubled according to the analogy of the language, to give it an intense or superlative power, whence bobo, or bubo. Buboes are chiefly found in the inguinal and auxiliary glands. They are sometimes simple glandular inflammations, unconnected with any constitutional or foreign evil, and require nothing more than the common treatment; but they are often a result of consti- tutional affection, and very frequently a symptom of lues and pestis, in which cases they can only be cured by curing the specific taint. Mr. Hunter asserts that he has seen buboes cured by vomits after suppuration has advanced. In an early stage the inguinal bubo has been confounded with a scrophulous tumour. A nice finger will generally discriminate them with ease. The bubonous tumour is smooth, uniform, and obtusely painful; the scrophulous is, to the touch, and sometimes to the eye, a cluster of small tubercles without pain. GE. U.—SP. VH] SANGUINEOUS FUNCTION. 189 SPECIES VII. PHLEGMONE PHIMOTICA. pUtmottc Phlegmon. TUMOUR SEATED IN THE PREPUCE; DIFFUSE; OBTUSELY PAINFUL; IM- PRISONING THE GLANS, OR STRANGLING IT BY RETRACTION. If at the attack of inflammation the prepuce be in its natural state and cover the glans, it cannot be drawn back and the glans is im- prisoned. If it should accidentally have been retracted, or be natu- rally short and truncated, it cannot, after the inflammation has firmly fixed itself, be drawn forward, and the glans is strangled. And hence the species offers us two varieties: a Incarcerans. The prepuce protracted and impri- Incarcerating phimosis. soning the glans. £ Strangulans. The prepuce retracted and strang- Strangulating phimosis. ling the glans. The first variety alone is denominated phimosis by some writers, the second being distinguished by the term paraphimosis, or circum- ligatura. But the inflammation is one and the same, and the same specific name should express it; for the difference is a mere acci- dent. This inflammation, like the last, though often produced by com- mon causes, and hence perfectly simple, is often, also, the result of a specific virus, as in lues and blenorrhcea. It arises frequently with great rapidity ; the prepuce is prodigiously distended with effused serum, and the mucous glands of the internal surface secrete an enormous quantity of pus before there is any ulceration or breach of surface. If the prepuce be retracted violently, and the glans strangulated, and cold applications, and topical bleedings prove inef- fectual, it is often necessary to divide the prepuce to set the glans at liberty. And occasionally it is also necessary to perform the same operation when the glans is imprisoned by a protraction of the prepuce: for ulceration is apt to take place under these circum- stances in either case, and the matter soon becomes erosive from communicating with the air: as much of it as possible, however, should be washed out by a syringe used several times a-day, and an astringent solution be afterwards injected, consisting of alum dis- solved in water in the proportion of about a scruple to a quarter of a pint. The imprisoning phimosis is said to occur not unfrequently from laborious exertion in a very narrow vagina.* I have not met with * Essich, in Ziegenhagen Anweisune alle venerische Krankheiten—zu be- handeln. A.D.B. XCV. 421. 190 HiEMATICA. [CL. HI.—OR. H. this result, but often with a lacerated prepuce. In many instances of both kinds relief has been easily obtained by grasping the penis with a very cold hand, and dextrously urging the prepuce forward or drawing it backward according to the nature of the case.* When the inflammation is very violent, whether in the strangu- lated or retracted variety, and surgical attention has been neglected, gangrene will readily ensue, and an amputation of a smallfir or larger portion of the penis may be absolutely necessary. In an instance of an amputation of this kind, recorded by Mr. Jamieson of Kelso, in the Edinburgh Medical Essays, the whole of the glans penis was restored by a process of pullulation: the new shoots hav- ing at first been mistaken for fungus, and attempted to be destroyed by escarotics. The fresh glans was well shaped and proportioned.t GENUS III. PHYMA. aruoerele. IMPERFECTLY SUPPURATIVE, CUTANEOUS, OR SUBCUTANEOUS TUMOUR ; THE ABSCESS THICKENED, AND INDURATED AT THE EDGE ; OFTEN WITH A CORE IN THE MIDDLE. Phyma, a Greek term importing a tubercle or small swelling, from Qvu, " produco, erumpo," was used among the Greek and Roman physicians with great latitude and no small want of precision: some- times, as by Hippocrates and Paulus of ./Egina, being applied to scrophulous, and other imperfectly suppurative tumours ; some- times, as by Celsus and Galen, to tumours perfectly and rapidly sup- purative, larger than a boil, but less painful and inflammatory, and without a core or ventriele : and sometimes by other writers, as Celsus also informs us, to fleshy excrescences or warts on the glans penis, which it was then the custom to destroy by caustics. And in consequence of this vague sense of the term, and the latitude of its original meaning, the great body of the Galenists, as Sauvages ob- serves, applied it to protuberances of every kind. Modern writers have, hence, been at a loss in what exact signifi- cation phyma should be employed. Linnfeus and Cullen have reject- ed it. Sauvages and Sagar have used it as the name of a distinct and separate order. Vogel, following the example of Hippocrates and Paulus, has reduced it to a genus of imperfectly supprative and glandular tumours ; and, as a genus, it thus occurs in Dr. Willan's * Andree, on the Gonnorrhcea.—Hecker, Von Venerischen Krankheisten, &c. t Vol. V. Art. xxxvi. GE.HI.—SP. L] SANGUINEOUS FUNCTION. 191 table of arrangement, including boils, carbuncles, and similar inflam- mations as its species. This seems to be the most accurate sense; and as such it is adopted in the present system, and made to include stye, boil, sycosis, and carbuncle; in all which we find some degree of imperfection in the suppurative or the ulcerative process of these small abscesses, or in both conjointly; and hence the pus is foul, and sanious, or the walls or edges of the abscess are thick and in- durated, or the dead matter is not completely carried off, and re- mains behind in the shape of a core or a fungus, sometimes black and spongy, and sometimes excrescent and granulating. The following, therefore, are the species included under it:— 1. PHYMA HORDEOLUM. STY. 2. ------ FURUNCULUS.' BOIL. 3.-----SYCOSIS. FICOUS PHYMA. 4. ------ ANTHRAX. CARBUNCLE. SPECIES I. PHYMA HORDEOLUM. St|>. TUMOUR SEATED ON THE VERGE OF THE EYE-LID; GRANULAR; HARD; REDDISH ; SORE TO THE TOUCH ; SUPPURATION CONFINED TO THE POINT. The vernacular term sty, or as it is sometimes written stian, is to be met with in the earlier writes, who obtained it from the Saxon, in which stihas signifies " a rising, springing up, or ascent;" and hence in Bede's Bible, Mar. iv. 7. (stihon tha thornas) " up sprung the thorns." Wicliffe spells the English derivation, stigh, but Spencer, who uses the word frequently, drops both the last letters of Wicliffe, as in the following couplet: To climb aloft and others to excel, That was ambition, and desire to sty. From the hardness of the margin of the tumour, and the imper- fection of the suppurative process, Sauvages compares it to a small boil: and asserts that it is often the result of a morbid state of the stomach ; adding that he knew a man who uniformly had a sty after drinking ardent spirits. The inflammation, though often very troublesome while it lasts, for the most part readily subsides upon the breaking the minute abscess, or puncturing it at its apex when mature. 192 HEMATIC A. [CL. HI.—OR. II SPECIES II. PHYMA FURUNCULUS. Moil. TUMOUR COMMON TO THE SURFACE; DEEP-RED; HARD; CIRCUMSCRIB- ED : ACUTELY TENDER TO THE TOUCH ; SUPPURATING WITH A CEN- TRAL CORE. The boil is a push with a central core; and like the push is found in persons of an entonic or phlogotic habit, with a peculiar suscep- tibility of irritation: on which account it often makes its appear- ance successively in different parts of the body, and sometimes synchronously, so that we meet with a crop at a time. This tu- mour is therefore chiefly found in persons of high health and in the vigour of youth. The existence of a core offers a singularity in this affection that is well worth attending to, and shows that from some cause or other the ulcerative part of the process is imperfect. Upon Mr. Hunter's hypothesis, this must depend upon a weak action of the absorbents; but as we have already endeavoured to show that the material to be removed must be prepared for absorption and conveyed to the mouths of the absorbent vessels before absorption can take place, and have suggested that it seems to be the office of the secreted pus to accomplish this purpose, it is probable that in the furunculus the pus, from some cause or other, is not quite genuine, and is pos- sessed of a less solvent power than in common abscesses : whence • a part of the dead matter remains attached to the living after the hollow has burst, and is thrown off from the base by sloughing. The mode of treatment is simple, and rarely requires medical or surgical assistance: though the diathesis should be lowered by bleeding, or purging, or both. SPECIES III. PHYMA SYCOSIS. iFtcous phgma. TUMOUR EXCRESCENT, FLESHY; FIG-SHAPED; SPROUTING FROM THK HAIRY PARTS OF THE HEAD OR FACE; GREGARIOUS; OFTEN COALESC- ING; DISCHARGE PARTIAL AND SANIOUS. The Greeks gave the name of sycosis from o-vkov " a fig," to vari- GE. III.—SP. III.] SANGUINEOUS FUNCTION. 193 ous tubercles and excrescences, the shape of which was conceived to resemble that of a fig. By Celsus, however, it is limited to a particular kind of inflammatory, and imperfectly suppurative tuber- cle of the head or face. Vogel has understood the term nearly in the same sense; and Dr. Bateman has, hence, correctly described it as such in his list of cutaneous diseases. It is seated sometimes on the beard, and sometimes in the hair of the head. In the former case it consists of small tumours, hard, roundish, pea-sized; commonly in clusters; occasionally confluent or running into one another; and spreading from ear to ear; the discbarge is small in quantity and of a glutinous texture, whence the beard becomes filthily matted. The variety that appears on the head consists of softer tumours, of different sizes, and in clusters; they are seated among the hair; and throw forth from a fungous surface, an ichorous, copious, and feted discharge. It is not often that this complaint is connected with any constitutional affection: and offensive as it is, it will generally be found to yield to cleanliness, and mild astringents; of which one of the best is starch-powder alone, or combined with an equal pro- portion of calamine. It makes an approach to one or two of the species of porrigo, but has characters sufficiently marked to keep it distinct, and to determine the present to be its proper station. SPECIES IV. PHYMA ANTHRAX. Gtarfcuncle. TUMOUR COMMON TO THE SURFACE; FLAT; FIRM; BURNING; PENE- TRANT; LIVID AND VESICULAR; OR CRUSTY ABOVE, WITH A SORDID GANGRENOUS CORE BELOW ; IMPERFECTLY SUPPURATIVE. Anthrax is a Greek term correspondent to the Latin carbunculus or carbuncle; literally a small live-coal, so denominated from the redness and fiery heat of the inflammation. The specific definition sufficiently points out its relation to the fu- runcle or boil, especially when the latter assumes an unkindly or malignant character from something peculiar in the part or in the constitution. " The inflammation that produces the carbuncle is, however, of a different nature from any of the former: it is station- ary, observes Mr. Hunter, with respect to place, and is pretty much circumscribed, forming a broad, flat, firm tumour. It begins in the skin, almost like a pimple, and goes deeper and deeper, spreading with a broad base under the skin in the cellular membrane. It pro- duces a suppuration, but not an abscess; somewhat similar to the vol. ii.—25 194 HJEMATICA. [CL. III.—OR. M. erysipelatous, when the inflammation passes into the cellular mem- brane: for, as there are no adhesions, the matter lies in the cells where it was formed, almost like water in an anasarca. This in- flammation attacks more beyond the middle age than in it, and very few under it. It is moft common in those that have lived well. T never saw but one patient of this kind in a hospital. It appears to have some affinity to the boil; but the boil differs in this respect, that it has more of the true inflammation, therefore spreads less, and is more peculiar to the young than the old, which may be the reason why it partakes more of the true inflammation."* The carbuncle occurs chiefly, perhaps uniformly, in weakly ha- bits, and hence, often in advanced life. But it is not all debilitated persons who have inflammations, that exhibit this disease : and wc have here, therefore, another striking proof of the influence of idiosyncrasy, or a peculiarity of constitution upon the general laws aiui progress of inflammation ; or of a peculiarity of that part of the constitution in which the inflammation shows itself; and, but for which, the inflammatory stages of the present disease would in all probability succeed each other in regular order, and the anthrax be reduced to the character of a common and benign abscess. Of the nature of this peculiarity we are too often able to trace out little or nothing: but so long as it continues, we have only a small chance of bringing the inflammation to a successful issue. The carbuncle shows itself under the two following varieties: x Pruna. With a black crust; and oozing an erosive Escar-carbuncle. ichor, or sanies. £ Tciminthus. Core or fungus spreading in the shape and Berry-carbuncle. colour of the pine-tree berry. The first of these varieties was called pruna by Avicenna, from its assuming the colour, and often the oval figure of the sloe, or fruit of the prunus sfiinosa, Linn. The second derives its name from its assuming the figure and blackish-green colour of the fruit or berry of the pine-nut, or reffcuiot of the Greeks, the pinus Abies, Linn, named by the Latins terebinthus; whence it has been called terminthus and terebinthus indifferently. As the carbuncle is an inflammation of great weakness set down on a peculiar predisposition, it sometimes shows itself among feeble infants in warm climates. According to Tournefort, in his Travels through the Levant, it attacks them chiefly in the back part of the throat, and proves quickly fatal. He describes it as endemic in his day among the islands of the Archipelago. In more advanced life, for the same general reason, we meet with it frequently in those who have debilitated their frames by an excess of good living, and are verging on the feebleness of age. We may hence also account for its appearing in an early stage of the plague, the most debilitating disease in the whole catalogue. It sometimes * On Blood, Inflammation, &c. Part II. Ch. IV. GE. HI.—SP. IV.] SANGUINEOUS FUNCTION. 195 shows itself in great numbers almost on its onset, or m* drop as the Arabians call it, who distinguish carbuncles by the name of jimme- rat. When unconnected with any other disease, a cure has been at- tempted by local stimulants, as cataplasms of tobacco and sal ammo- niac, which has been a common practice in Russia ; or of horse-ra- dish,* or stone-crop (sedum acre.-f) Cantharides,| camphor oint- ments, and lotions of zinc or mercury have also been tried. To which, as in the case of cancer, has been sometimes added the sucking of toads: as though it were possible to draw out the lurking virus with the swallowed humours. More generally, however, it has been attempted to be destroyed or extirpated. Arsenic was re- commended for this purpose as early as the age of Agricola; and has been employed in various forms, from that of orpiment to that of Plunket's caustic : above all which, however, Le Dran preferred corrosive sublimate. Riverius used other caustics, and Pouteauthe actual cautery; which has, indeed, been very successfully and skilfully adopted of late in a variety of similar affections by M. Maunoir. But radical success must after all entirely depend upon supporting and giving strength to the system by cordials, and tonics, for if this cannot be accomplished, it is perfectly clear that the pre- disposition will be neither subdued nor subside spontaneously: that the ulcerations will not heal, and the system must gradually sink under their constant discharge and irritation. The carbuncle of cattle is frequently owing to the poisonous sting of various insects; and hence a similar cause has, by some practi- tioners, been supposed to exist in mankind. Pallas suspects the fu- ria infernalis ; while others have mentioned the sirex gigas or large- tailed wasp. It is probable that these may have been occasional causes, where there has been a predisposition to the disease in the constitution. GENUS IV. ION THUS. aameifc. UNSUPPURATIVE, TUBERCULAR TUMOUR ; STATIONARY ; CHIEFLY COM- MON TO THE FACE. Ionthus (<«»0««) is literally-a " violet, or purple eruption, or efflores- * Par£, Lib. XXI. cap. 32. f Buchoz und Marquet neueste Heilkunde, Niirnb. 1777. t Riverius, Ob6erv. Med. lent. IV. 196 H.EMATICA. [CL. HI.—OR. 11. cence," from disease ; and is hence applied to the present in common with many other affections. The best description of the ignis sacer that has descended to us from the Roman writers, is that .of Celsus. He presents it as a genus comprising two species, the first of which is precisely paral- lel with the species before us, and the second with the erythema gangrenosum, or the preceding ; and, in order to prevent any doubt upon this subject, the definitions of both species are here given, as nearly as may be, in the words of Celsus himself. " It has," says he, " two species; one (the vascular erythema of the present sys- tem) is reddish, or a mixture of redness and paleness, rough with approximating vesicles (fiustulas,) none of which are larger than the rest, and which for the most part are very small. In these are al- most always found a fluid (pus,) and often a red colour with heat."* Then follows his description of the two varieties just given, the • De Medicin. Lib. v. Cap. XXVHI. Sect. 4. GE. VI.—SP.IV.] SANGUINEOUS FUNCTION. 209 benign and erosive, in the following words: " sometimes it trails along, the part healingthatwas first diseased ;" corresponding with the variety x of the present system. And " sometimes the part ul- cerating ; in consequence of which the vesicles (pustulae) break, the ulceration keeps spreading, and fluid escapes;" alike corresponding with the variety /3. Celsus then passes on to describe his second species, which answers to the character and almost to the words of erythema gangrenosum, or that we have just considered. " The other species," says he, " consists in an ulceration of the cuticle, without depth, broad, sublivid, but unequally so; and the middle heals, while the boundary lines advance ; yet not unfrequently the part that seemed healed again becomes exulcerated ; while the neighbouring parts, which are about to receive the disease, grow tumid and hard, and change from a blackish hue; the disease chiefly attacking the legs." In this passage the words fluid and vesicles are by Celsus named pus and pustulae; but that he hereby meant vesicles, and an icho- rous fluid, the PXvxtxivxi of the Greeks, is clear; first, because Cel- sus thus explains the term in another section of the same chapter; and secondly, because in the ignis sacer, which, as we learn from Thucydides and Lucretius, was a symptom in the plague of Athens, the former has given us pxvxTxtvxi, or vesicles, as the peculiar cha- racter of the eruption. " Yet the body," says Thucydides, " was not outwardly very hot to the touch, nor pale; but reddish, livid, and efflorescing with minute phlyctaenae (vesicles) and ulcers ;"* which Lucretius has thus forcibly rendered. Et simul ulceribus quasi inustis, omne rubere Corpus, ut est, per membra sacer quom diditur ignis. Wide-ting'd with purple dye, and brandish'd o'er With trails of caustic ulcers, like the blaze Strew'd by the hoit fire. It is perfectly clear, then, I think, that the ignis sacer of the Roman writers was an erythema, chiefly vesicular, and sometimes gangre- nous. It is also perfectly clear, that the present, like the preced- ing, species of erythema is the result of local or general debility, and requires warm and active local applications, and a tonic and bracing regimen. Where the skin is slightly broken, and the acrid fluid oozes through the minute openings, the vesications should be frequently dusted, as already recommended under the second species, with chalk, or starch ; or, where the latter is too harsh and drying, with a mixture of equal parts of starch and finely levigated calamine; carefully abstaining from all oleaginous or other applications that have a tendency to augment the relaxed state of the fibres. I have observed that the vesicular erythema is found, at times, as * Hist, II. 50. vol. n.—27 >H) HAEMATIC A. [CL. HI.—OR. H. d symptom in plague; it is also occasionally found, in the one or other of its varieties, as a sequel on the exhibition of mercury in ir- ritable habits ; and, under this form, has been occasionally denomi- nated by authors erythema mercuriale, and hydrargyria, as we shall have occasion to notice still further when treating of syphilis. SPECIES V. ERYTHEMA PERNIO. (Ehflfclain. INFLAMMATION OF A CRIMSON COLOUR, SUFFUSED WITH BLUE; OBSTI- NATELY ITCHING ; CHIEFLY AFFECTING THE EXTREMITIES DURINC* WINTER. This species offers us the two following varieties: * Simplex. The cuticle remaining unbroken. Simple Chilblain. (3 Exulceratus. Accompanied with ulceration. Kibe. The extremities principally affected by the chilblain ard the hands and feet; but in very cold climates, the nose, ears, and lips are aflected also, and the living power is destroyed as completely as by combustion. So correctly has our great epic poet described the power of severe frost: The parching air Burns frore, and cold performs th' effect ofjtre. That the pernio or chilblain belongs to the genus erythema is perfectly obvious, not only from its symptoms, but from the character or the age and constitution in which it is chiefly to be met with, and from the stimulant mode of treatment by which alone it is to be cured. The proximate cause of chilblains is a diminution of the excita- bility or vital energy of the extreme vessels; and as such diminu- tion is most readily produced in children, or older persons of relaxed fibres, these are most subject to the disease. For though we often meet with it also in strong and hardy boys, it will usually be found that the last, from the natural vigour and courage of their frames, have braved the cold and rigid reign of the winter-season beyond the venture of their school-fellows. Local stimulants then are the only applications that will answer; and particularly those which serve at the same time to defend the weakened organ from the severity of the external air. Hence,, « GE. VI.—SP. V-] SANGUINEOUS FUNCTION. 211 dog-skin socks worn day and night are useful, and warm diachylon, or Burgundy pitch, spread upon leather, still more so. For the same reason embrocations of spirits of turpentine, opodeldoc, liquor ammoniae acetatis, or equal parts of vinegar and spirits of wine, will usually be found serviceable. Linneus recommends bathing the part with diluted muriatic acid, and this has the advantage of being astringent as well as stimulant. The weakened vessels should never be too much distended, and hence, though gentle warmth and stimulants are indispensable, great heat, and especially a near approach to a fire, and more particularly still when very cold, will always be found injurious. When the inflammation becomes ulce- rated, or forms a kibe, warm and irritant dressings will alone suc- ceed in effecting a cure; and, if fungous granulations should appear, which they are very apt to do in all sores accompanied with debi- lity, they must be removed by a dressing of the unguentum hydrar- gyri nitratum, or some other mild escarotic. SPECIES VI. ERYTHEMA INTERTRIGO. iFret. SErosf on of the Shtn. UOLOUR OF THE INFLAMED PART BRIGHT RED ; CUTICLE ERODED ; THK EXPOSED SKIN OOZING A LIMPID AND ACRIMONIOUS FLUID. The fret or erosion which frequently takes place in different parts of the skin from an acrid secretion of the exhalants or sebaceous glands, and particularly behind the ears, about the groins, and around the anus, is usually accompanied with ery thematic redness, or inflam- matory blush ; and is hence generally, and correctly referred to the present place. It is an erythema with weak vascular action, and often considerable irritability in conseq-uence of such weakness. The most common example of this species is that which takes place behind the ears of children of a delicate habit, or who labour under irritation from teething, or from gross indulgence in luxuries. The discharge is often peculiarly offensive, and hence cannot pro- ceed merely from defective absorption, for it would then be nothing more than saline without fetor. It cannot be checked too soon; for if it continue for a few weeks, or perhaps even less, it may acquire a habit, the suppression of which may run the risk of super- inducing some worse disease than itself, as dyspepsy, diarrhoea, or convulsions. The organ affected should be kept well washed to prevent the spread of the morbid secretion, the discharge should be imbided by dry and scorched rags applied to the part, or starch frequently dusted over it. But the irritability is here best subdued 212 HjEMATICA. [CL. HI.—OR. H. by the tonic and astringent power of many of the metallic oxydes, particularly of cerusse, which is one of the most valuable, as well as one of those in most common use. GENUS VII. EMPRESMA. Visceral Xnflammatfon. DERANGED FUNCTION OF A VISCERAL ORGAN, MEMBRANOUS OR PAREN- CHYMATOUS ; WITH LOCAL PAIN; FEVER MOSTLY A CAUMA ; INFLAM- MATION MOSTLY ADHESIVE. The genus of diseases upon which we now enter consists of that numerous collection of visceral inflammations which, from the time of Boerhaave, have been generally distinguished by anatomical terms derived from the organ affected, with the Greek term itis added as a suffix, as cephalitis, gastritis, carditis and many others. Itis is sufficiently significant of its purpose: it is immediately derived from itfuti, which is itself a ramification from to, and imports, not merely action, " putting or going forth," which is the strict and simple meaning of tu, but action in its fullest urgency, " violent or impetuous action." As a suffix, therefore, we shall retain it in its common use, and proscribe it, to prevent confussion, from the few compounds, or proscribe the compounds themselves, in which this common use is departed from : as rachitis, hydro- rachitis, ascites, and tympanites, none of which convey any idea of violent or impetuous action, and some of which are peculiarly marked by a contrary state. This application of a common term in composition to so large a body of visceral inflammations, and the general use of the term for so long a period as that throughout which it has been employed, is a sufficient proof that practitioners have discovered between these inflammations other features of resemblance than the general symptoms of inflammatory disorder. In the prosecution of the subject, we shall find that this is the fact; and I have already observed, towards the commencement of the present order, that, with a very few exceptions, the inflammation in all the diseases is of the adhesive kind, and the fever a cauma. With a view, therefore, of simplifying, as far as simplicity may be of real use, the present system will, for the first time, comprize the whole of these under one genus, here distinguished by the name of empresma, or " internal inflammation," a term, in its simple form, employed both by Hippocrates and Galen ; and which it seems necessary to revive for the present purpose. GE. VII.] SANGUINEOUS FUNCTION. 21S Many of the organs included under the genus before us, and which we shall presently follow up in their respective order, sympathize with each other, and most of them with the stomach. The necessary consequence of which is, that the constitution is disturbed generally, though in very different degrees according to the organ affected; or, in Mr. Hunter's opinion, according to the different degree of its connexion with the stomach. If the heart, the lungs, or the brain be inflamed, whether prima- rily or secondarily, as by sympathy, the stomach is peculiarly influenced, probably from the essential importance of these organs to the lite itself (as all the vital organs, or those essential to the life, maintain a very close degree of affinity;) and the disease, originating in any of these, has, in consequence, a more violent effect upon the constitution than the same quantity of inflammation would have if it were not in a vital part, or in one with which the vital parts do not sympathize. The pulse, in such cases, is much quicker and smaller than when inflammatian takes place in a com- mon part, as a muscle, cellular membrane, or the skin, The progress, moreover, when the attack is so violent as to prove fatal, is, generally speaking, far more rapid than in other parts; so that, at its very beginning, it has the same effect upon the constitution as a farther advance of an inflammation in other organs that is equally sure of proving fatal in its result. The debility commences early, because the inflammation itself is immediately interfering with actions essential to the life; and, as already observed, the sympathy between these organs is peculiarly close, insomuch so as almost to make any single action common to the whole.* In inflammation of the brain, the pulse varies, perhaps, more than in inflammation in any other part; and we must rather depend upon other symptoms than upon the state of the pulse. It is some- times quick, sometimes slow, sometimes depressed, sometimes full, according as the disease is characterized by acute pain, delirium, stupor, or other concomitants. When inflammation is seated in the heart its action becomes extremely agitated and irregular. When in the lungs, the heart, possibly from sympathy, does not seem to allow of a free diastole. If the stomach be inflamed, the patient feels an oppression and dejection through all the stages of the disease. The vital energy, or simple animal life, seems to be impaired and lessened, in the same manner as sensation is lessened when the brain is injured. The pulse is generally low and quick; the pain obtuse, but urgent and overwhelming; so that the patient can hardly bear up under it. If the intestines be affected, the symptoms are nearly of" the same kind, especially if the inflammation be in the upper part of the canal; but if it be seated in the colon, the patient is more roused, and the pulse is fuller than when the stomach itself is inflamed. If the uterus be the organ attacked, the pulse is extremely quick • Hunter on Blood, &c. p. 325. 214 HiEMATICA. [CL. III.—OR. U. and low: if one of the testicles, the pain is depressing, and the pulse quick without much strength. With the uterus, the testicles, and the intestines the stomach peculiarly sympathizes; often, indeed, as much as if itself were primarily affected. If we contrast these species of inflammations with those that attack parts not very es- sential to life, but with such a degree of violence as to produce uni- versal sympathy and affect the vital functions, we shall find that in the latter the pulse is fuller and stronger than common; and the b^Iood is pushed further into the extreme arteries. The attack usu- ally commences with rigor; the patient then becomes somewhat roused because the action of the part is roused, and the effects on the constitution are not as yet such as to impede the operations of the vital organs. Much, however, will still depend upon the na- ture of the parts, whether active as muscles, or inactive as tendons ; as also upon the situation of the same description of parts, and espe- cially upon the character of the constitution: for if the last be ex- tremely irritable and weak, as in many women who lead sedentary lives, the pulse may be as quick, hard, and small, even at the com- mencement of the inflammation, as in inflammation of the vital parts. The blood, moreover, may be sizy, but will be loose and flat on the surface. Having premised these general remarks, we are the better pre- pared for examining the relations which the numerous species be- longing to the present genus bear to each other; and satisfy our- selves with a more summary account of several of them than would otherwise be necessary. SPECIES I. EMPRESMA CEPHALITIS Knflammatton of the Brain. PAIN IN THE HEAD ; AVERSION TO LIGHT J FACE MORE OR LESS FLUSH- ED ; CAUMA. The pathology of cephalitis, or inflammation of the brain, is, in, some degree, obscure and difficult, from the difference which occurs in several of its secondary or concomitant symptoms; occasioned partly, perhaps by the difference of its exciting cause, partly by the particular portion of the organ that is primarily or chiefly affected, and partly by circumstances which seem to baffle all research. From this occasional difference of symptoms some nosologists have endeavoured to establish as many distinct affections, and have hence multiplied a single specific disease into a considerable number of distinct species, and even genera, and treated of it under a fearful GE. VH.—SP. I.] SANGUINEOUS FUNCTION. 215 host of distinct names : and hence the disease before us has been described, not only under the term cephalitis, but under those of phrenitis, paraphrenitis, phrenismus, sideratio, siriasis, sphacelis- mus, and typhomania, calentura, and a great many others, which have burthened the medical vocabulary, and perplexed the medical student. The disease may commence in the meninges, or membranes of the brain, or in the substance or parenchyma of this organ; and if it were to confine itself strictly to the part first affected, instead of spreading from one part to another, there would perhaps be no great difficulty in determining, from the symptoms before us, its di- rect and actual seat: for while membranes and muscular inflamma- tion, before the access1 of gangrene, is accompanied with an acute and rousing pain, great heat, and a pulse considerably and perma- nently quickened, parenchymatous inflammation is rather distin- guished by a heavy, and often a stupefying, pain, a slight increase Of heat, and a pulse irregularly quickened, sometimes sinking even below its natural standard.* Now both these conditions are occasionally found in different cases of cephalitis ; and we may hence infer that in the one in- stance the diesase is seated chiefly, if not altogether, in the menin- ges, and in the other in some part of the substance of the brain it- self, thus presenting to us the two following varieties: « Meningica. Pain in the head acute; intolerance Phrenzy. of light and sound; cheeks perma- Brain-fever. nently flushed; eyes red; watch- fulness ; delirium ; pulse rapid. C Profunda. Pain in the head obtuse; cheeks ir- Deep-seated inflammation regularly flushed; pulse irregu- of the Brain; larly frequent; eyes oblique; Acute Dropsy of the Head. sleep heavy but unquiet, and oc- casionally interrupted by screams. Chiefly common to children. The above clear and distinctive marks, however, by which the two varieties are separated from each other in exact cases are not often to be met with ; as each, for reasons already given, is apt to assume something of the character of the other. And hence they have hitherto escaped the attention of all our nosologists, even of those who have subdivided inflammation of the brain into the great- est number of distinct genera or species of disease ; whilst Vogel expressly declares that all the most acknowledged symptoms of in- flammation of the brain are equivocal, not only as to a distinction of one morbid part from another, but as indicative of inflammation in any part; and Dr. Cullen asserts in a note subjoined to his generic definition (for he advances the disease to the rank of a genus, and • Hunter, on Blood, &c. p. 288, 289. 216 HJEMAT1CA. [CL. HI.—OR. II. a genus too without a species or a specific character,) that there are no symptoms capable at all times of distinguishing, with certain- ty, inflammation of the brain from inflammation of its meninges. On which account he deviates from the more complicated arrange- ments of Sauvages, Linneus and Sagar, and includes several of their genera in his own definition, which runs in more general terms as follows : " pyrexy severe; pain of the head; readness of the face and eyes ; intolerance of light and sound; watchfulness ; fierce de- lirium or typhomania." There is so much correctness in this remark of Dr. Cullen's,not- withstanding the error of his arrangement, that the present author yielded to it in the first edition of his Nosology, and introduced cephalitis, not indeed as a naked genus without a specific character, but as a single species without enucleating its varieties; or, in other words, without treating of deep-seated inflammation, constituting acute internal dropsy of the brain, separately from inflammation of the head generally. It may, perhaps, be doubted, whether acute dropsy of the brain ought to be regarded as an idiopathic inflamma- tion at all, and consequently whether the present is the proper place for it: but the reasons which will immediately be advanced will, I trust, settle this point completely. And, as, upon a closer attention to the subject, notwithstanding Dr. Cullen's remark, I am induced to think that there are cases in which parenchymatous or deep-seat- ed inflammation may be distinguished from meningic, I have so far deviated from the first arrangement as to give these distinctions un- der the form of the two preceding varieties. I admit, nevertheless, with Dr. Cullen, that there are no symp- toms capable at all times of distinguishing, with certainty, inflamma- tion of the substance of the brain from inflammation of its meninges; and only contend that the distinction may be drawn in certain cases in which the disease is simple, and the characters strong and un- mixed ; and strikingly indicative of membraneous or parenchyma- tous inflammation, according to the general rules just laid down up- on this subject. I believe this simplicity of appearance is more frequently to be traced in meningic than in profound or parenchymatous cephalitis; or in other words, that in primary inflammation of the substance of the brain, the meninges are more disposed to partake of the affec- tion either by continuous action or sympathy, than the substance of the brain is in primary inflammation of the meninges. And hence those nosologists that describe but a single species, or genus of this disease, as it has been often though incorrectly denominated, as Vo- gel, Cullen, and Parr, lean chiefly to the meningic variety,'and de- fine it by characters of great vehemence or acuteness, so as in reali- ty to limit themselves to this variety aloae. Yet as the symptoms do not always nor even most frequently mount up to this aggrava- tion, in consequence of the disease more commonly originating, or being more commonly seated, in the substance of the brain itself than in its membranes, they have all been dissatisfied with their respec- GE. VII.—SP. I.] SANGUINEOUS FUNCTION. 2H live definitions; and instead of enlarging or modifying their terms to meet the distinctive phaenomena as they vary according to the seat of the disease, have endeavoured to apologize for their own inaccuracy, by representing these phaenomena as irreducible and anomalous The first variety, therefore, exists in the judgment, and even in the description of all writers, who, where they have not entered into more minute subdivisions, have given it as the general charac- ter of the complaint. The existence of the second variety, or in other words, the pro- priety of regarding what has hitherto been denominated acute or internal hydrocephalus as a variety of cephalitis, requires to be ex- amined somewhat more at length. The absurdity of the usual arrangement of internal hydrocepha- lus, and of contemplating it as belonging to the ordinary family of dropsies with which it has scarcely a common symptom, has long been felt by pathologists, and is directly noticed both by Sauvages and Cullen. But the question is, if we remove it from its usual si- tuation, where are we to place it? if we do not regard it as a drop- sy, in what light are we to contemplate it at all? and how are we to regulate our treatment of it ? The professor of Montpellier tells us that, according to its symptoms, it is to be ranked in the coma- tose, spasmodic, or some other tribe of diseases; distinctly import- ing that, in his own opinion, he could not refer it to any single divi- sion in bis very extensive classification. Dr. Cullen's reply is, that it is an evident and idiopathic species of apoplexy, and ought to take its place under that genus; and he has hence distinguished it by the appellation apoplexia hydrocephalica, and in this manner assigned it " a local habitation and a name." In reference to this assignment he observes, however, that, in a nosological work, it is difficult to collate exactly diseases that in their progress assume a changeable form, and hence to allot a perfectly fitting place to hy- drocephalic apoplexy. Yet I prefer, says he, placing this disease under the head of apoplexy, to placing it under that of hydrocepha- lus (dropsy of the head;) first, as it differs extremely from the symptoms of sensible (external) dropsy of the head ; and next, as in its proximate cause, and at length in its symptoms, it bears to apo- plexy as near a relation as possible. Dr. Cullen evidently regarded the effusion or dropsy in the ven- tricles of the brain as a mere effect of the disease, rather than as the disease itself: yet the drowsiness or heavy sleep, or whatever else there is a-kin to apoplexy, and which he contemplated as the proximate cause of the disease, and consequently as the disease it- self, is a still more remote effect than even the effusion, for it is pro- bably the mere result of such effusion. In truth, it is only necessa- ry to run over Dr. Cullen's specific definition of this disease, to see how very little it has in common with apoplexy. This definition is as follows: " apoplexy arising gradually ; affecting infants, and the age below puberty, first with lassitude, feverishness, (febriculd,) vol. n.—28 • 218 H2EMATICA. [CL. III.—OR. 11 and pain of the head; afterwards with a slower pulse, dilatation of the pupil, and somnolency." The definition includes two stages of disease, if not two distinct diseases, a primary and secondary: and it is only in the second stage or secondary disease, the mere result of the first, that it bears any analogy to apoplexy. The first and leading spmptoms are evidently those of pyrexy, which is therefore the fundamental part of the disease; and had not Dr. Cullen been in some degree influenced by system, he would probably have coloured these symptoms a little more highly, as he might have done without any departure from the truth. And hence, while Dr. Parr, Dr. Young, and a few others, have adhered to Dr. Cullen's view of the subject, the great body of pathologists have been dissatisfied with it, and have correctly carried internal hydrocephalus over to the class of pyrexies, and regarded it as a fever or an inflammation. Thus in Dr. Macbride's table it occurs as a nervous fever, under the title of febris continua, nervosa, hy- drocephalica: and more simply under that of febris hydrocephalica, in Professor Daniel's edition of Sauvages ; while Dr. Quin of Dub- lin, Dr. Withering, Dr. Rush, Professor Martini, and a host of other ■writers of authority, have contemplated and treated it as an inflam- mation,—an inflammation of the brain,—and consequently a cepha- litis; the fever being regarded as a mild and somewhat irregular cauma, and the effusion into the ventricles of the brain as a mere effect of the inflammation. This is not the only instance, indeed, in which cauma assumes a mild character. In various other species of empresma it is often found to do the same, of which the reader will find an interesting example under the species laryngitis, a few pages further on: and of which every practitioner is meeting with daily'instances in pneu- monitis, and especially in inflammation of the parenchyma of the lungs producing suppuration. The general organ of the brain, however, seems to have less irritability than almost every other or- gan when in a state of health, and we often find it to be little irrita- ble in a state of lesion ; since nothing is more common than for a bul- let, or the broken point of a knife, sword, or other weapon, to be forcibly driven into it, and buried there for weeks, months, or years,* in one instance eleven years,t not only without danger, but some- times with little inconvenience. In the third number of the Medico-Chirurgical Journal, there is an excellent paper upon the subject before us, by Dr. Porter of Bristol, which commences with a very correct pathological view of the disease, minutely coinciding with the present arrangement, and confirming this view by a variety of strongly marked and well se- lected cases. And I am glad to avail myself of Dr. Porter's authori- ty in following up this second variety of cephalitis, into a distinct and extended illustration. * Gooch's Cases. Hoegg. Diss. Observ. Medico-chir. Jen. 1762. + Majanet, Journ. de Med. Tom. XLL 65. In. Tom. XX. 543. 0 GE. VII.—SP. I.] SANGUINEOUS FUNCTION. 219 In few words both varieties not only evince symptoms of inflam- mation during the progress of the disease, but anatomical proofs of the same upon dissection after the disease has terminated fatally; in the meningic subdivision the complaint commencing in and being ordinarily confined to the meninges or membranes of the brain, the blood-vessels chiefly affected with inflammatory action being the meningic branches of the external carotid; and in the deep-seated subdivision the complaint commencing in and being ordinarily con- fined to the posterior part of the brain, the blood-vessels chiefly af- fected being minute branches of the basilary artery. It is neverthe- less possible, and appears often to become a fact, from the anastomo- ses that are occasionally found between different arteries of the brain, from the continuous spread of morbid action from neighbour- ing sympathy,or from some unknown cause, that either variety may pass still deeper or wider into the substance of the brain, and make an approach towards the other; and hence, the mixt, anomalous, and even contradictory symptoms, by which the specific character is sometimes distinguished ; a striking example of which, but too long to be quoted, is to be found in the Edinburgh Medical Commenta- ries.* " In three cases," says Dr. Sagar, " I have found suppuration of the brain after death ; in each of which the patient during the pro- gress of the disease breathed sonorously but without stertor.t Whe- ther in the case of effusion between the membranes, the fluid be confined, where the disease commences in the meninges, to the space between the dura-mater and the arachnoid tunic, and where it commences in a contiguous part of the brain, to that between the arachnoid tunic and the pia mater, as asserted by Dr. Porter, I have not been able to determine." We may hence explain why the symptoms of irritation and op- pression should so much vary as we find they do in different cases; why there is sometimes no delirium and at other times a considera- ble degree; why the delirium is sometimes furious and impetuous, constituting the delirium ferox of medical writers; why in other in- stances it is mute or muttering, designated by the phrase delirium mite; and why there should occasionally occur examples of that comatose or heavy stupor to which the Greeks gave the name of typhomania; as also why the pain and pyrectic symptoms should vary from great acuteness to a mere disquieting head-ache and slight increased action. Phrensy is not often found as an idiopathic complaint, at least in this country; though it is a frequent attendant upon other diseases, as synochus, worms, various exanthems, trichoma, hydrophobia, in- juries of the brain, and severe grief. It sometimes makes a near approach to mania, but is easily distinguished by the nature of the exciting cause, where this can be ascertained, the abruptness of the * Vol. IX. p. 164. t Syst. Morb. Syrapt. CI. XI. Ord. III. Gen. xii. •^220 HJEMATICA. [CL. III.—OR. H, attack, and the violence of the fever; added to which there is in phrensy, for the most part, though not always, a hurry and confusion of th% mental powers, a weakness and unsteadiness of mind, which is rarely or perhaps never to be met with in genuine mania. It sometimes, however, runs into minia, of which Stoll has given a singular instance in a chronic case that continued for nine weeks before it assumed this change.* The remote causes are those of inflammation in general applied to the organ affected ; such as sudden exposure to cold after great heat; cold liquors incautiously drunk in the same state; inebria- tion, and especially from spirits; exposure of the naked head to the rays of a vertical sun; violent passions of the mind; obstructed menstruation ; and various kinds of poison. # The cure of phrensy must be attempted in the same manner as that of inflammation in general, or rather as the cure of inflamma- tion by resolution ; for resolution is the only means by which a cure can be effected in this case. Copious and repeated bleedings must here therefore hold the first place ; and the nearer the blood is drawn from the affected organ the better chance it gives us of suc- cess. The temporal arteries and the jugular veins have hence been recommended as the most effectual vessels to open ; but for various reasons it is better to begin with drawing blood liberally from the arm, and afterwards by a free application of leeches to the temples. The head should be shaven as soon as possible, and kept moist with napkins wrapped round it dipped in cold vinegar, or equal parts of water and the neutralized solution of ammonia; or, which is still better, with ice-water; all of which is preferable to blistering, which is too apt to increase the morbid excitement; and has the authority of Hippocrates, who was in the habit of applying cold epithems, not only in inflammation of the brain, but even of the abdominal viscera.t The bowels should be thoroughly evacuated, and even stimulated at first by calomel alone or mixed with jalap, and after- wards kept open by cooling saline aperients : and nitre should be given in moderate quantities, repeated as often as the stomach will bear; which is often considerably assisted by the tincture or infu- sion of digitalis. The chamber should be cool and airy; and no more light be admitted than the eyes can endure without inconve- nience. I have said that furious delirium, though generally laid down as a pathognomic of this variety of cephalitis, does not always occur; and in a very strongly marked case in which I was consulted about three years ago, the mental powers were not much interfered with. The patient was a lady of delicate habit, about thirty years old, who had caught cold by lying on an Indian mat, spread on the lawn, in the midst of a hot July. The first symptoms were those of inflam- • Rat. Med. Sect. HI. p. 179. f Utgi Noi/v, p. 448. GE. VII—SP. I.] SANGUINEOUS FUNCTION. 221 matory fever, with an acute pain in the head, which was not so much attended to as it ought to have been. I did not see her till the second or third day of the attack, when she had been bled only once, and that not very freely ; though the bowels had been freely evacuated. At this time the pain in the head was intense, with an intolerable acuteness of hearing and sight, insomuch that the slight- est light and sound, even the humming of a fly, were insupportable. The face was flushed: the eyes swollen; the head externally hot all over as a furnace; whilst a violent throbbing or thumping pul- sated within. Free bleeding now, though repeated till the system was weakened to its lowest ebb, produced little or no relief. The hair was immediately cut close to the head, and the entire scalp covered with napkins thoroughly wetted with ice-water, and renew- ed every half hour, by which time they became quite hot. This afforded some relief, as did also a large bladder about half filled with pound ice, and folded over the head like a night-cap. The fever, however, maintained itself, with little intermission, for a fortnight, during which time I advised the temporal artery to be opened once, and leeches applied to the temples several times; the bowels were kept sufficiently loose ; and nitrate of potash, tincture of roses, lem- onade, grapes, and other cooling medicines, were chiefly depended upon. As the weakness increased the mind wandered a little for a few minutes at a time, but never totally, nor without being easily recall- ed ; but every attempt to sleep produced, at this period, the most horrible ideas, accompanied with cold sweat and syncope on waking; even though the miserable dozing had continued only for a few minutes. This distressing state was relieved by ten grains of the compound ipecacuan powder, which produced quiet sleep for seve- ral hours. But opiates had hitherto uniformly disagreed with the patient's constitution, and did the same now, throwing out a rash over the entire surface of the body that produced an intolerable itching, and was accompanied with a deadly nausea at the stomach ; and this too, after the first dose, without any relief to the state of the head. They were tried in various forms, but had constantly the same effect; and we were obliged to relinquish it. Hyoscyamus and other narcotics were substituted, but proved of no service. Camphor, taken freely both in pills and solution, allayed in some degree the horror of the sleeping ideas; and as the fever began to subside, cascarilla, with sulphuric acid, appeared also to be service- able ; at the same time Madeira wine was allowed in small quantities in acidulated barley-water. Nothing, indeed, but gentle stimulants rendered the sleep supportable; for without these no sooner were the eyes closed, than the pulse became quicker and feebler, cold sweats succeeded, the most frightful and agonizing train of ideas usurped the brain, and the patient woke and fainted; evidently prov- ing that the debilitated brain was now nearly torpid and incapable, without adventitious excitement, of secreting a necessary supply of sensorial fluid. And, as this was not the case during wakefulness, 322 HJEMATICA. [CL. m.—OR. U. we have a clear proof also that the stimulus of the will answered the same purpose at this period. This distressing affection ceas- ed only by very slow degrees, and merely in proportion as the sys- tem acquired strength. Something of the same kind, however, was long felt after eating, at which time the sensorial power being peculiarly concentrated in the stomach to assist the process of di- gestion, every other organ was in a state of comparative exhaus- tion. It was, indeed, many months, before the brain recovered its habitual ease of action, and was free from all inconvenience. Profound or deep-seated cephalitis, or, as itis more commonly called, acute or internal hydrocephalus, so far as examinations after death may be depended upon, is almost always accompanied with effusion into the ventricles of the brain ; on which account indeed the name of hydrocephalus has been applied to it, though most incorrectly, for I cannot but agree with Dr. Porter that it has no other symptoms in common with chronic or idiopathic hy- drops cerebri, and that such a generalization has been a cause not only of much confusion in nosology, but of much mischief in prac- tice. This disease is sometimes found in adults, but mostly in young subjects, and chiefly from early infancy to seven years of age, par- ticularly in those of a fair complexion. After seven years the dis- ease is comparatively rare. The symptoms commence obscurely, and are those of irritation produced by worms : as irregularity, and especially costiveness in the bowels; listlessness ; impatience; knitting the brows into a frown ; heaviness of the head, which organ the patient is always desirous of reposing in a chair or some other place; irregular fever; and, occasionally, violent and deep-seated pain in the senso- ry shooting from temple to temple, or across the forehead ; fre- quently accompanied with sickness. The pulse is irregularly quick; the sleep unquiet, and interrupted by screams; and the eye has a look peculiarly oblique or squinting. These three last symp- toms are usually regarded as pathognomic. The eye, however, instead of taking an oblique direction, is sometimes turned upwards ; but either change is the result of spasmodic action; the pupil is often at first contracted, but at length unalterably dilated. The pyrectic symptoms appear chiefly in the evening ; but sometimes at other periods, for in this respect there is a strange and unac- countable anomaly; and as the disease advances they increase, and the stimulus of light becomes highly painful; shortly after which many of the symptoms are apt to assume deceitfully for a few hours, perhaps a day or two, a milder character; but the pulse evinces less power, stupor supervenes, occasional convulsions, more or less general, follow, and death very speedily closes the scene. I have thus given a brief sketch of the symptoms that principally mark the process of this disease in all their versatility ; and it is this versatility that has produced the chief differences of opinion that have been entertained concerning it, to which we have already adverted. GE. VH.—SP. I.] SANGUINEOUS FUNCTION. 223 The first symptoms are unquestionably rather those of irritation than of compression, as is obvious from their resemblance to those of invermination. The venous system in children, indeed, and especially the veins of the head, are not disposed to plethora, which is rather a characteristic feature of advanced years; nor does the small quantity of water which is often found in the ventricles seem adequate to the violence of the effect; and we have hence very strong grounds for supposing that the collection of water is only a secondary disease, dependent upon some previous idiopathic affec- tion in some part of the brain; and that affection, as Dr. Rush has long ago very ably shown, an inflammation. It has indeed been observed, in opposition to this opinion, that acute hydrocephalus is less frequently to be met with in strong and vigorous, than in weak and sickly children, dropsy being here, as in other species, far more commonly an effect of debility; whilst it is in strong and vigorous children alone that we have reason to expect inflammatory action in the brain, as in any other organ. Bleeding it is admitted has been serviceable at times, but we are told that it has often been unproduc- tive of any benefit whatever; and that it is possible to account for its occasional utility by other means than its taking off inflammato- ry action, as by simple removal or diminution of venous congestion. Yet we have already observed that venous congestion is not com- monly a disease of infancy, but of later life; that the first symptoms are those of irritation ; that post-obit examintions have very ge- nerally shown an inflamed state of the arteries; and that the fluid accumulated is not sufficient in many instances of itself to account far the symptoms by which the disease is characterised. The mode of practice, in consequence of this discrepancy of opinion, has been extremely undecided; whilst many practitioners are so despondent as to fear that every plan is equally unavailing. It has fallen to the author's lot, however, to see several patients recover both in infancy and verging towards adult age, who had all the characteristics of the disease, and were unquestionably labour- ing under it. Contemplating it as a variety of cephalitis, he has uniformly pursued the general plan recommended under the preceding vari- ety, and to this practice he can only ascribe whatever degree of success he has been fortunate enough to meet with. Blood should be drawn freely from the nape of the neck by cup- ping or leeches: the head should be shaven, and napkins dipped in ice water, or vinegar and water, be applied to the posterior part of it, and be changed every hour or half hour. The bowels should be free- ly purged with calomel, or calomel and jalap : an easy diapnoe should, if possible, be excited, and maintained on the skin; the chamber should be large and well ventilated ; and when it may be right to stimulate the head, epithems of neutralized ammonia should be preferred to blistering. The value of digitalis is doubt- ful; when used early it has seemed serviceable, but it should be avoided in the second stage of the disease. In later life tlnn in- 224 HJEMATICA. [CL. IIL—OU. II. fancy, where it has been necessary to draw blood repeatedly, I have occasionally' prescribed opening the temporal artery with great success ; for a small quantity, as six or eight ounces of blood, drawn in this way, will often answer the purpose of double or treble the quantity abstracted from the arm. In a young lady of nineteen, labouring under very prominent symptoms of this disease, I found the violent and deep-seated pain in the head cease instant- ly ; and the pulse sink from seventy to forty-four, as soon as a tea- cup-lull of blood only was taken away in this manner. Met cur}' employed both externally and internally, in a quantity sufficient to excite a pytalism, has also been used in many instances w h great success, both among aduhs and infants, but particularly among the h'ter. Dr. Percival gives the history of a child of his own, aged three years and a quarter, in which a perfect cure was obtained by this, and nothing else. In forty-eight hours signs of amendment appeared, and in six days the child was well ; during which time thirteen grains of calomel had been taken, and seven scruples of strong mercurial ointment had been rubbed into the legs.* Dr. Dobson of Liverpool employed quick-silver in the same double plan, and asserts that he found it equally useful, and most strikingly so in the following case. Four children in the same family had evinced this disorder in succession; three had fallen victims to it under a different treatment: one between three and four years old, was subjected to the mercurial plan of calomel and inunction. In forty-eight hours aptyalism was excited, the symptoms abated, and the child recovered.t In adults the ordinary proportion is ten grains of calomel and a drachm of strong mercurial ointment every night. Under this treat- ment various cases of success are recorded in the Edinburgh Medi- cal Journal. SPECIES II. EMPRESMA OTITIS. 2£ar=ache. SEVERE PAIN IN THE EAR; TENDERNESS UPON PRESSURE; DEAFNESS OR CONFUSION OF SOUNDS- This is a distressing rather than a dangerous disease; but the fever is sometimes violent, and delirium has occasionally been a conse- quence. It is often produced by cold, and hence frequently a symp- * Edin. Med. Com. Vol. VI. p. 224. f Id. VI. p. 221. GE. VU.—SP. II.] SANGUINEOUS FUNCTION. 225 torn of catarrh : and is still more commonly, perhaps, occasioned by some exotic substance which has accidentally entered into the ear, as a small piece of ragged bone,* a cherry-stone,f a worm, an insect, or the larve of an insect, as of an ant, a spider, a fly, or a cricket; of all which we have a variety of curious histories in the medical journals.} In a few rare instances the inflammation has extended to the brain, affecting the membranes and surface of the organ, and coating them with coagulable lymph, pus, or both; while even the temporal bone of the affected side has become carious. A case of this last kind is related by Dr. Powell in the Medical Transactions. The patient was a young gentleman of sixteen, who had been at- tacked with otitis once or twice before. The pain was intense, but the pulse never exceeded seventy-two : yet the disease proved fatal. The intellect was at no time disturbed.§ The general remedies for inflammation are here to be resorted to; and particularly warm, narcotic fomentations. Blisters behind the ear have often afforded relief; and for the same reason stimu- lant errhines and sialagogues: which, by evacuating the mucous follicles of the Schneiderian membrane, and the salivary glands, produce an influence on all the neighbouring parts, and often on the whole of the vessels of the head. And hence head-aches, oph- thalmies, and pains in the ear, are in many instances equally reliev- ed by these applications, and were often employed by Dr. Cullen for this purpose.|| When worms or the larves of insects are the irritating cause, a few drops of oil of almonds introduced into the ear will readily suf- focate them. SPECIES III. EMPRESMA PAROTITIS. flumps GAINFUL UNSUPPURATIVE TUMOUR OF THE PAROTID GLANDS, OFTEN EX- TENDING TO THE MAXILLARY : CONSPICUOUS EXTERNALLY; OFTEN ACCOMPANIED WITH SWELLING OF THE TESTES IN MALES, AND OF THE BREASTS IN FEMALES. The parotid glands are subject to a troublesome, and sometimes a * Hagendorn, Cent. I. Obs. 64. f Fabric. Hildan. Cent. HI. Obs. 4. * Stalpart Van der Wiel. Maget. Journ. de Med. Tom. LXIV. Moehring, Obs. 21. Samml. Medinischen Wahrnehmuneen, B. vni. p. 37. § Vol V. Art. xvi. p. 212. || Mat. Med. Vol. II. p. 436. 442. vol. II.—29 226 IIJEMATICA. [CL. 111.—OR. 11 fatal phlegmon, which we have already noticed under the name of phlegmone fiarotidea. The inflammation before us is altogether of a different kind; it is more extensive, more painful, and rarely tends to suppuration. In our own country it is vernacularly called mumps, and in Scotland branks. The tumour, though sometimes confined to one side of the neck, more usually appears on both: it is at first moveable, but soon becomes diffused to a considerable extent. It increases till the fourth day, and often involves the maxillary glands in the inflamma- tion ; is evidently contagious, and often epidemic. After the fourth day it gradually declines; and for the most part there is but little pyrexy, or need for medical aid; avoiding cold, and a brisk purga- tive or two being all that is called for. The sympathetic action of the testes and the mammae is most conspicuous towards the decline of the inflammation. And, in many instances, it is by no means an unfavourable sign; for it has been occasionally found that where the sympathy has not been manifested, or the glandular swelling has been suddenly repelled, the symptomatic fever has been greatly exacerbated, delirium has ensued, and even death has closed the scene. Where there is any danger of such a result, the swelling should if possible be brought back or sustained by stimulant cata- plasms or blisters. Dr. Hamilton has in several cases observed this sympathetic influence operating alternately: and mentions more than one instance in which after a very considerable enlargement of the testicle, upon the cessation of the disease, this organ entirely wasted away, insomuch that the tunica vaginalis became an empty bag.* In advanced life parotitis is sometimes apt to run into a chronic form, accompanied with very mischievous symptoms; in which state it is denominated a malignant parotid. This is more especially apt to take place in females when menstruation is on the point of ceas- ing, and the general action of the system labours under some dis- turbance. The tumor should, if possible, be carried off by leeches and cooling repellents: for if it proceed to suppuration, which it tends to though very slowly, the ulcer rarely heals; usually de- generating into a foul offensive sore, that sinks deeper and spreads wider, resisting all medical treatment and at length undermines the constitution, and destroys the patient. Vomits, frequently re- peated, have in this case been found highly serviceable: and those of the antimonial preparations are to be preferred to ipecacuan. They maintain a longer action, and determine more effectually to the surface, or rather to the excernents generally. * Edinb. Transact. 1773. GE. VH.—SP. IV.] SANGUINEOUS FUNCTION. 227 SPECIES IV. EMPRESMA PARISTHMITIS. REDNESS AND SWELLING OF THE FAUCES ; WITH PAINFUL AND IMPED- ED DEGLUTITION. This is the squinsy, or squinancy of our old writers; the cynanche or angina of medical books. Paristhmia from irxpx and je-fyw?, literal- ly morbus faucium or throat-affection, is the term employed by Hip- pocrates, and is only varied to paristhmitis, in the present system, in consonance with the general termination of all the species belong- ing to the genus before us. The term was used among the Greeks, as on the present occasion, in a specific sense; though the later Greek physicians gave different names to its different varieties: and hence we meet with cynanche, synanche, and parasynanche; the common signification of all which is angina or strangulation, while the prefixes cy- sy- and parasy- are of doubtful meaning, as I have further observed in the preliminary dissertation to the No- sology. Aetius attempted to justify cynanche, but Cselius Aureli- anus, and Paulus, used synanche after Celsus. The Latins employ- ed angina in the same extent as Hippocrates did paristhmia; quinsy is used in a parallel latitude among ourselves. Sauvages conjec- tures, and there is some ground for the opinion, that the synanche of the Greeks was the common quinsy of the present day, the pa- risthmitis tonsilaris of the system before us; their parasynanche the quinsy of the pharynx, paristhmitis pharyngea ; and their cynanche, croup, or p. trachealis. Quinsy presents itself to us under three varieties ; the common inflammatory sore-throat; the ulcerated or malignant; and the sore throat that peculiarly attacks the pharynx. x Tonsillaris. Swelling of the mucous mem- Common Quinsy. brane of the fauces, and espe- Inflammatory sore throat. cially of the tonsils; redness florid ; fever a cauma. £ Maligna. Redness crimson; with ulcera- Ulcerated; or tions covered with mucous Malignant sore throat. and spreading sloughs, of an ash or whitish hue : fever a typhus. Frequently epidemic; generally contagious. Found often as a symptom in rosalia, or scarlet fever. v Pharyngea. Redness florid, and especially 228 HJEMAT1CA. [CL. III.—OR. II. Pharyngic Quinsy. at the lower part of the fau- ces: deglutition extremely painful and difficult: fever a cauma. In the first variety or common quinst, the swallowing is, for the most part, greatly impeded : and the speech, and sometimes even the respiration rendered highly troublesome : the mucus is excre- ted sparingly, and consequently there is a considerable clamminess in the mouth; and the pain sometimes spreads to the ears. The disease is never contagious, and though violent while it lasts, is comparatively of short duration. It terminates by resolution, or suppuration ; hardly ever by gangrene; though a few sloughy spots sometimes appear upon the fauces. The usual cause is cold; and it is hence found most frequently in spring and autumn, when vicissitudes of heat and cold are most common. It is supposed to affect particularly the young and the sanguine—but, in my own practice, it has occurred as often at other ages and in other temperaments. When it has been re-produced several times within short intervals of each other, it is apt to estab- lish a peculiar diathesis or habit, so as to be excited readily and by very slight occasional causes. If attacked by a medical process early, much benefit has been derived from astringent and acid gargles, and vapours inhaled by any simple machine for this purpose. Blisters to the throat or behind the ears, ought also to form a part of the curative plan ; and if bleeding be had recourse to, it should be by scarification or leeches applied to the tonsils or fauces. An early use of leeches I have often found highly successful. Cooling purgatives, and a low regi- men should also enter into the general plan of treatment. If sup- puration cannot hereby be prevented, the better way will be to ex- pedite this termination by the steam of warm water, or water im- pregnated with the leaves of rosemary or chamomile : and when the fluctuation is clear to the touch, if the abscess do not of its own ac- cord break readily, it ought by all means to be opened with the lancet. In a few instances the suppuration has pointed and broken ex- ternally, and the termination has been favourable.* And, occa- sionally, from the extent and violence of the inflammation, there has been so much danger of suffocation, that it has been found ne- cessary to make an opening into the trachea :f which has been done sometimes as high as the larynx, and sometimes considerably lower; and under both kinds of operation the patient has recovered.} In the malignant or second variety, the inflammation passes * Schenck. Lib. II. Obs. 36. f Ballonius, I. p. 182. Fernire, Journ. de Med. Tom. LXH. * Fienus, Chir. Tract. IV. V. C. 1. Musgrave, Phil. Trans. N. 258. GE. VII.—SP.1V.] SANGUINEOUS FUNCTION. 229 at once into the ulcerative stage; and is consequently characterised by the symptoms stated in the definition : the sloughing often takes place rapidly, and spreads widely, and the fever is a typhus. This variety is frequently epidemic; generally contagious; and found often as an alarming symptom in rosalia, or scarlet fever. In its idiopathic form it is usually ushered in with a sense of stiffness in the neck, accompanied with some hoarseness of the voice, and occasionally with symptoms of a coryza. It is in effect a quinsy, taking an erythematic or erysipelatous, instead of a phlegmonous turn, in consequence of the peculiar temperament of the atmosphere, or of the patient, or of some unknown cause. The sloughs at first appear whitish,or cinereous ; but soon be- come brown, and often black; and spread over the whole of the fauces, and mouth, into the nostrils, and often down the oesophagus; the ulceration has, also, sometimes passed up the Eustachian tubes and affected the ears. And, as the sloughs appear to carry conta- gion with them, on being swallowed they have communicated the disease through the entire range of the alimentary canal. The danger is hence very great if the ulceration cannot be check- ed; and it is peculiarly so to children and adults of relaxed and delicate frames. The disease makes its appearance most commonlv in the autumn, though it has appeared in every season. Dr. Cullen regards the eruption of scarlet fever as a pathognomic symptom of this disease; but this is to confound two complaints that are very clearly distinct, as we shall have farther occasion to ob- serve when discussing rosalia, or scarlet fever. It is at present sufficient to remark that, even in the opinion of Dr. Cullen himself, quinsy is not essential to scarlet fever, or, in other words, does not always accompany it; and that, on the other hand, a scarlet eruption is not essential to the malignant quinsy, or does not always accom- pany it, though he contends that it does almost always;*—to show the proper bearing of these two diseases upon each other. The malignant or ulcerated sore throat may be without a scarlet eruption, or attended with it: if the former, it is an idiopathic af- fection, and constitutes a variety of paristhmitis, or cynanche. If the latter, it is a symptomatic affection, and constitutes a variety of rosalia* or scarlatina. Cleanliness, pure air, and a free ventilation, are hereof the ut- most importance : and as the contagion is often very active, the nurses should be cautious to remove speedily the sloughs and foul mucus that are washed or wiped from the mouth. The general treatment will necessarily be the same as that we have already pointed out for typhus. Emetics are often employed with great advantage at the commencement of the complaint; and the bowels should be gently opened, but not irritated with drastic purges. The throat should be gargled with port wine, made still more stimulant by spices or other aromatics ; or with a strong de- * Pract. of Phys. Part I Book HI. Ch. IV. Sect. DCLI. 230 HJEMATICA. [CL. III.—OR. H. coction of bark, or catechu, which is better, very sharply acidulated with mineral acids, or pungent Cayenne vinegar, or charged with an addition of Cayenne pepper in substance. Gargles of the mine- ral, and even the metallic astringents, have also been tried, but in general they want poignancy. Lunar caustic, in the proportion of one part to a thousand parts of water, has sometimes been found useful.* A strong decoction of mezereon root may, also, advantageously form the basis of a gargle ; though even this will be improved by an addition of capsicum or Cayenne pepper,! and the mineral acids. The stimulus of mezereon is less acrid than that of Cayenne pepper, but is more permanent, and acts more immediately on the fauces. The leaves of the flammula jovis, (clematis recta, Linn.) or, the upright traveller's joy, may be masticated for the same purpose when fresh, for their acrimony considerably diminishes by drying. They excite a pungent heat in the mouth and fauces, and if chewed in a large quantity, produce a blister. In Persia, a gargle is obtain- ed by boiling the leaves of the water-pepper, (polygonum hydrofii- fier, Linn.) better known in the pharmacopoeias by the name of per- sicaria, urens, which, in many instances, answers very effectually. And, in conjunction with these, camphor or ammonia has often been found beneficial when externally applied in the form of a liniment.\ Bark and wine, indeed, should be taken jointly, and in as large a quantity as the system will bear. Even sleep is less necessary than both these ; nor should the patient be suffered to rest for a period of three hours at a time, without fresh doses of both, though we wake him for the purpose. Time, indeed, is here every thing : if we make no progress in the first thirty-six hours we may tremble for the event; if we lose ground in twenty-four hours, we shall have to hope against hope. Women, unaccustomed to wine, have taken it successfully; under this disease, in the proportion of two bottles a-day, for more than a fortnight. Quinsy of the pharynx is, properly speaking, that which com- mences in this organ. It is met with but rarely ; nor is it, when it does occur, a case of serious importance. It is distinguished by the florid redness of the inflammation, especially at the lower part of the fauces, and by the nature of the fever, which is a cauma. The pain, indeed, extends sometimes behind the sternum, but is only felt in swallowing. The breathing is not affected. A cure is easily in- duced by swallowing slowly nitrous and mucilaginous medicines, and taking off the phlogotic diathesis, where it prevails, by bleeding and brisk purgatives. * Journ. de Med. Nov. 1789. f Collin. Med. Comment II. 27. Stephen, Med. Comment. Edin. V. * Rumsey, Lond. Med. Journ. X.—Medicus, Beobachtungen II. 505. GE. VII.—SP. V.] SANGUINEOUS FUNCTION. 231 SPECIES V, » EMPRESMA LARYNGITIS. Kuflaimuatton of the Havgnv pain about the larynx, epiglottis swollen and erect; breath- ing shrill and suffocative; great anxiety; deglutition im- peded ; FEVER A CAUMA. It is doubtful whether this severe and dangerous complaint has ever been described till of late years. It seems to have been known to Dr. Mead, whose general account coincides with a disease notic- ed by Hippocrates. It is minutely and accurately detailedby Dr. Home, in his Principia; and is the subject of several excellent pa- pers in the Transactions of the Medico-Chirurgical Society, particu- larly by Dr. Farre, Sir Gilbert Blane, Dr. Roberts, and Dr. E. Per- cival. The disease, as will be perceived by the definition, bears a considerable resemblance in many of its symptoms to croup; is highly acute, and destroys by suffocation in a day or two, unless very actively opposed. Frequently, indeed, it destroys much sooner. Brassavoli mentions a case, which seems to have been of this kind, that proved fatal in ten hours:* and Schenck, another, in which suffocation and instant death were produced by a fit of vomiting, the spasmodic action having extended to the stomach or its auxiliary muscles.f The disease makes its approach with the common symptoms of inflammatory fever, as chilliness succeeded by heat; the voice be- comes hoarse and indistinct; the breathing laborious, with a pain- ful sense of constriction in the throat; the fauces present a Modena red colour, and are considerably swollen and turgid, the swelling extending to the face and eyes, the latter not unfrequently pro- truding, as in cases of strangling; the pulse is quick and the tongue furred; and every attempt to swallow is accompained with great distress; the muscles of deglutition, and even those of the chest, being thrown into severe spasms, threatening the patient with in- stant death from suffocation, and making him call out for air and an opening of the windows. It is distinguished from croup by the existance of a perpetual and voluntary hawking, rather than a forcible and involuntary cough, as though to clear the passage by expectoration. It is also distinguish- ed from it by the nature of the expuition which is a viscid mucus, rather than a coagulable and membrane-like exudation. The two * Comment, ad Hippocr. de Rat. Vict. acut. Lib. IV. f Obs. 29. ex Trincavellio, lib. II. 232 ILEMATICA. [CL. HI.—OR. II. diseases differ, moreover, in their proximate causes as consider- ably as in their symptoms. Laryngitis consists in a suppurative in- flammation of the membranes of the larynx, extending backward to the membrane common to itself, and'the oesophagus, between which pus is often found lodged: while croup or bronchitis is a.peculiar in- flammation of the trachea, extending through the bronchial vessels, and exciting on their internal surface the secretion just noticed of a concrete filmy material which threatens suffocation by filling up the opening of the rima glottidis. In the treatment of this distressing malady, our object should be to takeoff the inflammation by the most active means. For this pur- pose eighteen ounces of blood should be instantly drawn from the arm, and eight or ten from the throat by leeches; and the bowels should be thoroughly purged by calomel and jalap, or some other active cathartic. In connexion with this process many writers ad- vise the application of a blister, and the use of relaxant inhalations. But, in preference to both, I would recommend gargles of ice-water acidulated, and epithems of pounded ice applied externally. If this plan) do not at once succeed, no time is to be lost, and bronchotomy must be had recourse to. But whether the opening should be made in the larynx, or below it, mtfetbe left to the judgement of the sur- geon to determine. In a few instances, however, this disease seems to commence with comparatively little violence ; and to run easily into a chronic form : a case of which kind is described by Mr. Wood in the Edinburgh Medical and Physical Journal. The child, a female, was ten years old when she was attacked. The symptoms for the first three or four days where even so trifling that no attention would have been paid to the complaint but for the croaking noise made in breathing, and particularly during sleep, which had a considerable resemblance to croup. The disease advanced gradually and almost impercepti- bly, except by occasional exacerbations, with a pulse from eighty to ninety in a minute, till the twenty-eight day, on the noon of which the patient ate with an appetite, and with tolerable ease. At this period a night exacerbation carried her off suddenly; and on examination, the larynx was found internally covered and nearly filled with coagulable lymph, which is said to have assumed a mem- branous form; and hence approaching to the nature of the exuda- tion in croup. GE. VII.—SP. VI.] SANGUINEOUS FUNCTION, 233 SPECIES VI. EMPRESMA BRONCHITIS. (tvoup breathing permanently laborious and suffocative; short, dry cough ; expectoration concrete and membranous ; fever a CAUMA. The writers on croup have given but one form of it, except what has been erroneously called spasmodic croup, a disease of a different kind, which has already been described under the name of laryngis- mus stridulus. Properly speaking, however, there are two* forms, an acute and chronic, under which the present species shows itself, and which may thus be distinguished as varieties: x Acuta. Sense of suffocation keen, and constrictive; Acute croup. chiefly seated in the larynx; respiration sonorous; voice harsh; cough'ringing; great restlessness; terminating in a few days. (6 Chronica. Sense of suffocation obtuse and heavy; chiefly Chronic croup. seated in the chest; cough severe,but in- Bronchial polypus, termitting; extending to some weeks or months. The disease, in both varieties, usually commences with the com- mon symptoms of a cough or catarrh; but essentially consists in a peculiar inflammation that spreads through different parts or even the whole range of the windpipe, from the larynx to the minutest ramifications of the bronchise. In this extensive sense, the tube was called bronchus by the ancients ; and I have hence preferred the term bronchitis to that of trachitis, or inflammation of the trachea, as such a term would imply a limitation of the inflammatory action to the upper part of the bronchus alone, to which it is not confined in either of the varieties before us. Bronchitis has indeed been ap- plied by Dr. Badham to a catarrhal inflammation of the bronchial membrane, but it would be better, perhaps, to regard this last af- fection as a variety of catarrh, than to treat of it as a distinct species under a distinct name. The first variety, importing the common or acute croup, the suf- focatio stridula of Dr. Home, who has the merit of having earliest called the attention of medical practitioners to it as a distinct dis- ease, though it extends thus widely, usually commences in the larger parts of the tube; during which a peculiar effusion is secreted, that readily assumes a membranous form, and lines, not only the trachea above itsdevarication, but also its minutest branches, though vol. ii.—30 234 H.&MAT1CA. [CL. HI.—OR. II. the larger parts of the tube are first affected. When chemically examined, the secretion appears to consist chiefly, if not entirely, of the gluten, or coagulable lymph of the blood, diluted with its sero- sity, and copiously combined with that peculiar substance of the blood, detected by the labours of modern chemistry, which, from its essential tendency to concrete into a fibrous, and even a membra- nous texture, has received the name of fibrin. By what means the mucous secernents throw forth this peculiar effusion on this peculiar occasion we know not. It is said by some writers to be secreted on no other occasion, and by no other.organ; but this is unquestionably a mistake. There are few practitioners, perhaps, of accurate observation, who have not found it discharged at times from the intestinal canal; of which I have already given examples under diarrhoea tubularis ; in which, as in croup, there is an inflammatory affection of the morbid organ, and a spasmodic constriction of the passage. In reality the effusion, distinct from the inflammation that gives rise to it, is not essentially different in its principles from what oc- curs in genuine polypus, or that of the nostrils, and those polypous concretions which are often to be found in other cavities : and hence Dr. Michaelis and some other writers have given to the disease the name of angina polyposa :* a term, however, inconvenient, and, in- deed, inaccurate, since angina, as commonly understood, imports in- flammation of the fauces accompanied with difficulty of swallowing, neither of which are necessary or even accidental symptoms of bron- chitis. This disease appears in the present clay to exist in most parts of the world, and in the American states is called hives, supposed by my distinguished friend Dr. Hosack to be a corruption of the term heaves, and probably so named from the heaving or violent efforts of the muscles of the chest and abdomen which take place in breathing during its course. It is hence extremely singular that till within the last century it should either not have had any existence or not have been definitively noticed or described by medical writers : for Dr. Cullen appears to be perfectly correct in referring to Dr. Home as the first person who has given any distinct account of it.f It is also not a little singular that children should be chiefly sub- ject to its attack, at whose age fibrin is not peculiarly abundant, and whose blood contains comparatively but a small proportion of azote, which in fibrin is so large a constituent. These are among the ma- ny curiosities which the prying eye of physiology has yet to follow up: and much has it to accomplish before it will be able to explain them. Dr. Cullen asserts that acute croup seldom attacks infants till af- ter they have been weaned; and that there is no instance of its oc- curring in children above twelve years of age. As a general rule * De Anguina polyposa. Auctpre Christ. Fred. Michaelis. 12mo. Argentor. 1779. f De Suffocatione stridula. GE. VII.—SP. VI.] SANGUINEOUS FUNCTION. 235 this remark holds, but the disorder has been found occasionally in persons considerably above twelve years of age. Those who have once had it are more susceptible of it than before ; though the sus- ceptibility gradually wears off as they grow older. It is found equally in midland regions and on the coast: but perhaps more fre- quently in low, marshy grounds, than in drier uplands. There is no unequivocal instance of its being contagious, though it seems to have been occasionally epidemic. It commences usually with a slight cough, hoarsness, and sneez- ing, as though the patient had caught cold and was about to suffer from a catarrh. And to these, in a day or two, succeed a peculiar shrillness and singing of the voice, as if the sound were sent through a brazen tube. At the same time, says Dr. Cullen, who has well described the progress of the disease, " There is a sense of pain about the larynx, some difficulty of respiration, with a whizzing sound in inspiration, as if the passage of the air were straitened. The cough which attends itis sometimes dry; and if any thing be spit up, it is a matter of a purulent appearance, and sometimes films resembling portions of a membrane. Together with these symp- toms, there is a frequency of pulse, a restlessness, and an uneasy sense of heat. When the internal fauces are viewed they are some- times without any appearance of inflammation; but frequently a redness, and even swelling appear: and sometimes in the fauces there is an appearance of matter like to that rejected by coughing. With the symptoms now described, and particularly with great dif- ficulty of breathing, and a sense.of strangling in the fauces, the pa- tient is sometimes suddenly cut off."* To which I may add that the countenance exhibits great distress; the head and face are co- vered with perspiration from the violence of the struggle; the lips and cheeks are alternately pale and livid. The essence of croup consists in the secretion of this viscid and concrete lining, which is perpetually endangering suffocation. Dr. Cullen does not dwell sufficiently upon this symptom ; but ascribes this danger principally to spasmodic action, and represent the ac- companying fever, which, on his hypothesis, is also a spasmodic ac- tion, to be very considerable; but spasm was with him, as we have already seen, a favourite doctrine, and his judgment was often warped by it. Dr. Marcus of Bamberg in Bavaria, who regards all fevers as inflammation of some organ or other, and as entirely seat- ed in the arterial system, regards croup also as a local inflammation alone, utterly independent of spasm, which neither exists here, nor in fevers of any kind: and attributes the danger to this symptom solely. That there is some degree of spasmodic action, however, as well as of fever, is unquestionable, though neither are very con- siderable ; and the locality of the disease as well as the peculiar character of the inflammation, sufficiently distinguish it from ca- tarrh, in which there is also some inflammation of the mucous mem- • Pract. of Phys, CCCXXIV. %36 HiEMATICA. [CL. HI.—OR. tl brane of the trachea, though of a common kind, and rarely limited to this organ. In children, however, it frequently treads close upon catarrh, measles, hooping-cough, and any other disease that has de- bilitated the powers of the lungs : for as Dr. Michaelis observes, whatever lends to weaken or produce any degree of irritation in the lungs, so as to occasion a preternatural secretion into that or- gan, may be considered as a predisposing cause of croup. The cure demands a prompt and active attention ; and must de- pend not so much upon searching into and correcting the remote cause, or even counteracting the spasm, as in counteracting and re- moving the membraneous secretion, which is every moment in dan- ger of producing suffocation ; and especially in children, in whom the natural aperture of the glottis is much smaller in proportion than in adolescents; and occasionally not more than a line and a half in breadth. There is in the patient a perpetual effort to remove this solid se- cretion by coughing; but the cough is for the most part dry and in- effectual, and nothing more than a little flaky mucus is excreted. Very copious bleeding* at the commencement of the attack, by breaking abruptly upon the inflammatory action, has sometimes car- ried off the disease at once. This M. Fieliz recommends from the jugular veins,t and M. Ghisi by topical scarifications; but leeches will usually be found to answer best in infancy. Emetics have afterwards been tried, but with doubtful success: sinapisms*, and blisters^ with as little. The inhalation of warm vapour, recom- mended by Dr. Home, can rarely be practised from the extreme restlessness of the little patient; and the remedy principally relied upon in the present day, and which certainly seems in many instan- ces to have operated like a charm, is large and repeated doses of ca- lomel; of this not less than five or six grains are commonly given to very young children, and continued every two or three hours till there is a discharge of a green bilious matter, which seems to be the criterion of its having taken effect, and broken down the thicker part of the blood, from which the membranous secretion is princi- pally furnished. If this should not succeed, Dr Michaelis recom- mends tracheotomy, and has so little apprehension of its being at- tended with danger, that he advises it to be had recourse to soon after the attack, as affording a convenient opportunity of bringing away the preternatural membrane which serves as a lining to the trachea.|| But this advice is given with more courage than judg- ment. Whenever performed it should be after every other remedy has failed, and not before any other has been attempted. * Michaelis. Richter's Chir. Bibl. v. B. p. 739. f Fieliz. Richter's Chir. Bibl. VHI. B. p. 531. i Fieliz, 1. c. § Inquiry into the nature, &c. of the Croup. U De Angina polyposa, &c. ut supra, GE. VII.—SP.VL] SANGUINEOUS FUNCTION. 237 Under the genus laryngismus belonging to the second order of the preceding class, I have observed that the spasmodic affection there described, from its inducing a sense of suffocation, and possessing various other symptoms resembling those of croup, has often been mistaken for this last complaint, and been denominated spasmodic croup ; though without the pathognomic sign of a membrane-like exudation, and for the most part without any inflammation whatever. It attacks children suddenly, most frequently in the night, and is apt to return in paroxysms, with short intervals of ease : whilst the real acute croup has no intervals, but continues its alarming course till it destroys the patient or yields to the means made use of. During the action of the spasm, however, there is a considerable hoarseness and shrillness in the voice, and, from the struggle, a profuse perspi- ration about the head and face. Violent as these symptoms are, they commonly yield to a brisk antimonial emetic : after the operation of which, the patient commonly falls into a sound sleep, and awakes with little remains of the complaint. The second or chronic variety of bronchitis, I have introduced chiefly on the high authority of Dr. Warren, who calls it, as I have already observed, a bronchial polypus ; a term which, as it often has done, may lead to mistakes; and which, in its application to anv other part of the body, does not import the febrile action which exists as a characteristic of this disease. A concrete parenchyma- tous material, obstructing the bronchial vessels, coughed up in smaller- or larger masses, sometimes easily and without any attach- ment to the sides of the bronchial tubes, and sometimes so exten- sively inoculated by radicles or radiating vessels, as to produce a fatal hemorrhage on their being thrown up with violence, has been noticed from a very early period in the history of medicine to the present day. Bartholine, Tulpius, Ruysch, Gretz, and Mor- gagni, have all been appealed to as giving examples of this affec- tion ; and it is very possible that even Hippocrates may allude to something of the kind in the case of Pherecydes who, he tells us, was accustomed to bring up from his lungs in a fit of coughing, yxXxwrohx, " white milky concretions,;" and at length before he died ciev tx. ftvfyq (jlvkvitx, %vveix.oTx, Xevxa pXey/uMTt weeie^o^evx, "firm mucus-like excrescences, surrounded with white phlegm."* But the complaint does not seem to have been distinctly described, till Dr. Warren's history of it in the Transactions of the College.f The case by which he chiefly illustrates it, and which is here chiefly alluded to, is that of a young lady eight years of age, of a strumous habit, who was suddenly attacked with a difficulty of breathing, attended with a short, dry, and almost incessant cough ; but without any pain in the side or chest. The symptoms diminish- ed in the ensuing night, and the complaint appears to have been productive of little inconvenience for six weeks ; when it returned • De Morb. Popular. Lib. VII. Sect. xli. t Vol. I. Art. XVI. 238 HJEMATICA. [CL. III.—OR. U. wit h additional severity, with costive bowels, a white but moist tongue, and a pulse too quick to be counted. Bleeding, purgatives, and the oxymel of squills relieved her, but the breathing was still laborious; she had wasting night sweats, and the pulse beat from a hundred to a hundred and twenty strokes in a minute for the ensuing twelve days, at the close of which period, §he woke sud- denly in the night and was almost choked in bringing up, by cough- ing, what Dr. Warren calls " a large polypous concretion." It came up without either blood or mucus, and instantly gave her great relief. For two months afterwards she seldom passed three days without coughing up masses of the same kind, but none so large; she was tolerably easy when sitting still or in motion in the open air; and though her pulse never beat less than a hundred and twenty strokes in a minute, she had a good appetite, gained some degree of strength and flesh, and entirely lost her night-sweats. She was now suddenly attacked at night with another paroxysm of distressful breathing, and a sense of suffocation, and in the morning threw up a larger membranous concretion than at any time antece- dently, and in the course of the four ensuing days, a quantity quite as large as in the six preceding weeks. From this time the op- pression on the lungs returned irregularly after intervals of five, eight, ten, or twenty days, always followed and always relieved by an expuition of the same concrete material; till at the close of a twelvemonth from the first attack, the patient complained of a pain in the right heel, an abscess formed there, and the os calcis was found carious. From this time the bronchial affection ceased, the breathing was perfectly free, and no more concretion was at any time thrown up. Dr. Warren conceived this concrete substance to have been an inspissated matter secreted by the mucous glands of the bronchial vessels. But the existence of fibrin, as a constituent part of the blood, was unknown at the period in which he wrote ; and his plates and description of the membranous matter expectorated show evidently, that, like that discharged in croup, and often from the intestinal canal, it was composed of this formative element inter- mixed with gluten, secreted in layers, and affecting a tubular struc- ture. " Some of these polypi" says he, " are of a much firmer texture than others, and bear shaking in water without breaking to pieces, others are so tender that a very gentle motion in water breaks off' a great many of their smaller branches. They are solid, composed of laminae, which are easily separated from each other, and are manifestly of a texture less and less firm as you ap- proach the centre or axis, which consists of a white pappy mucus as thick as cream. I observed one, about the size of a quill, which was tubular. It seemed to consist of a few lamellae only." In connexion with the plan of treatment already pointed out, it is highly probable that much benefit might, in this chronic form of bronchitis, be derived from the use of mercury and foX-gtove. And as a natural cure was obtained by a metastasis, or a morbid GE. VII.—SP. VI.] SANGUINEOUS FUNCTION. 239 action excited in a remote organ, we have a strong invitation to follow in a like path ; and should endeavour to obtain a like bene- ficial result by the use of seatons or caustics. SPECIES VII. EMPRESMA PNEUMONITIS. fterfuueumoug. INFLAMMATION OF THE LUNGS; OBTUSE PAIN IN THE CHEST; CON- STANT DIFFICULTY OF RESPIRATION, ALLEVIATED BY AN ERECT POSITION ; TUMID, PURPLE FACE OR LIPS J COUGH, GENERALLY MOIST, OFTEN BLOODY; PULSE USUALLY SOFT. Inflammation of the lungs has been described under so many names that it is scarcely worth while to give a list of them. The most common perhaps is peripneumonia, for which pneumonitis, em- ployed first, I believe, by Bourgard in his Dissertation published in 1754, is here substituted merely on account of the regularity of its termination. The disease as above characterized, is traced under the three following varieties:— « Vera. Fever a cauma ; pain severe, little True Peripneumony. expectoration in the beginning. P Maligna. Fever a synochus or typhus; the Malignant Peripneumony. debility extreme from an early period. Often epidemic. 7 Notha. Great secretion and expectoration Spurious Peripneumony. with a mild cauma. Occurring in weakly habits, and often con- nected with a catarrh. The first of these varieties, or true peripneumony, is, perhaps, the most common, and has been more generally treated of than the rest. Dr. Cullen has united inflammation of the parenchyma of the lungs, which is here alone contemplated, with inflammation of their membranes ; as believing that we have no means of ascertaining a difference from the course or concomitancy of the symptoms. It may be observed, however, that in pleurisy the face is compara- tively but little flushed, and far less tumid; that the pulse is harder; the cough less violent, and, from the beginning to the end, without expectoration; the seat of pain also is here fixed: while in peripneu- mony, it shifts not only to different parts of the same side, but often from the one side to the other; and, when the lower part of the 240 ILEMATICA. [CL. HI.—OR. n right lung is affected, is communicated to the liver, occasioning an uneasiness in the right hypochondrium, and accompanied with a yellow and copious expectoration. It is most commonly the case, however, that some degree of pleurisy accompanies pneumonitis from continuous sympathy ;* but then it is not idiopathic pleurisy, nor strictly possessed of its symptoms. Inflammation of the substance of the lungs bears nearly the same relation to pleurisy or inflammation of the membrane that lines it, as profound or parenchymatous cephalitis bears to meningic. The two former, however, are somewhat more distinct and less liable to run into each other than the two latter, because one half the pleura, from its duplicature, is more remotely situated from the lungs and less connected with them. And I have hence followed the ordinary division, and treated of pneumonitis and pleuritis as distinct species, rather than varieties of one common species, which is the view taken of meningic and profound cephalitis. In both sets of disease, however, the membranous is the more acute affec- tion, evinces more violent and painful symptoms, and runs through its course more rapidly. And hence, in pneumonitis, as in meningic phrensy, the pulse is sometimes soft,t the fever small,| and the pro- gress protracted occasionally to twenty days or more.§ The causes of true peripneumony are those of inflammation in general; particularly excessive exertion of, the lungs, or cold, applied when the system is generally heated, to the skin, mouth, or stomach. It attacks the robust and plethoric more frequently than the spare and delicate; and appears most frequently in cold weather, or sudden changes from hot to cold. Repelled eruptions have probably sometimes proved a cause ; and noxious exhalations cer- tainly. To the last we may refer the frequency of this disease in the outskirts of Mount Vesuvius, as remarked by Vivenzi;|| and on this account it is described by Baroniusl and Bovillet,** as ende- mic. The first symptoms also are those of inflammation in general; but there is usually more shivering, or cold fit, and the hot stage is proportionally violent; the head aches considerably, and the urine is high-coloured. The pain in the chest is rarely felt in any oppres- sive degree till these symptoms have continued for a day or two: though sometimes it is coetaneous. The cough is short, peculiarly distressing, and obstinate. The pulse is variable, in some cases hard and strong, in some soft or oppressed ; but with the advance of the disease, it becomes feeble, sometimes fluttering. Delirium * Morgagn. De Sed. et Caus. Morb. Ep. XXI. Art. 13,14. 37. f De Cabalis, Phxnom. Med. * Cleghorn. p. 262. § Stoll, Rat. Med. Part II. p. 376. Act. Nat. Cur. Vol. V. Obs. 124. || Epist. ad Haller. iv. •J Pleuropneumonia Ann. 1633. Flaminiam infestante. Fidi. 1536. ** Memoires sur les Pleuropneumonies epidemiques, p. 556. GE. VII.—SP. VH.] SANGUINEOUS FUNCTION. 241 is an occasional accompaniment, and is a highly dangerous symptom, except where it alternates with the pneumonic symptoms, in which case it augurs well. In favourable terminations the violence of the disease diminishes on or before the seventh day : if it increase beyond this, it commonly proves fatal. Peripneumony, like other inflammations, terminates in effusion, suppuration, or gangrene ; and it has also a termination peculiar to itself, which is that of hemorrhage from an increased vis a tergo. The most salutary mode is effusion, for the vessels hereby become relieved, and the secernents immediately add to the relief by com- mencing an increased action, and consequently an increased dis- charge of mucus. In consequence of effusion, however, we occa- sionally find adhesions take place between the lungs and the pleura ; and sometimes a collection of water in different parts of the chest; and not unfrequently a flow of blood, apparently from the mouths of the exhalants without any rupture of vessels, giving a bloody tinge to the sputum. This last has been often regarded as an alarming symptom, but the alarm is altogether unfounded, for it generally affords considerable relief. Indeed an hemorrhage itself from the lungs has not always been attended with fatal consequen- ces : it has occasionally proved critical, and carried off the disease in a few days: though a hemorrhage from the nose, no unusual at- tendant, is lar preferable, as producing a like benefit with less risk. If the inflammation run into suppuration, the change is generally indicated by shiverings, with a remission of pain, and sometimes perspiration where there has been none before. If gangrene en- sue, the pulse sinks, the debility rapidly increases, an'd the eyes are fixed with a ghastly stare. The best, the easiest, and even the natural cUre of peripneumo- ny is expectoration ; which, hence, ought to be excited, and en- couraged by all the means in our power. It forms the optima crisis ot Stoll, though, as he adds, a crisis too rarely obtained,* Bleed- ing, by giving some degree of freedom to the distended capillaries, affords one mean of accomplishing this object; but if the patient's strength be considerably reduced, the strength of the capillaries will be reduced also, and they will be too debilitated for the in- creased action. It is, hence, necessary to measure the general habit and constitution of the patient, as also the situation in which he resides; for if he be in an open and mountainous region, and ad- dicted to the pursuits of a country life, he wjll bear bleeding far more readily and freely than if he be the inhabitant of a crowded city, or accustomed to a sedentary life. In this case the bleeding should be prompt and copious, at least to eighteen or twenty ounces, and repeated twelve hours after if necessary ; and as the disease occurs chiefly in robust constitutions, it is rarely that venesection can be dispensed with. The chief evil is that the fever is apt, at times, to run into a typhous form, vol. ii.—31 • Rat. Med. III. 53. 242 HiEMATlCA. [CL. III.-OR. It. and assume the second of the varieties before us. And hence, where there is any doubt upon the subject, local bleeding is to be preferred, whether by leeches or cupping glasses, repeated accord- ing as the evacuation appears to be demanded. Laxatives and re- frigerants are next employed with the same general view of taking off" the entony of the arterial system. One of'he most common, and, at the same time, most useful refrigerants, is nitre ; which may be combined with the citrate of potash, or made to produce a more certain determination to the skin by the addition of camphor or of antimonial wine, or by a combination with the citrate or ace- tate of ammonia. Emetics have seldom been given except in an early stage of the disease, and then only as a gentle puke ; yet, from my own prac- tice, I can recommend them when the disease has made a consider- able advance : but they must be used boldly, or so as to produce full vomiting, and the action of vomiting must be maintained for an hour, or even two : and ,in this way they will often produce a transfer of action of as beneficial a nature as the same process is found to do in purulent ophthalmy ; and will, at the same time, peculiarly stimulate the exhalants of the lungs to an increased se- cretion of mucus. Blisters, as is the common practice, ought to form a concomitant in the general plan ; and the obstinacy of the cough may be alleviated by demulcents^or inhaling the steam of warm water. Opiates have been tried in every form, but have never been found of decisive benefit: if opium be used at all it should be in conjunction with gum ammoniac, or squills : but, upon the whole, either of these expectorants seem to answer best with- out opium. Dr. Saunders recommended the extract of the white poppy ; and that of the garden-lettuce has since been tried upon the recommendation of Dr. Duncan ; others may have been more fortunate than myself, but, in my hands, both have proved alto- gether insignificant in their effects. If the disease proceed favourably the pulse becomes slower and softer : the yellow tenacious, and perhaps bloody sputum, is mixed with points of a whiter matter, which increases with the amend- ment of every other symptom ; for the cough is less violent and straining, the breathing freer, the skin moister, and the tongue cleaner at the edges. If the progress be less favourable, the ex- pectoration becomes darker and more viscid ; the pulse lower, in- distinct, and often intermitting; a low, wandering delirium super- venes, with subsultus ; and the patient dies, apparently suffocated from the oppressed vessels no longer permitting an expansion of the lungs. When a salutary expectoration has commenced, it sometimes ceases suddenly from some unknown cause, or some irregularity in the mode of treatment. This symptom is alarming; and every means should be instantly taken to bring the discharge back; such, particularly, as increased doses of the expectorants already noticed, to which may be added the steam of vinegar, alone, or impregnat- GE. VII.—SP. VH.] SANGUINEOUS FUNCTION, 243 ed with the essential oil of aromatic plants, as rosemary. And if a diarrhoea, which sometimes proves a very distressing concomitant, should supervene, it will be best relieved by the pulvis cretae comp. cum opio. Inflammation of the lungs is, also, occasionally found as a symp- tom or sequel in rheumatism, lyssa, or canine madness, various ex- anthems, as small-pox, measles, miliaria, and commonly in phthisis; in which last it has a very frequent tendency to suppuration, as we shall have to notice when treating of this distressing complaint. The malignant peripneumony, contrary to the true or common inflammatory affection, is generally an epidemic, and may be easi- est explained by describing it as an epidemic synochus or typhus* occurring in such situations, at such seasons of the year, or in such a temperament of the atmosphere as has a tendency to excite inflammation of the lungs. The debility is often so extreme from an early stage of the disease, that the pulse ceases on the pres- sure of the finger; and the vascular action is too weak to ac- complish expectoration. It is supposed by many writers, and especially by Sarcone and Ludwig, to be a pulmonic erysipelas, by which they mean an erysipelatous erythema: and they are probably right in their conjecture. Whence Planchon regards erysipelas as its proximate cause.t The symptoms are those already de- scribed, with a great addition of sensorial debility and conse- quently with increased lajjoriousness of respiration. The disease is usually fatal on the fourth or fifth day; and if the system be in- cautiously lowered by venesection or a laxative of too much power, it often takes place earlier; and has sometimes occurred within twenty-four hours after bleeding. Our attention must here, therefore, be turned rather to the con- stitutional disease than to the local affection; and the plan recom- mended in typhus is to be pursued on the present occasion: for it will be in vain to attempt expectoration under circumstances in which the system will probably sink before the usual time arrives for affecting it. Camphor is here a medicine of considerable ser- vice, and may be used in conjunction with the aromatic confection, and wine in large quantities. It should be taken freely in the form of pills, rather than in that of julep: though both may be employ- ed conjointly. Even the bark has a powerful claim to be tried, and that too in as large quantities as in putrid fever; nor has it been found to produce difficulty of breathing. It may be advantageously combined with the aromatic spirit of ammonia, which of itself often proves a useful stimulus. If evacuations be necessary they should be obtained by injections alone. A light breathing perspiration, a free expuition,and a more animated appearance of the countenance, are among the most favourable diagnostics. * Pelargus, Medicinische Jahrgange I. i. p. 44. Tissot. sur l'Epidemie en Lausanne, &c. t Journ. de Med. Tom. XLVI. p. 24. 244 TLLMATICA. [CL. HI.—OR. II. The spurious or bastard peripneumony is usually allowed to of- fer another variety of this disease; and is described under the narne of peripneumonia notha by Boerhaave, Coze, and Sydenham. It is, in many instances, little more than a severe catarrhal affection of the lungs accompanied with great obstruction, occurring in habits of a peculiar kind; and is hence denominated by many authors catarrhus suffocativus. It is characterized by great secretion and expectoration, with a mild cauma; and is chiefly found in those of advanced life, op who have weakened their constitution by ex- cesses. Sydenham, however, has properly distinguished this malady from catarrh, notwithstanding the close resemblance it bears to it on particular occasions. The following is his description of the dis- ease :—The patient is hot and cold alternately, feels giddy, and complains of an acute pain in the head, especially when there is a teazing cough. He rejects all fluids, sometimes from paroxysms of coughing, and sometimes without: the urine is turbid, and of a deep red; the blood appears as in pleurisy. The patient breathes quick and with difficulty: complains of a general pain throughout the entire breast, and as he coughs discovers a wheezing to the attendants. The cheeks and eyes appear slightly inflamed; the pulse is small, often intermitting; and lying low, or on one side, is peculiarly distressing. As the fever is here of no great moment, we may, with consider- able advantage, carry our local stimulants to a greater extent, and thus excite the lungs more actively to throw off the burden of mucus with which they are overpowered. Squills, gum ammoniac, balsam of Peru, and even some of the turpentines, may be tried and will mostly be found serviceable. The tetradynamia, as char- lock, wild-rocket, and mustards of various sorts; and the alliaceous plants will form useful auxiliaries in the plan of diet. Blistering is highly serviceable; after which, as soon as the chest is a little un- loaded, a regimen directly tonic should be commenced, by means of bitters, chalybeate waters, a moderate portion of wine, gentle exercise, pure air, and the irritation of an issue or seton; for a common result of this disease is hydrothorax from atony of the ab- sorbents of the chest. And hence, perhaps, more frequently fall a sacrifice to some sequel of the disease than to the disease itself. GE. VII.—SP. VIIL] SANGUINEOUS FUNCTION. 245 SPECIES VIII. EMPRESMA PLEURITIS. Jllcurfeg. ACUTE PAIN IN THE CHEST, INCREASED DURING INSPIRATION; DIFFICULTY OF LYING ON ONE SIDE; PULSE HARD; SHORT, DRY, DISTRESSING COUGH. As the proper seat of the preceding species is in the substance of the lungs, or the pleuritic membrane that immediately lines its surface, or in both, the proper seat of the present is in the sur- rounding membranes of the pleura ; and as these differ, the differ- ence has laid some foundation for several varieties ; of which the three following may be noticed, as matter of curiosity, though the subdivisions lead to nothing of practical importance, as the causes are nearly alike, and the same mode of treatment is applicable to the whole. * Vera. Fever a cauma: pain felt chiefly on one True Pleurisy. side: the inflammation commencing in that part of the pleura which lines the ribs. £ Mediastina. Heavy pain in the middle of the ster- Pleurisy of the num, descending towards its ensiform mediastinum. cartilage ; with great anxiety ; the in- flammation, from its symptoms being obviously seated in the mediastinum. y Diaphragmatica. Painful constriction around the praecor- Pleurisy of the dia ; small, quick, laborious breath- diaphragm, ing : manifesting that the inflamma- tion is seated chiefly in the dia- phragm. We have already pointed out the distinction between true pleurisy and peripneumony; and observed that in the former the cough is dry and commonly without expectoration from the beginning to the end, contrary to what occurs in the latter ; that the seat of pain is fixt, instead of shifting from side to side ; and that the face is far less flushed and tumid. It must be conceded, however, to Dr. Cul- len, who has treated of these affections under one common defini- tion, that the general features of the two have a considerable re- semblance ; and, with the exception of expectorants, which in pleurisy are of little avail, the mode of treatment already proposed for the former disease, is the same that will be found necessary in the latter : the causes of both are alike, and as peripneumony rare- ly, though we have reason to believe sometimes, occurs without any 24b' HJEMATICA. [CL. HI.—OR. II. degree of pleurisy, so it is commonly affirmed that pleurisy rarely occurs without some degree of peripneumony ; in both which cases it has been called a pleuro-peripneumonia. Like the latter we also find the former an occasional symptom or result of typhus, catarrh, rheumatism, and various exanthems. The pleurisy, however, that is supposed to accompany rheumatism, is often an inflammatory af- fection of the intercostal or other thoracic muscles alone, since the pain is confineo to the origin and insertion of the muscles. Where this has been accurately attended to it has been distinguished'by the name of bastard pleurisy. Like the preceding species, true pleurisy commences with the usual signs of a febrile attack, as chilliness or shivering, succeeded by heat and restlessness. The pain is usually just above the short ribs, and, as already observed, the expirations are less painful than the inspirations. The pulse is hard, strong, and frequent; and though the cough is mostly dry and supprest, there is sometimes a bloody or puriform mucus spit up from the lungs, evidently proving that the substance of the lungs has participated in the inflammatory action. Like the preceding species also, pleurisy terminates in resolu- tion, suppuration, and gangrene. The former is the ordinary and most favourable issue. The last occurs rarely ; but suppuration is by no means uncommon; in which case, if the abscess do not point outwardly, an empyema will necessarily follow ; and the formation of pus is indicated by a remission of the pain, one or more shiver- ing fits, and, in some instances, a sense of fluctuation. This, how- ever, is a termination far more common to pleusiry from external injuries, than from internal causes. In the treatment of pleurisy, as we have no advantage to expect from expuition, we may employ bleeding far more extensively, and with far less caution than in peripneumony. Perhaps there is no disease in which profuse bleeding from a large orifice may be so fully depended upon, or has been so gene- rally acceded to by practitioners of all ages and all nations. The only question which has ever arisen upon the subject being, whe- ther the blood should be taken from the side affected or from the op- posite. The earlier Greeks recommended the former, the Galenists and Arabians, the latter ; and the dispute at one time rose so high that the medical colleges themselves, not being able to determine the point, the authority of the emperor Charles IX. was whimsical- ly appealed to ; who, with much confusion to the controversy, died himself of a pleurisy before he had delivered his judgment. He too had been bled, and his death was immediately ascribed to the blood having been drawn from the wrong side. At present from a knowledge of the circulation of the blood, we can smile at these nugatory solemnities. It is possible, however, that there are some controversies of our own times, that have as little ground-work, and at which future ages may smile with as much reason. With these exceptions the treatment of peripneumony and pleuri- GE. VIL—SP. VIIL] SANGUINEOUS FUNCTION. 247 sy should run parallel. Purgatives should be used freely ; blistering the side is very generally beneficial after bleeding has been tried and repeated, and should be accompanied with diluents and dia- phoretics. Opium may also be employed with less caution than in peripneumony. And where we have reason to suspect suppuration, warm cataplasms should be applied to the part to solicit an external opening. If the abscess break internally it must be followed by the operation for an empyema. The heart and pericardium are sometimes apt to associate in the morbid action, as well as the lungs themselves. This is particularly the case in the second variety. Dr. Perceval, in his manuscript commentary on the Nosology, has given me a striking example of this in a patient who complained of excruciating pain in the region of the heart with dyspnoea, not at all relieved by copious and re- peated bleedings. After death a slight effusion was discovered in the pericardium: but the mediastinum was more inflamed than the membrane of the heart. The treatment of this variety ought not to differ from that of the preceding. The cerebrum is, however, still more disposed to associate in the morbid chain of action than in the heart. And hence, when any of the varieties of pleurilis, and particularly the last, are combined with an affection of this organ, and produce delirium, the disorder was formerly distinguished by the' terms paraphrenesis, and para- phrenias ; terms derived apparently from the peripatetic philosophy, which supposed the seat of the ^sj», or soul, to be the praecordia; whence this region was denominated m the Cronica Meteorologica Toscana of 1323, by Targioni Tozzettilo Saillant'sTableau desEpidemicscatarrhales. " In all these instances," says he, " the phaenomena have been much the same ; and the disease has always been particularly remarkable in this, that it has been the most widely and generally spreading epidemic known. It has seldom appeared in any one country of Europe, without appearing successively in every other part of it." And, in some instances, the infection has passed the Atlantic with little or no remission of its severity, and attacked Americans, who had not had the slightest intercourse with Europeans. And hence we are capable of tracing it at sea as well as on land. In the epidemy of 1782, Lord Anson sailed in the month of May with a fleet for the Dutch coast; and Admiral Kempenfelt for that of France. The crews of both fleets were well on sailing: but in the same month both were attacked very generally, and the latter was obliged to return home. The previous state of the air, with respect to any of the sensible qualities of heat, cold, electricity, or damp, seem to have exercised but little power. Influenzas have recurred at every different season, in every state of the barometer, thermometer, and hygrometer. Thus the influenza of 1762, one of the severest on record, pro- ducing effects which continued, in many instances, for two or three years aftenvards, was preceded by weather uncommonly warm ; while in that of 1767, being the next in rotation Avhich was also very severe though productive of less durable mischief to the con- stitution, the Aveather was remarkable for being unusually cold4 We know nothing of the country from which the disease has at any time taken its rise; but it has frequently seemed to proceed from north to south, though it has occasionally travelled from west to east. That of 1781 and 1782 is said to have originated in China, and to have travelled through Asia into Europe; Avhence it crossed * Med. Trans. Vol. IU. p. 56. fMem. Med. Soc. of Lond. ut supra. t Dr. Heberden, Med. Transact. I. Art. XVni. GE. IX.—SP. II.] SANGUINEOUS FUNCTION. 299 the Atlantic, and arrived the ensuing year in America. But this assertion wants confirmation. ' If Ave allow its materies to depend upon specific miasm floating in the atmosphere, we can only ac- count for its preserving its agency so long, and operating in such distant theatres, by supposing that its particles are with great diffi- culty dissolved or decomposed in the air, even when in its purest state or higest degree of agitation by tempests. Of the specific miasms Ave are a little acquainted with, some seem to dissolve or lose their power much more readily than others, and hence spread their in- fluence through very confined peripheries; while others are only dissoluble in a pure atmosphere, and consequently retain all their virulence in an air already saturated with other foreign elements: properties which the author has already endeavoured to exemplify and illustrate in the inquiry into the Remote Cause of Fever.* The chief influenzas that have visited Europe within the last three centuries, occurred in the following order of time: 1510; 1557; 1580; 1587; 1591; 1675; 1709; 1732-3; 1743; 1762; 1767; 1775; 1781 and 1782: since which period ihe^return of the disease has been little noticed in respect to extent or violence. The remedial treatment need not detain us long, notwithstanding the violence with which the disease makes its assault. Bleeding, as Ave have already observed, is rarely required, and, from the de- bility so soon induced, should be avoided, except in urgent pleuritic pains, Avhich are not common. It was tried copiously by many practitioners in 1782, but they soon reverted to the cautionary track of Sydenham. Quiet, diluent drinks, and the promotion of that easy breathing perspiratiori which Chenot has distinguished by the name of dipnoe, will usually be found sufficient, if the bowels be kept free from confinement. If the chest be much loaded, an emetic will af- ford the best relief. And if the cough be troublesome, and the breathing laborious, both Avhich, however, are generally alleviated by an emetic, small doses of ipecacuan, with or without oxymel of squills, will promote an easy expectoration, and take off the sense of oppression. Dr. Cullen joined these with opium, and was particu- larly attached to the use of Dover's poAvder in all catarrhal affec- tions, asserting that there is no disease in which opium has been found more useful.f But it generally agrees better in common ca- tarrhs than in influenza. The subsequent debility may be removed by a free use of the bark, gentle exercise, pure air, cold bathing, and a liberal regimen: which last, indeed, should be continued through the disease itself. The cough occasionally produced, re- mains sometimes as a sequel, long after the other symptoms have disappeared: and, in this case, opium with camphor, or the resi- nous balsams,often affords essential relief, and especially at night; yet it has not been found that even the symptom of a cough has proved any impediment to the use of the bark, or even to that of • Vol. II. p. 53. t Mat. Med. Part II. Ch. VI. 300 HJEMATICA. [CL. HI.—OR. II. cold bathing, or been augmented by the practice, as influenza has rarely terminated in phthisis; and according to Dr. Carmichael Smith, is less disposed to produce this complaint than a common catarrh. GENUS X. DYSENTERIA. Jigaenterg. Mocrtig iHtt):. INFLAMMATION OF THE MUCOUS MEMRBAHF. OF THE LARGER INTES- TINES ; GRIPING AND TENRSMUS ; FREQUENT AND OFTEN BLOODY DE- JECTIONS; THE FECF-S SELDOM DISCHARGED, AND IN SMALL QUANTI- TIES. From the mixed character of this malady there is some difficulty in fixing its exact place in a nosological classification. The severe local symptoms give it a close affinity to the enteric diseases; while the fever that is so general, though not a constant concomitant, of- ten most alarming from its violence and malignity, and frequently assuming a remittent character, seems to mark it for some order in the pyrectic class. There is also another discussion to which .dysentery has given rise and which has sometimes been conducted with considerable warmth. When it is accompanied with a high degree of fever, and a copious discharge of mucous, bloody, membranous, or filmy mat- ter, it is admitted on all hands to be contagious, though it has been debated whether the matter of contagion is thrown forth from the body of the sick, or from the putrescent recrements. But the grand question that has been agitated is, whether dysentery ever exists without contagion ? or, in other words, whether, when the disease exists without those virulent symptoms which are clearly indicative of contagion, it is entitled to the name of dysentery ? t)v. Cullen, who, if he did.not first start this controversy, has fol- lowed it up with a more peremptory opinion than perhaps any other Avriter, has contended for the negative of the question; and has hence not only arranged the disease under his class pyrexle, but generically distinguished it by the character of pyrexia contagio- sa : asserting in his Synopsis, that he has never met with more than one species; and still more distinctly in his First Lines, that " the disease is always contagious," and that the contagion is proba- bly at all times specific* Dr. Parr and Dr. Young make a nearer approach to the general * Part I. Book. V. Chap. II. Sect. MLXXV. GE. X.] SANGUINEOUS FUNCTION. 301 opinion of Dr. Cullen than any other nosologist I am acquainted with. They regard the disease as an inflammatory affection; but seem to differ from Dr Cullen in believing it tojbe essentially and at all times contagious: the former limiting himself to the expres- sion that it is generally so; the latter, that it is often so. The earlier nosologists, however, have laid little or no stress on either the pyrectic or the contagious character of the disease; and hence in Sauvages, Linneus, Vogel, Sagar, and Macbride, it occurs as a genus under the division, not of fevers but of fluxes, without any notice of fever or contagion except as a distinctive symptom in some of their species. * In these Circumstances Ave cannot do better than turn back our footsteps to the minute and accute description of Sydenham, and take him as our pole-star: under whose clear guidance Ave shall seldom fall into error, and whose view of the subject has best har- monized with Avhatever degree of practical information has fallen to my oAvn share. In the running comment to this disease, contain- ed in the volume of Nosology, I have endeavoured from a careful perusal of all his writings that relate to the subject, to give a brief summary of his history of dysentery, and the arrangement under which he had contemplated it from year to year; and as this sum- mary cannot well be further curtailed, I must beg leave to quote it as it is there written. " In the year 1662," says he, " cholera, dry gripes, or colic with- out stools (immania ventris tormina sine dejectionibus,) and dysen- tery, were very frequent. In the following autumn the last two dis- eases returned; and in the midst of their raging appeared a new kind of fever (novum febris genus) which accompanied both dis- eases, and not only seized those that were afflicted either with the one or the other, but even those that were free from each; resem- bling the fever that not unfrequently (non infrequenter) attended the two preceding diseases, and which was hence distinguished by the name of febris dysentcrica." Omitting the consideration of the tormina or gripes, we here meet with a brief account of, 1. simple dysentery, or without fever; 2. dysentery complicated with the fever that not unfrequently attend- ed it; and 3. a new fever resembling this last. And we also find that simple dysentery, or that without fever, may at times be epi- demic or contagious, as Avell as that with fever. The foregoing passage, however, forms only the opening of the first chapter. It is in the third that this admirable observer and excellent writer enters fully into a description of the epidemical dysentery of the period before us; in which he tells us, that in the course of the autumn of 1669 the dry gripes (ventris tormina sine dejectionibus) and dysenteries raged nearly equally; and that sometimes a fever accompanied them, and sometimes not:" febris nunc iis accessit nunc aberat. " At \imes," says he, " the dysente- ry commences with rigor and shivering, succeeded by a heat of the whole body, as is the case in fevers—but frequently there is no afi- 302 HiEMATICA. [CL. HI.—OR. H. pearance of fever, for the host of gripings take the lead, and the de- jections follow." He pursues his description of the simple dysente- ry, or that without fever, observing that in this species an excre- mentitiousstool is sometimes interposed without considerable pain; and then enters upon the species accompanied with fever. " In the mean time," says he," if the patient be in the vigour of life, or have been heated by cardiacs, a fever arises, his tongue is covered Avith a thick white mucus, and if he have been much heated, it is black and dry; there is great prostration of strength, exhaustion of spi- rits, and every symptom of an ill-conditioned fever." It is not necessary to pursue his description of this second species further. It must be obvious to every one, that, in the opinion of Sydenham, dysentery, as a genus, embraces at least two distinct species, both of which, at the period of his writing, were epidemic ; the one of a milder nature without fever, the other of a malignant nature with it. The former of these is often met with in private practice, of spo- radic origin,and without evincing any contagious character. The latter is perhaps, as Dr. Cullen asserts, at all times contagious. Since Avriting the above, the author has met with Dr. Harty's " Ob- servations on the Simple Dysentery and its Combinations, con- taining a revieAV of the most celebrated authors who have written on this subject:" in Avhich much of his own opinion is confirmed, and copiously illustrated. It is only necessary to observe further, that though there may be at times, no contagion, and little or no fever, there seems to be al- ways some degree of inflammation in the colon or rectum, occasion- ally perhaps extending higher; an inflammation of a peculiar kind, with a strong tendency, when violent, to run rapidly into a state of gangrene; but, when milder exciting that increased flow of mucus, Avhich is common to the inflammation of all mucous membranes, and which is especially conspicuous in ophthalmy and in catarrh. On this last account it appears to me that the proper nosological place for dysentery, as a genus is immediately after these two dis- eases ; though,from too close an adherence to the concurrent arrange- ment of the earlier nosologists, it will be found placed, in the phy- siological synopsis, under the order enterica of the class Cceliaca, a position which I now beg the reader to correct. The febris nova or dysenterica of Sydenham seems hardly enti- tled to consideration as a distinct species. It was the common epi- demy of the season, accompanied with or succeeded by a few of the slightest symptoms of dysentery, without the pathognomic evacua- tions. Putting this, therefore, out of the question, dysenteria, as contemplated by this great writer, and as confirmed by the general experience of the present day, seems to include .the two following species: 1. DYSENTERIA SIMPLEX. 2 - - PYRECTICA. SIMPLE DYSENTERY. DYSENTERIC FEVER. GE. X.—SF. I.] SANGUINEOUS FUNCTION. 303 SPECIES I. DYSENTERIA SIMPLEX. Stmjle Bgsenterg. FEVER SLIGHT OR UNPERCEIVED J THE FECES, WHEN DISCHARGED, EVACUATED WITHOUT CONSIDERABLE PAIN, OF A NATURAL QUALITY AND AFFORDING EASE. The atmospheric temperaments chiefly calculated to produce severe bowel complaints are those of summer and autumn ; when the liver is excited to a larger secretion of perhaps more pungent bile, from the greater heat of the weather ; the skin is exposed to more sud- den transitions from free to checked perspiration; and the exhala- tions that rise so abundantly from marshes and other swamps too often give an epidemic character to the atmosphere, and lay a foundation for intermittent and remittent fevers. We have here sufficient ground for local and general affection, and may readily see how it is possible, from the operation of one of these causes singly, or of two or all of them jointly on an irrita- ble state of the intestines, for all or any of the local symptoms to be produced Avhich enter into the generic or specific definition of the disease before us; as also how it is possible for these symptoms to be combined Avith fevers of various kinds and various degrees, so as to render the complaint peculiarly complicated and danger- ous ; though Ave have not yet been able to find out what are the precise causes that, operating locally, produce the distinctive symptoms of dysentery rather than those of diarrhoea; cholera, or any other irritation or spasmodic action of the intestinal canal. This may, perhaps, sometimes depend upon idiosyncrasy, some- times upon accident, and, in the severer cases, upon contagion or a specific miasm. The symptoms, hoAvever, already noticed sufficiently point out the general seat of the disease; the tormina or griping pains, the region most affected by them; and the costiveness or nodules of feces that are dejected, the existence of spasmodic constriction in or about the colon or the upper part of the large intestinss. And while such is the state of the canal above, the excessive straining or tenesmus, accompanied with a discharge of simple or bloody mucus, shows, as distinctly, the existence of great irritation in the sphincter and its vicinity. In some cases one of these parts is more affected, and in some another; and hence the origin of the dispute concern- ing the precise spot of the disease, which Stoll places altogether in the colon,* and other writers in the rectum ;t while Piso contends * Nat. Med. Part. IU. p. 294—826. t Cawley, Lond. Med Journ. 1786. 304 1LKMATICA. fCL. HI.—OR. H. that the liver is always affected, and indeed the organ principally concerned ;* reasoning from the bloody or atrabiliary dejections that are a symptom in the severer cases. That the irritation existing in the larger intestines may occasion- ally extend to the mouth of the hepatic duct, and produce a sym- pathetic excitement in the liver, is highly probable ; and indeed appears obvious from the increased fliw of bile, often of a keener colour, that sometimes accompanies the dejections, in the remis- sion of the spasmodic constrictions, and points out some alliance be- tween this disease and cholera; both which, as Sydenham has suffi- ciently shown, in certain seasons co-exist as epidemics. But a mere increased secretion of bile cannot readily be contemplated as the proximate cause of dysentery; for its u>.ual effect is to quicken the natural motion of the intestinal canal, and to produce looseness rather than constriction. How far any other irritant, as putrid vapours, crude fruits, or acrid food, accidentally introduced into the intestines when under a state of peculiar morbid sensibility, which it seems necessary to pre-suppose, is capable of exciting dysentery, may perhaps admit of a doubt; though we have no reason to conceive that any such irritants are a common cause. And still less can we concede to the hypothesis of the Linnean School, that the disease is produced by the larves of a species of tic or acarus, which the Swedish natu- ralist has too hastily introduced into his classification under the name of acarus dysenteric: and which Rolander, who laboured un- der repeated attacks of this affection while residing with Linneus, pretended to trace from water deposited in a cistern of juniper- wood.f The ordinary exciting cause of simple dysentery, there can be little questibn in the present day, is suppressed perspiration or a sudden chill applied to the surface, acting in conjunction with the predisposing cause of an atmosphere varying rapidly from heat to cold and from moist to dry: on which account the disease is to be found most frequently in the aestival and autumnal months; and occasionally as an epidemic of the season. But by what means this exciting cause operates upon the larger intestines rather than upon any other cavity, or produces the symptoms of dysentery rather than those of diarrhoea, cholera, or colic, we seem to be incapable of determining We perceive, however, in the events of every day that sudden chills on the surface are possessed of a revellent pOAver, and throw the action which is lost on the skin on various internal organs, and especially on cavities of mucous membranes, which in consequence of this excitement, become inflamed, and pour forth an additional secretion. Such is especially the case in rheumatism and catarrh, both which terms are derived from the same Greek root, and import.defluxion. And from this common * Discours sur la Nature, &c. des Maladies accompagnees de Dysenteric t Amoen. Acad. V. 82 et alibi. GE- X.—SP. I.] SANGUINEOUS FUNCTION. 305 character the three diseases have by some pathologists been con- ceived to be so much alike, that dysentery has been regarded as an intestinal rheumatism by Coelius Aurelianus, Akenside, Stoll, and Richter; and is actually set down, by Dr. Parr, as a species el catarrh, in his nosological classification. The diagnostics are arranged by Sydenham as follows, after ob- serving that the disease sometimes begins with the febrile symp- toms of rigor, shaking, and a hot fit. " But frequently there is no appearance of fever ; for the host of gripings take the lead and the dejections follow. The gripings are always severe, and a sort of painful descent of the bowels accompanies every evacuation. The discharges are chiefly mucus, but an excrementitious stool some- times intervenes without considerable pain. The mucous stools are generally streaked with blood; but in some cases there is no such appearance through the whole course of the disease. Never- theless, if the stools be frequent, mecous, and accompanied with gripings, the disorder may as justly be called a dysentery as if blood were intermixed Avith them." He afterwards observes, that, however severely the disease may make its attack on adults and aged persons, which last fall a sacrifice to it more frequently, it proves very gentle in children ; who sometimes have it for several months if left to nature, and even this without inconvenience. Where the patient was of a plethoric habit, and the symptoms violent, and especially if accompanied with a pyrectic onset, the usual practice of this master of his art was to begin with A'enesec- tion, to give an anodyne at night, and an aperient of tamarinds, senna, and rhubarb in the morning, in the proportion of half an ounce of the first, two drachms of the second, and a drachm and a half of the third. " I prefer," says he, " the use of rhubarb in this form to giving it alone or in a smaller quantity, because unless it acts thoroughly it does not much conduce to a cure; and because, also, though more powerful cathartics might be employed, they would but aggravate the gripings and increase the general disorder and especially the depression of spirits. And hence even after the rhubarb purge, I commonly give the anodyne at an earlier hour than usual; indeed at any time in the afternoon, as soon as the laxative has ceased to operate, and thus get rid of the excitement it has occasioned. This purgative I repeat twice every other day, always following up the dose with an anodyne as above ; and I re- sort to the anodyne every morning and evening, even when no aperient is given, that I may repress the violence of the symptoms, and gain a truce while I am evacuating the peccant humour. The anodyne I make use of is sixteen or eighteen drops of laudanum in a dose of cordial-water of any kind : and after the first bleeding and purging, I allow any temperate cardiac to be taken occasionally in compound scordium or some other distilled water, through the Avhole course of the disease." For common drink he prescribed milk and water, or the white decoction, with crumbs of bread, or posset-drink ; and Avhere there vol. n.—39 306 ttffiMATICA. [CL. Ill—OR. H was much debility, he allowed a beverage of half a pint of sack to a quart of spring-water. The ordinary food was panada or mutton broth. Dr. Sydenham's sheet-anchor, however, was his own celebrated liquid laudanum, the vinum opii of the London College, but with a much larger proportion of the narcotic: though he only preferred the liquid to the solid laudanum, as purified opium was then called, because of the greater conveniency of dividing it into doses. So at- tached was he to this medicine, and so persuaded of its permanent efficacy, that where the symptoms were more violent he increased the dose, and gave it three times instead of twice a-day, besides prescribing daily an opiate injection: while in the milder cases of the disease, or where it was but little affected by an epidemic temperament, he asserts that even the evacuating plan may be safely omitted, and the cure be more summarily performed by laudanum alone.* The principles on Avhich this mode of practice is founded, are peculiarly clear and rational: for they indicate an attempt to take off inflammatory action ; to relax the spasmodic constriction which both blocks up the feces, and produces the griping pains ; and to assist the discharge of the feces as the natural passage is sufficiently opened. Rhubarb has been objected to by Dr. Cullen and other modern practitioners on account of its astringency : but Dr. Fordyce has advocated its employment as clearing the primae vise better than any other purgative Its astringent effect, however, is sufficiently guarded against in Dr. Sydenham's prescription by its union with tamarinds and senna. Yet as senna is apt to gripe, even in ordi- nary cases, it ought to be less employed in dysentary than in any disease whatever; and its place may be well supplied by the neu- tral salts, calomel, or small doses of tartar emetic. In simple dysentery, opium under any form is an admirable remedy; for it not only tends to quiet the local pain and irritation, but, by aug- menting all the secretions except that of the intestinal canal, to ex- cite a general relaxation, and make a revulsion towards the sur- face. By taking off the spasmodic constriction, it acts, indeed, in- directly as a laxative, and in this way is also of great advantage. But as its immediate effect on the bowels is to constringe them, it may be very much improved by uniting it with small doses of tar- tar emetic, or Dr. James's powder; or which, perhaps, in the pre- sent disease, is still better, with some neutral salt and ipecacuan, as in the admirable composition of Dover's powder. And with these few alterations it would be difficult, perhaps, to improve upon the plan laid clown by Sydenham, for the treatment of dysentery in its simple and uncomplicated appearance. Under this form it is, per- haps, rarely, if ever, contagious ; but to guard against the possibi- lity of such a fact, the dejections should be removed with attentive speed; and the sick room be large, and freely ventilated. * Sect. IV. Cap. HI. passim, K E. X.—SP.IL] SANGUINEOUS FUNCTION. 307 SPECIES II. DYSENTERIA PYRECTICA. Bggenterte iFetier. ACCOMPANIED WITH FEVER, GREAT LOSS OF STRENGTH, AND DEPRESSION OF SPIRITS : THE FECES, WHEN DISCHARGED, OF VARIOUS COLOURS AND CONSISTENCE ; HIGHLY FETID, AND MIXED WITH PUTRID SANIES, SEBACEOUS MATTER, OR MEMBRANOUS FILMS : CONTAGIOUS. This species, like the last, when an original disease, is chiefly, if not altogether, produced by obstructed perspiration in the more variable temperatures of summer and winter; not limited to local symptoms, but acting in full concert with the fever of the season, or that to which the season predisposes : Avhence Sydenham asserts, " febrem esse sui scilicet generis, in intestina introversam," " that it is a fever of its own kind thrown inwardly upon the intestines." I have said that obstructed perspiration is the chief exciting cause, when this species of dysentery appears as an original disease : for it cannot be denied that under the present form, it appears in innumerable instances as a derivative complaint generated by a very active contagion, and hence spreading Avith tremendous rapidity, through camps or crowds of any kind, consociating too closely without sufficient ventilation, and particularly in swamps or other moist lowlands. The fever of the season, or that to which the season predisposes, may vary : for it may give an inclination to an inflammatory or to a typhous type: or even, where the season is so equally balanced and salubrious as to give no inclination either way, the constitution of the individual may favour the one rather than the other, and thus furnish us at least with the tAvo following varieties, as already laid down by Dr. Macbride: a Caumatodes. The accompanying fever being a cauma. £ Typhodes. The accompanying fever being a typhus. In the present day the latter seems to be by far the most common; and the description by Sydenham is a sufficient proof that the fact was not very different in his time. And I am hence induced to believe, that it is chiefly in sporadic cases that the dysenteric fever is a cauma; while in those of epidemic or contagious origin, the fever is of a typhous, or at least of a synochous character : of a mixt breed, with a strongly marked tendency to run from a caumatic to a typhous type. The general symptoms of this species are drawn up, like those of the last, with so much correctness and strength of colouring by 308 (LEMATICA. [CL. HI.—OR. H. Sydenham, that Ave cannot do better than take them in his own words. The dysentery he is describing was an epidemic that raged to a great extent in our own country,in the autumns of 1670 and of the two following years. Having stated how it appeared in its simple form or without fever, he proceeds to its more complicated and severer character as follows. u If the patient be in the vigour of life, or if he have been treated with cardiacs, a fever arises, and the tongue is covered Avith a thick white mucus; and if he have been much heated, it is black and dry ; and there is at the same time great loss of strength, depression of spirits, and all the signs of an ill-conditioned fever. The disease is attended with violent pains and sickness, and, if unskilfully treated, with extreme peril. For when the spirits are much exhausted, and the vital heat diminished by frequent stools, before the matter can be expelled from the blood a coldness of the extremities ensues, and there is danger of death, even Avithin the periods of acute diseases. But if the patient should escape death in this way, still numerous symptoms of a different kind succeed. Sometimes in the progressof the disease, instead of the sanguineous filaments, which are usually mixed with the stools at the commencement, pure blood in a large quantity, and unmixed Avith mucus, is evacuated at every dejection, which alone threatens death, as manifesting an erosion of some of the larger vessels of the intestines. Sometimes an incurable gangrene seizes the intes- tines, in consequence of the violence of the inflammation produced by the afflux of hot acrid matter to the affected parts. Towards the close of the disease aphthae frequently affect the interior of the mouth, especially if the patient have been kept hot for a long time, and the morbid material have been checked in its evacuation by astringents, the fomes of the disease not having been first carried off by purgatives ; and such aphthae generally foreshow imminent death. If the patient survive these symptoms, and the disease prove lasting, the intestines are progressively affected downwards, till the malady reaches the rectum and ends in a tenesmus. And in this case, contrary to what occurred during the afflux of mucus, even the excrementitious stools occasion great pain in the intestines generally ; the feces in their passage through them abrading the small guts, while the former evacuations only molested the rectum, where alone the mucus was formed and ejected." The epidemic or pyrectic dysentery of foreign climates does not seem to differ essentially from the above : for Dr. Sydenham ex- pressly states that that common to the African coast, on the return of every autumn, was in his day of the same kind, and yielded to the treatment adopted by himself as he was fully informed by Mr Butler, British Envoy in that quarter : while the history of the dysentery that raged among the British troops in Jamaica in April 1780, as given by Dr. Moseley, is nearly a repetition of the above symptoms : with the exception that it appears to have commenced something more in the form of a cholera, with sickness at the stomach and copious purgings, and that its march Avas more violent GE. X—SP. II.] SANGUINEOUS FUNCTION. 309 and fatal; for Ave are told by this distinguished writer that pure arterial blood, to the amount of several ounces, was voided in a stream every half hour, anil that some patients bled to death in this manner; while others perished, from the severity of the general symptoms, Avithin three or four days from the time of seizure. The pathological doctrine of Sydenham, however, that the inflam- mation of the intestines is produced by the afflux of a hot acrid humour conveyed by the mesaraic arteries, has not been able to maintain itself in the present day, notwithstanding the correctness of his general description ; and has long passed into oblivion with the hypothesis of acrimonidus bile. The nature of the dejections show the fearful mischief produced in the larger intestines. The mem- branous films are abrasions of the villous tunic ; the putrid and fetid sanies evinces the existence of gangrene; and the flow of blood in streams, an erosion of important blood-vessels. The sebaceous matter it is not so easy to explain. In treating of scybalous concre- tions forming the third species of the genus enterolithus under the first order of the first class, I had occasion to show that unctuous matters are unquestionably excerned in the intestines when in a diseased condition of a peculiar kind: and Sir Everard Home has endeavoured to prove that it is a part of the natural and ordinary function of the intestines to secrete fat.* This may perhaps give us an imperfect glimpse at the mode in which the sebaceous matter which, by its evacuation so peculiarly marks the disease before us, is generated. And it is unnecessary to follow up the subject further at present, as we have already discussed it at large under the genus Enterolithus just referred to. In one instance the inflammation extended so far that the caput coli was separated and thrown off; and yet the patient recovered; and in others the corrupt and sanious discharge has been found to inclose clusters of animalcules, which have been singularly deposited in the gangrenous tunics of the intestines as their proper nidus. In laying down a curative plan, our first attention must be paid to the nature and degree of fever with which the disease opens; for if this be very violent, the intestinal inflammation may run with resistless speed into gangrene, and the patient sink from mortification or loss of blood in a day or two, perhaps in a few hours. Where, therefore, the pulse is hard and full, and particularly where there is general pain and tension over the belly, indicating an inflam- matory diathesis, blood should be draAvn copiously and with all possible speed, and repeated, if necessary, without fear. There is, nevertheless, no disease that requires the exercise of a sounder judgment upon this point than dysentery : for we have already observed that the fever, if not typhus from the first, has a general tendency to pass into this type ; and the intestinal inflammation is perhaps of the erysipelatus kind. And hence, unless the indica- tions for it are strong and prominent, this mode of cure had better not be ventured upon. • Phil. Trans. 1813 and 1816. 310 HJEMATICA. [CL. in.—or. n. The next most probable means of diminishing the febrile action is by the use of general relaxants, and especially those which may operate equally on the skin and on the whole range of the alimen- tary canal: and these are emetics and diaphoretics, and especially those medicines that produce both these effects at the same time. In using emetics, nauseating doses have been recommended by many high authorities in preference to those that excite full vomit- ing, as possessing a more relaxant poAver ; and on this account some have even ventured to advise that the nausea should be maintained by a repetition of the medicine for some hours.. But I cnnnot regard such a preference as the result of a sound judgment. The relaxation that follows upon nauseating medicines is of the most depressing kind; scarcely any thing so much exhausts the living power; the languor hereby produced is intolerable, and sometimes amounts to deliquium. And hence, hoAv serviceable soever such a state might be in the high tide of an inflammatory fever, it is still more to be avoided in the disease before us, as a general practice, than venesection; for here, with perhaps a few exceptions, we have too much languor and depression already; and stand in need of rousing and strong revulsive action, rather than increased pros- tration of strength. Noav, full vomiting, forming, as I have formerly had occasion to observe, a direct contrast to the effects of nauseat- ing, stimulates and excites the system in every part; and by urging the circulation to the surface, and promoting a copious perspiration, throAvs back the febrile action to this quarter, and produces the re- vulsion Ave stand in need of. The best emetics for this purpose are the antimonial prepara- tions, and particularly emetic tartar, the antimonial or Dr. James's powder, and the glass of antimony, or rather the cerated glass. All these relax generally, and operate on the larger intestines and on the skin, as well as on the stomach. Sir George Baker, Dr. Adair, and Dr. Saunders, preferred the emetic tartar; the first, alone; the second with calomel; the third, with opium. In the present day, Dr. James's, or its valuable substitute, the antimonial powder, seems to be the favourite form. Yet, I cannot avoid thinking that the cerated glass of antimony, the vitrum antimonii ceratum, in Avhich the virulence of the glass is greatly subdued by its mixture with the wax, has very unadvisedly grown obsolete. Sir John Pringle's patronage of this medicine is fully justified by the numerous and irresistible authorities in its favour in the case of dysentery, collected by him, and read before the Royal Society; and afterwards published in the Edinburgh Medical Essays.* It is said to be uncertain in its operation ; but this is an objection which has been made by Henermann to all the preparations of antimony ;t and to the present not more than to any of the rest: for it must be admitted that the degree of their action depends very much on the * Vol. V. Art. XV. + Bemerkungen, &c. Band, I. p. 184. GE.X.—SP. II.] SANGUINEOUS FUNCTION. 311 state of the stomach, and not a little on the idiosyncrasy. It was long in the hands of empirics before it found its way into regular practice; and the world is, or ought to be, much indebied to Dr. Young for having first introduced it into professional notice. 1 he ordinary dose for an adult is ten grains; but where the bowels alone are intended to be moved, or rather where the object is not to ex- cite sickness, it should be diminished to six grains ; in which quan- tity it rarely excites nausea; and upon the whole, in Avhatever dose administered, it has a less tendency to irritate the stomach than the antimonial powder; and operates upon the lower belly, especially in dysentery, more efficaciously than any of the cognate forms of the same metal. When, however, the bowels have been by these means thorough- ly cleansed as well as the stomach, it will be inconvenient to con- tinue this medicine, and, for the most part, any of the preparations of antimony alone; and Ave may, with great advantage, have re- course to narcotics for the purpose of mitigating the griping pains and resolving the spasmodic action. Sydenham, as we have already seen, was in the habit of administering a narcotic by itself; after having premised his rhubarb purgative, and preferred his liquid laudanum to all other anodynes whatever. Some practitioners of considerable eminence have evencommencedwiih opiates, upon the ground that to employ purgatives where the intestines are in a state of high irritation and spasmodic constriction, will only increase the obstinacy of the costiveness from the additional stimulus they con- vey; and consequently that the only means of enabling even purga- tives to obtain their proper end, is, in the first instance, to allay the morbid sensibility of the bowels and torpify the spastic power. But, in reply to this, it maybe observed, that there can be no worse source of irritation in the bowels at the time than pent-up and indurated feces, increasing in hardness and acrimony, by the aug- mented heat and absorption which are essential accompaniments of inflammation ; and that though the constrictive force never entirely subsides, it occasionally remits and allows the hardened recrement to be squeezed downwards in the form of nodules or buttons. Emol- lient or narcotic injections may, indeed, at any time be employed to assist their escape, and to these Sydenham himself often had re- course with great advantage: but the violence of the tenesmus »nd the acute sensibility of the sphincter frequently rendei ir impossible for us to avail ourselves of their use. Opium has often been applied to the rectum in its solid substance, in the shape of a small pill or suppository : but here again it wii! oe unadvisable if there be much irritation of the sphincter : for v.. a hard body, it will excite more soreness by its pressure thai pro- duce relief by its narcotic effect; and if the tenesmus be considera- ble it Avill be impossible to retain it. The only mode in wb'ch I have found it useful under these circumstances is, when rubbed nto an impalpable pulp with a little of the oil or butter or :!■«-• cocoa- nut, and rolled up into small pastiles of a sufficient consistency to bear the touch. 312 HJEMATICA. [CL. HI.—OR. II The best method, however, of employing opium in dysentery is, by combining it with small quantities of ipecacuan and some neutral salt, as in the preparation of Dr. Dover's powder, already recom- mended under the preceding species. This may be given in a dose of five grains immediately after the stomach and bowels have been cleared, and continued every five or six hours till the gripings and flux of blood subside, and the pulse becomes softer and slower ; which will generally be effected with considerable perspiration in twelve or fourteen hours; beyond which period the sweating fit should not be pressed at a single time. Much, however, of the benefit to be derived from Dover's pow- der, as a sudorific, depends upon its proper administration, and the care taken to co-operate with its influence by a proper adjustment of clothing. For this purpose Dr. Cullen lays it down as a rule that it should be given in the morning, when the ordinary sleep, or term of sleep, is over; " For sleeping," says he, " though not incompati- ble Avith, is commonly not favourable to, sweating." This, how- ever, would be, in many instances, to lose much time ; and we must always begin as soon as we have it in our power. There is more importance in another part of Dr. Cullen's course, that no drink should be taken into the stomach till some degree of sweat breaks out, lest the powder should be thrown up by vomiting. Beyond which he recommends that the covering on the body generally should not be more than is merely consistent with the intention of sweating; in many cases not more than is ordinarily made use of; but that some considerable addition should be laid over the feet and legs; and that if the sweat should not, by these means, extend to the extremities, boiled bricks or bottles filled with warm water should be applied to the soles of the feet: and further, that as the heat and perspiration advance, if the patient feel himself too hot and restless, whatever additional covering has been put upon the body generally, and even a part of what has been put upon the low- er limbs, should be Avithdrawn by degrees. He also advises that the patient should, from the first, be wrapt in a flannel shirt and laid be- tween the blankets alone, by a removal of the linen sheets, so that he may be surrounded by nothing but a woolen covering. Hillary, in the warmer temperature of the West Indies, obtained a like ef- fect from small closes of ipecacuan alone; as Dr. Lind affirms he has done in our own country, though in cases of great costiveness he employed Ethiop's mineral as an auxiliary. Dr. Darwin amuses us with a singular mode of producing the same result, and one which, if continued long enough, might probably prove as powerful a re- vellant as any of those already noticed, but Avhich we should not al- ways recommend, nor find our patients disposed to carry into effect. " Two dysenteric patients," says he, " in the same ward of the In- firmary at Edinburgh, quarrelled and whipped each other with horse-whips a long time, and were both much better after it."* * Zonoorn. CI. 11. i. 3. 19. GE. X.—SP. II.] SANGUINEOUS FUNCTION. 313 The only narcotic that has acquired any reputation in this com- plaint, besides opium, is that species of strychnos which is best known by the name of nux vomica. It was at one time in consider- able use in Sweden and the north of Europe. It is less astringent than opium, but has a much more temulent effect on the head. It was, however, chiefly employed, as we learn from Dr. Hagstroom, as an anthelmintic, from the mistaken view of Linneus, thai dysen- tery was produced by the irritation of certain animalcules or larves of a species of acarus, accidentally lodged on the villous coating of the intestine affected. With the fall of this hypothesis the practice has fallen also, and is not worth reviving on any account: for it this medicine possess the tetanic power ascribed to it of late by Dr. Fouquier, and which we shall have occasion to notice more at large when treating of paralysis, it must have such a tendency to increase the constriction as far more than to counterbalance any advantage that may be supposed to result from its narcotic effects. Odhehus, however, asserts that he employed it with success in doses of from ten to fifteen grains given once or twice a-day.* If the costiveness continue, and the flux of blood should at the same time suddenly cease during the perspiration, no danger is to be apprehended; for we have a pretty full proof in the diaphoresis itself that the morbid action of the intestines has been transferred to the surface, and will spend itself there. In general, also, Ave find this still further confirmed by a moderation of the pulse, and a miti- gation of the torminal pains. The diagnostics of a moist skin and a soft pulse are the best signs of amelioration: and without these Ritcher does not think the dis- ease can be radically subdued. He allows, indeed, of purgatives, when there is evident proof of too large a secretion of bile; but deducing his opinion from three distinct courses of epidemic dysen- tery, he regards the bilious affection as merely accessary, and only secondarily to be attended to in the cure of the disease. As a purga tive, moreover, he prefers calomel to rhubarb: contending that the former, while it proves more powerful in removing the accumulat- ed bile and correcting its acrimonious flow, operates at the same time more gently than any other cathartic; while rhubarb, under these circumstances, is even a dangerous medicine, and sure to in- crease the irritation. This view of the case, Avith the limitation to a bilious afflux, is founded on a sound judgment; but it does not amount to a total proscription of rhubarb in every form of the dis- ease: for even Ritcher himself employs it in the latter stage of the complaint, as combining the two desirable properties of being a mild aperient and tonic. In the less violent cases of the disease, he commences at once with his diaphoretic plan, by a combination of laudanum with small doses of ipecacuan or antimonial wine; and, where there is much fever, he premises an emetic: and, in this * K. Lazarettet i Stockholm, &c. p. 27.—Abhandl. der Schwed. Acad, der Wissensch. Band. XXV.—Rese, Diss, de Nuce Vomica. Jen. 1788. VOL. II.—4G 314 HjKMATICA. |CL. HI.—OH. li, case, he also recommends that the abdomen should have warm fo- mentations or a blister applied to it, or be well bathed with cam- phorated or some other rubefacient liniment. If, however, the local symptoms and particularly the flux of blood or bloody feces, or mucus, continue in spite of this treatment, they must be opposed by some astringent or tonic as well as by a sedative plan: for the debility alone which will hereby be produced may be sufficient to threaten the life, even though the fever should dimi- nish. And in this case great benefit has been obtained by the mine- ral acids in union with sulphate of zinc or with opium. The former combination was a favourite medicine with Dr. Mose- ley, who, of the mineral acids, preferred alum, and varied the pro- portions according to the strength or age, the degree of costiveness or of hemorrhage, of the patient: sometimes giving two or three grains of each at a dose, to be repeated three or four times a-day; where the hemorrhage is considerable, increasing the alum; and where feculent evacuations were required, diminishing it or even omitting it altogether. The preparation is valuable as it unites a powerful metallic tonic, which is a true character of the sulphate of zinc, with an acid which has the singular virtue of proving astrin- gent to the sanguineous and secernent system, while it produces lit- tle effect upon the peristaltic motion, and by some physiologists is thought rather to quicken it. Dr. Adair employed alum alone; but it is greatly improved by the addition of the white vitriol. A like beneficial effect, however, has been derived from uniting the mineral acids with laudanum. The sulphuric, though the plea- santest to the taste, is more apt to irritate the bowels than the nitric. But the best mode of giving the latter is by combining it with muriatic acid in the proportion of two thirds of the former to one of the latter, imitating hereby the chrysulea of Van Helniot, or the aqua regia of later chemists, the nitro-muriatic acid of the present day, in doses of two drops of the nitric, one of the muriatic, and ten minims of laudanum, intermixed with infusion of roses or that of the more powerful astringents logwood, catechu, and gum kino. I have employed this medicine with peculiar advantage, not only in dysen- teric, but in many other loosenesses, and hemorrhages of the bowels, increasing the proportion of the acid or the laudanum as the urgen- cy of the symptoms require. When, however, the thirst is considerable, and acidulous drinks are called for, we may for this purpose use the sulphuric acid as the most grateful; though in this case the citric acid will usually be preferred, and the patient may be allowed to exercise his choice. Yet the one or the other of the above compounds should be con- tinued without any alteration in consequence of such a beverage. As the disease declines, there will often be found a very consider- able degree of debility, and a chronic diarrhoea, with occasional discharges of blood from the excoriated slate of many of the minute blood-vessels of the mucous membrane of the intestines, or perhaps from a simple relaxation of the mouths of the capillaries. And in GE. x.—sp.n.] SANGUINEOUS FUNCTION. 315 this situation, and especially where the disease has assumed a highly malignant character, many of the bitters of the Materia Medica may be resorted to, in connexion Avith the acids, with great advan- tage. They have indeed occasionally been given from the first; and in a few very slight cases and very infirm constitutions the practice may have succeeded; but as a general rule of conduct it is highly rash, and has rarely been tried without repentance. Some of them may have a power of stimulating the intestinal canal; or, in large quantities, this, as conjectured by Dr. Cullen, may be a poAver common to all of them ; but their chief virtue is that of in- creasing the tone, and they cannot therefore be employed at the commencement of the disease, when the fever is severe and the constriction rigid, without certain and essential mischief. In the decline of the disease however, we may take our choice The simarouba has been exposed to various fluctuations of opi- nion. It was at one time regarded as little less than a specific for dysentery, and was eulogized not only in the West Indies, but in Europe, as combining the desirable qualities of an excellent tonic, antispasmodic, sudorific, cardiac, and anodyne.* This was to carry its praise too high. By Dr. Cullen it has, on the contrary, been un- justly degraded, who regards it as nothing more than a simple bit- ter ; and even in this view places its virtue below that of chamomile flowers.f Of late years, however, it has again been rising in public estimation; and as a truly valuable tonic, and particularly in intesti- nal debilities, I am pleased to see it taking a stand in the Materia Medica of the London College. The cinchona is of more doubtful efficacy. It will be greatly beneficial where the disease has assumed an intermittent or a putres- cent character, but it is apt in many idiosyncrasies to irritate the bowels, and when had recourse to must be closely watched. Of the nerium antidysentericum of Linneus, formerly in high re- pute, under the name of conessi bark, as an invigorating bitter and tonic in the present and all other debilitating complaints of the ali- mentary canal,| I cannot speak from personal trial; but it seems to have fallen into oblivion too suddenly, and deserves a further in- vestigation. The virtues of columbo need not be enlarged upon; they are known to every one in the present day : and under every form this medicine will be found a powerful auxiliary in the hands of a practitioner§ who has judgment enough to seize the proper moment in which it ought to be employed in the progress of dysen- tery. In conjunction with this process, the very great tenderness of the interior of the larger intestines, from erosion or abrasion, will often * Lewis's Mat. Med. in verbo. Beauma Journ de Med. LVH, 507. Quarin, in Dys. Malign. Animadvers. Gooch's Cases, &c. p. 421. f Mat. Med. Vol. II. p. 79. * Monro Edin. Med. EBsays, Vol. in. Art. iv. $ Percival's Essays, H. Hist, de la Societe de Medicine, p. 340.1776. 316 H.EMATICA. [CL. 111.—OR. If. for a long time demand peculiar local attention; and demulcent or bland oleaginous injections, as the infusion or oil of linseed, or olive-oil with a little wax and soap dissolved in it, together with a grain or two of opium if there should be much pain (the whole not to exceed three or four ounces in quantity,) will often be found of great assistance, as well in affording present ease, as in forwarding the expansion of a new cuticle. In long protracted and chronic cases, lime-water drunk freely has occasionally also proved useful. The coat of the intestinal canal is here, hoAvever, sometimes very considerably thickened and indu- rated. And in such cases the best remedy we can have recourse to is mercury. Houlston recommends such a course to be persisted -, iii to salivation.* Libavius commenced his mercurial plan with mercurial ointment.t Stoll, on dissection, found in sevearl instances the affected intestines thickened, indurated, rigid, yet without ulcer- ation ; and sometimes evidently marked with chronic inflammation.! GENUS XI. BUCNEMIA. 2TttmCtr=2Lefl. TENSE, DIFFUSE, INFLAMMATORY SWELLING OF A LOWER EXTREMITY ; USUALLY COMMENCING AT THE INGUINAL GLANDS, AND EXTENDING IN THE COURSE OF THE LYMPHATICS. This genus is new to nosological classifications: but it is necessary, in order to include two diseases which have hitherto been regarded by most writers as totally unconnected, and treated of very remotely from each other ;fc>ut which, though occurring under very different circumstances, are marked by the same proximate cause, affect the same organs, and demand the same local treatment. They consist of the following species : I. RUCNEMIA SPARGANOSIS. PUERPERAL TUMID-LEG. 2. --------- TROPICA. TUMID-LEG OF HOT CLIMATES. As the present genus is neAv, it has been necessary to distinguish it by a new name ; and on this account the author has made choice of that of Bucnemia, from £««, a Greek augment, probably derived from the Hebrew yi or nj>3 " to swell, augment, or tumefy," a * Observations on poisons, &c. f Hornung, Ctsta, p. 2. § Rat. Med. Part III. p. 277. GE. XL—SP. L] SANGUINEOUS FUNCTION. 317 particle common to the medical vacabulary ; and the Greek noun ww, " cms," or, " the leg," literally, therefore, " bulky or tumid leg." SPECIES I. BUCNEMUA SPARGANOSIS ^neqieral &umttr=2iLeg. THETUMID LIMB PALE, GLABROUS, EQUABLE, ELASTIC, ACUTELY TENDER; EXHIBITING TO THE TOUCH A FEELING OF NUMEROUS IRREGULAR PRO- MINENCES UNDER THE SKIN ; FEVER, A HECTIC : OCCURRING CHIEFLY DURING THE SECOND OR THIRD AVEEK FROM CHILD-BIRTH. I have observed above, that the tumid-leg of child-birth has mostly been contemplated as a very different affection from that of hot cli- mates, and has rarely been treated of in connexion with it. Dr. Thomas, however, has been sensible of their relation, though he has still placed them at a distance from each other. " The disease," says he, " to which in my opinion it bears the strongest resem- blance, (meaning the species before us,) is the glandular affection so frequently met with in the island of Barbadoes."* It is singular that, with this impression, so able a writer should still have regard- ed the latter as a species of elephantiasis, and arranged and de- scribed it accordingly. In the present author's first edition of his Nosology the ordinary arrangement was so far yielded to as to place the two species remotely, though a distinction between elephantiasis and the tumid-leg was strongly enforced. The tumid-leg of lying-in women, has been described by different authors under a variety of names, as phlegmatia dolens, phlegmatia lactea, ecchymoma lymphatica, and by Dr. Cullen, as anasarca serosa; few of Avhich express the real nature of the affection, and some of them a source obviously erroneous. By Dioscorides it was denominated sparganosis, from peculiarly affected and dis- * Works, Vol. 1. r. 549. 4to edit. 1799. OE. XL—SP. II.] SANGUINEOUS FUNCTION. 323 tended to an enormous magnitude; while occasionally the glands of the axilla participate with those of the groin, and the fore-arm be- comes also enlarged. In a few instances the disease is said to have commenced in the axilla ; but sflch cases are very rare, and not well established. In this manner the disease at length assumes a chronic character : the monstrous size and bloated wrinkles of the leg are rendered permanent; the pain felt acutely at first subsides gradually, and the brawny skin is altogether insensible. Yet even from the first, except during the recurrence of the febrile paroxysms, the patient's constitution and general functions are little disturbed : and he some- times lives to an advanced age, incommoded only by carrying about such a troublesome load of leg; Avhich, however, as we have noticed already, is regarded in the Polynesian isles as a badge of honour. In our own country the disease is rarely met with but in its con- firmed and inveterate state, after repeated attacks of the fever and effusion have completely altered the organization of the integuments and rendered the limb altogether incurable. In this state the distended skin is hard, firm, and peculiarly thickened, and even horny; while the muscles, tendons, ligaments, and bones, are, for the most part, little affected. In this advanced stage, the disease seems to be altogether hopeless : nor in any stage has the practice hitherto pursued been productive of striking success. This has consisted chiefly in endea- vours to alleviate the febrile paroxysms by laxatives and diapho- retics, and subsequently to strengthen the system by the bark. It would be better perhaps by active and repeated bleedings, as well general as local, and powerful purgatives, to endeavour to carry off the whole of the first effusion as quickly as possible; and then to direct our attention to a prevention of the paroxysms to Avhich the constitution appears to be peculiarly subject, after a single one has taken place, by prohibiting exposure to the damp air of the evening, and by the use of tonics. An original and chronic affection of this kind, in which the inte- guments of the legs were much thickened, the limbs swelled to such an extent as to prevent the patient from Avalking, and incrusted with such a vast quantity of brawny scurf and scales, that handfuls of them might be taken out of his bed every morning, was successfully attacked many years ago by a mistake of one plant for another. The case is related by Dr. Pulteney in a letter to Dr. Watson; and the patient, who had been recommended to swallow a table spoonful of the juice of the water-parsnep, with two spoonfuls of Avine every morning fasting, was erroneously supplied with half a pint of what afterwards appeared to be the juice of the roots of the nemlock-dropwort (oenanthe crocata, Lin ) : the first dose produced such a degree of vertigo, sickness, vomiting, cold sweats, and long continued rigor, that it almost proved fatal. So strong, however, was the patient's desire of relief, that, wjth the intermission of one SM HJEMATICA. [CL. III.—OR. h; day he repeated the dose with a slight diminution in the quantity. The effects were still violent, though someAvhat less alarming; and he persisted in using half the quantity for several weeks. At the end of a month he was very greatly improved, and shortly after- wards the whole of his symptoms had nearly left him.* Amputation of the affected leg has sometimes been made trial of, but apparently without any success. Dr. Schilling informs us that in some a locked jaw takes place about the seventh day from the operation, which is soon followed by tetanus, and ends in death; that in others, fatal convulsions ensue immediately ; and that those who survive the operation have wounds hereby produced that Avill not heal; while the disorder, still tainting the constitution, often seizes on the other foot.t And in this last assertion he is corrobo* rated by one or two cases related by Dr. Hendy.| GENUS XII. ARTHROSIA. Articular Xnflammatton. INFLAMMATION MOSTLY CONFINED TO THE JOINTS; SEVERELY PAINFUL} OCCASIONALLY EXTENDING TO THE SURROUNDING MUSCLES. Arthrosia is a term derived from »e.6eoa>, " to articulate," whence arthrosis, arthritis, and many other medical derivations. The usual term for the present genus of diseases, among the Greek physicians, was athritis, which would have been continued without any change, but that, for the sake of simplicity and regularity, the author has been anxious to restrain the termination itis to the dif- ferent species of the genus empresma that have just passed in review before us ; whence arthrosia is employed instead of arthritis, and precisely in its original extent of meaning. Arthritis then, among the Greeks, Avas used in a generic sense, so as to include articular inflammations generally. But as almost every sort of articular inflammation has, in recent times, been advanced to the rank of a distinct genus in itself, it has frequently become a question to Avhich of them the old generic term should be peculiarly restrained. And hence, some writers have applied and limited it to gout; others have made it embrace both gout and rheumatism; others again have appropriated it to white-swelling: * Phil. Trans. Vol. LXH. f G. G. Schilling!! de Lepra Commentationes, 8vo. Lugd. Batav. 1776. t On the Glandular Disease of Barbadoes. GE. Xn.] SANGUINEOUS FUNCTION. 325 while a fourth class of writers, in order to avoid all obscurity and dispute, have banished the term altogether. Now gout, rheumatism, whether acute or chronic, and white- swelling, however they may differ in various points, as well of symptoms as of treatment, have striking characters that seem naturally to unite them into one common group. Gout and rheuma- tism are so nearly allied, in their more perfect forms, as to be distinguished with considerable difficulty ; and, in many instances, rather by the collateral circumstances of temperament, period, of life, obvious or unobvious cause, antecedent affection or health of the digestive function, than from the actual symptoms themselves. Stoll maintains that they are only varieties* of the same disease: Bergius, that they are convertible affections. White-swelling, in one of its varieties, is now uniformly regarded as a sequel of rheumatism, or the result of a rheumatic diathesis; while the other variety cannot be separated from the species. All these, therefore, naturally and necessarily form one common genus, and are correct- ly so arranged by Dr. Parr. From the close connection between gout and rheumatisn, Sau- vages, and various other nosologists, distinguish some of the cases of disguised gout by the name of rheumatic gout. Mr. Hunter warmly opposed this compound appellation; for his doctine was that no tAvo distinct diseases, or even diseased diatheses, can co-exist in the same constitution. And, as a common law of nature, the observation is, I believe strictly correct; one of the most frequent examples of which is the suspension of phthisis during the irritation of pregnancy. But it is a law subject to many exceptions ; for Ave shall have occasion, as we proceed, to notice the co-existence of measles and small-pox; and I have at this moment under my care a lady in her forty-ninth year, of delicate health and gouty diathesis, who is labouring under a severe and decisive fit of gout in the foot, which is prodigiously tumefied and inflamed, and has been so far several days, brought on by a violent attack of lumbago, to which she is till a victim, and which renders her nights more especially Sleepless and highly painful. The constitutional disease has in this case been roused into action by the superadded irritation of the accidental disease; and the two are noAv running their course con- jointly. It is also a striking fact that one of the severest illnesses that attacked Mr. Hunter's own person, and which ultimately proved to be disguised gout, podagra larvata, he suspected, in its onset, to be a rheumatic ailment. The case, as given by Sir Everard Home, in his Life of Mr. Hunter, is highly interesting and curious; as showing the singular forms Avhich this morbid Proteus sometimes affects, and the various seats it occupies ; as also that a life of temperance and activity is no certain security against its attack ; for Mr. Hunter had, at this time, drunk no wine for four or five years, and allowed himself but little sleep at night. * Rat. Med. Part HI. p. 122—137. V. p. 420. 326 HEMATIC A. [CL.HI.—OR.II- Arthrosia, therefore, as a genus, may, I think, be fairly allowed to embrace the following species : 1. ARTHROSIA ACUTA. ACUTE RHEUMATISM. 2.----------CHRONICA. CHRONIC RHEUMATISM. 3. ——----- PODAGRA. GOUT. 4. —------ HYDARTHRUS. WHILE SWELLING. SPECIES I. ARTHROSIA ACUTA. &cnte Hhenmattsm. PAIN, INFLAMMATION, AND FULNESS, USUALLY ABOUT THE LARGER JOINTS AND SURROUNDING MUSCLES; OFTEN WANDERING; URINE DEPOSITING A LATERITIOUS SEDIMENT J FEVER A CAUMA. The disease varies in respect to violence of the fever, and seat of the pain. The varieties, determined mostly from the last feature, are as follow: x Artuum. Pain felt chiefly in the joints and Articular rheumatism. muscles of the extremities. £ Lumborum. Pain felt chiefly in the loins; and Lumbago. mostly shooting upwards. y Coxendicis. Pain felt chiefly in the hip-joint, Sciatica. producing emaciation of the nates on the side affected, or an elongation of the limb. (J" Thoracis. Pain felt chiefly in the muscles of Spurious pleurisy. . the diaphragm, often produc- ing pleurisy of the diaphragm. The common remote cause of articular rheumatism, as of all the other varieties, is cold or damp applied when the body is heated; though it may possibly be produced by any other cause of inflam- matory fever, where the constitution has a peculiar tendency to a rheumatic action. This tendency or diathesis seems to exist chiefly iii the strong, the young, and the active; for, though it may attack persons of every age and habit, these are principally its victims. We may hence, as well as from its symptoms, prove rheumatism to be an inflammatory disease. Even in the weak and emaciated, ob- serves Dr. Parr, the pulse is hard, the blood coriaceous, and bleed- ing often indispensable. It is an inflammatory disease, also, of the muscles, for motion is painful, the muscles are sore to the touch ; and we may assume it as a position that muscular organs are alone GE. XII.—SP. I.] SANGUINEOUS FUNCTION. 327 affected.* The chief pain, indeed, is usually felt in the joints ; for the more closely compacted organs, or parts of organs, though in- sensible in a sound state, are peculiarly alive to pain when diseased ; the same arteries belong to both the muscles and tendons of the affected organ ; and in the latter we have reason to expect the pain to be more violent as they admit of distension with greater difficulty. How far the observation of Sir C. Wintringham is true, that those who have suffered amputation are susceptible of this dis- ease more than others,t the author cannot say from his own prac- tice ; but it is the remark of a physician who Avas not accustomed to form a hasty judgment. As a general rule it may be asserted that rheumatic inflammution does not tend to suppuration. In a feAV rare instances the contrary has been known to take place;! and in one or tAvo cases I have my- self been a Avitness to an extensive abscess. But the general rule is not disturbed by such rare exceptions. The inflammation there- fore is of a peculiar kind. There will often, indeed, be effusion, and the limb will swell considerably; but the effusedTluid is gradu- ally absorbed; and the swelling not unfrequently, though not al- ways, is accompanied with an alleviation of the pain. Sometimes the pains take trie precedency of the fever ; but in other cases the fever appears first, and the local affection does not discover itself till a few days afterwards. There is no joint, except perhaps the extreme and minute joint of the fingers and toes, but is susceptible of its attack, although it usually commences in, as al- ready observed, and even confines itself to, the larger. Among these, however, it frequently wanders most capriciously, passing ra- pidly from the shoulders to the elbows, wrists, loins, hips, knees, or ancles, without observing any order, or enabling us in any way to prognosticate its course; always enlarging the part on which it alights, and rendering it peculiarly tender to the touch. Sometimes it darts internally upon organs we should little expect, as the dia- phragm and the pleura ; and I have occasionally known the stomach as suddenly and severely affected as in gout. It is also said at times to pitch upon the heart and the intestinal canal, and to produce ex- cruciating torture in both these organs. The urine is often at first pale, but soon becomes high-coloured, and deposits a red sediment. It may be distinguished from gout by being little connected Avith dyspepsy, commencing less suddenly, evincing more regularly mark- ed exacerbations at night; but less clear remissions at any time : to which, as already noticed, we may add its attachment to the larger rather than the smaller joints. It runs on from a fortnight to three weeks : and the average of the pulse is rarely under a hun- dred. • Smyth, Med. Commun. II. 19. f Comment, de Morbis quibusdam. Art. 79. t Morgagni, He Sed. et Caus. Morb. Ep. LVH. Art. 90. Med. Comment. Edinb. Vol. IV. p. 198. 328 HiEMATICA. [CL. III.—OR. U. The fever is generally accompanied with copious and clammy sAveats; but the skin still feels tense and harsh; nor does the sweat issue freely from the immediate seat of pain. It seems to be an in- effectual effort of the instinctive principle or remedial power of nature to carry off the complaint: for it is by this evacuation alone that Ave can at length succeed in effecting a cure. But the perspi- ration Avill be always found unavailing so long as it continues clam- my, and the skin feels harsh, and there is a sense of chilliness creep- ing over the body or any part of it during the perspirable stage. The exacerbation, which regularly returns in the evening, increas- es during the night, at which time the pains become most severe ; and are then chiefly disposed to shift from one joint to another. Where the fever is violent, and especially where the frame is ro- bust ; our only effectual remedies are copious bleeding and the use of diaphoretics; by the former, which will often demand repetition, we take off the inflammatory diathesis, and by the latter we follow up the indication Avhich nature herself seems to point out, and en- deavour by still farther relaxing the extremeties of the capillaries to render that effectual, which without such collateral assistance is, as already observed, for the most part exerted in vain, and an un- profitable expenditure of strength. The most useful diaphoretic we are acquainted with is Dover's powder; and its benefit will often be increased if employed in union Avith the acetated am- monia, and sometimes if combined with camphor. Aperients are useful to a certain extent, but they have not been found so ser- viceable as in various other inflammations. Small doses of calo- mel have occasionally, however, seemed to shorten the term of the disease, though they have not much influence in diminishing the pain. To obtain this Dr. Hamilton has combined calomel with opi- um ; and in his hands it appears to have been successful. Opium alone is rather injurious; nor has any decided benefit resulted from other narcotics, as hyoscyamus, hemlock, and aconite. They are recommended by several writers, but I have seen them tried both in small and large quantities without effect. We have observed that there is no constitution invulnerable to the attack of rheumatism, although the young and the vigorous fall most frequently a prey to its torture. Hence not unfrequently we meet Avith in persons of weak and irritable habits, who will not bear the lancet with that freedom which gives any chance of its being useful. Local bleeding is here to be preferred ; but it can- not be depended upon: since, though the pain may diminish, or even totally subside, it is, in many cases, only to make its appear- ance in some other quarter. Here, also, if in any case, we have reason to expect benefit from uniting stimulants Avith diaphoretics, as ammonia, camphor, and the resinous gums and balsams. In such habits and particularly if opium should disagree with the system, it may be worth while to try the rhododendron (r. Chrysan- thum, Linn.) This plant is a native of the snowy summits of the Alps and mountains of Siberia; and in Russia, as Ave learn from Dr. Guthrie, is employed very generally both in gout and rheu- bE. XII.-SP. L] SANGUINEOUS FUNCTION. ;}2U matism with a full assurance of success, a cure seldom failing 'o be effected after three or four doses:* in consequence of Avhich it has formed an article in the Materia Medica of the Russian Phar- macopoeia for nearly a century. Dr. Home tried it upon a pretty ex- tensive scale in the Edinburgh Infirmary, and found that it acts both as a powerful diaphoretic and narcotic ; and is at the same time one of the most effective sedatives in the vegetable kingdom. In most of the cases it retarded the pulse very considerably, and in one in- stance reduced it to thirty-eight strokes in a minute. It has also the advantage of occasionally proving aperient. But it sometimes pro- duces vertigo and nausea; and as a general medicine is not to be preferred to Dover's powder,f or even the antimonial powder Avith opium, where the latter can be borne without inconvenience. It is possibly also in habits of this irritable kind, if in any, that we are to look for that extraordinary and decisive benefit from a free use of the bark at an early period of the disease, which we are told has accompanied it, by authorities Avhich we cannot dispute. Contemplated as a highly acute inflammatory affection, nothing could at first sight appear to be more inconsistent with all rational prac- tice than the use of such a medicine, and every one must feel pre- disposed to coincide with Dr. Cullen, when he tells us, in reference to acute rheumatism, "I hold the bark to be absolutely improper, and have found it to be manifestly hurtful, especially in its begin- ning, and in its truly inflammatory state."!; Yet in direct opposition to such feelings and such assertion, confirmed by numberless testi- monies of equal weight, Ave find the bark freely prescribed from the onset of acute rheumatism, apparently with success, by Dr. Morton, Avho seems first to have employed and recommended it for this pur- pose, doAvn to our own day, through a stream of the most celebrated physicians, as Sir Edward Hulse, Dr. Fothergill, Dr. George For- dyce, and Dr. Haygarth of Chester. Dr. Fordyce affirms distinctly that, at the time of writing, he had for fifteen years relinquished bleeding in favour of the bark; and that during this period of time he had not above two or three patients out of several hundreds for which he had prescribed it; and had rarely met with any instance of a metastasis, a very common occurrence Avhen he was in the ha- bit of employing copious bleeding.§ The success of Dr. Haygarth is not less striking and extraordina- ry : and the history of it is given with an air of candour, that enti- tles it to full attention. Dr. Haygarth's residence was at Chester; and his tract lays before us, the result of an extensive practice in rheumatic diseases, in that city and its neighbourhood, during a pe- riod of thirty-eight years. His cases amount to four hundred and seventy; and of these, one hundred and seventy, or something more * Med. Comment. Vol. V. p. 434. f Clinical Experiments, Histories of Dissections, 8vo. Edin. 1780. * Mat. Med. Part II. Ch. II. p. 100. § On Fever, Dissert. HI. vol.. II.—42 330 HJEMAT1CA. [CL. III.—OR. 1L than a third of the entire number, appear to have been cases of acute rheumatism, or rheumatism in conjunction Avith fever, the rest being of a chronic kind. In the acute cases, by far the greater number of patients had the joints alone principally affected, a few the muscles alone, and the rest both the muscles and the joints. The average of the pulse in the above hundred and seventy cases, was a hundred strokes in a minute, and the blood always exhibited the inflammatory crust when drawn. Other remedies were tried, but the bark was by far the most successful. In four cases only out of a hundred and twenty one, it is allowed to have failed; so that we cannot be much surprised at Dr Haygarth's conclusion, that the bark does not cure an ague so certainly and so quickly as it does the acute rheumatism.* How are Ave to reconcile such conflicting results and harmonize the authorities now adverted to ? 1 have also tried the bark in va- rious instances from an early period of the disease, and when the bowels Avere free from confinement, but I have rarely met with suc- cess : and have often, like Dr. Cullen, had reason to think it injuri- ous. Is it that in certain habits, as those of great weakness and irri- tability; in certain districts, as in low and swampy grounds, charged with the fomites of intermittents; or, in certain temperaments of the atmosphere, as in sudden successions of wet and sultry weather, the bark has a tendency even in acute rheumatism, as we know it has in spasmodic affections occurring in weakly constitutions, to take off tension and rigidity as well as to take off relaxation; and thus to in- duce a healthy tone by letting down the action of muscular fibres^ Avhen necessary, as Avell as raising it when necessary also ? This view of the subject may account for its beneficial effects in many of the above cases, but will not explain the general and indiscriminate success which seems to have attended it: and hence, there is still a something behind, some unknown principle or contingency, which yet requires to be brought forward before we can reconcile these " factis contraria facta." The above remarks will apply to other varieties of acute rheu- matism as well as to the first, that which affects the joints generally, and is the most common form under which the disease shows it- self; yet the few folloAving observations more immediately direct- ed to the other varieties may not be altogether unprofitable. Lumbago has sometimes been confounded with nephritis, or a calculus in the kidneys or ureters; but the proper nephritic affec- tions are distinguished by some irregularity in the secretion of urine, and as we have already had occasion to observe, with a numbness shooting down the thigh, and a retraction of either testicle. Rheumatism of the hip-joint was called among the Latins ischias, from <«■#<««, the Greek term for hip; which was afterwards corrupt- ed into isciatica or sciatica, a word that has occasionally found its * Clinical History of Diseases, 1805. GE. XII.—SP. L] SANGUINEOUS FUNCTION. 33vJ way into the dramatic poetry of our OAvn country, as in Shakspeare's Timon, The cold sciatica Cripple our senators, that their limbs may halt As lamely as their manners. This variety, at its onset, has sometimes been mistaken for a phlegmonous inflammation of the psoas muscle. But in the latter there is, from the first, less tenderness to the touch, but much more enlargement, and the pain shoots higher into the loins. In sciatica, indeed, the whole limb, instead of continuing to swell, soon Avastes away, and the emaciation extends to the nates of the affected side, so that the muscles have neither strength nor substance; while the thigh becomes elongated from the fibrous relaxation that takes place. When acute rheumatism attacks the pleura, or any of its dupli- catures or appendages, it exhibits many of the symptoms of pleu- risy or peripneumony. But here, also, as in every other case of rheumatism, we have much greater tenderness upon pressure than in phlogotic inflammation, while the pyrectic symptoms are consi- derably less, and often highly disproportionate to the pain that is endured, so that the degree of pain and of fever becomes no mea- sure for each other. There is this peculiar character belonging to the three last varie- ties, that though they are less disposed to wander generally than the first, they are peculiarly apt to run into each other's proper field, and to affect the stomach, which, in consequence, becomes sometimes enormously flatulent and expanded, with a sense of heat like that of a burning coal. If the back or loins be pressed hard to obtain ease, the pain is transferred to the side or stomach ; and if the pressure be followed up into the side, it returns with violence to the back or hips; or the breathing is impeded, and can only be carried on in an erect position.* Generally speaking, however, in these three varieties, the dis- ease is less erratic than in the first, and particularly in lumbago and sciatica. And it is owing to this fact, that the loins and the hip, from having been more uniformly affected, are often so long, even after the complaint has subsided, before they recover any degree of tone, so that the patient is frequently a cripple for many months ; and still suffers from chronic rheumatism, which in these cases proves no uncommon sequel to acute. Local applications, which are rarely of service in the first or ar- ticular variety, as the pain is so apt to wander from every joint to every joint, may in all these be frequently employed with more advantage; and where general and capious bleeding may be con- traindicated, leeches or cupping have often afforded considerable * Cartheuser Diss, de Lumbagine rheumatica. Fr. 1755. Scbeid, Diss, de Lutnbag. rheumat. Arg. 1704. 332 HJEMAT1CA. [CL. III.—OR. II relief. The compound camphor liniment, as an elegant rubefacient, is perhaps more frequently employed than any other medicine of the same tribe ; but it dries too soon upon the skin, and heats and stimulates Avithout exciting moisture ; and hence it is less useful than camphor dissolved in oil, or oil united with ammonia. In all these applications, hoAvever, the friction Avith a warm hand is of itself highly serviceable, and should be long persevered in and fre- quently repeated. And on this account it is that essential advantage has often been derived in cases of lumbago, or where the rheuma- tism has fixt itself between the shoulders, by a waistcoat of the coarsest brown paper, worn close to the skin> which excites a gentle moisture, both by its perpetual friction and the stimulus of the tar with which it is so largely impregnated. Blisters seem rarely to be of all the advantage we should expect; but the vesication from sinapisms succeeds better than that from cantharides, probably because it operates with a Avider continuous sympathy, produces more general excitement, and hence proves a better diaphoretic. The burning of moxa is a favourite remedy on the continent, but has been little tried in our own country. It does not seem to afford so much promise of relief as sinapisms or epi- thems of scraped horseradish. The tartar emetic ointment has been also frequently made use of, and sometimes with success : it gives a permanent irritation, but the exulcerations it produces frequently prove foul and troublesome. Dr. Percival of Dublin, in a manu- script note to the volume of Nosology, tells me that, in sciatica, he has knoAvn the pain removed by a SAveating course of James's pOAV- der, after a considerable emaciation of the nates. Bark and gentle stimulants, as guaicum, bardana, and seneka, may in every instance be used with advantage, with a liberal regi- men and chalybeate waters. SPECIES II. ARTHROSIA CHRONICA. atlivonte Uneumatism. pun, weakness, and rigidity of the larger joints and sur- rounding muscles; increased by motion; relieved by warmth; limbs spontaneously, or easily growing cold j fever and swelling slight, often imperceptible. Concerning the proper position, and, in.some sort, the nature of this disease, Dr. Cullen confesses himself at a great loss. In his Synopsis, he arranges it as a sequel of acute rheumatism, and so ex- plains it in his definition: yet he gives it a distinct name, that of GE. XII.—SP.II.J SANGUINEOUS FUNCTION. 333 Arthrotlynia, for the express purpose, as he tells us, of having a dis- tinct name at hand ior any one who may choose to regard it as a separate genus ; and whoever is so disposed is at full liberty, he adds, as to any objection of his own. Yet in his First Lines he takes a different view; and perhaps a more correct one than either of the above. Chronic rheumatism, instead of being a mere sequel of acute rheumatism, or a distinct genus, is here made a separate sfiecies of a common genus. " Of this disease," says Dr. Cullen, " there are two species; the one named the acute, and the other the chronic rheumatism." And in his subsequent description of the latter, in- stead of the universal assertion in his earlier worky»"pro sequela rheumatismi acuti rheumatismum chronicum dictum semper habeo," he modifies it by the word commonly, " The chronic," says he, " is commonly a sequel of the acute rheumatism."* There can be do doubt indeed, that it is so; but as, in many in- stances, it is a distinct disease, characterised by symptoms of its own, and demanding a very different treatment, there can be as little doubt that it ought to be arranged as a distinct species ; and in the present system it is thus arranged accordingly. Chronic rheumatism has as many, and nearly the same varieties as the acute. It becomes fixt in the loins, in the hip, in the knee, but sel- dom in the thorax. Its symptoms are,in most respects like those of acute rheumatism, only that there is little or no fever ; so that while the general heal is very considerable, and the pulse usually up- wards of a hundred strokes in a minute in the acute species, the skin in the chronic species seldom exceeds its natural temperature, and the pulse is rarely quicker than eighty strokes ; the joints are less swollen, and of a pale instead of being of a reddish hue, cold and stiff, and roused with difficulty to a perspiration; and always comforted by the application of Avarmth. The disease continues for an indefinite period, and sometimes only terminates with the life. The affected joint is occasionally de- bilitated to the utmost degree of atony, so as, Avhen the acute pain is not present, to resemble very nearly a stroke of palsy. Cold, the common cause of the acute rheumatism, is also a com- mon cause of chronic, even where the acute species has not preced- ed : and violent strains and spasms may be enumerated as other causes. But it is probable that in these cases the constitution is peculiarly disposed to rheumatic action. Every symptom proves most distinctly that the present is a dis- ease of debility; and the mode of treatment must be founded upon this idea. It is hence that stimulants of almost all kinds are found serviceable. Warm active balsams and resins, as those of copaiva and guaiacum, essential oils of all kinds, from resinous substances, as turpentine and amber; from aromatic or pungent plants, as cam- phor and mustard, and especially cajeput, the greenest distilled oil * Aph. CCCCL. 334 HiEMATICA. [CL. IU.—OR. II from the leaves of the melaleuca Leucodendron, are all employed in their turn; sometimes alone, where they combine a sedative Avith a stimulant power, as camphor and cajeput, and sometimes in union with opium, which often proves a very valuable addition. Most of these are, also, powerful diuretics ; and as acute rheuma- tism is best and soonest removed by warm sudorifics, so chronic rheumatism seems to be chiefly relieved and, indeed, radically cured, by diuretics of a like stimulus. Hence, horse-radish and garlic are often found serviceable ; and turpentine still more so; Avhich in truth forms the basis of the greater number of the medi- cines just enumerated. How far the arum, or dulcamara, may be specifically entitled to this character I cannot determine from my own practice. They are both introduced into the table of diuretics by Dr. Cullen, and are highly commended by many physicians of great celebrity for their arthritic virtues. But it is possible that whatever virtues of this kind they possess are rather derived from their stimulating the excretories generally, and rousing the entire system, than from their acting specifically upon the kidneys. The colchicum autumnale, which has sometimes proved serviceable, has more decided pretensions to a diuretic character. Local stimulants are, here, of more service than in the preceding species. The cautery of moxa has been more generally used on the continet for chronic than for acute rheumatism,and is certainly more entitled to a trial. In our own country, hoAvever, practition- ers have far more generally had recourse to cataplasms of ammonia, cummin, and mustard-seeds, occasionally intermixed with cuphor- bium or cantharides: or, in their stead, have made use of friction, and, Avhich is far preferable, the vapour-bath, brine, warm-bathing: and have afterwards kept the joint well clothed Avith flannel; and sent through the organ small shocks of electricity, or roused it by the stimulus of the voltaic trough. And, when every thing else has failed, the patient is usually advised to try what perhaps, it would be better that he should try at first, the mysterious agency of the Bathwaters. "The subject ought not to be dropped without briefly adverting to the internal usejof the oleum jecoris aselli, common train oil, or that obtained from the liver of the cod-fish, not long ago so extensively tried, I had almost said so fashionable a remedy, in consequence of the warm and confident recommendation of Dr. Percival. This offensive material is procured by the process of putrefac- tion, and appears to derive its stimulant poAver, at least, as much from rancidity as from any natural quality. Dr. Percival tried it upon a large scale in the Manchester Infirmary, and with so much success, that, nauseous as it is to the taste, rheumatic patients, from being eye-witnesses of its benefit, were in the habit of applying to him for a course of it. Dr. Bardsley has since spoken of it in terms of nearly equal commendation; and Dr. Parr asserts, that "he thinks he has seen chronic rheumatism yield to a steady constant use of this oil, which had resisted every other remedy." Dv GE. XII.—SP. H.] SANGUINEOUS FUNCTION. 335 Bradsley's dose Avas from one to three table spoonfuls in the course of the day. Some years ago the author of this work tried the train oil very steadily and perseveringly in several severe cases of chro- nic rheumatism, but with very doubtful success in every instance ; and certainly without any advantage whatever in one or two, in which the oil was punctiliously persevered in for a month, in the proportion of two ounces a-day. In slight cases, it may sometimes prove salutary, but its virtues cannot fairly stand in competition with those of the terebinthinate oils. The arsenic solution I have never tried in this complaint. It is strongly recommended by Dr. Bardsley,* and, in his hands, it seems often to have succeeded. It may be commenced in doses of ten drops, and gradually increased to double this quantity, and should be united with a few drops of laudanum if it sit uneasy on the stomach by itself. SPECIES HI. ARTHROSIA PODAGRA (Scont. AAIN, INFLAMMATION, AND FULNESS, CHIEFLY ABOUT THE SMALLER JOINTS : RETURNING AFTER INTERVALS ; OFTEN PRECEDED BY, OR ALTERNATING WITH, UNUSUAL AFFECTIONS OF THE STOMACH, OR OTHER PARTS J UNSUPPURATIVE. The origin of the term gout, or goute in French, is little known, or rather is almost forgotten. Among the ancients most diseases accom- panied with tumefaction were ascribed to a flow of some morbid fluid or humour to the part affected, which Avas called a rheum or defluxion : and the rheum or defluxion was denominated cold, hot, acrid, saline, or viscid, according to the nature of the symptoms. The Arabian writers ascribed even this cause to various diseases of the eyes, which were hence called .gutta serena and gutta obsura. " clear or cloudy drops or defluxions," according to the external appearance. Rheumatism and gout were alike attributed to the same origin : and as the terms rheuma and gutta were used in medi- cine synonymously, both importing defluxion, the old opinion is still verbaHy preserved, and has descended to us in the names of rheu- matism and gout, though the old pathology has been abandoned. "We have still," says Dr. Parr," the treatise of Carpinati publish- ed at Padua m 1609, De Gutta seu Junctuarum dolore;" but the term may be traced to Valescus de Tarenta, who wrote his Com- * Medical Reports, 336 HiEMATICA. [CL. HI.—OR. If. mentary early in the fifteenth century; and Schneider in his Liber Catarrhorum Specialissiinus, published at Wittenbergh in 1664, usu- ally denominated the sixth volume, and peculiarly scarce, describes the gout as a catarrh."* The resemblance betAveen gout and rheumatism is so close that the one is often mistaken for the other; and both by Bergius were regarded as convertible : yet, while the former chiefly fixes on the small joints, the latter attacks the large; and the first is often here- ditary, Avhile the second is rarely or never so. We have also ob- served already that gout is far more connected Aijjth a dyspeptic state of the stomach than rheumatism ; that its incursions are, for the most part., more sudden, its nocturnal exacerbations less strik- ing, but its remissions much clearer. Gout, moreover, is a far more complicated complaint than rheu- matism : and hence there is no disease to Avhich the human frame is subject that has lead to such a variety of opinions, both in theory and practice, many of them directly contradictory to each other, as the gout; and I may add, there is no disease concerning the nature and treatment of which physicians are so little agreed : so that to this moment it constitutes perhaps the Avidest field for empyricism, and the hottest for warfare, of any that lie within the domain of medical science. Is the gout a local or a constitutional affection ? is it a spasm or a poison? is its course beneficial or mischievous ? should its inflam- mation be encouraged or counteracted? is it to be concentrated or repelled ? is it to Be treated with cordials or evacuants ? with cold or with heat ? wfth a phlogistic or an antiphlogistic regimen ? No sets of questions can be more repugnant to each other than these are ; and yet there is not one of them but we may obtain an answer to either in the negative or in the affirmative, by applying to diffe- rent practitioners for this purpose. Shutting the door to disputation and unfounded theory as far as we are able, let us, in as few words as possible, attend to the clear and established history of this disease, as we would to that of any other, and draw our pathology, and our mode of practice from the principles Avhich it will be fairly found to inculcate. In the first place, it is admitted on all hands, or at least with ex- ceptions so few as scarcely to disturb the general consent, that gout, in whatever Avay it shows itself, is a disease of the system ; or, in other words, is dependent upon a peculiar diathesis or state of the constitution. And, next, it is as commonly admitted that this dia- thesis is, in some instances, original, and in others hereditary or de- rived. There are many persons in whom this complaint makes its appearance, Avho can trace no such affection in the blood of their an- cestors ; and as such persons are specially distinguished by a habit of indolence, luxury, and indulgence, and particularly in the plea- sures of the table, it is from this habit that the gouty diathesis is • Med. Diet. App. GE. XII.—SP. III.] SANGUINEOUS FUNCTION. 337 supposed to originate. There are others, who, though exhibiting a life of great regularity and abstemiousness, afford proofs of the same diathesis in occasional paroxysms to which it gives rise: and such persons are almost always capable of tracing it hereditarily. For the diathesis having once established itself, keeps its hold on the system, and is propagated from race to race whatever be the man ner of life of the individual, or the general state of his constitution ; though there can be no question that those descendants are most subject to its paroxysms who indulge in the excesses that laid its first foundation. A gouty diathesis thus produced, like a phlogotic diathesis, to which in may respects it makes a near approach, may remain quiescent and not discover itself for years, till it meets with some occasional cause of excitement, Avhen it shows itself by a sudden and painful disturbance of some part of the system, but a distur- ance of a very different kind, as well as affecting very different or- gans, according to the temperament, constitution, manner of life, or some incidental circumstance of the individual where the general health is sound, fixing on one or more of the extremities in the form of a peculiar but very acute inflammation that runs through a regu- lar paroxysm and gradually subsides : and, where the health is in- firm, and the general form debilitated, exciting great derangement in some internal organ or set of organs, and particularly those of digestion ; or shifting from one form to another, and thus proving itself under every form to be the same disease, and laying a foun- dation for the three following varieties :— * Regularis. Pain, swelling, and inflammation of the Regular fit of gout. affected joint considerable and acute; continuing for several days, often with remissions and exacerbations; then gradually resolving, and leaving the constitution in its usual or improved health. p Larvata. Disguised and lurking in the constitution Disguised ; lurking; and producing derangement in the di- atonic gout. gestive or other functions, with only slight or fugitive affection of the joints. y Complicata. The disease fixing on some internal or- Retrograde; recedent; gan instead of on the joints; or sudden- misplaced gout. ly transferred from the joints after having fixed there; producing in the internal organ affected, debility or in- flammation according to the state of the constitution. The predisposing cause of a gouty diathesis, when it first forms itself in an individual, it has already been observed, is plethora with entonic condition of the vessels. And hence in its origin, u> Avell as VOL. II.—43 338 HiEMATICA, [CL.HL—OR. H in the symptoms it evinces under a regular paroxysm, gout makes a near approach to various other inflammations of which we have al- ready treated; and is more disposed to show itself, where it has been transmitted hereditarily in men of robust and large bodies, of large heads, of full and corpulent, and especially gluttonous habits, or whose skin exhibits a coarser surface in consequence of being covered with a thicker rete mucosum. Castration is said to act as a general preventive ; but on Avhat facts I know not: though, ad- mitting the truth of the assertion, it is not difficult to explain the reason, from the entonic energy demanded for the first production of the disease. Such is a brief history of the origin, hereditary transmission, and effects of the podagric diathesis ; which must be distinguished from the paroxysms to which it gives rise, and which constitute the only manifest indications of its existence. The paroxysms of gout are excited by certain occasional causes, some of which are obvious and some doubtful, or altogether un- known ; but, without the co-operation of these, the gouty diathesis may remain unnoticed or quiescent in the body for years, or pre- haps through the whole term of a man's life. And hence it is that Ave often see an individual, whose ancestors have been notorious for this complaint, pass the whole of his days Avithout betraying any marks of it, Avhile it appears in one or more of his children, perhaps in their A'ery boyhood. The occasional causes are very numerous; for where the diathe- sis exists strongly, almost any thing that is capable of producing a general disturbance in the system, or of throAving it off the balance of ordinary health, is sufficient to become a cause ; and this whether the incitement be of an entonic or an atonic character. And hence paroxysms in different individuals are often produced by intoxica- tion, or excess of eating ; violent emotions of the mind, particularly the depressing passions, as grief and terror; sudden exposure to cold Avhen the skin is in a state of perspiration ; wet applied to the feet; great labour of the body; severe application of the mind, especial- ly when protracted so as to break in upon a due allowance of sleep; co'ld, flatulent fruits, and often acidulous liquors; a sudden change from a spare to a full, or from a full to a spare, diet; excessive eva- cuations of any kind ; and, occasionally, a sudden cessation of such as are habitual, as the suppression of a periodic hemorrhoidal flux, the cessation of the catanienia, or even the closing of an issue that has long been in a state of discharge. It seems, moreover, indisputable that the more violent the attack of a paroxysm, and the longer its continuance, the more the dia- thesis is confirmed, and the oftener the attack is renewed. On which account it is of great importance to alleviate and abridge the paroxysms as much as possible, and especially when they are as yet new to the system. Whether particular climates or countries are more disposed to favour the existence of gout than others, separate from the occa- GE.Xn__SP. III.] SANGUINEOUS FUNCTION. 339 sional causes just adverted to, may be doubted. Such an opinion, however, has prevailed among the vulgar as well as among many of the more learned in most ages. Thus, among the Greeks, it was a popular belief that Attica was the hot-bed of gout, as Achaia was of ophthalmy ; whence Lucretius, Atthide tentantur gressus, oculeique in Achxis finibus.* Gout clogs the feet in Attica, the sight Fails in Achaia. And thus, too, in more recent times, we are told that China,t and even some of the German provinces, are exempt from the attack of gout, while in our owr, country it exercises an almost irresistible sway. The last assertion is true enough, but we are not driven to the variable nature of our climate to account for the fact. Thus far we can proceed safely respecting the general pathology of this Proteus-disease. But the moment we enter upon the field of its proximate cause, we are bewildered in a hopeless labyrinth, without a thread to guide our entangled footsteps amidst the growing darkness. There has, indeed, been no want of attempts to explain the subject, but thus far they have been attempts alone—ingenious conjectures rather than enucleated facts. Thus some, among whom was the learned Boerhaave, resolved the proximate cause of gout into a morbid texture of the nerves and capillaries ; and others, into a peculiar acrimony of the fluids ; respecting the nature of which, hoAvever, those who adopted this view were never able to agree ; several of them, like Hoffman, affirming it to be a tartaric salt, several a bilious salt, several again an acid, and several again an akali. This morbid material, in whatever it consists, was supposed to be separated from the system and thrown offf during the continuance of the paroxysm, which, consequently, it became the duty of the physician to encourage. And by some pathologists it was held that the morbid matter thus despumated has, in various instances, proved contagious, and this not to man only, but to other animals as well: thus M. Pietsch informs us that he has known dogs affected with the same disease by licking the ulcers that have followed upon a fit of gout accompanied with chalk-stones. Dr. Cullen has taken great pains in a series of nine consequutive arguments to prove the error or absurdity of most of these opinions ; and then proceeds to establish his own ; which consists in regard- ing the proximate cause of a gouty diathesis as dependent upon a certain vigorous and plethoric state of the system ; and the proxi- mate cause of a gouty paroxysm as produced by an occasional loss * De Her. Nat. VI. 1117. f Le Conte, Nouvelles Memoires sur P£tat present de la Chine. Paris, 1696. * Schaffer Vera. II. p. 176, who denies it: and Degner De Dysenteria, who maintains it. 340 1I.SMATICA. [CL. III.—OR. 11. of tone in the extremities, often communicated to the whole system, but especially to the stomach, succeeded by a p'owerful re-action in the same quarter, which constitutes the pain and inflammation, and is an effort of the vis medicatrix naturae to restore the tone thus injured,* But by this hypothesis we gain as little as by any of the preceding. It is obviously a mere extension of the Cullenian doctrine of fever to the disease before us, and is chargeable with the same incongruity ; for here, as in fever, the stage of strength or increased energy is made to depend upon the stage of weakness ; as the weakness or loss of tone is made dependent upon a peculiar vigour and plethoric state of the system. There is, indeed, no great difficulty in conceiving how loss of tone may follow upon excess of energy ; but by what means recovered energy is to be a result of loss of tone, is a problem of more laborious solution. I have dwelt the longer upon this subject because it involves a very essential point in the remedial process, and one which has rarely been sufficiently attended to : before Ave enter upon which, however, it may not be inexpedient to take a fuller glance at the symptoms by which the different varieties of the disease are distin- guished. One of the marks by which a regular paroxysm of gout is said to be distinguished from that of rheumatism, is the suddenness of its onset. This is true, as Sydenham has correctly observed, with regard to the general course of regular or entonic gout, in which the constitution is in other respects perfectly sound. But in other cases the fit is often preceded by certain prodromi which those who have suffered from it before very sufficiently understand, and uniformly take as a warning ; such as a coldness or numbness of the loAver limbs, alternating with a sense of pricking or formication along their entire length : frequent cramps of the. muscles of the legs ; a crassament in the urine ;t slight shiverings over the surface; languor and flatulency of the stomach; and sometimes a pain ovei the eye-lids or in some other organ.$ The paroxysm is said by Dr. Sydenham, who has drawn its picture to the life, to show itself most commonly in January or February; but I have known it occur so often towards the close of the summer, and in the autumn, and have attended so many patients who have never had it except in the latter seasons, that the rule does not seem to be any way very well established. The first attack is usually in one of the feet, most commonly about the ball or first joint of the great toe; it commences at night or during the night, and there is sometimes, though not always, a slight horror, succeeded by a hot stage. The local pain and swelling increase in violence, the joint assumes a fiery redness, and the whole body is in • Pract. of Phys. Part I. B. II. Ch. XIV. DXXXI1I. f Butler, Nadere out dekkinge der menschelyke Waters. Harlem. 1697. * Eph. Nat. Cur. Dec. 1. Ann. III. Obs. 252 GE. XII.—SP. HI.] SANGUINEOUS FUNCTION. 341 a state of great restlessness. The symptoms remit sometimes towards the next morning, yet occasionally not till the morning after; but they still return during the night, though in a more tolerable degree, for three or four days, or even a week; Avhen the inflammation subsides as by resolution; the foot almost instantly recovers its vigour, as though nothing had been the matter with it; and if the patient have been antecedently indisposed, he enjoys, as on recovering from an ague, an alacrity of body and mind beyond what he has experienced for a long time before ; the constitutional indisposition disappearing with the paroxysm. At the commencement of the disease, the return of it may be annual, or not oftener than once in three or four years ; but it is perpetually encroaching on the constitution, so that the intervals gradually become shorter, and the attacks more frequent and of longer continuance: Avhence, as Dr. Cullen has justly observed, " in an advanced state of the disease, the patient is hardly ever tolerably free from it, except perhaps for two or three months in the summer." Nothing can be more specific, more true to itself, or more distinct from every other kind of inflammation than that of the disease before us, when thus exhibited in a regular fit; the inflam- mation of erythema does not differ more from that of phlegmon than both these, and indeed every other from that of gout: it never suppurates, never ulcerates when simple and genuine, however violent may be the attack, and though to the eye of inexperience the skin may seem to be on the point of bursting; while, in the midst of the severest pain, there is a sense of numbness, Aveight, and want of energy; insomuch, that if the pain could for a moment be forgotten, the limb would feel paralytic; and though the muscles which move the limb be not affected, they raise it or drag it along like a dead load. If the inflammation run through its course where it first fixes, it subsides by a resolution that leaves no external discoloration or internal weakness or disability; and if it make a transfer from one extremity to another, it passes with inconceivable rapidity; the limb now affected being loaded with all the vehemence of the inflammatory action ; and that lately the seat of pain being all of a sudden restored to perfect soundness. It is rarely, however, that any metastasis takes place on its first appearance in a healthy constitution ; nor indeed till after various organs or the entire habit has been weakened by repeated assaults. We have already observed that it is the nature of the disease to weaken the habit in this manner, till the system is completely broken down, as well in mind as in body, and becomes a prey to its tyrannic control. In this case the paroxysms, though much longer and more frequent, are less violent and painful than at first; but there is no joint exempt from its incursion, nor perhaps an inter- nal organ that does not suffer from induced Aveakness: so that, in the language of Sydenham, " the patient exists only to be wretched and miserable, and not at all to taste of the happiness of life." 342 II^MATICA. [CL. HI.—OR. II. It is a remarkable fact, hitherto indeed little dwelt upon and alto- gether unaccounted for, that as the system advances in years and debility, and every other secretion progressively fails, that of calcareous earth seems to increase. Hence the bones of aged persons are more fragile and apt to break upon slight concussions; and the arteries and various other parts become ossified or loaded with nodules of lime-stone; and where a poAverful sympathy exists between the kidneys and the stomach, and either of these is in an infirm state, we have a larger deposit of the same material in the kidneys or the bladder. A similar increase of calcareous earth takes place in the Aveakness of chronic gout; every aflected joint becomes loaded Avith its secretion, which collects and hardens into nodules in its cavities, or in the adjoining cellular membrane, or bursae mucosae, and renders motion uneasy or destroys it altogether. The lime-stone, moreover, as it hardens, acts as a foreign irritant to the distended integuments, and produces, what simple inflam- mation of the gout never does, ulcerations and an offensive dis- charge. For the same reason nephritic calculi are often a sequel of gout when it has assumed a chronic form ; and the children of gouty parents are said to be hereditarily disposed to both complaints, some of them exhibiting a podagric and others a nephritic affection. Thus far we have followed up the progress of a regular attack of gout in a constitution otherwise healthy and vigorous. But the same diathesis exists in systems of delicate and infirm health, and where there is a want of sufficient energy to work up a fit of inflammation, and throw it off at its appropriate outlets. And in such case, as soon as it becomes roused into action by any of the causes of excitement already enumerated, it constitutes the second variety, assumes the guise of various other diseases, as dyspepsy, hysteria, hypochondrias, palpitations of the heart, vertigo, hemi- crania, with several modifications of palsy or apoplexy. The stomach and bowels, however, form the chief seat of affection; the appetite is fastidious or destroyed; a spasmodic stricture of painful oppression is felt in the epigastric region, or the stomach is distended almost to bursting with flatulence; nausea, eructations, vomiting, and all the symptoms of indigestion follow, and are alter- nated with severe colic or costiveness. In the mean while the disease shows itself at times, in one or more of the joints in slight and fugitive pains, as though making an ineffectual effort to kindle up a paroxysm of proper inflammation, but which there is not energy enough in the system to accomplish; whence the articular pains cease almost as soon as they appear; and the visceral derange- ment is renewed; sometimes slowly subsiding after a continuance of several weeks; and sometimes wearing out the entire frame, and terminating in abdominal or cellular dropsy. In sometimes happens, however, that while the general constitu- tion of a podagric patient is tolerably sound, one or more of the internal organs form an exception to the general rule, and are less healthy than the rest. And as upon an excitement of gouty inflam- GE. XII.—SP. HI.] SANGUINEOUS FUNCTION. 343 mation in a gouty habit, the inflammation seizes ordinarily upon Hie weakest part of the body, it makes its assault upon such organ rather than upon tne hands or the feet; or, if it commence in the latter, is readily transferred to it; constituting the third of the va- rieties before us, and which has usually been called retrograde or misplaced gout. And if the general system should, at the same time, be below the ordinary tone of health when the paroxysm is thus excited by the force of some occasional cause, the organ affect- ed may evince great languor and painful inertness, as in the second variety, rather than acute inflammation, as in the first. The sen- sation in the stomach, instead of being that of a fiery coal, is that of a cold lump of lead ; in the head it changes from maddening pain to oppressive horror, in which the patient suddenly starts from sleep almost as soon as he has began to doze, from the hideousness of the ideas that rush across the mind and form the distracting dream. The fit is sometimes transferred to the bladder; in which case there is acute pain at the neck of the organ, siranguary, and a dis- charge of thin acrid mucus from the urethra. The rectum has also been occasionally the seat of metastasis, and has evinced vari- ous species of affection, as simple vehement pain, spastic constric* tion, or hemorrhoidal tumours. When thrown upon the lungs it mimics the symptoms of a peripneumony. In applying the art of medicine to the cure or alleviation of gout, our attention must be directed to the state of the patient during the paroxysms, and during their intervals: and particularly to the state of his constitution or previous habits, which according to their character may demand a different and even an opposite mode of management. Let us commence with the paroxysmal treatment : and, first of all, with that of the inflammatory attack, as it shows itself in a re- gular fit of the disease. It was formerly the belief, as we have already seen, that a gouty paroxysm was an effort of nature to throw off from the constitution, and thereby restore it to a state of perfect health, some peccant matter forming the proximate cause of the distemper; and it Avas hence, also, conceived, in addition, to adopt the language of Syden- ham, that the more vehement the fit, the sooner it will be t. er, and the longer and more perfect the intermission. And in his view of the subject there can be no question that the wisest plan must have been that of leaving the paroxysm to run through its regular course without interruption. Yet, as this hypothesis has long fallen into discredit, we are not in the present day prevented, on such ground, from endeavouring to subdue the inflammation of a gouty paroxysm by the ordinary means resorted to in inflamma- tions of any other kind, as bleeding, purgatives, sudorifics, local as- tringents, and even refrigerants. But a very general objection has since been taken to this plan on another ground, and that is, the great danger of repelling the disease to some internal organ of 344 H-EMATTCA. [CL. III.—OR. H. more importance, and thus of converting a regular paroxysm into a case of retrograde or atonic gout. And in consequence of this ap- prehension, the practice, even in the hands of many of our most celebrated physicians, has, for a long period, been in the highest degree vague and vacillating. Sydenham prohibited equally purg- ing and sweating of every kind, whether gentle or copious, and only allowed bleeding where the patient was young and vigorous, and on the first or second paroxysm : while of cold applications he takes no notice whatever. He admits, hoAvever, the use of lauda- num where the pain is very acute: trusting chiefly for the cure of the disease to an alterant regimen and apozems to be resorted to in the intervals. Dr. Cullen allows bleeding with the same restric- tion as Sydenham, though he recommends the application of leeches to the inflamed part, as at all times a safer practice than the use of the lancet. Of cathartics and sudorifics he takes no notice other- wise than as these may enter into the general course of an anti- phlogistic regimen ; he is decidedly adverse to the use of cold ; and thinks that warm-bathing and emollient poultices, blistering, burn- ing with moxa, camphorate and aromatic oils, induce the inflam- mation to shift from one part to another, and consequently tend to repel the inflammation from the extremities to some more import- ant organ : while opium, though it affords relief in present parox- ysms, occasions them to return Avith greater violence; and, there- fore, he observes, by way of conclusion, " The common practice of committing the person to patience and flannel alone, is establish- ed upon the best foundation."* Now, as we have already seen that the gout, after it has shown itself in paroxysms, is never idle ; that one paroxysm, in the opinion of Sydenham, Cullen, and every other physician, hastens on another, renders its intervals shorter, and its duration longer; and progres- sively saps all the energies both of mind and body, and renders life itself a burden ; it is of serious importance to inquire whether this fear of a repulsion, however well founded in some instances, is not allowed too generally ; whether it be not possible to draw a definite line between the form of the disease in which it ought to operate, and that in which it ought not ? and whether in the latter case we may not derive all the benefit from a full use of a reducing process, Avhich is obtained in other inflammations, accompanied with a like degree of constitutional vigour ? From the history of this disease, as it has already passed before us, we may draw this general corollary: that the specific inflam- mation of gout, or whatever other morbid character it may evince, when once excited by some occasional cause into action, has a pe- culiar tendency to fix and expand itself upon the weakest parts of the system, and Avhere several parts are equally weak, to pass in sudden transitions from one part to another, though transitions are rare where the system is sound. • First Lines of the Practice of Physic, Aph. DLX1X. GE. XII.—SP. HI.] SANGUINEOUS FUNCTION. 345 In healthy constitutions the weakest parts are the extremities; and hence, in such constitutions, these are the parts, as we have already seen, in which the gout uniformly opens its assault. Here it commences, and here it runs through its course, seldom migrat- ing, or, when it does migrate, only passing from one extremity to another; as from foot to foot, or from one of the feet to one of the hands; and limiting itself to these quarters, because they are the weakest parts of the system : though, as just observed, in a tho- roughly sound constitution such migrations are not common. In unhealthy habits, however, the extremities are not the Aveak- est parts of the system, but perhaps the stomach, or the heart, or the head, or the lungs, or some other organ ; while several of these organs may, moreover, be equally debilitated, according to the idiosyncrasy, or to accidental circumstances. And true to the general rule, we see the gouty principle, when roused into action in habits of this kind, fixing itself from the first on one of those im- portant viscera rather than on the extremities; or roaming from one to another, on its alternating its course from these organs to the extremities, or from the extremities to these organs. And as metastases are rare where the system is sound, they become fre- quent in proportion as it loses this character, and especially in pre portion to its debility in particular. These are rules which we cannot tob closely study and commit to memory, and they seem to point out to us the line of distinction between that form of the disease in which we ought to entertain a prudent fear of revulsion, and that in which we may safely act Avithout any such fear whatever. They directly lead us to two states of constitution that require a very different, and in many in- stances a very opposite mode of treatment; and seem to settle the important question before us, under what circumstances it may be expedient to employ a palliative plan ; and under what a cooling and reductive. Let us commence with the first of these two states, forming a regular but violent fit of gout as it shows itself in a sound constitu- tion, and inflicts its torture on the hand or the foot. Guiding our- selves by the laws just laid doAvn, there seems no reason why, in- stead of " committing the person to patience and flannel alone," we should not pursue the evacuating and refrigerant means employ- ed in entonic inflammations of any other kind, and have cause to expect a like success : such as bleeding, so strongly recommended by Dr. Heberden, and allowed occasionally by Sydenham, and emptying the bowels, relaxing the skin generally, and cooling the fiery heat of the affected limb by cold water or any other frigorific application. With a transfer of morbific matter we have now no longer to contend. Yet, even where such a cause is admitted, as in most exanthems, the plan thus proposed is, in many instances, pursued Avithout hesitation. Thus, in measles, cathartics and vene- section arc not only in general use, but often indispensable; in the height of malignant scarlet fever, Ave sponge or wash the eniir^ vol. n.—44 346 ILEMATICA. [CL. III.—OR. IF surface of the body Avith cold Avater; and in small-pox, not only purge freely, but expose the patient to the coldest atmosphere of the winter-season. In weakly habits, or idiosyncrasies, or incidental debilities of particular organs, Ave have admitted that a metastasis, as we have already seen, is a frequent result, and peculiarly marks the charac- ter of gouty inflammation; and here, indeed, refrigerants, violent purgatives, and venesection ought to be most sedulously abstained from; and not unfrequently the best practice Ave can adopt is that of " committing the person to patience and flannel alone." But what I am anxious to establish is, that, agreeably to the laws which regulate the progress of gout, a metastasis in sound and vigorous constitutions is rarely to be expected, and perhaps never takes place except from one extremity to another. In order that some internal organ may become the seat of transferred gout, it is neces- sary that it should possess a weaker action than the part from Avhich the inflammation is to be transferred: but the parts of Aveak- est action in a sound and vigorous constitution are the extremities themselves: and it is probably because the living energy is, in all the extremities, upon a balance, that in a sound frame a metastasis, even from one extremity to another, is a rare occurrence. Local infirmity seems to form the only ground for a metastasis ; but where health prevails generally, and all the organs are equally sound, admitting the inflammatory action, instead of being reduced and resolved, to be repelled, there is no one organ to which it seems capable of being transferred rather than to another; and in such case it would be most reasonable to suppose that the morbid entony Avould be throAvn back generally and divided amongst the whole, from which division of labour little mischief could happen. As far as I have seen, the inflammation of a regular fit of gout subsides gradually, though rapidly, under the treatment now propos- ed, Avithout any repulsion whatever. Yet, in a few instances, it has seemed to be repelled in part, whilst it has chiefly passed off by re- solution. For during the use of a cold pediluvium or shortly after- wards, I have known patients speak of a peculiar kind of aura creep- ing over them and through them, and exciting an undefinable sense of glowing which has lasted for a few minutes, without any inconve- nience at the time, or even any change in the pulse; and certainly without any ill effect afterwards. But it may be replied, there is no resisting facts. The cases are innumerable in Avhich great mischief has resulted from the deplet- ing and the refrigerant plan; and, as we cannot always tell that all the internal organs are or are not in a state of sound health, it is most prudent to abstain from a practice which may prove highly in- jurious in case of a mistake. The answer to this remark is, that here, as well as in every other disease, professional judgment is to be called into exercise, and the practitioner is to draw largely upon that skill and discrimination which it Avas the object of his education to bestow upon him: and GE. XII.—SP. HI.] SANGUINEOUS FUNCTION. 341 thus bestirring himself, he will rarely fall into an error. That mis- chief has resulted, and frequently, from the use of the plan before us, cannot be denied by any one; but that great and essential good, and an easy and rapid cure have been also, in hundreds of instances effected, must be admitted as readily. No clear distinctive line, however, has hitherto, as far as I am acquainted with been acted upon or even laid doAvn: and hence it is rather to be ascribed to a Avant of discrimination upon this subject-that the evils adverted to are chargeable than to any mischief in the plan itself. Yet it may be doubted whether the injury produced even by an injudicious use of evacuants and refrigerants amounts to a thousandth part of that entailed on the constitution by allowing the gout to make its inroads tacitly and unresisted; till by degrees it triumphs equally over all the powers, as well of the body as of the mind, and in the forcible language of Sydenham, " The miserable wretch is at length so hap- py as to die." Of the benefit produced by the external use of cold water the au- thor can speak from a trial of several years upon his own person, and is only anxious that others should participate in what has prov- ed so decisive a comfort to himself. The author, in the enjoyment of undisturbed health, amidst great exercise of body and mind, which however acted as a relief to each other, was, for the first time, in his forty-seventh year, attacked with a regular fit of gout, in one of his feet, some of his ancestors having been subject to the same complaint. Having long before drawn the distinctive line of treatment just adverted to, and carried it successfully into practice, he Avas on the point of trying it on him- self, and particularly the affusion of cold water; but his family were so alarmed at the proposal, that he consented for the term of three days but no longer, to follow the Cullenian prescription, and to em- ploy nothing but flannel and as much patience as he could command. The foot was in consequence warmly wrapped up, and the sofa re- ceived him when he quitted the bed. The inflammation was exten- sive, and very painful, the pain, however, remitted occasionally in the day, yet returned towards night with a vehemence that en- tirely deprived him of sleep, and kept him in a profuse perspiration; but a perspiration that afforded no relief. The limited time having expired, and the inflammation having gradually augmented instead of subsiding, early on the third morning he called for a large basin of cold Avater, stripped off the flannel, and boldly plunged the foot into it for four or five times in succession. The application was pecu- liarly refreshing; the fiery heat and pain, and all the inflammatory symptoms diminished instantly ; he repeated the cold bathing tAVo hours afterwards, and continued to do so through the whole of the day; the complaint gradually diminishing upon every repetition. He slept soundly all night, the pain was trifling, and the inflamma- tion had almost subsided by the morning: he was able to hobble a little in the course of the day ; and in four and twenty hours more the fit completely disappeared, and he was capable of resuming his 34S H.fcMATJCA. [CL.II1—OR. II. accustomed exercise of walking. For five or six years afterwards he suffered annually from a like attack, but always had immediate recourse to cold immersion or affusion. No paroxysm continued • longer than about three days, nor any one ever confined him totally to his house for a single day. Since this period, the use of a car- riage has prevented the excess of fatigue which he had hitherto of- ten undergone; but from a love of walking he still, frequently in- dulges in it; and for about the last three years he has had neither gout nor any other complaint to interrupt his usual career of good health. During the preceding paroxysm, the appetite being good, the bowels regular, and the pulse not much quickened, he made use of no collateral means, nor ever found the use of the cold water productive of the least inconvenience ; though he has occasionally been sensible of a gradual creeping through the system of the pecu- liar aura just adverted to, which may perhaps be called the aura fiodagrica, but which constituted no unpleasent sensation. The practice before us, hoAvever, is by no means of mpdern inven- tion, however it may have become a subject of warm controversy in the present day. An active evacuant plan, both by venesection and purging has never ceased to be in use among many practitioners, and is particularly alluded to by Sydenham, though with a vieAV of entering his protest against it, as injurious to a free discharge of the peccant matter, which in his opinion, required to be carried off; Avhile, Avith respect to the external use of cold water, not to men- tion that it seems to be alluded to by several of the Greek writers, and especially by Hippocrates,* it has descended in a stream of re- commendation from Zacutus Lusitanusf in 1641 to Kolhaas,f and Keck§ in 1788 and 1789 ; Bartholin speaks of the use of snow as a common application in 1661,|| and Pechlin both of snow and cold sea-water towards the close of the same century .If But this treatment, I am ready to admit, has often been employed rashly and sometimes with great and even fatal mischief. It ought never to. be ventured upon, except, as already stated, where the con- stitution is decidedly sound and vigorous; for though I subscribe to much of Dr. Kinglake's therapeutic plan, I cannot agree with him that a gouty paroxysm is a merely local affection. The treatment before us should be limited to those who are in full vigour, and per- haps entony of health ; and is especially to be avoided where the stomach is dyspeptic, the lungs asthmatic, the heart subject to pal- pitation, the head to nervous pains or drowsiness; or where there is any knoAvn disability in any other important organ. * Aphor. Sect. V- p. 25. f De Medicorum Princip. Historia, Lib. Ill Amsterd. 1641. i Baldinger, Neuer, Mag. Band. V. p. 521. 1788. § Abhandlungen und Beobachtungen. Berl. 1789. jj De usu nivis medico, 1661, 8vo. % Observ. Physico-med. Hamb. 1691, 4to< GE. X1L—SP. III.] SANGUINEOUS FUNCTION. 349 Yet even here avc need not, I think, condemn the sufferer to the torture till cured by patience and flannel; for it will often be in our power at least to palliate his pain, and not unfrequently to expedite his cure, without any risk whatever of affecting his general state of health. Leeches may, in many instances, be applied Avhere vene- section Avould be of doubtful expediency; a liniment of oil of al- monds impregnated with opium, rubbed on the tumefaction Avith a pro- tracted and very gentle friction, I have often found highly serviceable in mitigating the pain ; and epithemsof tepid Avater,as recommend- ed by Dr. Scudamore, alone or mixed with a portion of ether or al- cohol, formed by cloths wetted with the fluid, and applied to the in- flamed part, renewable as they become dry, in many cases prove a grateful substitute for cold water; and are preferable to poultices, Avarm Avatcr, or even vapour-baths, which too generally relax and weaken the joint, and prevent it from recovering its elasticity, after the paroxysm is over, so soon as it otherwise Avould do. At the same time the body should be cooled Avith gentle aperients or injections; and while drenching sAveats are avoided,Avhich never fail to be injurious, the breathing moisture or diapnoe should be imi- tated, which often breaks forth naturally in an early part of the morning, and is sure to afford relief after a night of distraction. Nor should opium be omitted Avhere the pain is very acute; for, Avhile it affords temporary ease, it diminishes the duration as well as the violence of the paroxysm. Dr. Cullen, in his Practice of Phy- sic, seems disposed to postpone the use of this medicine till the pa- roxysms have abated in their violence, for when given in the begin- ning of gouty paroxysms he asserts that it occasions the fits to return with additional fury. Yet it should never be forgotten, that it is a law in the history of gout, and one to Avhich we have already adverted, that the frequency and vehemence of the ensu- ing paroxysms are measured by the violence of those that have preceded. In the mean Avhile, the regimen should be light and inirritant; and the diet below the standard to which the patient has been accustom- ed ; though to guard against a metastasis to the stomach, we must be cautious that we do nqt reduce it too much. His beverage should be cool and unstimulant: Sydenham alloAVs him sound table beer, and, if he have been accustomed to stronger malt liquors, such a drink may be conceded to him. His chamber should be well ven- tilated, and his dress light and easy. In the two ensuing varieties, constituting atonic and retrocedent gout, we have a podagric diathesis grafted upon an unsound frame; the unsoundness being general or local: and, however fearless we may be of the disease fixing on any internal organ in the preceding variety, we have here a constant apprehension that it may do so, and in many cases see it commence in such organs. In atonic gout, our uniform attempt should be to produce a trans- fer from the part on which it has seized, and fix it in the extremi- 350 HJEMATICA. [CL. HI.—OR. H ties. In retrocedent gout, on the contrary, to render the vacillat- ing attack on the extremities more permanent, and prevent it from shifting to any other quarter. To obtain the first intention, we have to strengthen and even sti- mulate the system generally by warm tonics and a generous diet, and above all things to take offthe'severe suffering, in whatever it may consist, from the affected organ ; for the longer the fit conti- nues there, the weaker it will become, and the less capable of any instinctive remedial exertion. At the same time Ave may so- licit the paroxysm to the extremities by putting the feet into warm water, and thus unstringing the tone of their vessels; so as to bring the standard of their atony below that of the affected organ. In atonic gout, the sufferings, though widely different according to the seat of the disease, are almost insupportable. In the head the pain is maddening, or the disorder is accompanied with great horror, or mimics the stupor of an apoplexy : in the stomach there is a faintness like that of death, with the sense of a cold lump of lead lodged Avithin it; or there is a gnawing or a burning agony, or a spasmodic stricture which cuts the body in two, and renders breath- ing almost impossible; often also accompanied with a rapid and sinking palpitation of the heart. It is of importance, before wc proceed, to determine accurately that these anomalous symptoms are really those of gout; of which we have chiefly to judge from the general character of the patient's constitution, his hereditary predisposition, habits of life, and the ailments to Avhich he has been previously subject. In most cases, during the paroxysm, and especially where the stomach is affected, the warmest cordials are necessary, as brandy, the aromatic spirit of ammonia, the tincture of ginger or of capsicum ; or, what is still better, usquebaugh. And it is always advantageous, and especially Avhere the bowels are confined, to add to it some warm aperient, as aloes of rhubarb. Most of our family gout-cordials are made upon this principle, and judiciously consist of some active aperient and the hottest aromatics dissolved in ardent spirits. And the patient who is subject to these attacks should never be without having some- thing of this kind at hand, since the paroxysm often makes its onset Avithout any warning. Yet he should resolutely forbear having re- course to any such medicine except in the time of necessity ; for an habitual indulgence in any of them will still farther debilitate the affected organ, and indeed the entire system ; and hence quick- en the returns of the paroxysm, and render the stimulant antidote less availing. Most of the preparations of ether contained in the current Phar- macopoeia of the London College, may be employed with benefit in the variety before us, and particularly in that icy coldness of the stomach, accompanied with the numbness of the limbs and a rapid palpitation of the heart, under which it occasionally exhibits itself. Phosphorus itself has sometimes been ventured upon in this case? GE. XII.-SP. III.] SANGUINEOUS FUNCTION. 351 in the proportion of two or three grains to a dose dissolved in dou- ble the proportion of ether; but I have never employed it, and cannot speak of its good effects. Musk seems in many instances to have been of decided advantage if given in sufficient doses, as well in gouty affections of the head as of the stomach. The case related by Mr. James Pringle is strikingly in its favour,* and seems to have induced Dr. Cullen to make trial of it in similar instances, who found it produce sudden relief by free doses repeated after short in- tervals ; and this where the lungs as well as the head and stomach were the seat of transferred disease.f External irritants may also be beneficially employed at the same time, and particularly those of rapid action, as the compound cam- phor liniment, sinapisms, and the burning of moxa, or coarse flax as recommended by Hippocrates : at the same time the extremities, as already advised, should be plunged into theAvarm bath. But our sheet-anchor is opium : and it should be given freely, and in union Avith some preparation of antimony, so as to act towards the surface generally, and thus restore to the living power its in- terrupted equilibrium. Small doses of opium will here be of no avail; and we may generally repeat or increase the quantity to a large amount with perfect safety. "In a case of the gout in the stomach," says Dr. Cullen, « I have by degrees gone on to the dose Sf ten grains twice a-day ; and when the disease was overcome, the dose of opium was gradually diminished, till in the course of two or three weeks it was none at all; and in all this no harm appeared to be done to the system. We frequently find, that Avhen a strong ir- ritation is to be overcome, very large doses may be given without procuring sleep, or showing any of those deleterious effects that in other cases appear from much smaller quantities given. All this appears from the practice now well known in tetanus, mania, small- pox, gout, and syphilis."| In retrocedent.gout the same plan is to be pursued Avherethe at- tack has actually shifted from the feet or hands to some internal organ. But where it still lingers in the extremities, though Avith slight pain and inflammation and frequent cessations, as though it were on the point of removal, we should increase the morbid ac- tion by local irritants applied to the joint, as camphor, ammonia, blisters, sinapisms, or the cautery of moxa or coarse flax; and at the same time prescribe a light, but generous diet, with rather more wine than the patient is in the usual habit of taking; carefully avoid- ing all violent cathartics, and keeping the boAvels moderately open with rhubarb, aloes, or the compound colocynth pill. In gout, however, the intervals of the disease are of as much importance to be attended to as its paroxysms: and here, also, the mode of management under the first form should differ essentially • Physical and Literary Essays, Vol. II. Art. XII. t Mat. Med. Part II. Ch. VHI. t Mat. Med. Part n. Ch. VI. 352 HJfcMATICA. lCL. HI.—OR. I! from that under the second : for though the occasional causes may in many cases be the same, they have in the former to operate upon a vigorous, perhaps upon an entonic scale of power, and in the latter upon a scale decidedly reduced and atonic. In every variety all known occasional causes must be equally avoided. Where the diet has been too rich it must be lowered, and where too spare and abstemious, made more liberal. Indolence and a sedentary life must give Avay to regular exercise, and over-exer- tion of body or mind to repose and quiet. In the young, robust, and corpulent, whether the disease result from too great indulgence at the table, or an habitual taint, it may be requisite to abstain from animal food, Avines, and fermented liquors altogether; but where the sufferer has passed considerably beyond the zenith of life, and the luxuries of the table have become habitual, his ordinary fare should be reduced or diminished rather than entirely commuted. And in every change it is better to proceed slowly than to rush rapidly from one extreme to another: since nothing has so great a tendency to prepare the internal organs for gouty paroxysms, as such sAfdden and violent transitions. The bowels should be kept in regular order, and the hour of rest be early. A due and unsAverving attention to these general rules of the hygiene will often be sufficient to keep those free from all distur- bance of the gout for many years, and perhaps for the whole of their subsequent life, who have only knoAvn it in the form of a few regular paroxysms. But where the system, and especially the digestive function, is weak, and the patient has had anticipations of a tonic or recedent gout, or has actually suffered from its assaults, it will be necessary to superadd a course of invigorating medicines. There are three classes of remedies that generally pass under this name, stimulants, bitters, and astringents. The first increase the action, the two last augment the tone. Stimulants can rarely be employed alone, except in cases of emergency, for a lax state of fibres will bear little increase of action without, at the same time, suffering an equal increase of debility. But they may often, and in the case of gout perhaps always, be combined Avith astringents and bitters with great and decisive benefit. Upon this subject, hoAvever, I have already treated so largely under limosis dyspepsia, or indi- gestion,* that it is only necessary to refer the reader to that part of the work for the present purpose. Most of the celebrated specifics for preventing a return of gout, have been formedof these classes of medicines in combination, and especially of bitters and aromatics : and it is singular that although the variety of them which nature offers to us is almost infinite, they have been employed with little change from the time of Galen and Caelius Aurelianusin the second century to that of Sydenham in the seventeenth. The famous powder purchased by the second Duke of Portland, Avho distributed its receipt for general use from the * Vol. I. Class I. Ord. I. Gen. V. Spec. 7. p. 100 GE. XII.—SP. HI.] SANGUINEOUS FUNCTION, 353 service it appeared to have rendered him, is formed for the most part of the very same ingredients, modified either from the Greek writers, or Dr. Sydenham's prescription ; though it is a simplifica- tion of the latter, by omitting several of the articles that enter into its composition, one or two of which had better be retained. In this reduced form it consists of equal parts of the five following ma- terials, finely powdered and intimately commixt: birthwort, gen- tian, germander, ground-pine, and the tops and leaves of the lesser centaury.. The dose is a drachm taken fasting every morning for three months; after which it is to be reduced to three quarters of a drachm for three months longer; then to half a drachm for the remainder of the year: and after this the same dose is to be con- tinued every other morning only, through the next twelve months; by which time it is presumed that a cure will be accomplished. The real effect of this and similar medicines is very doubtful, and the doubt arises from the gradual mischief Avhich a gouty dia- thesis has a tendency to produce in the corporeal system; and the benefit which the exact and abstemious regimen that is prescribed during the use of the Portland or any other course of bitter tonics, is calculated to afford of its OAvn accord. In some instances such medicines seem to have produced little or no effect of any kind; in others the joint result of remedy and regimen seems to have been highly salutary; while in others again, the patients, though freed from open and decided fits of the gout, appear to have sunk gradu- ally under complaints more distressing and fatal than the gout itself, as dyspepsy, lowness of spirits, and dropsies of almost every part, especially hydrothorax, ascites, and anasarca. Now it is possible that the regimen alone may have produced the good, where good has been experienced, and the gouty diathe- sis the evil, Avhere the evil has followed; or that the bitter tonics themselves may have done both, according as the individual to whom they have been administered has been in a proper or im- proper state of body for a trial of them: For as most bitters are sedatives as well as tonics, and some of them direct narcotics, there can be no question that they have a tendency to prevent local in- flammation in a vigorous and robust frame, as well as in a relaxed and debilitated. But tonics and even sedatives are as little called for in the former condition of body as they are demanded in the latter; and may perhaps prove as mischievous in the end as a sedentary life combined with prodigal eating and drinking. There must in both cases be too great an excitement of the sensorium, and secre- tion of sensorial fluid, and consequently too great an exhaustion of organic poAver with a perpetual tendency to torpitude in every part of the system. In both cases fuel is added to fire, and the constitu- tion if not bursting into open inflammation, seems to be equally consumed by a secret and smothered flame. The gouty diathesis is no doubt fed and confirmed; and as regular fits of gout are kept off probably by the sedative quality of the bitter tonics employed, we VOL. II.—45 354 HiEMATICA. [CL. HI.—OR. H. have reason to expect indigestion, low spirits, dropsy, and all the effects of high living, although the latter is relinquished. I have thus endeavoured to account for the very different effect which tonics and especially bitter tonics, appear to produce in dif- ferent cases of gout, and to justify the caution with Avhich they Avere given by the Greek physicians, as well as by later pathologists of high repute. They are not to be used indiscriminately : for while the relaxed and debilitated, those who are subject to atonic and re- trocedent gout, may have recourse to them with great advantage, they Avill be sure to prove injurious to those of high entonic health, and who are distinguished by attacks of gout in regular but vehe- ment paroxysms. It is nevertheless easy to conceive that some bitters, even among those in common use, possess more of the sedative and narcotic principle than others; and Avere this is the case, though such may be fittest for employment in the first instance, they ought to be drop- ped for others of a different kind, as orange-peel, bark, columbo, and serpentaria, as soon as all local irritation has ceased. The strongest bitter we are acquainted Avith is the nux vomica, and the narcotic quality of this is known to every one. Opium possesses it in a still higher degree. It has of late been suspected to exist in wormwood, and been distinctly traced in the hop and some of the lettuce tribe. Dr. Cullen, however, has taken a different vieAv of this subject. He supposes all bitters to possess a deleterious quality of some kind or other; and that in all gouty persons, or at least he makes no dis- tinction, they have a power of Avarding off fits of this disease; but that, from this deleterious property, Avhen long persevered in, they weaken the stomach and other organs of digestion, to Avhich at first they gave a tone; and thus ultimately induce the diseases we have just noticed, and Avhich are too apt to follow upon a debility of these viscera. And in proof of this opinion, he tells us of the fate of nine or ten persons who had been liable for some years before to have " a fit of a regular or very fiainful inflammatory gout, once at least and frequently twice in the course of a year; but who, after they had taken the Portland poAvder for some time, Avere quite free from any fit of inflammatory gout;" and, having completed the course prescribed, " had never a regular fit nor any inflammation of the extremities for the rest of their life. In no instance, however," continues Dr. Cullen, " that I have knoAvn, was the health of these persons tolerably entire. Soon after finishing the course of their medicine they became valetudinary in different shapes, and par- ticularly were much affected with dyspeptic, and Avfiat are called neiA'ous complaints, with loAvness of spirits. In every one of them, before a year had passed, after finishing the course of the powders, some hydropic symptoms appeared, which, gradually increasing in the form of an ascites or hydrothorax, especially the latter joined Avith anasarca, in less than two or at most three years, proved fatal. These accidents, happening to persons of some rank, became very GE. XII—SP. HI.) SANGUINEOUS FUNCTION. 355 generally known in this country, and have prevented all such ex- periments since."* No testimony could be more confirmatory of the hypothesis I have ventured to lay down respecting the different effects of a tonic plan in different constitutions than the present. For the cases are taken entirely from persons who, upon this hypothesis, would entail upon themselves the very evils Avhich are here described. And as Dr. Cullen gives us no account of any mischief that has fol- loAved the use of bitter tonics in constitutions of an opposite charac- ter, or marked by general debility and atonic gout, the evils he has described seem, on his own evidence, to be limited to those whom we have already cautioned against the employment of such a course. No proper classification or line of distinction seems to have been drawn or adhered to; which would probably have presented us with very different results if it had been ; and have superseded the clash- ing and unsatisfactory explanation of atonic effects uniformly pro- duced by a continuance of tonic medicines. The subject, however, requires to be further examined into by a more accurate classification of gouty patients who may be put under the influence of medicines of this kind; and I throw out the hint for this purpose. Yet that a persevering course in bitter tonics does not uniformly prove in any way injurious to those who engage in it, is I think demonstrable from the daily use of table-beer in al- most every family throughout the country, and its appearing to be one of the wholesomest beverages Ave can adopt. Dr. Darwin, indeed, ventures to ascribe part of the mischief produced by high- ly spirited malt liquors to some noxious quality in the hops they contain; but the stronger and headier malt liquors are uniformly prepared Avith a much smaller proportion of hops than the weaker, and especially than those which go under the name of table beer. For the only point aimed at by the employment of hops is to pre- vent an acetous fermentation; which is effectually guarded against by the larger proportion of spirit contained in ale and strong beer; but which every one knows would soon take place in table-beer if it were not powerfully impregnated with this grateful bitter. And hence the remark of Dr. Darwin seems to have no foundation what- ever, since the stronger bitter affords a beverage proverbially wholesome; while the weak bitter is that which proves injurious. There have also, in all ages, been offered to the public specifics for the sudden cure or removal of the paroxysm when present, as well as for preventing its return hereafter. Lucian, in his Trago- podagra, gives us Avith great humour, a list that occupies a page of such as were chiefly in vogue in his day; and the catalogue is certainly not diminished in our own. Those that have acquired the highest reputation appear to have been composed of some species of hellebore, or of meadow-saffron; the,first of which is among the remedies quoted by Lucian; though it is probable that the />*£<*» * Mat. Med. Part. II. Ch. 11. 356 H.EMATICA. [CL. HI—OR. II. 'EAAEB'OPOY of the Greeks was a different plant from either the white or black hellebore of modern dispensatories. The favourite specifics of the present day M. Husson's Eau medicinale, and the vinum colchici, or wine of meadow-saffron, in- troduced in the current Pharmacopoeia of the London College chiefly upon the authority and recommendation of Sir Everard Home. The exact components of the former are kept a secret; though its basis is well knoAvn to be either the one or the other of the above plants, most probably the meadow-saffron. The effects of the Eau medicinale and of the colchicum-wine do not essentially differ; for after taking about sixty drops of either the pulse becomes slower, and at length sinks, in about tAvelve hours, from ten to twenty strokes in a minute below its natural number, at which time the in- flammation subsides. The action of both medicineB is accompanied with great languor and a deadly nausea or sickness, which termi- nates in vomiting, or a discharge from the bowels, or both. If the dose be in a small degree in excess, the symptoms are syncope, cold sweat, extreme prostration of strength, violent vomiting and purg- ing, a wiry and almost imperceptible pulse, or a state of utter and very alarming insensibility. And in some constitutions these effects have followed from the use of even a common dose. So that these preparations seem to be rather stronger drugged than the celebrat- ed oxymel colchici of Stoerck. Sir Everard Home made several trials of the colchicum wine on a dog, both by the stomach and by infusing it into his juglar vein. From thirty drops he recovered in about seven hours; from sixty drops in eleven; but a hundred and sixty drops, thrown into the juglar vein, killed him, after having suffered great agony, in five hours. On opening him, the stomach, smaller intestines, and colon Avere highly inflamed.* And it is hence obvious that this me- dicine, like many other emetics and cathartics, acts rather upon the stomach, through the medium of the circulation, than on the system,. through the medium of the stomach. It is possible that the colchi- cum may act by a specific power on the peculiar inflammation of a regular fit; yet, as other intestinal irritants have occasionally pro- duced a like effect, and particularly the gratiola officinalis (hedge- hyssop) and ranunculus Flammula, the disappearance of the parox- ysm may also be ascribed to a transfer of action to the stomach and intestines. Generally speaking, specifics operate by a secret and in- explicable power, as the bark in intermittents, the vaccine virus in shielding the constitution against small-pox, and mercury in syphi- lis ; for though a ptyalism gives proof that the system is impreg- nated with the last, there are few practioners so attached to the Cullenian doctrine in the present day as to contend that the vene- real virus is carried off by the salivation, since we are perpetually beholding it carried off under the influence of mercury without any salivation whatever. * Phil. Trans. 1816. Art. XII. XHI. GE. XII.—SP. III.] SANGUINEOUS FUNCTION. 357 Admitting yet, that the colchicum has a specific power over a re- gular inflammatory paroxysm of gout, it is clear that it has no such power over the gouty diathesis, since the paroxysm has never been so removed as not to return again. And it hence becomes a serious question, Avhether the mischief produced in the constitution by the employment of such violent means be not greater than the tempo- rary good obtained by the suppression of the inflammation ? and I do not think that either the Eau medicinale or the colchicum-winc have been noticed with a sufficient degree of discrimination fairly to determine this point. From the rapidity and force of the operation, it is clear that they ought never to be tried except in the first variety of gout, or where the system is firm and healthy, and the disorder shows itself in a regular fit. And as it is highly desirable, for reasons already stated, to restrain the violence of the paroxysm, shorten its duration, and carry it off as soon as possible, the use of the one or the other of these medicines may be judicious so long as the system is able to recover itself with speed from their influence, and provided the patient limits himself to the smallest dose that will answer the pur- pose. Yet these medicines, from too little attention to their real effects, and from a mistaken idea that they are a specific for gout under every form, have not been confined to the entonic variety, but have been very generally employed also in the second and third varieties as well; in which the system, and particularly the digestive organs, are in a state of chronic debility, and the inflammatory fit, Avhen it shows itself in the hands or feet, is incomplete and evanescent. In all such cases, such medicines cannot fail to do serious injury to the constitution; they must of necessity increase the ventricular weak- ness, and hereby render the system more open to all the miseries which gout is so perpetually entailing. And hence the reason of the very general complaint among those who have tried these remedies, that, although they remove the fit at the time, they shorten the in- tervals, and render their frames more obnoxious to relapses. The subject must not be quitted without a brief glance at Dr. Bal- four's proposed mode of treatment, which consists in the use of com- pression and percussion alternately applied to the inflamed gouty joint; as they are applied in like manner to parts labouring under acute rheumatism or any other kind of inflammation. The opera- tor is directed to seize the aching foot forcibly, by grasping the ball of the toe in his right hand, and gradually to increase the pressure, and continue it till the impetus of the vessels has yieded to the greater impetus of the hand; only occasionally letting go his grasp for the purpose of interposing a discipline of gentle percussion as it is called. This plan I have never tried, for I have never been able to summon fortitude enough to propose the addition of a remedial torture to that already endured from the disease; nor do I think I have ever attended a patient who would have consented to the advice if I had 358 HjEMATICA. [CL. IH—OR. U. given it. The direct object is to overcome the inflammatory action by constringing the vessels; but this effect is more readily obtained, and in a far easier way, and with quite as little risk, by cold Avater. If in the course of the compression the inflammatory action do not soon yield, it should certainly be relinquished: for a violent re- action will accompany the resistance, and the inflammation be great- ly augmented. I have seen one or two striking examples of this on applying the same method to inflammations of other kinds. A young woman Avith a small ulcer in the leg of about three months stand- ing, which, apparently, had continued open merely from neglect, was received not long since as a patient into a public establishment of this metropolis, and a tight compressing bandage applied to the entire limb. A forcible re-action ensued, the local irritation extend- ed, the leg swelled in spite of the bandage, and the pain Avas acute. A few palliative means were interposed, but the compressive plan was still persevered in: the inflammation spread deeper and wider, gangrene soon followed, and the patient died within three weeks from the commencement of the trial. Linneus pursued a far more inviting specific for the cure of the gout, in his OAvn personv which was that of eating strawberries. The story is pleasantly told by M. Hedin in the Amoenitates Aca- demicae. And having in this agreeable manner driven away the paroxysm by which he Avas then assaulted, he persevered in the same mode of relief through five other fits which attacksd him an- nually, every attack hoAvever being slighter than the preceding; till, by persisting in the same fruit, the disease, it is said, did not show itself for nearly twenty years. We are told in some of the foreign journals of like cures being effected by eating sour cherries. And, as astringent tonics are often as useful as bitter tonics, it is possible that the gouty diathesis has, in some instances, been check- ed or subdued by acids of various kinds, though we should be often deceived if we placed any dependence upon them. SPECIES IV. ARTHROSIA HYDARTHRUS. amttr=StoeUing. tense, permanent, colourless swelling, chiefly of the larger joints: inflammation slow, and deep-seated: pain fixed and severe : imperfectly suppurative : FEVER a hectic. This inflammation, like that of rheumatism, attacks the larger rather than th»smaller articulations. Yet, as the joints are uniformly the seat of its assault, and it runs through its course without the produc- GE. XII.—SP. IV.] SANGUINEOUS FUNCTION. 359 tion of genuine pus, however severe its symptoms and fatal its ter- mination, it has a manifest relation to the two preceding species, and ought to be arranged under the same genus. The ordinary occasional cause is a strain, or some other injury to the joint affected ; but this cause does not equally operate in all per- sons to the production of such a result; and it is hence obvious that there is, as in the case of gout and rheumatism, a predisposition or peculiar diathesis favouring the origin of hydarthrus, existing in some individuals to which others are strangers. And Ave find this predisposition showing itself also, as Ave have already seen, in the podagric diathesis, both in persons of a strong, robust, and entonic state of health, and in persons of relaxed and inelastic fibres, par- ticularly in those who inherit a scrophulous taint. And hence the disease exhibits itself under iavo distinct forms; seats itself in dif- ferent parts of the joint, and demands a very different mode of treat- ment. The varieties therefore are the following: x Entonicus. Entonic White-Swelling. £ Atonicus. Atonic White-Swelling. The first variety is the rheumatic white-swelling of Mr. B. Bell who has treated of the disease very fully and very judiciously in his work on ulcers.* It occurs, indeed, as he remarks, most fre- quently in young plethoric people in whom the rheumatic diathesis is predominant: or rather that firm elasticity of health and fibre, which, upon the application of accidental causes, gives rise to rheu- matism as well as to the present variety of hydarthrus : and on this account the epithet of entonic is preferred to that of rheumatic. The causes I have stated to be chiefly strains, and other exter- nal injuries to the larger joints, as bruises and luxations : but, like rheumatism, it is also frequently excited by. a current of cold damp air. The pain is diffused, the swelling considerable from the first, and the inflammation, on dissection, is found to originate and be chiefly seated in the synovial membrane and surrounding liga- ments of the joints: though, according to Mr. Brodie, it sometimes commences in the circumambient cellular substance.t The intu- mescence feels tense and elastic, but there is little discoloration at any time. From the increased and morbid action of the vessels there is not much effusion of coagulable lymph, but a considerable surplus of synovial fluid, not less than four ounces of Avhich was dis- charged in a case related by Dr. Simson, by making an opening through the integuments and synovial membrane. The occasional cause Avas in this instance of a singular kind ; for it consisted of a small supernumerary bone, somewhat above the size of a kidney- bean, which lay loose in the knee-joint and was covered Avith cartilage. * Treatise on Ulcers with a Dissertation on White-swellings, &c. 8vo. | Pathological and Surgical Observations on Diseases of the Joints, 8vo. 1818. 360 IIJEMATICA. [CL. HI.—OK. II. At first it seems to have been attached, for the patient does not ap- pear to have noticed it till about the commencement of the inflam- mation, when he frequently felt it, as a hard body of Avhose nature he was ignorant, immediately under the patella, generally on the inside, but sometimes on the opposite, and could get no ease till by chafing the joint with his hand he made it disappear. Upon a re- moval of the preternatural bone by an incision and an evacuation of the synovia, the patient appears to have been instantly relieved ; for, contrary to the advice of Dr. Simson, he shortly afterwards mounted his horse and rode home through a distance of two miles and in a frosty night. But he had soon reason to repent of his im- prudence, for he caught cold, and suffered excruciating pain from inflammation, and did not recover the full use of his limb for nearly a tAvelvemonth. A caustic applied to the part and kept open seems to have been of essential service.* The inflammation, if not checked at its commencement, soon ex- tends into the cellular substance and even the integuments, but rarely in this variety effects the bone : but it has as little tendency to the adhesive as to the suppurative character, and hence the effused fluid runs in every direction, and, from losing its finer parts by absorption, becomes viscid and glairy, and occasionally ex- hibits a congeries of hydatids. If, hoAvever, the inflammation pro- ceed farther and the integuments be affected, pus is also secreted; the periosteum is ulcerated, and the bone itself rendered carious; so that on an examination, by dissection, the interior of the joint displays a confused union of different materials and substances blend- ed into a common mass. It is rarely that this variety is taken notice of so soon as it should be ; for when a strain occurs in the knee or elbow of a robust and high-spirited school-boy, he will generally rather suffer the pain it produces as long as he can, than run the risk of an abridgement to his liberty. When, however, the disease produced by such accident is taken in hand soon, it will usually yield in a feAv weeks to the ap- plication of leeches, succeeded by a repetition of blisters, which, if the joint be the knee or ancle, should be accompanied Avith a reclin- ed position ; for perfect quiet is of the utmost importance, and the joint should be kept as much as possible free from motion. If the swelling and inflammation should nevertheless proceed, the pain augment, a fluctuation be perceptible, and relaxing cataplasms have proved of no avail, the joint must be opened by a seton, which should be of sufficient depth and length to form an exit for the puru- lent fluid now contained in all the little abscesses that constitute the disease, and which are generally separate from each other. As the bone does not readily become affected nor even the periosteum, the joint may in this manner often be preserved and restored to use. A very considerable degree of stiffness, indeed, * Edinb. Med. Essays, Vol. IV. Art. XX. GE. XII.—SP. IV.] SANGUINEOUS FUNCTION. 36! will commonly remain long afterwards ; but which in most cases will gradually yield to friction with the hand alone, or, which is better, illined Avith warm oil (and the animal oils are for this pur- pose preferable to the vegetable,) continued for an hour at a time and repeated at least twice a-day. The rigidity, indeed, is owing. in almost every instance, to the motionless state in which the flex- or-tendons have been kept for many weeks, and not to any inflam- mation that has extended itself to them, which, in nineteen cases out of twenty, according to Mr. Bell's calculation, never takes place: and still less are we to fear such a result from an union of the ends of the adjoining bones, in consequence of the abrasion of their sur- rounding cartilages ; or from an inspissation of the synovial fluid by which they are surrounded. For it has already been observed that such abrasion rarely or never happens but in a very late stage of the disease; while it is very uncertain that such a state of the syno- via as is here alluded to takes place at any time. And hence no such apprehensions should slacken our endeavours to remove the stiffness of the joint by a long course of friction and emollient appli- cations. When the use of the seton has produced no benefit, and the bone has manifestly become carious, our last resource is ampu- tation. The atonic variety commences, and consequently is chiefly seat- ed, in the bone itself of the affected joint, originating, as Mr. Brodie observes, in its cancelli.* The pain, therefore, is here more cer- cumscribed, and appears to shoot almost from a point, and the swell- ing is inconsiderable. The pain, however, though more limited, is very acute, and increased by the least attempt at motion ; so that in this case also, the muscles being always kept quiet and in a bent position, a stiffness of the joint is readily superinduced. The inflammation proceeds more slowly than in the entonic form, but it produces at length the same effect; the tumour ac- quires the same elastic feel; varicose veins appear on the surface, and collections of matter take place in different parts of it. The minute and separate abscesses burst one after another, and discharge an ichorous or cheesy and purulent fluid, and small exfoliations of the subjacent bone are occasionally thrown out at the openings. This variety constitutes the scrophulous white-swelling of Mr. Bell; and, if not always confined to scrophulous subjects, is most common to those who give proofs of this diathesis, or of an approach to it. " I conceive all such collections of matter," says Mr. Hunter, " to be of a scrophulous nature: they are most common in the young sub- ject, and seldom found in the full grown or old. The suppuration is not proper pus, nor the swelling proper inflammation."t The occasional causes are sometimes those of the preceding va- riety ; but the disease more generally commences without our being * Patholog. and Surg. Observ; t On Blood, &c. p. 391. vol. II.—46 362 HEMATIC A. jCL. 111.—OK. II. able to trace any occasional cause whatever : and is far more dispos- ed than the preceding to terminate in a fatal hectic. The practice is most disheartening and the prognostic most me- lancholy. No course of medicine promises much success; while even a removal of the limb may only lead the way to an appearance of the disease in some oilier joint. The pain may be soothed with opium; and local stimulants have been found useful in an early stage of the disease, or Avhere the diathesis is not decidedly scrophulous. Of the last class of medicines almost every preparation has been tried in its turn according to the inclination of different practitioners: as solutions of muriated ammonia, sometimes commixed with acetic acid; essential oil of turpentine; camphor; acetated ammonia; tincture of cantharides ; mezereon in various forms; mercurial or other irritant emplasters ; the actual cautery both by moxa and heat- ed irons; fumigations and the vapour-bath impregnated with essen- tial oils; setons and electricity.* While internally have been adminis - tered the compound decoction of sarsaparilla, hemlock, pulsatilla nigra, and various preparations of almost all the metals.t Where these fail, and they fail too often, our only resource against the cer- tain destruction of hectic fever is amputation, however doubtful its issue. Dr. Akenside thought he derived advantage from large blis- ters, freely kept open, in conjunction Avith the internal use of calo- mel : but he candidly admits that nothing can be expected even from this treatment, or indeed any other treatment, where the disease has made much progress, or if " there is any sensible collection of a fluid within the joint." In two or three of the cases he has describ- ed, the tumour, when in an incipient state, seems to have been quite as favourably acted upon by the attack of some unforseen ex- anthem, as small-pox or miliary eruption, as by any topical plan whatever.! * * Heister, Wahrnehmungen, B. I. Wendt, Nachricht von dem Institutum clinicum. De Meza, Anhang zer Strack Abh. von der Petetschenkrankeit. Plater, Observ L. III. p. 704. Uromtield's Observations. Kirkland on the present state of Surgery. Percival, Med. Com. Edin. VII. 67. j- Proett, Versuche einer Chirurg. Gesillschaft in Kopenhagen. Baylie, Pract, Essays. Michaelis, in Richter, Chir. Bibl. B. V. p. 113. Stoerck, von der Schwarzen Kuchenschelle, p. 82. i Med. Trans. Vol. I. p. 104, CLASS HI. HiEMATICA. ORDER 111. EX ANTHEM ATIC A. JSnqrtfbe iPefoera OUTANEOUS ERUPTIONS ESSENTIALLY ACCOMPANIED WITH FEVER. The term Exanthemata among the Greeks from t%xv6ea, " efflores- co," " per summa erumpo," " to effloresce, or break forth on the surface," imported cutaneous efflorescences or eruptions generally. It has since been limited to express cutaneous eruptions accompanied with fever, a boundary assigned to it by Sauvages, Linneus, Vogel, Sager, Macbride, Cullen, and various others, and this, in effect, is its general meaning in the present day. Dr. Cullen, however, in his note on Exanthemata, thinks it worth considering whether the word should not be restrained to eruptions (he does not say febrile eruptions) produced alone by specific contagion : " eruptiones a contagione specific! ortae;" while Dr. Willan has still more lately narrowed it so as to include those eruptions only which fall within the meaning of the English term rash, whether febrile or not fe- brile. The two last senses of exanthemata, or exanthematica, are new and singular. Dr. Cullen, however, has not followed up his own suggestion into his own classification; while Dr. Willan has not al- ways continued strictly true to his own views and definition, as I have observed in the running comment introductory to the present order in the volume of Nosology to which the reader may turn, for a fuller examination of this subject, at his leisure. The term, therefore, in the present work, is employed in its common and current sense, so as to include all cutaneous eruptions m which fever exists as an essential symptom ; whether accompa- nied with or destitute of contagion ; which last is a doubtful and perhaps inappropriate ordinal character. Doubtful, because we cannot very precisely tell where to draw the line ; and inappropri- ate, because it is a character that applies to diseases of very differ- ent kinds, and that are scattered over the entire classification, as ii6'l HiEMATICA. tCL. HI.—OR. 1H dysentery and influenza, in which there is fever without cutaneous eruption; itch, and many varieties of tetter, in which there is cu- taneous erruption without fever, and blennorhoea or clap, in which there is neither fever nor cutaneous eruption. The genera includ- ed in the order are distinguished by the nature of the eruption as consisting of red, level or nearly level patches of pimples filled with a thin ichorous fluid; of pimples filled with a purulent fluid ; and of foul imperfectly sloughing tumours, and hence consist of the four following :— 1. enanthesis. rash exanthem. 2. emphlvsis. ichorous exanthem. 3. empyesis. pustulous exanthem. 4. anthracia. carbuncular exanthem. Each of these, with the exception of thethird, comprises seve- ral species; and all concur in evincing the existence of morbid and specific poisons in the blood, acting the part of animal ferments, converting the different fluids into their own nature, exciting the commotion of fever, and being eliminated on the surface, as the best and most salutary outlet to Avhich they can be carried, by the very fever which they thus excite. The whole is a wonderful circle of morbid and restorative action, evincing the most striking proofs of that instinctive or remedial poAver of nature whose presence in every part of every living frame, whether animal or vegetable, is continually discovering itself; and which, under the general control of an infinite and omniscient Pro- vidence, is perpetually endeavouring to perfect, preserve, and re- pair the individual, and to multiply its species. We have many times had occasion to observe, that wherever any diseased action is taking place internally, there is a constant effort exhibited in the part or in the system generally, to lead it to the surface where it can do least mischief,* rather than let it spread it- self on the deep-seated or vital organs where its effects might be fatal. Mr. John Hunter was peculiarly fond of dwelling on this ad- mirable economy of nature, and of illustrating it from the course pursued in inflammations of every kind ;t which to obtain this bene- ficial end, often wind their way outwardly through a multiplicity of superincumbent organization, instead of opening into some momen- tous cavity in the interior, from which it is perhaps only separated by a thin membrane. But there is no part of pathology in which this display of a final cause, of an operative intention admirably adapted to the end, is more striking than in the order of eruptive fevers. It is by means of the fever that the disease works its own cure: for it is hereby that a general determination is made to the surface* and the morbid poison is thrown off from the system. * See especially Class II. Ord. II. On Inflammation, p. 161. f On Blood, Inflammation, &c. pp. 236, 450, 467. I'L.IH.—OR. III.] SANGUINEOUS FUNCTION. 365 But the fever may be too violent; and, from accidental circum- stances, it may also be of the wrong kind : both which facts occa- sionally occur in inflammations, and require the art of medicine for their correction. When a febrile poison, producing a cutaneous eruption is gene- rated, or has been conveyed into the blood, a small degree of fever is sufficient to throw it upon the skin; and if it exceed the proper extent, the specific virus will be multiplied, and the fever itself may become a source of real danger. It was formerly the practice to encourage the fever by cardiacs, a heated atmosphere, and a load of bed-clothes, from an idea that we hereby solicit a larger flow of morbific matter from the interior to the surface. The fact is un- questionable ; for be the exanthem what it may, the skin will hence, in almost every instance, be covered with eruption. But it did not occur to the pathologists of those times, that the morbid virus was an animal ferment, capable of multiplying itself by accessories; and that heat and febrile action, beyond a very low medium, are among the most powerful accessories we can communicate. And hence the advantage of the modern practice of applying cold Avater in scarlet fever, and cold air in small pox, with a view of mitigating the fever that often accompanies these diseases: for, by diminishing the fe- brile violence, we do not, as was formerly imagined, lock up the contagion in the interior of the system, but prevent it from forming afresh and augmenting there. But the fever, though the natural mode of cure, may not only be too violent, but it may be also of the wrong kind. And here, again, the whole scope of professional skill is often demanded. Some of the morbid poisons we are now adverting to, have a na- tural tendency to excite a fever of one description, and others of another. Thus, the fever of small-pox and measles is ordinarily in- flammatory; that of scarlet fever may commence with an inflamma- tory type, but it has a strong tendency to run into a typhous form: while that of pemphigus.and plague is typhous from the beginning. Much also, in this respect, will depend upon accidental circum- stances, as the constitution of the year, and the prevailing epidemic ; the constitution of the patient, his habit of life, or hereditary pre- disposition. For under the control of these we sometimes see an eruptive fever, having naturally a typhous turn, restrained in its tendency ; and, on the contrary, a fever with an inflammatory turn, as in small-pox or measles, converted into a malignant or a typhous. Yet the general intention pursued by the instinctive or remedial power of nature is one and the same: and it is the duty of the medi- cal practitioner to watch over that intention, and co-operate with it; to moderate the natural means when in excess ; to quicken them when deficient; and to correct them when deflected by accidental circumstances. 366 HAMATICA. [CL. III.—OR. HI. GENUS I. ENANTHESIS. Hash 25j:antfiem. eruption of red, level, or nearly level patches; variously figured; irregularly diffused; often confluent; termi- nating IN CUTICULAR EXFOLIATIONS. The term enanthesis is derived from the Greek t* " in, intra," and wfaa, "floreo,"—" efflorescence from within or from internal affec- tion." Whence the term stands opposed to exanthesis, which, in the present system, constitutes a genus under the sixth class, and comprises such efflorescences as are merely superficial or cutane- ous, and not necessarily connected with internal or constitutional affection. Enanthesis is here, therefore, used to express fever ac- companied with rash, the latter word being employed in the broad- er of the two senses assigned it by Dr. Willan, as importing red, irregular, confluent patches, whether simple, as in the case of scar- let-fever, compounded of papulae, small acuminating elevations of the cuticle, not containing a fluid, as in the case of measles; or ex- isting in the form of wheales, as in that of nettle-rash. And hence enanthesis, as a genus, furnishes us with three spe- cies :— 1. ENANTHESIS ROSALIA. SCARLET-FEVER. 2. ——— RUBEOLA. MEASLES. 3. . URTICARIA. NETTLE-RASH. ■ ■ ' ■ SPECIES I. ENANTHESIS ROSALIA Scarlet=iPetar. RASH, A SCARLET FLUSH, APPEARING ABOUT THE SECOND DAY ON THE FACE, NECK OR FAUCES; SPREADING PROGRESSIVELY OVER THE BODY; AND TERMINATING ABOUTTHE SEVENTH DAY : FEVER A TYPHUS. This is the scarlatina of most modern writers: a barbarous and un- classical term that has unaccountably crept into the nomenclature of medicine, upon the proscription of the original, and more classical name, of rosalia, which it is the author's endeavour to restore. GE. I.—SP.l.] SANGUINEOUS FUNCTION. 36?/ Upon this subject I must refer the reader to the running comment in the volume of Nosology, where he will find it explained at full length. At present it is sufficient to observe, that although, since the introduction of scarlatina, its use has been generally tolerated, no classical scholar has been satisfied with the term; while several have peremptorily refused to adopt it. Dr. Morton had so mortal an aversion to the term, that he pre- ferred the error of blending scarlet fever with measles, and of ar- ranging the varieties of the two diseases under the common generic name of morbilli, to employing scarlatina. De Haen appears to have had nearly as great a dislike to it.* Dr. Huxham, for a long time, eluded the term by using febris miliaris rubra, or maligna, for some of the varieties of scarlatina, and febris anginosa miliaris for others: Dr. Heberden has still more lately exchanged it for febris rubra ; and Thiery, in direct allusion to the original name, calls it expressly mal de la rosa; Dr. Willanf continues scarlatina, but thinks it necessary to apologise for its continuance. " The de- nomination scarlatina," says he, "was first applied to this disease by British writers: however offensive the term may be to a classical ear, it cannot well be displaced, having found admission into all the sys- tems of nosology. Another age will correct and refine the language now used in subjects untouched by the masters of Physic."\ It will not be the present author's fault if the correction,^ so ge- nerally called for in the case before us, should be postponed to another age; or the error complained of be chargeable on future nosologists. In saying that " the denomination scarlatina was first applied to this disease by British writers," Dr. Willan can only mean that it Was by British writers first applied technically, and introduced, as a professional term, into the Medical Vocabulary : for the term itself is Italian, and was long, as a vernacular name, in use on the shores of the Levant before it was imported into our own country. Scarlet-fever, measles, and small-pox seem, indeed, equally to have reached us from the East, and to be diseases of compaiatively modern origin. Some writers fancy that they can distinguish a few traces of one or two of these in the works of Paulus Mgina, and other Greek physicians ; but the passages referred to are too gene- ral and imprecise to establish any such conclusion. No such dis- eases are described ; and had they existed at the time, a few deter- minate and scattered hints, which may apply to other diseases as well, could not have been the whole to which they would have given rise. The names, indeed, by which they were at first known as variola, rubeola, or rather rubiola, rosalia, and even morbilli evidently point to the school of Cordova, and lead us to the Arabian • Med. Contin. Tom. I. Cap. VII. t Recueil Periodique. II. 337. * Cutaneous Diseases, p. 253. 336 HiEMATICA. [CL. III.—OR. HI. or Saracenic physicians for our first account of them. And it is not to be wondered at, that in such accounts we should meet with some degree of confusion and many inaccuracies; and should perceive that as measles were for a long time confounded with small-pox, so scarlet-fever Avas with measles; whence it is difficult, in one or tAvo instances, to determine what is the precise species of disease refer- red to by Avicenna, Haly Abbas anc. Khazes: for while they seem to allude to the scarlet-fever, we are not sure that they mean it. On this account it is that rosalia, rossalia and rubeola, alike de- rived from the colour of the efflorescetice, are, among the earliest Avriters who used these terms, applied equally to scarlet-fever and measles ; and when some distinction was at length attempted by the introduction of the word morbillo, or morbilli, in like manner a Spanish or Cordova diminutive, the line of distinction not being accurately drawn or adhered to, this term was also erroneously ap- plied to both ; and the confusion became more intricate. So ronge- ole, which among the French Avriters is the common name for measles, imported also, at one time, scarlet-fever: and this so ge- nerally that, when in process of time physicians became sensible of the difference between the two maladies, and it was necessary to establish distinct terms, we learn from Chevenau that, among the Marsellois, rougeole was at first appropriated to the scarlet-fever, while the measles were denominated senafiion.* And, in this man- ner, both diseases continued in every country till Avithin the last half century, to be regarded and even treated of with but little dis- crimination ; sometimes as different species, sometimes as a common species, and sometimes as varieties of a common species. And hence, even in our own country, we find them united in several of their varieties, not only in the Avritings of Dr. Morton, but still more lately in those of Sir William Watson. Since, however, they have been considered, and most correctly, as different diseases, another extreme has been run into ; for rosalia itself has been broken into subdivisions that are in no respect worth contemplating separately; one or two of which, as we shall per- ceive pffesently, have themselves been elevated by some patholo- gists into the rank of distinct maladies. For all the purposes of perspicuity, it will be sufficient to study it under the two following varieties:— x Simplex. Fever moderate, and terminating Simple scarlet-fever. with the rash; little prostra- tion of strength : slightly conta- gious. /3 Paristhmitica. Fever severe; throat ulcerated; Scarlet-fever with sore throat, rash later in its appearance, and less extensive ; often chang- ing to a livid hue : highly con- tagious. • Observ. Med. p. 454. GE. I.—SP. I.] SANGUINEOUS FUNCTION. 369 Children are by far the most frequent subjects of both these va- rieties, and communicate it readily to each other. They are both occasionally epidemic, and in this form occur most usually at the close of the summer. The anticipating symptoms are those of fe- ver ; about the second day from which, in the first variety, nume- rous specks or minute patches of a vivid red colour appear about the face and neck : and within twenty-four hours a like efflorescence is diffused over the surface of the body, and occasionally even tinges the inside of the lips, cheeks, palate and fauces. Sometimes the efflorescence is continuous and universal; but more generally on the trunk of the body, there are intervals of a natural hue between the patches, Avith papulous dots scattered over them. There is an exacerbation in the evening, at which time the rash is most florid, as it is least so in the morning. In some cases that have occurred to me it has only shown itself in the day time in the form of, scattered patches, or even specks, though the skin has been very generally roughened and rendered anserine from a more than usual determina- tion of blood to the cutaneous papillae. Yet even in these cases the pa- thognomic efflorescence has appeared in a greater or less degree in the evening. On the fifth day the eruption begins to decline; the inter- stices Aviden, and the florid hue fades. On the sixth the rash is very indistinct, and is wholly gone on the seventh. The pulse, during the eruptive stage, is usually very quick and feeble; the tongue is covered with a whitish fur in the middle, often interspersed Avith scarlet points from an elongation of the turgid papillae; while the sides of the tongue are of a dark red. The face is considerably tumefied ; and there is great anxiety and restlessness, with a sense of tingling or itching in the skin, and sometimes at night a slight delirium. Though the fever is in most cases moderate, it sometimes runs high, but in the present variety is rarely alarming. In many cases, indeed, the eruption appears and passes through its course with little inconvenience of any kind from fever, itching, or restlessness. Sauvages, and Cullen, Avho has copied Sauvages's definition, re- present the efflorescence as not taking place till the fourth day after the attack. Dr Heberden, on the contrary, fixes it on the first or second day :* Dr. Willan, " usually on the second day." This last is the ordinary period, and as such I have entered it in the defini- tion. It is obvious, however, that the interval observes some va- riety : though not a little of the apparent difference may be ascribed to the different stages of the disease in which a physician is first con- sulted ; and his inability of fixing very accurately the commence- ment of the febrile incursion. Dr. Plenciz, on this account, pursues a middle course, and avails himself of unallowable latitude; " About the second or third day," says he, " and sometimes later, the red, unequal eruption, makes its appearance."t Generally speaking, the * Med. Trans. Vol. III. p. 397. f M. A. Plenciz, Med. Vindom. Tractatis de Scarlatina. 1776. vol. II.—47 370 1LEMATICA. [CL. III.—OR. III. more violent the attack the sooner the efflorescence is throAvn forth: and hence, during a severe and extensive range in Newcas- tle-upon-Tyne in 1778, Dr. Clarke tells us that, avIiere it began with great vehemence, the eruption was often observed on the first day : but commonly it did not make its appearance till the second or third, and sometimes not till the fourth. We have seen that rosalia has been often confounded Avith measles, to which, indeed, it hears, in many cases, no small degree of resemblance. The following distinctive characters, therefore, may be of use to prevent a mistake. The efflorescence of the measles does not appear till two days later than that of scarlet fever; and though it consists at first of broad patches amidst the general suffusion of red, stigmatized with interspersed dots, the dots are of a deeper colour, and are never lost in the efflorescence. It commences, moreover, with symptoms of a severe catarrh, Avhich do not belong to scarlet-fever ; and is Avithout, that restlessness, anxiety, and depression of spirits by Avhich the latter is peculiarly distinguished. From the great determination of blood to the cutaneous vessels, an effusion of coagulable lymph sometimes takes place in the papulous elevations, Avhich is not entirely absorbed by the time the efflorescence subsides ; and hence there is occasionally, though not often, an appearance of vesicles, sometimes nearly empty, and sometimes nearly filled with a pellucid fluid, according as the effused serum has been more or less carried off. I have seen them exhibit the semblance of minute chicken-pox ; and they have been thus noticed by many writers, particularly by Dr. Rush,* Dr. Withering, and Dr. Plenciz : the last of whom compares them to white miliary spots ; and expressly states that he observed them on the sixth or seventh day from the commencement of the eruption, chiefly in the hands and feet: in other words, at the time when the turgid cuticular vessels had contracted and the efflorescence was on the decline. On examination, he further tells us that they appear- ed to be nothing more than cuticular elevations filled Avith minute bubbles of air. More correctly, perhaps, they were quite empty, the effused serum being carried off by absorption.! M. de Sauvages has made this form of the disease a distinct species, as scarlet-fever, with him, constitutes a distinct genus ;\ and as the effused fluid, when its finer parts are first absorbed, occasionally appears thick and opake, and has some resemblance to minute pustules of small-pox, he has distinguished it by the name of scarlatina variolodes. There is another peculiarity which the disease sometimes exhibits, and to which .the attention of the profession has of late been particularly called by Dr. Maton.§ The disorder, in the case * Medical Inquiries and Observations, p. 123, f Class III. Ord. Exanth. Gen. VIII. * Tractat. de Scarlatina. § Med. Trans. Vol. V. Art. XI. GE. I.—SP. I.] SANGUINEOUS FUNCTION. 371 alluded to, shoAved itself in a large family and evinced all the com- mon symptoms of a mild rosalia; and like rosalia, it proved itself contagious, for every member of the family, elder or younger, to the number of eight, received it in succession. But its singularity was the great length %f interval betAveen the time of exposure to the attack in those Avho sickened nearest to each other in the order of its descent, and any sensible effect on the system; Avhich instead of being, as in ordinary cases, four, five, or six days, Avas, upon an average, not less than tAventy-one days; varying in different indivi- duals, from seventeen to tAventy-six days. And on this account, in conjunction with one or two other signs of minor importance, Dr. Maton, though he at first regarded the disease as a modification of rosalia, was afterwards inclined to believe it a neAv complaint requiring a distinct designation. Yet if Ave reflect Iioav often a similar, or nearly similar retardation takes place in particular families after inoculation from either the small-pox or cow-pox, in which we have a much more definite period to calculate from, Ave shall rather perhaps be justified in adopting Dr. Maton's first view of the disorder, and contemplating it as a rosalia modified by a peculiar family temperament, or some other accidental control. In the paristhmitic variety or that accompanied with sore throat the eruption is always later in its appearance than in the simple form: in a case I shall have to quote from Dr. Perceval, not less than eight days later; though I have never known it protracted to so late a period as in the modification noticed by Dr. Maton, Avhere the febrile symptoms have taken place as early as usual from the time of exposure. The efflorescence in the measles, however, sometimes evinces a like procrastination, and has appeared as late as the twenty-first day.* ^ In the second or paristhmitic variety the morbid virus is chiefly directed to the fauces, instead of to the surface of the skin gene- rally. And hence, in some cases, the cutaneous efflorescence is very slight, and consists of a few scattered patches of flush instead of a diffused sheet. The rash, moreover, appears later by a day or two, sometimes even a week; probably delayed by the same cause that interferes with its generftl spread over the skin, being the local irritation about the throat. This last symptom will be found to commence very early if the throat be minutely inspected; for though no complaint is usually made of uneasiness in the throat previous to the febrile symptoms, yet if it be closely examined, the vellum pendulum palati will be found redder than natural, and sometimes the uvula will appear to be a little inflamed, the pulse being at this time not more than slightly disturbed, or flurried rather than feverish.f Dr. Willan asserts, that this takes place as one of the first effects of the contagion, and describes it, as " a dark-red line extending along the vellum pendulum palati and lower part of • Buchholz Tode Med. Chir. Bibl. Band. I. p. 86. f Dr. Sims, Memoirs of the Med. Soc. of Lond. Vol. I. p. 394. 372 HiEMATICA. [CL. HI.—OU. III. the uvula.* Gradually, however, the tonsils become enlarged, and exhibit a florid paleness on their surface, which extends over the whole range of the palate, its velum pendulum, the uvula, and the posterior part of the fauces: the tongue assumes a high red colour, the papillae over its entire surface #rs greatly elongated, and very tender to the touch ; there is often a considerable stiffness in the muscles of the neck and lower jaw; the throat is rough and straightened from the second day of the eruption; and deglutition is performed Avith difficulty. All the common symptoms are more violent; the fever is severer, accompanied with nausea, vomiting of bile, great heat,*and languor ; considerable inquietude and anxiety, head-ache, and delirium; evidently proving a copious determination to the head as well as to the fauces. The pulse is feeble, the respiration quick; the throat becomes excoriated and throws off a large quantity of minute superficial whitish sloughs, which intermix with the increased flow of viscid mucus, and augment the difficulty of swallowing. The sloughs generally separate about the fifth or sixth day, or at the decline of the efflorescence; but sometimes they remain a day or two longer. This is the ordinary course ; but, in many cases, the symptoms run still higher; and the disease is alarmingly dangerous from its irruption. The pulse is small, indistinct, and irregular from the first; there is a stupid, heavy coma, or violent delirium with deafness ; the ulcerations in the throat are deeper and broader, and covered with dark instead of Avith Avhitish sloughs ; the tongue is lined with a black, chappy crust, and is exquisitely tender; the breath is fetid; the rash, extensive from the commencement, assumes a livid hue with intermixed patches of ghastly paleness; and death ensues shortly after the seventh day, sometimes on the sixth. The affection of the throat, in this last and most virulent attack, bears so near an approach to the malignant paristhmitis, and its peculiar symptoms commence so early, that some pathologists of great authority, and particularly Dr. Cullen, and Dr. Withering, have regarded it rather as a variety of paristhmitis or cynanche than of rosalia, whence in Dr. Cullen's synopsis it occurs under the designation of cynanche maligna. But as the scarlet or crimson eruption must be contemplated as a pathognomic symptom, this is to give us two distinct diseases, with the same essential signs; and Dr. Cullen has done this; for while he places this most virulent form of rosalia under his genus cynanche, he continues it, in the less virulent form under which we have just described it, as a subdivision of his genus scarlatina. The distinction, hoAvever, is altogether unnecessary, and leads to no advantage either patholo- gical or practical in the writings of those who have* adopted it. With the exception of a higher degree of danger in the one than * Cutaneous Diseases, loc, cit. p. 269. GE. I.—SP. L] SANGUINEOUS FUNCTION. 37o the other, from the fever assuming the character of a more malig- nant typhus, both forms of the disease are the same; they are equally produced by a specific virus; equally contagious and at times epidemic; accompanied with a similar rash ; demand a like mode of treatment; and even, according to Dr. Cullen's own admis- sion, so frequently run into each other as to be extremely difficult of discrimination. In consequence of which few later Avriters have allowed any such distinction whatever. De Haen, therefore, had reason to say, as he does, apparently in reference to Dr. Cullen's arrangement that different and improper names have been affixed to scarlet-fever by different writers : but that varieties in climate or constitution produce the distinctions under which it has been described. Dr. Withering, however, who was contemporary with Dr. Cul- len, embraced and strenuously supported his view; contending that in scarlet-fever with sore throat the fever is inflammatory, and in sore throat Avith scarlet-fever it is putrid. Yet, in describing the treatment of this inflammatory fever, he seems to have lost sight of his critical characteristic, for he tells us that its nature is debilitat- ing or sedative rather than entonic; and condemns, both purging and bleeding, as the pulse will not allow of these evacuations. In endeavouring still further to lay down the distinctive charac- ters of the tAvo, he observes, after Dr. Fothergill, that the angina gangrenosa (sore throat Avith scarlet-rash) usually commences in the winter or the spring, and chiefly attacks persons of delicate ha- bits, as women and children ; while the scarlatina anginosa (scarlet- rash Avith sore throat,) on the contrary, usually commences in the summer or autumn, and commonly fastens upon the vigorous and robust. The scarlet-rash, however, of Newcastle-upon-Tyne in 1778, seems to have reversed this rule in its most essential point; for Dr. Clarke to whom I have just referred, and who has given a very minute and interesting history of this epidemy, tells us that it made its first appearance in June, extending from Newcastle over many towns and villages in the neighbourhood ; that it was most frequent in August, September, and October, declining about December; and that it raged chiefly among children and young persons, although a few adults exposed to the contagion did not escape.* Dr. Clarke therefore concludes that both these diseases proceed from the same specific contagion, and ought rather to be considered as distinct forms of the same exanthem, than as distinct affections. It is accurately, also, observed by the same writer, that the epidemy of 1748, which Dr. Fothergill has so ably described under the name of Putrid Sore Throat, is essentially the same as that remarked upon by Dr. Cotton in his letter to Dr. Mead, and which he then denominated Scarlet Fever, from an objection to any alteration of the name in common use. * Observations on Fevers, especially those of the continued type, and on the Scarlet Fever attended with ulcerated sore throat, 8cc. 8vo. 1779. 374 HiEMATTCA. [CL. IU.—OR. III. The subject ought not to be closed without adding the following note from Dr. Perceval's manuscript comment on the author's vo- lume of Nosology, already noticed on many occasions. It adds a high authority to the present arrangement of this form of the dis- ease ; and contains one or two remarks which very agreeably dis- play the observant tenour of the Avriter's mind. " Cynanche tonsilaris and maligna, I consider with you as a spe- cies of rosalia. All have been produced by the same specific con- tagion, Avhich in one instance was imported here (Dublin) from England in a Pandora's box, containing plumed soldiers which had served to beguile the convalescent hours of a young family, and Avere sent by them as a present to their quondam playmates in this capital. We have had no severe visitation of rosalia in this place for upAvards of ten years. In some instances, besides, I have traced the progress of contagion from England, and believe it loses some- thing of its ferocity by the way. Do you think it comes from the continent? A remarkable case occurred to me of rosalia fiaristhmi- tica characterized most distinctly with symptoms of what is called cynanche maligna. This, with sunk pulse, great prostration of strength, and haggard countenance, ran a course of seven days with- out eruption ; during which time it was treated with wine and bark which removed the affection of the throat. On the eighth day, after a rigor, a fever supervened of rather an inflammatory type with a rosalia eruption. After proper evacuations the patient re- covered." That rosalia, under every form is contagious, and sometimes epidemic, is now admitted Avithout a question : and for the later appearance of the efflorescence in the paristhmitic than in the sim- ple variety I have endeavoured to account. But whether some countries are more disposed to favour its appearance in the form of an epidemy than others, and particularly whether under this form it be more common to England than to Ireland, as hinted at by Dr. Perceval, I have no data to determine. There are three modes by which this, or indeed, any other dis- order may become epidemic, using the epithet in its general sense, as importing a disease of whatever sort that contaminates the at- mosphere of a district or neighbourhood. It may proceed from a specific miasm generated from local or accidental circumstances in the atmosphere itself, as in the miasm of intermittent, and often of remittent fevers; from a like miasm generated in the body of a sick individual, and communicated to the atmosphere, as in typhus; or from a peculiar temperament in the atmosphere predisposing the entire population that inhale it to a common morbid affection. Of any specific miasm originating in the atmosphere, and producing ro- salia, we have no proof whatever: but Ave have abundant proof of its issuing from the bodies of those who are sufferers under it; and if I mistake not, of a peculiar temperament or constitution of the atmosphere in a peculiar district or season, that predisposes to its general production; for it often becomes common to many families GE. I.—SP. I.] SANGUINEOUS FUNCTION. 375 so simultaneously that they have had no power of communicating it directly or indirectly to each other. And hence, however it may be favoured by external concurrent circumstances, we have good rea- son for believing that the miasm is always ingenerated; and that the disease, when communicated, is always by specific contagion. We may hence account for its being in a pure and healthy, or un- predisposing atmosphere but slightly infectious: for, in treating of the laAvs of febrile miasm which, under different circumstances, ori- ginates both within and without the living body, we had occasion to observe that, Avhen generated in the former manner, it appears to be less volatile than when in the latter, and less readily impregnates a periphery of pure air: whence the infection of typhus, which is commonly derived from this source, may be more easily avoided than that of intermittents or even remittents. The miasms of all the exanthems seem subject to the same law, as they all probably issue from a specific affection of the living body; and hence all of them are comparatively confined in the range of their actions, though some radiate their influence to a much greater distance than others, and are not so soon dissolved or decomposed. We may hence, also, see why the contagion of rosalia is received much more readily at some periods than at others. Nothing is more common than for a sporadic case of rosalia to occur in a fami- ly without communicating itself to the surrounding children, al- though no pains may have been taken to keep them separate; while a few month's afterwards it may possibly be received from a neigh- bour's house merely by an incidental visit for a few minutes. In the former case there was no predisposition in the habit to receive the complaint; in the other, the altered state of the atmosphere has, perhaps, produced such a predisposition in a very high degree, and prepared the way for the disease to become a very general epidemy. What this peculiar state of the atmosphere is has not yet been very accurately ascertained. It does not seem to depend altogether upon the season; though, commonly speaking, rosalia is more fre- quent towards the close of the summer, the common harvest-time of all debilitating diseases; and we also perceive that it is usually checked, at all periods, by a cold, dry, and bracing air, and hence is less frequent in the winter. But, with these exceptions, it has been found to range as an epidemy nearly equally from February to November; and sometimes through the whole of this term with- out ceasing: or only slackening its career when a keen dry breeze has sprung up from the north or the east. We see, also, another peculiarity in this disease, and that it is in its ordinary limitation to children; and we see this character ac- company it equally, whether the disease be sporadic or epidemic. Or, in other words, Ave behold the predisposing state of the atmos- phere observing the same restriction as the disease itself when it operates independently of any such predisposition. Adults, indeed. 376 ILEMAT1CA. [CL. HI.—OR. Ill do not entirely escape, but their attacks are rare, and for the most part less violent. The remote cause of rosalia, then, is a specific virus, or a speci- fic miasm generated in the living body. Of its occasional or excit- ing causes, separate from the predisponents just adverted to, we know nothing. It has sometimes seemed to follow upon catching cold, and at others upon a surfeit of the stomach; but as these arc perpetually taking place without producing such effect; and as ro- salia has often occurred where nothing of the kind could be traced, we can lay very little stress upon such casualties. All exanthems and nearly all fevers produce an influence on the system that renders it less susceptive of the same complaint for a certain period of time afterwards: yet the period varies from the plague, which exempts but for a few weeks, to the small-pox and measles, which usually extend the exemption to a term equal to that of a man's life : in consequence of which these disorders, except in a few anomalous cases, never appear but once in the same individu- al. Scarlet-fever seems to hold a middle range. It renders the sys- tem far less susceptible, and perhaps for several years; but the in- fluence, in many individuals, wears off by degrees, and does not pro- tect the Avhole of a man's subsequent life. Yet, as rosalia is a dis- ease of infancy rather than of adult age, it is not often that persons suffer from it a second time, though examples of such a recurrence are occasionally to be met with. Rosalia is at all times a disease of debility ; it prostrates both the body and the mind: but it has, in many cases, a peculiar tendency to weaken the absorbent system, arid incapacitate it for carrying off the fluids that are exhaled into the internal cavities of the body; and hence to produce dropsy. This calamitous sequel usually creeps on insidiously and without suspicion, and does not distinctly shoAv itself till the twelfth or fourteenth day, and often considerably later, Avhen the patient and his friends are flattering themselves that all danger is over. It commences with a peevishness, and a feeling of increased weakness and languor: the face is found to swell, and the urine to decrease in quantity, and to assume a somewhat bloody appearance, like the washings of flesh. The leuco-phlegmacy of the face extends gradually to the hands, feet, abdomen, and scro- tum, till the whole body becomes puffed up. " I have known these swellings," says Dr. Perceval, " to attack all the cavities, the ven- tricles of the brain not excepted, and in one instance fatally, upon an eruptive affection so slight as hardly to be noticed. The child was not confined, but went out, and was exposed to air." This last hint should not be dropped in vain : for the torpitude produced on the mouths of the absorbents by a sudden or injudicious exposure to cold air on recovering from rosalia, is one of the most common causes of this lamentable result: and hence we see, also, why it should be more common in Avinter than in summer; and in children than in adults, from the greater delicacy of their age. Dr. Withering confirms the instance just offered by Dr. Perceval, that GE. I.—SP. I.] SANGUINEOUS FUNCTION. 377 it is occasionally to be found after the mildest form of the disease; but adds, that it succeeds chiefly to its malignant or worst species. The curative treatment needs not long detain us. In slight cases of the simple variety, Ave may say Avith Dr. Sydenham, that the dis- ease hardly calls for medical assistance of any kind. When the fever is mild, it forms, as we have already observed in respect to exanthems of all kinds, the natural means of cure by determining the specific poison to the surface. An emetic may assist this deter- mination, and has hence been almost aUvays found serviceable ; and if the bowels be confined, an aperient may follow : but violent purg- ing Avill add to the irritation, and distract the remedial course that is taking place. In the paristhmitic variety, the determination, instead of being to the skin generally, is powerfully deflected to the throat and head, and the fever is alarming from its violence. The therapeutic in- tention is here to counteract this morbid flow and redness of the fe- brile action, always having regard to the nature of the fever as well as to its severity. Bleeding is the most direct and obvious means of reduction ; but it is open to the same objection as in typhus ; Avith the additional fact, that we have here to deal chiefly Avith children who have at all times less surplus of strength to spare than adults. Dr. Plenciz is, however, a strenuous advocate for the use of the lancet, and Dr. Armstrong has recommended it still more lately. Where the head is manifestly oppressed from contagion, it may be risked as a mode of local relief, and may be so far of service: but it is a risk at all times, and ought by no means to form a part of the general curative plan. With the exception of typhous miasm, there is nothing ihat so much exhausts, or rather perhaps suppresses the secretion of sensorial power as the miasm of rosalia ; nor is there any evacua- tion that adds so immediately to the direct debility of the system as venesection : and consequently none that ought to be so studiously avoided as a general rule. And hence, often as the practice has been introduced by different individuals, it has never been common or established. Even Dr. Withering, who denominated the fever inflammatory, rigidly abstained both from bleeding and purgatives ; and confined himself, in the onset of the disease, to emetics.* Vomiting, which has just been recommended in the first species, is still more necessary in the present; for it not only tends to take off the dry burning heat of the skin by relaxing it, but unloads the fauces of the mucous and serous fluids that gorge and distend them. Whether also, as conjectured by Dr. Withering, it arrest the matter of contagion received from the breath of the sick, in its threshold, and prevent it from assimilating the confined and viscid mucus to its own nature, is a question which is not necessary to examine into. Its practical advantage is sufficiently obvious, without leaning upon * Account of the Scarlet Fever in 1778, 8vo. vol. II.—48 378 HiEMATICA. [CL. HI.—OR. HI. any hypothetical good; and it Avill often be proper, as recommended by Dr. Withering, to repeat it occasionally, as the foul and infarcted state of the fauces may require. We have just observed that this distinguished physician prohibit- ed purgatives as well as bleeding. But in doing this he discovered still further the trammels of hypothesis; for while he conceived that emetics tended directly to throw off the matter of contagion from the organ in Avhich he supposed it to be chiefly concentrated, he conceived at the same time that purgatives, on the contrary, only promote its diffusion along the course of the intestinal canal. This reasoning, hoAvever, cannot be allowed : the system should not be weakened by their violence, but their use can rarely be dispensed with. As aperients they remove whatever acrimonious material may be lodged in the intestines, and as revellents they poAverfully recall all morbid determination from the head. Calomel, as operat- ing upon all the excretories, is commonly to be preferred to any other cathartic, or may be conveniently combined with rhubarb. The great inquietude that characterises this disease has induced many practitioners to try opium, but it rarely affords relief in any form or combination ; and generally renders the head worse. Acids, Avhether vegetable or mineral, are always grateful to the patient, and seem more than any other internal mean to diminish the burn- ing heat of the skin. But our chief dependence for this purpose must be upon Dr. Currie's bold and happy plan of employing cold water freely. Sponging will rarely be found sufficient, or rather will rarely be found of equal advantage with affusion ; the fluid may, indeed, in this case be dashed against the patient till the heat is subdued, and the process be repeated as fast as it returns. The refreshment is often instantaneous, and operates like a charm ; and seems to show, as I had occasion to observe formerly, not merely a refrigerant, but an exhilarating power, as though the water Avere decomposed and a part of its oxygene were swallowed greedily by the thirsty absorbents of the skin, Avhich immediately becomes softer and moister as well as cooler. The throat must in the mean while be deterged with antiseptic gargles of oxymel and port-wine, port-wine-negus, or any of those already noticed under malignant paristhmitis ; or fumigated Avith the vapour of mineral acids. Blisters may also be applied with good effect. Dr. Withering objects to them ; but the general practice is very much in their favour. In severe cases Dr. Plenciz,* had recourse to the aurum fulminans, as recommended by De Haen,t and speaks warmly of its success. Its design was to operate on the bowels and bladder, and it was given in composition with calomel, rhubarb, and squills. I have never tried it, nor can I very easily trace out the path by Avhich any benefit may be hence expected. Wine and nutritious food may * Tractat. de Scarlatina. t Rat. Med. Continuata. Tom. I. Part. I. 8vo. Vienna. GE. I.—SP.TI.] SANGUINEOUS FUNCTION. 379 be allowed, but somewhat less freely than in malignant quinsy. The convalescent state requires great care; and a damp cold at- mosphere should be especially avoided from the tendency to drop- sical swellings. SPECIES II. ENANTHESIS RUBEOLA. JHeasles, RASH IN CRIMSON, STIGMATISED DOTS, GROUPED IN IRREGULAR CIRCLES OR CRESCENTS ; APPEARING ABOUT THE FOURTH DAY, AND TERMINAT- ING ABOUT THE SEVENTH ; PRECEDED BY CATARRH : FEVER a CAUMA. Of the earliest accounts we possess of measles, the origin of the name of rubeola, and the frequency with which it was at first mis- taken for rosalia, some notice has been taken under the last species. In its perfect form it is unquestionably contagious from a specific miasm, though we shall presently have to notice one variety that is inactive in this respect. Like rosalia, also, it is at times epidemic, and probably from the same cause,—a general predisposition in the population of the affected district or country to receive its conta- gion, perhaps to originate it, from some peculiar but unknown tem- perament or constitution of the atmosphere. It occurs under the three following varieties :— Rash slightly prominent extend- ing over the mouth and fau- ces ; harsh, dry cough, inflam- ed, watery eye. Rash running its regular course, with little fever or catarrhal affection; affording no certain security against the common or regular disease. Rash about the seventh or eighth day assuming a black or livid hue, interspersed with yellow : prolonged in its stay; and ac- companied with extreme lan- guor and quickness of pulse. The only predisposition or exciting cause of rubeola that we are acquainted with, is the peculiar constitution of the atmosphere just referred to. And under the influence of this cause the first variety « Vulgaris. Common Measles. £ Incocta. Imperfect Measles. y Nigra. Black Measles. 380 HiEMATICA. [CL. III.—OR. IH. usually shoAvs itself as an epidemic ; generally commencing in the month of January, and ceasing soon after the summer-solstice. There seem, however, to be some other exciting causes than a peculiar state of the atmosphere, or of the season ; for we meet with a few scattered cases of it in almost every month of the year, evidently proving an ingenerate origin, and that the atmosphere is not auxiliary to its diffusion, from its continuing to be merely scat- tered; yet possessing its ordinary principle of contagion, which only appears to be less generally active because there is a less general predisposition, in those who have never undergone it, to be acted upon. It occurs most usually in children, though no age is altogether exempt from it. As rosalia is accompanied with a typhoid fever, rubeola is accompanied with a catarrhal; and hence, the opening symptoms consist of some degree of hoarseness, with a harsh dry cough, and frequently uneasy respiration ; the eye-lids are tumefied, the vessels of the conjunctiva turgid and inflamed, the cheeks are Avet Avith a flow of acrid tears, and the nostrils loaded with acrid serum, that irritates them and excites an almost perpetual sneez- ing; the head aches or is droAvsy; and the stomach, from sympathy, rejects its contents. On the fourth day the rash makes its appear- ance and assumes the character described in the specific definition. The stigmatised and pathognomic dots are sometimes at first attend- ed by so general a flush as to be lost in them, and to give the ap- pearance of scarlet-fever. I have already noticed several signs by which the tAvo diseases may be distinguished, and the following may be added to the number. In scarlet-fever there is no cough, the eyes do not Avater, and the eye-lids are not red and swelled. In measles the papulae are more acuminated, of a crimson instead of a scarlet hue, and do not appear till two days later than in scarlet- fever. In small-pox the fever abates as soon as the eruption makes its appearance. In scarlet-fever this is by no means the case, and as little so in measles; the vomiting, indeed, subsides ; but the cough, fever, and head-ache groAv more violent; and the difficulty of breath- ing, Aveakness of the eyes, and indeed all the catarrhal symptoms, remain without any abatement till the eruption has completed its course. In rosalia we have also seen that the sooner the efflorescence breaks forth after the febrile attack, the slighter and more favoura- ble the disease. The same occurs in rubeola. The ordinary period we have already stated to be the fourth day, but it occasionally appears on the third, when the patient commonly escapes Avith but little inconvenience.* A few rare examples may be found of its exceeding, instead of anticipating its proper term ; and this so con- siderably, that Buchholz gives us an instance of its not appearing * Van der Haar, Waarneemingen. GE. I—SP. II.] SANGUINEOUS FUNCTION. 381 till the twenty-first day: thus precisely rivalling the singular anoma- ly of scarlet-fever already quoted from Dr. Maton.* On the third or fourth day after the eruption first appears, the redness diminishes, the spots fall off in branny scales, which some- times, however, are scarcely perceptible from their minuteness and tenuity ; leaving a slight discoloration on the skin, with considerable itching. On the ninth day from the beginning, when the progress has been speedy, and on the eleventh when it has been slow, no trace of measles remains. The eyes, however, in many cases con- tinue still inflamed, and the cough is followed with severe peripneu- monic symptoms Avhich terminate in phthisis. Yet these sequelae rarely occur except where the treatment has been improper, or there is a predisposition to consumption from a strumous stale of the lungs or some other phthisical diathesis. If, on inoculation for small-pox, rubeolous contagion should have been previously received into the system, the variolous action will generally be, though not ahvays, suspended till the measles have run through their proper course, when the inserted virus will re- sume its power and the variolous eruption follow in its due order. This quality of suspension, however, is not peculiar to the measles. " I have known," says Dr. Perceval in his manuscript comment on the present species," bex convulsiva yield the pas to variola, and then resume its station." In like manner consumption is generally sus- pended during the entire courseof pregnancy, and recommences its inroad on child-birth. Measles in their more perfect form, which is that we are noAv contemplating, may be said, as a general rule, to occur but once in the courseof a man's life; for though a few instances of a second attack are to be found excefitio firobat regulam ; they are so rare as rather to maintain than disturb the laAv.f Dr. Willan asserts that he never met with an instance. The anomaly is unquestionably less frequent than in scarlet-fever, and shows that the influence pro- duced by the rubeolous action on the habit is more rooted and effec- tive. In its ordinary course measles is a disease unaccompanied Avith danger. It is in fact a catarrhal fever with a specific eruption. The fever, as we have observed already respecting exanthems in gene- ral, is necessary to a certain extent for the purpose of throwing the virus upon the surface ; as inflammation in a certain extent is ne- cessary to produce healthy suppuration. But a small degree of py- rectic action is in both places sufficient; for if this be exceeded, the natural means of cure itself becomes the disease rather than the morbid condition it is intended to remove. In all instances the extent of the eruption will depend upon the fever Avhenever the latter is in excess. And hence our attention is to be mainly directed to the fever itself; for by diminishing the fe- * Tode Med. Chir. Bibl. B. I. p. 86. f Roberdiere, Recherches sur la Rougeole. Paris 1776. 382 HJKMATICA. [CL. III.—OR. HI. ver we necessarily diminish the eruption also. In measles, there- fore, the remedies we have already enumerated for a catarrh are those we are to have recourse to. An emetic is always useful on the incursion of the disease ; and should be succeeded by cooling aperients and demulcents, the skin being kept moist, and its heat subdued by mild diaphoretics. Dr. Cullen recommends blood-letting during every period of the disease; and it has hence often been practised at its commence- ment. It is rarely, hoAvever, that this can be called for except in the case of pneumonic inflammation; and as such an affection does not commonly appear till the close of the measles, Ave should, generally speaking, as recommended by Sydenham, reserve blood-letting till this period, and not exhaust the patient's strength beforehand ; and the more so, as even here the fever has sometimes proved a sy- nochus, and terminated in a typhous form, as particularly noticed by Sir William Watson in the children of the Foundling Hospital in 1763 and 1768, who gives to this modification the name of putrid measles:* if, indeed, this were an example of the genuine disease, of Avhich there is some doubt, though there is little doubt that in a few constitutions the disease has taken this turn. " In a charity school, where measles prevailed," says Dr. Perceval, in comment- ing on this species as given in the Nosology, " typhous infection was introduced ; hence the variety x changed to £." It is highly proba- ble that some such accidental cause occurred in producing Sir Wil- liam Watson's modification. Exposure to cold, so highly serviceable in small-pox, has, from a supposed analogy, been recommended also in measles by some rash practitioners, and adopted by others. All fair analogy, however, is against the practice : the fever in measles is directly catarrhal, and the analogy should be drawn, not from small-pox, but from catarrh, in Avhich exposure to cold Avould, in the opinion of every one, be absurd and mischievous; nor can any thing be so likely to produce pneumonic inflammation, Avhich, in truth, is most commonly the re- sult of carelessness upon this very point. The room should be large and air, free from currents of cold, but not hot; the drink Avarm, the food light, diluent, and in a liquid form. If the cough be troublesome, it will be useful to breathe the steam of warm-Avater, not through an inhaler, but over a large basin, with the head cover- ed with a flannel large enough to hang over its edges; and by this mean the inflamed eyes will also have the benefit of the relaxing va- pour. If the oppression of the chest, pain, and coughing should return, as they are apt to do on the disappearance of the eruption, venesection or cupping must again be had recourse to, however they may have been employed antecedently. Opium does not, in this case, afford the relief we might expect: it increases the heat and restlessness, but rarely conciliates sleep. A supervening diarrhoea * Medical Observations, Vol. IV. Hoffman. Opp. Tom. n. p. 67. GE. I.—SP. II.] SANGUINEOUS FUNCTION. 383 proves the most favourable crisis, and should be very cautiously corrected. And where it does not take place naturally^ it may be wise to imitate it by gentle laxatives. From a peculiarity of constitution, or some accidental influence exercised over it at the lime, the rubeolous rash is sometimes found to run through its regular course with little fever or catarrhal affection, as though it were a simple cutaneous eruption and without appearing to afford an immunity to the individual against a future attack; constituting our second species.* This has usually been called, and especially by the German writers, spurious measles; but as it occurs most frequently Avhen the genuine measles are epi- demic, and is doubtless a result of their contagion, it is less properly a spurious than an imperfect or immatured rubeola; and I have hence exchanged the term spuria for incocta. Dr. Willan denominates it rubeola sine catarrho ; but as the genuine measles themselves, ca- pable of affording emancipation, have sometimes appeared with very slight catarrhal symptoms, incocta seems preferable. "Some," says Dr. Heberden, " have been so fortunate as to have the measles appear after suffering so very little from fever, or any of the pre- paratory symptoms, that they could hardly say they had been ill." In this case the constitution is protected by a natural insusceptibility of the disease; Avhich is the best protection Ave can possess. In the case of imperfect measles, it is only operated upon by some tempo- rary influence; and hence as soon as this influence ceases, the com- mon susceptibility returns. The third variety, or black measles, seems to consist in an in- termixture of dark, discoloured, or petecchial spots from effused blood, with the proper rubeolous rash. It is found chiefly in persons of debilitated and relaxed fibres : and the dark patches will sometimes remain for ten or twelve days after the commencement of the erup- tion, with no oiher symptoms of fever than a quicker pulse and an increased degree of languor. It is rarely of serious consequence, unless a typhous infection be accidentally communicated, as men- tioned by Dr. Perceval, and usually yields Avith ease to an infusion of bark Avith sulphuric acid. Inoculation has been tried for the measles by employing the acrid serum from the eyes, or from minute vesicles that sometimes appear between the patches of the rash. Dr. Home, not being able to obtain a contagious ichor from either of these quarters, drew blood from a turgid cutaneous vein Avhere the eruption was most confluent; and impregnating a dossil of cotton with it, he ap- plied the cotton to a wound made in the arm. It has occasionally succeeded, but more frequently failed ; nor does it seem to operate with any certainty in producing a mild modification; for many of the cases of inoculated measles have been quite as severe as we might reasonably have expected from a natural attack. It is in truth a very unnecessary caution in a disease that in its ordinary * New-Yoix Medical Repository, Vol. V. Art. III. 384 II EMAT1CA. [CL. III.—OR. III. range excites so little alarm; and which leaves no blemish, like the small-pox, on the skin. SPECIES III. ENANTHESIS URTICARIA. J£cttlc=lta8n, RASH IN FLORID, ITCHING, NETTLE-STING WHEALS ; APPEARING ABOUl THE SECOND DAY ; IRREGULARLY FADING AND REVIVING, OR WAN- DERING FROM PART TO PART : FEVER A MILD REMITTENT. This, like the last species, is rather a troublesome than a dangerous complaint; though it is always attended Avith some slight disorder of the constitution, as head-ache, drowsiness, coldness, and shivering, succeeded by great heat and a white fur on the tongue. But the stomach seems chiefly to suffer: and hence there is not unfrequently pain and sickness in this organ, with great languor, faintness, and anxiety. And, as a sympathetic affection, the eruption has often followed on any violent disturbance of the stomach alone, as surfeit, cold, cucurbitaceous or other indigestible vegetables, mushrooms, crab-fishes, muscles, cupreous or other mineral poisons, introduced into the stomach by mistake. The exciting cause, however, of genuine idiopathic nettle-rash, is usually concealed from us; for it often makes its appearance with- out any of these irritants, or indeed any other that we are acquaint- ed with ; and hence Dr. Heberden inclined to believe that the skin itself is often the chief seat of disorder, and that the stomach and the system only suffer secondarily.* He has hence contemplated it as a modification of lichen, closely connected with the prickly heat of the West Indies, the essera or rather eshera of the Arabian writers. The resemblance is close; but there are characters by which the two diseases may be distinguished with tolerable ease. In nettle-rash the efflorescence is in scattered wheals Avith few pa- pulae ; in lichen, in scattered papulae with few wheals. In the latter the itching is more mordant and aculeate; the eruption instead of terminating in a few days runs on to an indeterminate period; and, however irritating, produces little or no fever, and but a slight con- stitutional affection of any kind. In Sauvages, on the contrary, nettle-rash, is treated of as a scar- let-fever under the name of scarlatina urticata. But its character as given in the specific definition is sufficient to distinguish it from any form of rosalia, Avhich has no wheals or elevated beds with a defined outline, and no sensation of stinging. * Medical Transactions, Vol. H. p. 173. *iE. I.—SP. III.] SANGUINEOUS FUNCTION. 685 The nettle-rash occurs chiefly in summer, and more frequently among persons of a plethoric or sanguine habit, especially those who indulge too freely in eating and drinking. In children it seems sometimes to be connected with teething or irritation of the bow- els. The eruption commonly takes place at night after the febrile symptoms just noticed have prevailed for about thirty or six-and- thirty hours; and on this occount the Arabians elegantly and cor- rectly denominated the coloured wheals (benat-allil,) " offspring or daughters of the night." By the length of the precursive symptoms the idiopathic disease is distinguished from the sympathetic affection, so closely resem- bling it, which is occasioned, as already observed, by crapulence, or substances introduced into the stomach that disagree with it. In this last case the general swelling and eruption take place immedi- ately, and subside as soon as ever the occasional cause is removed. Wheals of a similar appearance are sometimes found with other pe- culiarities, as of a whiter hue, or interspersed with small tubercles, or of very small diameter except when they unite in clusters: some of these sorts trouble the skin permanently ; others vanish and re- appear several times in the course of the day ; others subside for a week or two, and then rally and re-occupy their stations. But all of them are of chronic duration, are little accompanied with fe- ver; and cannot be considered correctly as varieties of the idio- pathic disease. They occur, however, as such in Dr. Willan's treatise. A cooling regimen, and subacid diluents, with a free exposure t© pure air, generally succeed in effecting a cure of nettle-rash with- out any other medical treatment. A gentle laxative or two how- ever should be added to the domestic means: and if the itching be very troublesome it may be often allayed by the use of campho- rated vinegar. The juice of fresh parsley has the reputation of pro- ducing an equally good effect; but evaporation by means of any other fluid applied to the itching parts would probably be found as beneficial. Dr. Willan describes a single case in Avhich urticaria proved fa- tal.* This patient was a man of about fifty years of age, who had impaired his constitution by hard labour and intemperance. The precursive symptoms were all violent, and the sickness and languor were followed by fainting fits; and he had great pain in the sto- mach, which was increased by pressure. The fever was consider- able, and soon attended with delirium. While the rash was most vivid his internal complaints abated; but he gradually got worse, and died on the seventh day. Here, again, however, the urticaria seems to have been only symptomatic. It afforded him relief, and offered the only chance of a recovery. • Cutaneous Diseases, p. 401. VOL. II.—49 AH(< II/EMATICA [CL. UL—OK. IH GENUS II. EMPHLYSIS. Udiorous Spantfiem. ERUPTION OF VESICULAR PIMPLES FILLED PROGRESSIVELY WITH AN ACRID OR COLOURLESS, OR NEARLY COLOURLESS FLUID; TERMINAT- ING IN SCURF, OR LAMINATED SCABS. The term emphlysis is derived from the Greek *i«.or ev, « in, intra ;" and GE. IV.—SP. II.] SANGUINEOUS FUNCTION. 441 opake whitish fluid when broken, and concrete into dense scabs or crusts. The larger are fungous excrescences, and, in their granu- lar surface, as well as in their size and colour, bear a near resem- blance to the fruit from which they derive their name. These sprouting tumours have but little sensibility, and suppurate very im- perfectly; discharging rather a sordid ichor than a matured pus. They originate in scattered groups over different parts of the body, but are chiefly found, like the eruption of plague, in the groins, parotid glands, axillae, and about the arms and pudenda: though they often disfigure the neck and face. The colouring matter of the hair, wherever they are seated, is obstructed in its secretion, and, as in old age, the hairs themselves,from a brown or a black, be- come a dead white. Dr. Thomas, who has given a very accurate account of this variety, apparently from personal knowledge, ob- serves that," in general the number and and size of the pustules are proportioned to the degree of eruptive fever. When the febrile symptoms are slight, there are few pustules; but they are mostly of a larger size than when the complaint is more violent and exten- sive."* The duration of the eruption is uncertain, and seems to depend considerably upon the state of the habit, and its power of promoting their maturity. They sometimes acquire full perfection in four or five weeks, and sometimes demand two or three months. In their progress to this state, there is usually some one that appears larger and more prominent than the rest, and is called the master-yaw. It is, in truth, a broader and more sloughy fungus, and discharges a larger portion of erosive sanies, which if not washed off as it issues will spread widely, and sometimes work its way to an adjoining bone, and render it carious. When the tumours point from the soles of the feet, they cannot press through the thickness of the skin, and hence acquire form imperfectly, and produce highly elevated cal- luses, Avhich are called tubba or crab-yaws : and often very much im- pede the power of walking. As soon as the eruption has attained its height, the tumours, when the disease proceeds favourably, be- come covered with crusts or scabs, Avhich fall off daily in whitish scales; and, in the course of a fortnight, the skin is left smooth and clean; the master-yaw alone remaining and demanding attention. In attempting the cure of this disease, the first step should consist in separating the patient from his associates, to whom he will otherwise assuredly communicate it by contagion. He should then take freely of decoction of sarsaparilla or some other warm di- luent, for the purpose of attenuating the specific virus in the blood, and quickening its passage towards the surface. And it is highly probable that the warm aperient bolus, composed chiefly of a scru- ple of sublimed sulphur and five grains of calomel as recommended by the anonymous writer of a very excellent treatise upon the sub- * Pract. of Pbyg. p, 643. ed, 1819. 448 HiEMATICA. [CL. HI.—OR. 111. ject in the Edinburgh Medical Essays,* may be found serviceable, continued every night. The master-yaw must be attacked with es- carotics, for it is to be destroyed in no other way. The callous tu- mours on the soles of the feet should be softened by warm water, or cataplasms of some gentle stimulant; and, when on the point of breaking, are best attacked with a slight application of the actual cautery which proves the most advisable escarotic. The diet should be nutritious and liberal, so as to support the strength during the progress of the disease. And under this mode of treatment it is rarely that a patient fails to do well. Mercury was at one time given in great abundance from the com- mencement of the complaint, under an idea that it would prove as beneficial as in the case of lues. But it is now sufficiently knoAvn to be productive of great mischief, and particularly when carried, as it used to be, to a state of salivation. It retards the cure, and generally aggravates the symptoms. It is often given in small doses as an alterative, when the disease is on the decline, and per- haps Avith advantage; but it ought never to be employed in any other form. When the excrescences discharge a sordid ichor, they may also be stimulated Avith the nitric-oxyde mercurial ointment: but the na- tives themselves, who rigidly abstain from the internal use of mer- cury, employ, instead of this, a liniment of the rust or sub-carbon- ate of iron and lemon-juice, which proves a very useful application; though probably a solution of sulphate of zinc might answer better. And during the maturation of the eruption they excite a profuse sweat by Avhat may be called a Avarm air bath, which consists in putting the patient into a cask with a fire at the bottom in a brazier or small fire pan; the top being covered over with a blanket. Un- ner this mode of treatment a cure is said to be often effected in three weeks, and the funguses thoroughly healed.t The second, or American variety, is a far more terrible com- plaint; or rather is the same complaint in an exasperated and chro- nic form; and hence, though incomparably slower in its progress than the plague, is accompanied with a carbuncular eruption quite as mischievous and disgusting, and mere certainly fatal in its issue. It was first distinctly described by M. Virgile of Montpellier, who had practised with great reputation at St. Domingo. There can be lit- tle doubt of its being imported into the West Indies along with the slaves from the African coast; and is here called, as already ob- served, pian or epian, precisely synonymous with the African term yaw : the master-fungus being named mama-pian, or mother-yaw, as supposed to be the source or supply of the rest. The fungous ber- ries in this form, precisely correspond to the carbuncle already de- scribed under the trivial name of terminthus, which consists of a " core of fungus spreading in the shape, and assuming the figure, * Vol. V. Part. H. Art. LXXVI. t Edin. Med. Com. Vol. II. p. 90. GE. IV.—SP. H.] SANGUINEOUS FUNCTION. 449 and blackish-green colour of the fruit or berry of the pine-nut, or terminthus of the Greeks."* And it has hence been conjectured, but without sufficient foundation, that the disease of yaws is refer- red to by Galen and Dioscorides under this name. The erosive secretion from the carbuncles of this variety, gene- rally, but especially from the mother-yaAv, spreads widely, and, in its meandering, destroys all the surrounding parts, not excepting the bones. Nothing can exceed the revolting scene of a yaw-house, or hospital for the reception of slaves suffering under this disease in the West Indies " Here," says Dr. Pinckard, " I saw some of the most striking pictures of human misery that ever met my eyes. Not to commiserate their sufferings is impossible, but their offen- sive and wretched appearance creates a sense of horror on behold- ing them. Of all the unsightly diseases which the human body is heir to, this is perhaps the worst. Some of these diseased and truly pitiable objects were crouching upon their haunches round a smoky fire ; some stood trembling on their ulcerated limbs; others, sup- porting themselves by a large stick, were dragging their wretched bodies from place to place ; while many too feeble to rise, lay shivering with pain and torture upon the bare boards of a wooden platform."t Dr. Pinckard adds, that " unhappily this most odious distemper has not hitherto been found within the power of medi- cine : that it often exists for years, and even Avhere it sooner yields, its removal is more the effect of time and regimen, than of medical treatment." This view of the case is too generally true : but from the length of time which, under the best treatment, is required to effect a cure, it seldom happens that these miserable wretches receive all the attention Avhich their situation deserves ; and they are rarely suffi- ciently heedful of personal cleanliness, which, even alone, is of the utmost importance. This, with a generous diet to support the strength, pure air, regular hours of rest, and such exercise as can be used without fatigue, with Avarm balsamic applications to the sores, have not unfrequently succeeded, Avhere the bones have not become extensively carious. But the latter stages of the disease are horrible when it proves fatal: for the pains are excruciating, the debility extreme, and the bones are covered over with a quag- mire of foul exostoses and corrupt ulcerations. It is happy for the European inhabitants of the West Indies that they are less liable to this miserable malady than their slaves : pro- bably from using a better diet and being more attentive to cleanli- ness. * CI. III. Ord. II. Vol. II. p. 194. t Notes on the West Indies, Vol. II. Letter XXII, vol, II.—-57 class in HiEMATICA. ORDER IV. DYSTHETICA. (Eacneirtes. MORBID STATE OF THE BLOOD OR BLOOD-VESSELS J ALONE OR CONNECT- ED WITH A MORBID STATE OF THE FLUIDS, PRODUCING A DISEASED HABIT. The words ordinarily used to import the diseases meant to be comprehended under the present order are cachexia and impetigo, or, as the Greeks expressed it, Xvik, lues, or lyes. None of these, however, exactly ansAver ; and that, on two accounts; first, because the order is limited to those depravities which seem to originate or manifest themselves chiefly in vessels or fluids of the sanguineous function ; and, secondly, because no very definite sense has hitherto been assigned to either of these terms; and they have, in conse- quence, been used in very different meanings by different writers, from the time of Celsus to our own day. Upon this subject the author has dwelt at large in his volume of Nosology, and it is not necessary to add to the remarks there offer- ed. The word dysthetica has hence been adopted for the purpose of avoiding confusion, and is justified by theEusiHESiAand eusthe- tica (ETS0ESIA and EY20ETIKA) of Hippocrates and Galen, im- porting a " well-conditioned habit of body," as their opposite dys- thetica, from the same root, imports an " ill-conditioned habit," but a habit as just observed, originating in, or dependent upon the or- ganized parts or fluids of the sanguineous function. Thus explain- ed, it will be found to embrace the following genera : 1. plethora. plethora. 2. H.SMORRHAGIA. hemorrhage. 3. MARASMUS. EMACIATION. 4. STRUMA. SCROPHULA. KING'S EVIL. 5. CARCINUS. CANCER. 6. LUES. VENEREAL DISEASE. GE. I.J SANGUINEOUS FUNCTION. 461 7. elephantiasis. elephant-skin. 8. BUCNEMIA. tumid-leg. 9. CATACAUSIS. SPONTANEOUS IGNESCENCE. 10. PORPHYRA. SCURVY. 11. EXANGIA. VASCULAR DIVARICATION. 12. GANGRjENA. GANGRENE. 13. ULCUS. ULCER. GENUS I. PLETHORA. Plethora. complexion florid ; veins distended ; undue sense of heat and fulness ; oppression of the head, chest or other internal ORGANS. Plethora is seldom ranked as a disease, and hence seldom treated of in a course of medical instruction. From what cause this omission proceeds I know not, nor is it worth while to inquire. That it is an important omission will be obvious to every student before he has been six months in practice; for there will probably be few affec- tions on which he will be sooner or more frequently consulted. Yet the subject has not always been neglected by nosologists, for plethora, as a genus, occurs in the classifications both of Linneus and Sagar. In a state of health, the quantity of blood produced from the sub- stances that constitute our common diet bears an exact proportion to the quantity demanded by the vascular system in its ordinary diameter, and the various secretions which are perpetually taking place in every part of the body. But the quantity of blood produced within a given period of time may vary; and the diameter of the blood vessels, or the call of the different secernent organs may vary; yet, so longas a due balance is maintained, and the proportions of new-formed blood is answerable to the demand, the general health continues per- fect or is little interfered with. Thus, a man exhausted and worn down by shipwreck, or by having lost his way in a desert, or who is just re- covering from a fever, will devour double the food, and elaborate double the quantity of blood, in the course of four and twenty hours, to what he would have done in the ordinary wear of life; but the whole system demands this double exertion ; the doubly supply is made use of, and the general harmony of the frame is as accurately maintained, as at any former period; there is no accumulation or plethora. It should also be observed, that in this case the same remedial or 452 HJEMATICA. [CL. III.—OR. rV. instinctive power that stimulates the sanguific organs to the forma- tion of a larger proportion of blood, stimulates also the blood-ves- sels to a diminution of their ordinary capacity ; and lessens the acti- vity of the secernents; and hence the difficulty to Avhich the animal machine is reduced is also met another Avay; and a balance be- tween the contained fluid, and the containing tubes, is often pre- served as completely during the utmost degree of exhaustion, as in the fullest flow of healthy plenitude. We sometimes, however, meet with cases in which an increased supply of blood is fabricated when no such increase is wanted, and the vessels remain of their ordinary capacity. And we also some- times, meet Avith cases in Avhich, from a peculiar diathesis, the capacity of the vessels is unduly contracted, Avhile no change takes place in the ordinary supply of blood. It is evident that in both these contingencies there must be an equal disturbance of the ba- lance between the substance contained and the substance containing, and that the measure of the former must be too large for the mea- sure of the latter. In other Avords there must be in both cases an excess of fluid or a plethora, though from very different, and Avhatare usually regarded as opposite causes; and hence it has been distin- guished by different names; that proceeding from an actual surplus of blood being denominated a plethora ad molem, or a plethora in respect to its general mass, or absolute quantity; and that proceeding from a diminished capacity of the vessels being denominated a plethora ad sfiatium, or a plethora in respect to the space to be occupied. It is possible, however, for both these causes of plethora to exist at the same time, and for the vessels to evince a contractile habit or diathesis, Avhile the blood is produced in an inordinate proportion. And this, in truth, is by no means an uncommon state of the animal frame; for where the excess of blood is the result of a highly vigor- ous action or entony of the organs of sanguification, we often see proof of the same entony or highly vigorous action through the whole range of the vascular system, and indeed of every other part of the machine; the pulse is full, strong, and rebounding; the mus- cular fibres firm and energetic, the complexion florid, the whole figure strongly marked. We have here the sanguine temperament; and this kind of plethora has hence been called the Sanguine Ple- thora. But we often meet Avith an inordinate formation of blood in a con- stitution where the vascular action is peculiarly weak instead of being peculiarly vigorous, the muscular fibres are relaxed instead of being firm, and the coats of the vessels readily give way, and become enlarged instead of being diminished in their diameter; and where instead entony or excess of strength, there is considerable irrita- bility or deficiency of strength in the organs of sanguification. Yet, though the cause is different, the result is the same; the ves- sels, notwithstanding their facility of dilatation, at length become distended, and a plethora is produced which has been denominated GE. I.—SP. I.] SANGUINEOUS FUNCTION. 453 a plethora ad vires ; or a plethora as it respects the actual strength of the system. The pulse is here indeed full,but frequent and fee- ble; the vital actions are languid ; the skin smooth and soft; the figure plump, but inexpressive ; all which are symptoms of debility of the living power, or rather of that peculiar diathesis which has been distinguished by the name of the serous, phlegmatic, or pitui- tary temperament; and hence this sort of plethora has been com- monly denominated Serous Plethora. We have, hence, a foundation for the two following very distinct Species of this affection, the names for which are derived from their proximate causes. 1. PLETHORA ENTONICA. SANGUINE PLETHORA. 2. ■ ATONICA. SEROUS PLETHORA. SPECIES I. PLETHORA ENTONICA. Sanguine plethora. PULSE FULL, STRONG, REBOUNDING : MUSCULAR FIBRES FIRM AND VIGOROUS. Sanguine plethora is more common to men, serous to women. It is the disease of manhood, of the robust and athletic. Plethora of this kind must be distinguished from obesity ; in effect, they are rarely found in conjunction, for the entony or excess of vigorous action is common to every part of the animal frame, and hence, though it is probable that a larger portion of animal oil is secreted than in many other conditions of the body, yet it is carried off by the activity of the absorbents, and there is no leisure for its accumulation in the cellular membrane. And hence persons labouring under sanguine plethora are rather muscular than fat, and their distended veins lie superficially and appear to peep through the skin. In this state of the blood-vessels, slight excitements produce con- gestion in the larger vessels or organs. The head feels heavy and comatose ; the sleep is disturbed by tumultuous dreams; the lungs labour in respiration, and the muscles feel a want of freedom or elasticity in exercise. If fever arise, it will assume the inflammato- ry type; and a slight excess in feasting or conviviality will endan- ger an apoplexy. The cure, however, is not in general accompanied with much difficulty; and far more easily effected in this species than in the ensuing: for the entonic power may readily be lowered by vene- section and purgatives; and its disposition to return may commonly 454 HJEMATICA. [CL. HI—OR. IV. be prevented by the use of refrigerents, as nitre, or other neutral salts, and an adherence to a reducent diet and liberal exercise; at the same time it should be observed, that where the plethora de- pends upon a sanguinous temperament, or phlogistic diathesis, venesection, though rightly employed at first, should be repeated with great caution, as it will tend to generate in the system a peri- odical necessity for the same kind of depletion, and consequently promote the disease it is designed to cure. SPECIES II. PLETHORA ATONICA. Serous plethora. PULSE FULL, FREQUENT, FEEBLE : VITAL ACTIONS LANGUID ; SKIN SMOOTH AND SOFT; FIGURE PLUMP, BUT INEXPRESSIVE. The general pathology we have already treated of: and the reasons given under the last species for the usual appearance of sanguine plethora in persons of a spare and slender make, will explain the plumpness of figure and glossiness of skin which so peculiarly mark the species before us. In the first, there is great and universal vi- gour and rapidity of action ; the secretions are all hurried forward in their elaborations, and carried off as soon as produced. In the se- cond, there is little vigour or activity of any kind, and whatever is eliminated is suffered to accumulate. Hence costiveness is a com- mon symptom ; the ankles are cold and pituitous ; and the animal oil, when once separated and deposited in the chambers of the cel- lular membrane, remains there, becomes augmented, and produces corpulency and sleekness. The inertness of the body is communi- cated to the mind ; every exertion is a fatigue ; and the mind thus participating in the inertness of the body, the countenance, though fair and rounded, is without expression, and often vacant. Debility is always a source of irritability : and hence there is great irregularity, and a seeming fickleness in many of the symptoms by Avhich this species of plethora is characterized, and the results to which it leads. The bowels, though usually quiescent and costive, are sometimes all of a sudden attacked with flatulent spasms, or a troublesome looseness. The appetite is languid and capricious ; the heart teased with palpitations, the chest with dyspnoea and wheez- ing ; the head is heavy and somnolent; the urine pale, small in quantity and discharged frequently. In this species, as in the last, we are compelled to begin with cupping or the use of the lancet. But, though the distended and overfloAVing vessels demand an abstraction of blood, it should never GE. I.—SP. n.] SANGUINEOUS FUNCTION. 455 be forgotten that the relief hereby afforded is only temporary; and that, as the disease is, in this case, an effect of debility, we are directly adding to the cause as often as we have recourse to the lancet. Our leading object should be to give tone to the relaxed fibres; and to take off the morbid tendency to the production of a surplus of blood by counteracting the irritability which gives rise to it. Our attack must be made upon the entire habit, which as far as possible should undergo a total change. The diet should be nutri- tious, but perfectly simple, and the meals less frequent or less abun- dant than usual; the sedentary life should give Avay to exercise at first easy and gentle, but by degrees more active, and of longer ex- tent or duration. Tonics, as bitters, astringents and sea-bathing, may now be employed Avith advantage; and the muscular fibres will become firmer as the cellular substance loses its bulk. The whole, however, must be the Avork of time ; for although in mrals it is a wholesome principle that bad habits cannot too spee- dily be thrown off, it is a'mischievous doctrine in medicine. Health being the middle term between excess and deficiency, every day is giving us a proof that where either of these extremes has become habitual, the system can only be let up or let down by slow degrees so as to reach and rest at the middle point with certainty, and with- out inconvenience. Professor Monro has furnished us with several very striking examples of this fact; and particularly among those who had acquired a habit of drinking very large quantities of spiri- tuous potation. A man of this description who had broken both bones of one leg, and was put, for a more speedy recovery, upon a diet of milk and water and water-gruel, was hereby throAvn into a low fever with an intermitting pulse, twitching tendons, and deliri- um ; during which he got out of bed and kicked away the box in which his leg was confined. A by-stander and friend of the patient's of the same irregular habit, ventured to tell the professor that he would certainly kill him if he did not allow him ale and brandy; since, for several years antecedently, he had been accustomed to both these as his common drink ; a little of each was in consequence, permitted him; but the patient's friends did not tie him down to this little: for extending the grant of an inch to an ell, they instant- ly gave the man a Scot's quart of ale and a gill of brandy, which Avas his usual alloAvance for the evening, he slept well and sound; the next morning Avas free from delirium and fever; and, by a perseve- rance in the same regimen, obtained a speedy cure without the least accident.* * Edin. Med. E»3. Vol. V. Part II. Art. XLVI. 45G HJEMATICA. {CL- HI.—OR, IV GENUS II. HiEMORBHAGIA. Utemorrhase. FLUX OF BLOOD WITHOUT EXTERNAL VIOLENCE. The term haemorrhagia, or hemorrhage, is derived from the Greek xiput, " sanguis," and pva-e-u, " rumpo." Dr. Cullen has adopted the same name for an order of diseases ; but there are few parts of his arrangement that are more open to animadversion, and which in fact have been more animadverted upon than the present. The order of hemorrhages, or fluxes of blood, ranks in Dr. Cullen's sys- tem under the class pyrexiae, or febrile diseases. Pyrexy, however, is only an accidental symptom in idiopathic hemorrhages of any kind, and has hence been omitted by all, or nearly all, other noso- logists in their definitions ; while Dr. Cullen himself has found it impossible to apply it to many hemorrhages, among which are all those that are called passive ; and he has hence been obliged to transfer the whole of these to another part of his system, notwith- standing their natural connexion Avith the active, and to distinguish them by the feeble name of profusions, instead of by their own pro- per denomination. Blood, from whatever organ it flows, may have two causes for its issue. The vessels may be ruptured by a morbid distention and impetus ; or they may give way from debility and relaxation, their tunics breaking without any peculiar force urged against them, or their exhalants admitting the flow of red blood, instead of the more attenuate serum. To the former description of hemorrhages Dr. Cullen has given the name of active; to the latter that of passive. The distinction is sufficiently clear ; and, under the names already employed in the preceding genus of this system, will lay a founda- tion for the two following species:— 1. H.EMORRHAGIA ENTONICA. ENTONIC HEMORRHAGE. 2. ————- ATONICA. ATONIC HEMORRHAGE. GE. 11.—SP. I.] SANGUINEOUS FUNCTION. 457 SPECIES I. H.EMORRHAGIA ENTONICA. SEutome l^emorrhase. ACCOMPANIED WITH INCREASED VASCULAR ACTION : THE BLOOD FLORID AND TENACIOUS. As the outlets of the body are but feAv, and all of them communi- cate with numerous organs, we cannot ahvays determine with strict accuracy from what particular part the discharge flows. We have, however, sufficient reason for the following varieties :— et Narium. Entonic bleeding at the nose. P Haemoptysis. -------spitting of blood. y Haematemesis. ------ vomiting of blood. ^ Haematuria. ------- bloody urine. t Uterina. ------- uterine hemorrhage. £ Proctica. ------- anal hemorrhage. The great predisponent cause of active hemorrhage, Avherever it makes its appearance, is plethora or congestion. A plethoric dia- thesis will, however, only predispose to a hemorrhage somewhere or other ; and hence there must be a distinct local cause that fixes it upon one particular organ rather than upon another. The chief local cause is a greater degree of debility in the vessels of such or- gan than belongs to the vascular system generally. But there are other and more extensive causes that operate upon some organs, and which consist in an unequal distribution of the blood and its peculiar accumulation in some vessels rather than in others. Thus, some organs acquire development and perfection sooner than others, of which the head, peculiarly large even in infancy, furnishes us with a striking example : and, in the promotion of such development, the floAv of the blood is directed with greater force and in greater abundance. And hence, while the coats of the blood-vessels in this organ are yet tender, and destitute of that firmness which they de- rive from age, Ave have reason to expect hemorrhage as a frequent occurrence, and particularly from the vessels of the nostrils; be- cause there is in the nose, for the use of the olfactory sense, a con- siderable net-work of blood-vessels expanded on the internal surface of the nostrils, and covered only with thin and weak integuments. And, on this account, we see why young persons are so much more subject to bleedings from this organ than those in mature life. Hae- moptysis, or spitting of blood, takes place more commonly a few years later, and when the animal frame has acquired its full growth, and consequently the vascular system its full extent or longitude. Antecedently to this, the impetus and determination of blood are vol. ii.—58 458 H7KMATICA. [CL. HI.—OR. IV greater in the aorta and its extreme ramifications than in the pul- monary artery, because more of the vital fluid is demanded for the progressive elongation of the very numerous arteries that issue from the former : and, consequently, a greater tendency to plethora ex- ists in this direction till the age of about fifteen or eighteen than in the direction of the lungs. Till this period of life, therefore, we have no reason to expect hemorrhage from the respiratory organs. When this term, however, has arrived, the bias is thrown on the other side ; and the vessels of the corporeal and of the pulmonary circulation being equally perfected, the tendency to accumulation will be in the latter, in consequence of their shorter extent. This tendency will continue till about the age of thirty-five; which is exactly correspondent Avith the observation of Hippocrates, Avho h as remarked that haemoptysis commonly occurs between the age of fifteen and that of five-and-thirty. We have explained why it does not often occur before fifteen, but what is the reason of its seldom occurring after the latter period ? Dr. Cullen has ingeniously ex- plained it in the following manner. The experiments of Sir Clifton Wintingham, he observes, have shown that the density of the coats of the veins Compared with that of the arteries is greater in young than in old animals; from Avhich it may be presumed that the resist- ance to the passage of the blood from the arteries into the veins is greater in young animals than in old ; andAvhile this resistance con- tinues, the plethoric state of the arteries must be perpetually kept up. The very action, however, of an increased pressure against the coats of the arteries gradually thickens and strengthens them, and renders them more capable of resistance; whence in time they come not only to be on a balance Avith those of the veins, but to prevail over them ; a fact which is also established by the experiments just adverted to. After thirty-five, therefore, the constitutional balance becomes completely changed, and the veins instead of the arteries are chiefly subject to accumulation. The greatest congestion will usually, per- haps, be found in the vena portatum, in which the motion of the venous blood is slower than elsewhere ; and such congestion alone will frequently act upon the neighbouring arteries, and induce what may be called a reflex plethora upon them in consequence of their inability of unloading themselves : and hence, the chief origin of haematemesis, anal hemorrhage, and various other hemorrhages from the abdominal and pelvic organs. All these organs, however, are exposed to hemorrhage from inci- dental causes, as well as that constitutional change Avhich has a ten- dency to produce the disease vicariously. T^hus, hemorrhage in all of them is occasionally produced by vio- lent exertion, as great muscular force ; vehement anger, or other passions or emotions of the mind ; severe vomiting, or coughing ; suppressed evacuations of various kinds, especially hemorrhoids of long standing, catamenia, habitual ulcers, issues, or chronic erup- GE. II.- SP. I.] SANGUINEOUS FUNCTION. 459 tions of the skin :* as also by the wound of a leech swallowed acci- dentally.! But in this last case it is probable that the living princi- ple of the stomach is in a state of Aveakness, as in all other cases in which exotic worms are found to continue alive under its action: since we know that this action when in full vigour is sufficient to destroy oysters, frogs, slugs, leeches, and various other cold-blooded animals in a short time. Haemoptysis is also said by many writers to have been produced by leeches accidentally taken into the sto- mach by a draught of water.!. But it is probable that in this case there is a deception : and that the blood discharged by coughing from the trachea has first passed into it from the stomach and mouth. Local stimulants are also an occasional cause. Thus the vessels both of the kidneys and rectum have been excited to hemorrhage by an injudicious use of aloes, terebinthinate preparations, and pun- gent aliaceous sauces. And the former by cantharides, whether ap- plied externally or internally : for Schenck and other writers have given examples of haematuria excited in irritable constitutions by vesicatories alone.§ Occasionally, hoAvever, all the various kinds of hemorrhages be- fore us have assumed a different character, and proved salutary and critical. Thus, cephalitis has often ceased suddenly on a free and sudden discharge of blood from the nostrils; pneumonitis, from Avhat has been deemed an alarming haemoptysis; visceral infarc- tions, from a liberal evacuation of the hemorrhoidal vessels; a jaun- dice has been carried off by a profuse haematuria,|| and fevers of va- rious kinds have instantly yielded to a spontaneous appearance of any of them. Such hemorrhages, however, though salutary in their onset, must be cautiously watched ; since, if not checked Avhen they have ac- complished their object, they are apt to pass into a chronic or pe- riodic form. Hence many persons have monthly discharges from the rectum; others from the nostrils ; others again, occasional or periodic, from the lungs ; and a few from the stomach.If Tulpius gives a case of chronic haemoptysis that continued for thirty years;** and others, instances of much longer duration.ft There is also another reason for an early attention to spontane- ous hemorrhages ; and that is, the profuseness of the discharge * Percival's Essays, II. p. 181. f Galen. De Loc. Affect. Lib. IV. Cap. V.—Riverius, Observ. Med. Cent. IV. Obs. 26. * Galen. De Loc. Affect. Lib. IV. Cap. V.—Borelli, Cent. I. Obs. 24. § Schenck, Lib. VII. Obs. 124. ex Langid.—Hist. Mort. Uratislav. p. 58. || Schenck, Obs. Lib. HI. Serm. II. N. 258. i Rhodius, Cent. II. Obs. 64.—Ab. Heer. Introduct. in Archiv. Archei. •• Lib. U. Cap. II. *t N. Act. Nat. Cur. Vol. I. Obs. I, 460 HJEMAT1CA. [CL. HI.—OR. IV. Avhich sometimes takes place, and the alarming exhaustion which follows. Dr. Banyer, in the Philosophical Transactions,* gives a case of this sort, in which the discharge was from the bladder; Buchner, another case from the same organ, in which it amounted to not less than four pounds :f and other writers bring examples of its having proved fatal. The largest quantities, however, are usually lost from the nostrils. Ten, tAvelve, and upwards of tAventy pounds have been known to flow aAvay before the hemorrhage has ceased. Bartholin mentions a case of forty-eight pounds,:} Rhodius another of eighteen pounds lost Avithin thirty-six hours ;§ and a respectable Avriter in the Leip- sic A cta Erudita, a third of not less than seventy-five pounds with- in ten clays ;|| which is most probably nearly three times as much as the patient possessed in his entire body at the time the hemorrhage commenced. In the Ephemera of Natural Curiosities is a case in which the quantity indeed is not given, probably from the difficulty of taking an account of it, but Avhich continued Avithout cessation for six weeks.l In active hemorrhages from the nostrils,the epistaxis of many writers, the discharge is usually preceded by some degree of local heat and itching; and occasionally by a flushing of the face, a throb- bing of the temporal arteries, a ringing in the ears, or a pain or sense of weight and fulness in the head. Yet not unfrequently the blood issues suddenly without any of these precursers ; for, as we have already observed, the arteries distributed over the schneide- rian membrane are very numerous and superficial, and a very slight irritation is often sufficient to rupture them. That insolation or ex- posure to the direct rays of the sun, a cold in the head, or cold ap- plied to the feet or hands, coughing, or sneezing, especially upon the use of sternutatories, an accidental blow upon the upper part of the nose or forehead, or a jar of the entire frame, as on stumbling, should be sufficient to produce this effect, can easily be conceived; and these, in truth, are the common occasional causes : but it is sin- gular that it should follow, in some highly irritable idiosyncrasies, upon such very trivial excitements as have been noticed by many pathologists. Thus, Bruyerin** gives an example in which the nos- trils flowed with blood upon smelling at an apple; Rhodius, upon the smell of a rose ;ft and Blancard,t»pon the ringing of bells ;*4 and * Vol.XLII. f Miscell. 1728. p. 1496. $ Anat. Renov. Lib. II. Cap. VI. § Cent. I. Obs. 90. !| Act. Erudit. Lib. 1688. p. 205. K Dec. I. Ann. HI. Obs. 243. ** Bruyerinus De Re cibaria. Lib. I. cap. 24. ft .Rhodius, Cent. III. Obs. 99. H Blancard, Collect. Med. Pbys. Cent. VI. Obs. 74. GE. II.—SP. I.] SANGUINEOUS FUNCTION. 461 Avhen we find the same effect produced by various emotions of the mind, as terror, anger, and even a simple excitement of the imagi- nation,* we may readily trace by what means the philosophers and poets of the eastern world, and even some of those of the western were led to regard the nose as the seat of mental irritation, the pe- culiar organ of heat, wrath, and anger; and discover how the same term HN (ap or aph) came to be employed among the HebreAvs to signify both the organ and its effect, the nose, and the passion of anger to which it was supposed to give rise. We have already observed that the quantity of blood discharged by a spontaneous hemorrhage from the nostrils is sometimes enor- mous. This, however, is a more common result of passive than of active hemorrhage; and is more usually found in advanced than in early life. If it be evidently connected with entonic plethora, or accompanied with the local symptoms just enumerated, it will afford a more effectual relief than bleeding in any other way, and should not be restrained till it has answered its purpose. Even a small portion of blood, not amounting to more than a table-spoonful or two, Avhen thus locally and spontaneously evacuated, has afforded, on some occasions, a Avonderful freedom and elasticity to an oppressed and heavy head: and when more copious, has probably prevented an apoplectic fit, as it has often formed a salutary crisis in inflammation of the brain, or fevers in which the brain has been much affected. But when these reasons do not exist, the bleeding should be checked by astringent applications. Cold is the ordinary application for this purpose, and it commonly succeeds without much trouble. Cold water may be sniffed up the nostrils, or thrown up Avith a syringe; but the exertion of sniffing, or even the impetus of the water alone, where a syringe is employed, sometimes proves an excitement that more than counterbalances the frigorific effect. Independently of which there is an advantage in leaving the blood to coagulate on the ruptured orifice of the vessel, which thes» methods do not allow. By means of a syringe, however, we can throw up, when necessary, astringents of more power than cold water, as vinegar, or the sulphuric acid properly diluted, or a solu- tion of sulphate of zinc, copper, iron, or lead, after Avhich we should force up tents of lint moistened Avith the same, and particularly with extract of lead diluted with only an equal quantity of water, as high as we are able with a probe or small forceps, so as to form a tight compress: the styptic agarics can be rarely used to advan- tage. The face may, at the same time, be frequently immersed in ice-Avater, or water artificially chilled to the freezing point; and the temples, or even the whole of the head be surrounded with a band or napkin moistened with the same, and changed as soon as it acquires the warmth of the skin. When tents are used, they have sometimes been illined with moistened powder of charcoal, which * Rhodius, Cent. I. Obs. 89, 462 HAIMATICA. [CL. HI.—OR. IV. of itself has proved an excellent styptic. Cold applied to the back will succeed, but often fails; it is more certain of success Avhen applied to the genitals. Emetics have occasionally been of service, and are recommended by Stoll.* The principle upon which they may be presumed to act will be noticed under haemoptysis. The bleeding has sometimes been checked by a sudden fright,t probably from the cold sweat that so often attends such an emotion: and Reidlin gives a case in which it was cured by sneezing;} but this was probably a case of atonic hemorrhage, in which the spasmodic action might assist in corrugating the mouths of the bleeding vessels. It is rarely necessary or even proper in this variety of hemorrhage to employ any internal astringent or other tonic: but if this discharge should be excessive, and produce debility, the same plan may be resorted to as will be recommended under the ensuing species. In haemoptysis or spitting of blood, it is not always easy to de- termine from what vessel or even from what organ the bleeding proceeds: for the blood may issue from the posterior cavity of the nostrils, or from the fauces as well as from the lungs. If, however, from the first, it will cease upon bending the head forward or lying procumbent, and will probably flow from the nose: if from the second, we shall commonly be able to satisfy ourselves by inspec- tion. Blood from the stomach is of a darker colour, thrown up by vomiting, and betrays an intermixture of food. If the haemoptysis be produced from the lungs, and belong strictly to the present species, and more especially if it be a result of entonic plethora, the blood will be chiefly thrown up by coughing; and the discharge will be preceded by flushed cheeks, dypsnoea, and pain in the chest. There is usually, also, a sense of tickling about the fauces, which often descends considerably lower; Salmuth asserts that he has known it extend to the scrobiculus cordis.§ These symptoms, moreover, indicate that the blood flows from a branch of the pulmonary rather than of the bronchial artery. The blood is here of a florid hue, and the hemorrhage sudden and often copious. If a branch of the bronchial artery give way, the flow of blood is usually much slower, and smaller in quantity : there are no precursive symptoms, the blood is rather hawked or spit up intermixed with saliva, and, from being longer in its ascent, is of a darker colour. From its lodgment, however, in the air-vesicles, it becomes a cause of irritation, and a frothy cough ensues, some- times accompanied with a little increase of the pulse and other febrile symptoms, as a feeling of heat and some degree of pain in the breast, which subsides after the ejection, and returns if there be a fresh issue. * Rat. Med. Part III. p. 21. f Panarol. Pentecost, v. Obs. 27. * Linn. Med. Ann. I. Obs. 24. § Cent. HI. Obs. 43. GE. II.—SP. I.] SANGUINEOUS FUNCTION. 463 If the structure of the lungs be sound, we have no reason to prognosticate danger. On the contrary, it often affords great relief to a gorged liver, and has proved critical in obstructed menstruation. Excreted with the sputum it is frequently serviceable, as Ave have already observed, in cases of asthma, pleurisy, and peripneumony. But if it have been preceded by symptoms of phthisis, or a strumous diathesis, there is great reason for alarm; for Ave can have little hope that the ruptured vessel will heal kindly and speedily, and have much to fear from the fresh jets, by which the extravasated blood becomes deposited and forms a perpetual stimulus in an irritable organ. The general pathology has been already laid doAvn The in- cidental causes are misformation of the chest"; undue exertionof the respiratory muscles, Avhether in running, wrestling, singing, or blow- ing Avind-instruments; excess in eating and drinking; or a violent cough. As a symptom or sequel, it occurs in wounds, phthisis, or the suppression of some accustomed discharge. In active hemorrhage from the lungs, venesection is one of the most important steps towards a cure; and the blood should be drawn freely at once, rather than sparingly and repeatedly; though a second and even a third copious use of the lancet will often be found expedient. Emetics have been recommended, but they are of doubtful effect. They augment the vascular volume by relaxing the capillaries ; but they stimulate locally by the act of rejection. Drastic purgatives are avoided because of the straining; but the straining in vomition is greater and more direct. Dr. Brian Robinson of Dublin, who was one of the most strenuous promoters of this mode of practice in his day, accounted for the benefit of emetics by the constriction which he conceived they produce upon the extreme vessels every Avhere; but to act thus they should rather nauseate than vomit; for in nausea Ave have great vascular depression, and a cold and general collapse on the surface; while vomiting is known to rouse the system generally and determine towards the surface. Upon the recommendation of Dr. Robinson, Dr. Cullen followed the plan in several cases : " but in one instance the vomiting," says he, " increased the hemorrhage to a great and dangerous degree; and the possibility of such an acci- dent again happening has prevented all my further trials of such a remedy."* Nauseating has on this account been preferred on the continent to full vomiting in hemorrhage from the stomach, and indeed various other organs as well as from the lungs ; and ipeca- cuan in small doses has been generally preferred to the metallic salts, as more manageable ; half a grain or even a quarter of a grain being given every quarter of an hour for many hours in succession.! In general, however, we shall find it as successful and far less * Mat. Med. Part II. Ch. XIX. p. 470. f Keck, Abhandlunjr, und Beobachtungen, Medinisches Wochenblatt, 1783. No. 49, 464 HJEMATICA. [CL. HI.—OR. IV. distressing to employ mild aperients and sedatives. The first, and particularly neutral salts, are alone of great benefit, and their action should be steadily maintained. Sedatives are of still higher impor- tance, and especially those that reduce the tone of the circulation, as nitre and digitalis. The first, in about ten grains to a dose, should be given in iced water, and swallowed while dissolving; the dose being repeated every hour or two according to the urgency of the case. If there be much cough, it must be allayed by opium and blisters. Local astringents we cannot use, and general astringents are here manifestly counter-indicated, however useful in passive hemorrhage : though it should be recollected, that Avhen an active hemorrhage from the lungs is profuse and obstinate the vessels lose there tone and fall into a passive state. In h-smatemesis the blood is evacuated from the alimentary canal at either extremity, Avhether that of the mouth or of the anus : for the term is used thus extensively by the Greek writers. In both cases it is discharged in active hemorrhage with a considerable expulsive effort; and the discharge is preceded by tensive pain about the stomach; and accompanied with anxiety and faintness. The quantity discharged from the stomach is in most cases larger than what is discharged from the lungs, and of a deeper hue: it is also thrown up by the act of vomiting, and usually intermixed with some of the contents of the stomach. And hence, there is no great difficulty in determining as to the source of the hemorrhage. Haematemesis, however, is far more frequently a disease of atony than of entony, and hence chiefly belongs to the next species. Its usual exciting causes, when it occurs under an entonic character, are concussion or other external violence, as a shock of electricity,* some strong emotion of the mind, as rage or terror, vomiting, or pregnancy. It has also occasionally been found, and often affords relief, in suppressed catamenia. The pathology we have already given ; the blood may proceed from the spleen, the liver, the pancreas, the stomach itself, or the smaller intestines ; and the mode of treatment should be as already advised for haemoptysis. In hematuria the. blood is evacuated at the urethra; and the evacuation is preceded by pain in the region of the bladder or kidneys, and accompanied Avith faintness. The blood is sometimes intermixed with urine, but occasionally flows pure and uncombined: and in this last state the disease is called by Vogel stymatosis, and the bleeding is supposed to proceed from the bladder rather than from the kidneys; that from the latter being smaller in quantity, and remaining a longer time in the passages, and consequently of a dark colour. There is some ground for this opinion ; for when the bladder is the seat affected, there is far more local pain and faintness, than where the affection is in the kidneys. Hippocrates, indeed, has observed, that where the blood flows pure, copiously. * Percival's Essays, Vol. II, p. 181. GE. II.—SP. I.] SANGUINEOUS FUNCTION. 465 and suddenly, and without pain, it proceeds from the kidneys; but where it is small in quantity, and of a blackish colour, and accompanied with much heat or pain, or both, its source is the bladder. But this remark, instead of opposing, tends rather to corroborate the preceding; for according to both views the seat of disease is distinguished by the greater or less degree of uneasiness that attends the discharge; and this whether the quantity discharged be larger or smaller. It is not often, though sometimes, an entonic disease or an active hemorrhage. Its exciting cause is frequently a stone in the bladder; or a violent blow on the kidneys, or on the bladder, especially Avhen the latter is full. It is also said by Schenck* and other writers to be occasionally produced by cantharides whether employed exter- nally or internally; for vesicatories alone are accused of occasion- ally exciting this complaint in irritable constitutions.t In connexion with the general course of treatment already re- ' commended in the preceding varieties, the compound poAvder of ipecacuan may here be employed with great advantage ; for the pain and irritation are often intolerably distressing, and on this ac- count demulcent drinks are frequently found to produce considera- ble relief. In uterine hemorrhage the blood is discharged from the womb Avith a sense of weight in the loins, and of pressure upon the vagina. This is the menorrhagia of most of the nosologists, and is often, but very erroneously, described as an excess of the menstrual flux. It is in truth a real hemorrhage or issue of blood, instead of menstrual secretion, which is often entirely suppressed, though sometimes a small but inadequate portion is intermixed with the uterine bleed- ing : and hence Hoffman has properly denominated it uteri haemorr- hagia. It occurs both in an entonic and an atonic state of the ves- sels, and especially of the general system : and from the remarks of- fered under Plethora, it is not at all to be wondered at, that he- morrhage should in both conditions take place from the uterus very frequently, and perhaps more so than from any other organ. For reasons we shall have occasion to explain in a subsequent part of this work, the uterus, from the period of the completion of the female form, is stimulated once in every lunation, to the secre- tion and elimination of a peculiar fluid, which exhibits the colour, though it is deficient in many of the properties of blood; and for this purpose the uterine arteries are, at such seasons, peculiarly turgid and irritable. There is hence always a tendency on such. occasions to an hemorrhage in this quarter in females of a firm and robust texture, and of a plethoric habit. But if from cold or any other cause the uterine secernents do not at these seasons fulfil their office, and throw forth their proper fluid, the uterine arteries will be inordinately gorged ; the regular stimulus will be greatly augment- * Lib. VII. Obs. L. 24. ex Langid. f Hist. Mert. Uratislav. p. 58. vol. II.— r>9 466 HiEMATICA. [CL. HI.—OR. IV. ed; pain, tension, and spasm will extend over the loins; and the ex- tremities of the vessels be ruptured, or their mouths give way by anastomosis; and a considerable hemorrhage be the consequence. This is the ordinary period in which uterine hemorrhage takes place; though it may occur during any part of the interval between the catamenial terms, upon any of the occasional causes that operate upon other organs, and from the preceding varieties: as it is also well known to occur at times, with great violence, during pregnan- cy and in child-bed. When we come to treat of diseases appertaining to the sexual organs, Ave shall have to notice some singular cases of precocity in female infants, and especially that of a regular menstruation. It is upon this principle alone that we can account for uterine hemorr- hage in new-born infants; of which the medical records give several examples ; and especially the Ephemerides of natural Curiosities. In suppressed menstruation uterine hemorrhage affords relief to the spasms and pains that harass the loins, and the head-ache and difficulty of breathing which have usually preceded the lumbar dis- tress. But the discharge may be immoderate, and become habitual. And it is hence best to be upon our guard, and to use venesection as a substitute ; and to prevent or diminish the spasmodic action by gentle aperients and the sedatives already recommended in haemop- tysis; after which the case will become a disease of suppressed menstruation alone, and must be treated according to the method recommended under that malady; for a restoration of the catamenial secretion is its natural cure. I may here, however, observe, that Avhen the suppression of this secretion has been of some standing and an uterine hemorrhage has periodically taken its place, accom- panied with distressing pains in the whole circle of the pelvic re- gion, we can sometimes suddenly restore a healthy action to the organ by a plan of anticipation. For this purpose I have prescrib- ed venesection about ten days before the return of the monthly paroxysm'; and having thus taken off the plethoric impetus. I have, a few days afterwards, recommended the hip bath to be used in a tepid state, every night, and persevered in till the period of relapse ; Avhen I have often found that there has been neither tension nor spasm; that the loins have continued easy, and the hemorrhage has yielded to the natural secretion. In hemorrhage strictly anal, the flux of blood issues chiefly from the haemorrhoidal vessels; and as these are large, and but little sup- ported by any surrounding organization, they readily give way both in an entonic and atonic state of the frame, and particularly in case of plethora, upon very slight excitements: as in straining to expel hardened feces, taking cold in the feet, or Avalking a little too far. Irritants introduced by the mouth have also proved a frequent cause of this variety of hemorrhage; as an injudicious use of aloes, tere- binthinate preparations, or even pungent aliaceous sauces. The irritation of piles is also a very common cause; and hence by some Avriters anal hemorrhage is only treated of as a symptom of that GE. II—SP. I.] SANGUINEOUS FUNCTION. 467 variety of this last disease which is known by the name of bleeding piles. But this is highly incorrect; as anal hemorrhage often oc- curs, and very profusely, where no piles have ever been experi- enced. This power of hemorrhage when active, as it is called, or in an entonic habit, is usually preceded by a sense of weight and pain within the rectum, and sometimes by a load in the head. And it has often, as already observed, proved critical and salutary, and car- ried off congestions from the abdominal viscera. It is, however, peculiarly apt to become profuse, and to establish an order of re- currence; and hence must be overpowered by the reducent and sedative plan recommended in most of the preceding varieties, and particularly in that of haemoptysis. The aperient employed, how- ever, should here be peculiarly mild and alterant; and sulphur, which does not readily dissolve in the course of the intestinal canal, and often reaches the rectum in an unmixed state, is one of the best, and is often found strikingly serviceable. All stimulant foods, more- over, must be especially avoided; and the ordinary drink should be water, soda-water, or lemonade. Here also we are able, as in the case of hemorrhage from the nose, to employ local astringents, though it would be improper to use those that act generally, so long as plethora or an entonic habit continues. The patient may sit in a bidet of ice-water or water cool- ed artifically to the freezing point, or may use a cold hip-batb, and have injections of cold-water, or astringent lotions, as of alum, zinc, or even lead, thrown up the rectum ; the latter of which should be in such proportion as to remain there for half an hour or an hour. SPECIES II. HEMORRHAGIA ATONICA. atonic f^emorrhafle. ACCOMPANIED WITH GENERAL LAXITY OR DEBILITY ; AND WEAK, VAS- CULAR ACTION ; BLOOD ATTENUATE, AND OF A DILUTED RED. Though the effect in this species is the same as in the preceding, the proximate cause, as well as the more obvious signs, are directly opposite. The general pathology has been given in the introducto- ry remarks to the genus, and the more common organs from which the hemorrhage proceeds are the same as already noticed under the preceding species; and hence the varieties of that may be regarded as those of the species before us. When the plethora is the remote cause, which it often is, it is ato- nic plethora, or plethora of debility; but whatever has a tendency to 468 HJEMATICA. [CL. HI.—OR. IV. loosen or enervate the tone of the solidum vivum, or living fibre, will lay a foundation for this kind of hemorrhage. It is hence a characteristic disease of advanced age, as entonic plethora is of youth and adult life ; and often takes place in those whose vigour is reduced by meagre or innutritious food, close confinement without exercise in a foul and stagnant atmosphere, or immoderate indul- gence in the pleasures of wine or sexual intercourse. Hence too its frequent occurrence, as a symptom, in tabes, atrophy, struma, scurvy, and low fevers. The characters of the several varieties of this species, as distin- guished from those of the preceding, are as follows:— In hemorrhage from the nostrils, the blood flows without heat or head-ache. In that from the respiratory organ, it is usually produced with- out even the exertion of coughing, and is often accompanied with a scirrhous or calculous affection of the lungs; the countenance is pale and emaciated. In hemorrhage from the alimentary canal, the blood is dis- charged without tensive pain: though there must necessarily be an expulsive effort; and from the inanition hereby produced, some degree of nausea and faintness. When evacuated by the urethra, there is, for the same reason, faintness, but little or no previous pain. The most singular and severest examples of hemorrhages from the urethra are those that have occurred during coition ; sometimes intermixed Avith semen, sometimes instead of it, and sometimes immediately after emission. The individuals have been generally persons of highly irritable and delicate habits; and Avho have weakened themselves by too free an indulgence in pleasures of this kind. Numerous instances of this sort of hemorrhage are given in the Collections of Medical Curiosities, and especially in several of the German Ephemeride6. There is little pain in atonic hemorrhage from the uterus: and it generally occurs at the natural cessation of the menstrual flux, or Avithin a few years afterAvards. As a concomitant, hemorrhage from this quarter is also frequently found in a scirrhous, cancerous, or other morbid states of the uterus, in Avhatever period of life these may occur ; which, however, they do most usually after the age of forty or fifty. Atonic hemorrhage from the anus usually takes place spon- taneously with little or no pain ; but commonly with varices or con- gestions of the hemorrhoidal vessels, and is very apt to produce a habit of recurrence. In all these varieties venesection must be had recourse to spar- ingly ; and never, unless where we have satisfactory evedence of atonic plethora or congestion. It may sometimes be requisite to use the lancet in nasal hemorrhage, for the head may feel oppres- sed and drowsy : and it will still more frequently be necessary in hemorrhage from the uterus; but the blood abstracted should rare- ly exceed seven or eight ounces; and in all other varieties, as a GE. II.—SP. II.] SANGUINEOUS FUNCTION. 469 general rule, it will be better to withhold our hand, and to proceed at once Avith a tonic plan of treatment. Into this plan we may, in the present species, freely admit the use of general astringents in conjunction with their local application, hoAvever objectionable in the preceding; for a laxity and inelastici- ty of the fibrous structure are among the chief symptoms we have to oppose : and hence the mineral acids and metallic salts may be had recourse to Avith great advantage along with bitters; and, with a feAV exceptions, we cannot well err in the selection. The prepa- rations of iron may be rather too heating in haemoptysis, and per- haps in all atonic hemorrhages accompanied with much irritability. One of its mildest and best forms is that of a subcarbonate ; and per- haps the best mode of obtaining it in this form is by the celebrated composition of Dr. Griffiths. The myrrh is also in this preparation a useful article for the present purpose, and Ave shall rarely do bet- ter than employ it. In the London Pharmacopoeia, it is given un- der the name of mistura ferri composita. From the manifest power of opium to restrain most evacuations, it has often been employed in hemorrhages. It does not appear, how- ever, to have any direct effect in checking the discharge ; and in en- tonic hemorrhages, and especially when employed early, has been highly mischievous. But where in haemoptysis there is a perpetual cough from irritation, or in uterine hemorrhages a frequent recur- rence of spasmodic pains, it has been tried Avith considerable suc- cess. And the same remark will apply to hyoscyamus, and various other narcotics, which seem to be only useful on the same account. Cinchona, which is peculiarly objectionable in the preceding spe- cies, may be had recourse to with considerable promise. It seems, however, to be chiefly serviceable in uterine hemorrhage, where the disease depends upon a laxity of the extremities of the vessels, which are therefore readily opened by every irritation applied to the system or to the diseased part. Whether in this case it acts altogether as a bitter, as supposed by Dr. Cullen, or partly also as an astringent, it may be difficult to determine ; but the ques- tion is not of importance. ✓ For other general roborants to which it may be necessary to have recourse, the reader may turn to the treatment of limosis dysfiefisia,* or indigestion; and he may govern the patient's diet and regimen by the general plan there laid down. The local astringents and refrigerants, already recommended un- der the former species, may be here employed with even less re- serve ; and Avhen the bleeding has become chronic, which it is far more likely to do than in entonic hemorrhage, or has been so pro- fuse as very considerably to exhaust the system, a little wine or some other cordial should be administered as soon as we are consulted : for, hoAvever small the vessel that is ruptured, its orifice is incapa- ble of contracting from a total loss of tone : and hence a diffusible Class I. Ord. I. Vol.1, p. 111. 120. 470 HJEMATICA. [CL. IU.—OR. IV. stimulus gives it the irritation it stands in need of, and forms a salu- tary constringent. A striking case of this kind has already been given in treating of accidental hemorrhages from extracting teeth :* and it is only a few weeks ago since the author was requested to at- tend in a similar hemorrhage from the nose. The patient was a lady of about fifty years of age, of slender and delicate frame, who had for some years ceased to menstruate. The bleeding had con- tinued incessantly for three or four days, during which she had been restrained to a very low diet, and allowed nothing but toast and wa- ter for her common drink. She was faint, felt sick, and had a fee- ble pulse, and must have lost many pounds of blood, though no ex- act measure had been taken. I gave her instantly a free draught of negus made with port wine, prescribed camphor mixture with the aromatic spirit of ammonia, had the nostrils syringed with equal parts of tincture of catechu and water, and applied a neckerchief wetted with cold water round the temples, directing it to be re- newed every ten minutes. In half an hour the hemorrhage ceased, and on the ensuing day I found no other symptom than weakness, for which a nutritious but inirritant regimen was prescribed. A few days afterwards, the hemorrhage returned from sneezing or some other incidental stimulus, and was restrained, as I was told, for I did not see her, by a recurrence to the same plan. I recommend- ed, however, carriage exercise, and an excursion to the sea coast, which has been complied Avith, and there has been no recurrence of the disease. To effect the same intention, I have occasionally advised cardiacs combined with astringents in haematemesis, where the discharge of blood has been profuse, and has continued for some days, and the patient has become considerably exhausted : and I do not recollect an instance in which the plan has proved unfriendly. In like man- ner, in very great faintness or deliquium produced by a copious and protracted hemorrhage from the uteris, I have had the vagina in- jected Avith equal parts of port wine and Avater acidulated with sul- phuric acid, and have found it equally successful. The subacetate of lead is also a preparation which in all such cases ought to be tried internally. It Avas at one time greatly out of favour from the writings of Sir George Baker and the concurrent opinion of Dr. Heberden. Of the mischievous effects of various preparations of this metal when employed internally, the former has given numerous examples, and concludes with the following co- rollary : " that lead taken into the stomach is a poison ; I do not say ex proprietate naturae et totS. substantia ; but which is capable of doing much more hurt than good to the generality of men in all the known ways of using it; and, consequently, that it cannot be avoided with too much caution."t In corroboration of which Dr. Heberden tells us that its good effects are by no means so certain •Vol.1, p. 31. f Med. Transact, Vol. I. p. 311. GE. II.—SP. II.] SANGUINEOUS FUNCTION. 471 as its mischief; and in most cases would be far overbalanced by it. In the form of a subacetate, however, all its evils seem to be sub- dued by a combination with opium; for the first distinct knowledge of which the medical Avorld is indebted to the penetration and judg- ment of Dr. Reynolds, who tried it, in this state of union, in various cases with the most perfect success, and without the least unfavour- able symptom whatever, whether of pain or even costiveness. He also employed with equal benefit the old tinctura saturnina, and the sugar of lead; of the former, giving eighteen drops with three drops of laudanum to a dose, and repeating the dose every four hours in a little barley-water; of the latter, giving one grain with three drops of laudanum mixed into a pill with conserve of roses ; to be repeated every six hours. And under both forms he em- ployed these materials with great and unalloyed advantages in hemorrhages of most sorts, especially uterine, pulmonary, and nasal.* Dr. Lathamf has since confirmed this practice of Dr. Reynolds in its fullest degree, and even extended its range ; and so little incon- venience has he found from the use of the superacetate that he has employed it" in doses of a grain three times a-day for six, eight, and ten weeks successively; usually, but not always, combining it Avith opium or conium ; without any other precaution than desiring the patients to obviate any costiveness by oleum ricini or confectio sen- nae." He has occasionally, given two grains of the superacetate as an evening dose ; once, in consultation with Dr. Reynolds, five grains ; and mentions another case in which he was concerned where ten grains a-day were taken without any inconvenience. By a mis- take for sugar, a young woman, respecting whom he was consulted, swallowed at one time about two drachms of it, yet without any se- rious evil: the fauces and oesophagus were considerably constring- ed, and this seems to have been the chief mischief; for the bowels were opened by oleum ricini and other purgatives in the course of the day, and the patient was not at all worse for the accident on the ensuing morning. Emboldened by these facts, Dr. Latham has employed the same medicine in other diseases in which irritant astringents and tonics seem requisite, as in colliquative diarrhoeas and hectic perspirations, and more especially in that semipurulent expectoration which too often terminates in pulmonary ulceration and consumption ; and, as he confidently assures us, with great advantage. And he hence concludes that whatever deleterious properties may appertain to lead in some of its salts and oxydes, nothing pernicious exists in its superacetate ; in the process for Avhich he conceives it either to be more completely freed from arsenical or other poisonous minerals than in its other forms, or rendered innocuous by the addition of the acetic acid. • Med. Transact. Vol. 1U. Art. XIII. f Vol. V. Art. XXI. 472 HAEMATIC A. [CL. 111.—OR. IV. It only remains to be added, that where entonic hemorrhage has occurred so profusely, or has continuerf so long as to reduce the system to an entonic state, it then becomes a disease of debility, and is to be treated as though originating under the present species. GENUS HI. MARASMUS. Emaciation. general extenuation of the BODY WITH DEBILI1 1 Marasmus is a Greek term, derived from putgxiva, " maresco," " marcescere reddo." It was long ago used collectively to compre- hend atrophy, tabes, and phthisis; and in employing it therefore in the present system as a generic name, we only restore it to its earlier sense. The generic character is common to all these subdivisions ; for each is distinguished by a general emaciation of the frame ac- companied with debility, and consequently forms a species to maras- mus as a genus. With these species, the reader, however, will find a fourth united upon a high authority, with which I fully coincide, and to which I shall presently advert. Under the name of climacteric marasmus it is designed to embody that extraordinary decline of all the corpo- real powers, Avhich, before the system falls a prey to confirmed old age, sometimes makes its appearance in advanced life without any sufficiently ostensible cause, and is occasionally succeeded by a re- novation of health and vigour, though it more generally precipi- tates the patient into the grave. Extenuation or leanness is not necessarily a disease ; for many persons who are peculiarly lean are peculiarly healthy; while some there are who take pains to fall away in flesh that they may increase in health and become stronger. But if an individual grow weaker as he grows leaner, it affords a full proof that he is under a morbid influence ; and it is this influence, this conjunction of exte- nuation Avith debility, as noticed in the definition, that is imported by the term marasmus, and its synonym emaciation. It is curious to observe how much more easily the body wastes under a disease of some organs than of others ; and it would be a subject of no small moment to inquire into the cause of this, and to draw up a scale of organs effecting this change from the lowest to the highest degree. Dr. Pemberton, in a Avork of considerable merit, published many years ago, threw out some valuable hints upon this subject, which it is to be lamented that he has not since GE. III.] SANGUINEOUS FUNCTION. 473 followed up to a fuller extent. The following passage is well wor- thy of notice, and aptly illustrative of what is here intended. " Let us take," says he, " the tAvo cases of a diseased state of the mesen- teric glands, and a diseased or scrophulous affection of the breast. In the former Ave shall find there is a great emaciation ; in the lat- ter, none at all.—In an ulceration of the small intestines, great ema- ciation takes place; in scirrhus of the rectum, none.—In a disease of the gallbladder, which is subservient to the liver, the bulk of the body is rapidly diminished ; but in a disease of the urinary blad- der, which is subservient to the kidneys, scarcely any diminution of bulk is to be perceived. In an abscess of the liver, the body be- comes much emaciated; but in an abscess of the kidneys, the bulk is not diminished. " If we examine into the function of those parts, the diseases of which do or do not occasion emaciation, we may perhaps be led to the true cause of this difference of their effect on the bulk. In or- der, however, to understand more clearly how the functions of these parts bear relation to each other, it may be necessary to premise that the glands of the body are divided into those which secrete a fluid from the blood for the use of the system, and those which se- crete a fluid to be discharged from it. The former maybe termed glands of supply; the latter glands of waste. " The smaller intestines, in consideration of the great number of absorbents with which they are provided for the repair of the sys- tem, may be considered as performing the office of glands of sup- ply. Large intestines, on the contrary, may be considered as per- forming the office of glands of waste : insomuch as they are furnish- ed very scantily with absorbents, and abundantly with a set of glands which secrete or withdraw from the system a fluid which serves to lubricate the canal for the passage of the feces, and which itself, together with the feces, is destined to be discharged from the sys- tem. The glands which secrete a fluid to be employed in the system, as well as the glands of direct supply, may be considered the liver, the pancreas, the mesenteric glands, perhaps the stomach, and the small intestines; and the glands of Avaste are the kidneys, breasts, exhalent arteries, and the larger intestines." The first set are, in fact, the general assemblage of the chylific organs; and it is upon their direct or indirect inability to carry in- to execution their proper function, that the first of the species we are now about to enter upon, that of atrophy, is founded in all its varieties. How far these remarks will apply to the other species of the present genus is not quite so clear. The seat of the second and third may be doubtful, perhaps variable; that of phthisis, or the fourth, admits of no debate. Are the lungs to be regarded as an or- gan of waste or of supply ? The question may be answered in op- posite ways, according to the hypothesis adopted respecting the doctrine of respiration. They throw off carbonic acid gas. Do they introduce oxygene or any other vital gas into the circulating system ? As an organ of waste, we cannot upon the principle here vol. ii,—60 382 HJEMATICA. [CL. ni.—OR. IV. laid down, account for the emaciation which flows from a diseased condition of them. If it can be substantiated that they are an or- gan of supply, they confirm and extend the principle. Will this principle, moreover, apply in dropsy, in which there is even more emaciation than in phthisis? The subject is worth enucleating; but we have not space for it, and must proceed to arrange the four species that appertain to the genus before us :— 1. marasmus atrophia. atrophy. 2. ■----CLIMACTERICUS. decay of nature. 3.--------TABES. DECLINE. 4.--------PHTHISIS. CONSUMPTION. All these follow in regular order, as genera or species in most of the nosological arrangements, and are set down as subdivisions of macics or marasmus. By Dr. Cullen, phthisis is regarded as a mere sequel of haemoptysis, upon which we shall have to observe in its proper place : while atrophia and tabes are given as distinct dis- eases under the ordinary head, only that for macies or marasmus he employs the term marcores as an ordinal term. The common dis- tinguishing marks are, that atrophy is emaciation Avithout hectic fever: tabes, emaciation with hectic fever; and phthisis, emacia- tion and hectic fever coupled with pulmonary disease. And such, with the exception of phthisis, is the distinction continued by Dr. Cullen in his Synopsis. But in his Practice of Physic he informs us that his views upon the subject had undergone a change, not only in respect to the subdivisions or varieties of these two diseases, but as to the diseases themselves. " I doubt," says he, " if ever distinction of tabes and atrophia, attempted in the Nosology, will properly apply ; as I think there are certain diseases of the same nature, which sometimes appear with, and sometimes without fever."* Thjs is written in the spirit of candour that so peculiarly characterizes this great man. But I cannot thus readily consent to relinquish a distinction which has received the sanction of so many observant pathologists, and which appears to me to have a sufficient foundation. It is difficult undoubtedly to assign a proper place to all the varieties, or subdivisions of those species ; but this is a difficulty common to many other diseases equally; for we per- ceive fevers, nervous affections, and those of the digestive organs, perpetually running into each other in different varieties, while we find it convenient to arrange and describe them as distinct diseases notwithstanding. And, with the caution attempted to be exercised in respect to the species before us, I trust that the reader will not discern a greater transgression of boundary in the present than in various other cases of general allowance. * Vol. IV. Part HI. Book I. Sect. MDCXVHL 6E. III.—SP. I.) SANGUINEOUS FUNCTION. 475 SPECIES I. MARASxMUS ATROPHIA. ^tro^hg. COMPLEXION PALE, OFTEN SQUALID : SKIN DRY AND WRINKLED : MUS- CLES SHRUNK AND INELASTIC : LITTLE OR NO FEVER. The specific is a Greek term deduced from x privativa, and rpz^a "nutrio," and is literally, therefore, innutrition: a designation pe- culiarly significant, as the disease in all its forms or varieties seems to be dependent on a defect in the quantity, quality or application of the nutrient part of the blood : and thus lays a foundation for the three following varieties: * Inopiae. Blood innutritious from scarcity Atrophy of want. or pravity of food. /* Profusionis. Blood deprived of nutrition by Atrophy of waste profuse evacuations. y Debilitatis. Nutrition not sufficiently intro- Atrophy of debility. duced into the blood by the chylific organs, or not sufficient- ly separated from it by the as- similating. In order that the body should maintain its proper strength and plumpness, it is necessary that the digestive organs should be sup- plied with a proportion of food adequate to the perpetual wear of its respective parts: for this wear, as we all know, produces a waste; and hence the emaciation sustained by those who suffer from famine, in which there is no food introduced into the stomach, or from a meagre or unwholesome diet, in which the quantity intro- duced is below the ordinary demand. It is this condition that forms the first of the subdivisions or varieties, the atrophy of want, un- der which the species before us is contemplated in the present ar- rangement. But the ordinary demand may not be sufficient for the body, or some part of it may be in a state of inordinate wear and waste, as in very severe and protracted labour, in which the supply is rapidly carried off by profuse perspiration, or in rupturing or puncturing a large artery, in which the same effect is produced by a profuse hemorr- hage. Any other extreme or chronic evacuation may prove equal- ly mischievous, as an excessive secretion from the bowels, from the vagina, from the salivary glands, from the breasts ; as where a de- licate wet-nurse suckles two strong infants. And hence the origin of the second of the above varieties, or the atrophy of waste, 176 1LEMATICA. [CL. III.—OR. IV. Now, in all these cases, Avherevcr the system is in possession of an ordinary portion of health, there is a strong effort made by the di- gestive powers to recruit the excessive expenditure by an additional elaboration of nutriment; and the instinctive effort runs through the entire chain of action to the utmost reach of the assimilating poAvers, or those secernents Avith Avhich every organ is furnished to supply itself Avith a succession of like matter from the common pabulum of the blood. Hence the stomach is always in a state of hunger, as in the case of famine, profuse loss of blood, or recovery from fever; all the chylific organs secrete an unusual quantity of resolvent juices, an almost incredible quantity of food is demanded, and is chymified, chylified, and absorbed almost as soon as it enters the stomach; the heart beats quicker, the circulation is increased, and the neAv and unripe blood is hurried forwards to the lungs, which more rapidly expand themselves for the purpose, to be completed by the process of ventilation: in which state it is as rapidly laid hold of by the assimilating powers of every organ it seems to fly to, and almost instantly converted into its own substance. Such is the wonderful sympathy that pervades the entire frame ; and that runs more particularly through that extensive chain of ac- tion Avhich commences with the digestive and reaches to the assi- milating organs, constituting its two extremities. So long as the surplus of supply is equal to the surplus of ex- penditure, no perceptible degree of waste ensues; but the greater the demand, the greater the labour, and the turmoil is too violent to be long persevered in. The excited organs must have rest, or their action will by degrees become feeble and inefficient. And if this lake place while the waste is still continuing, emaciation will be a necessary consequence even in the midst of the greatest abun- dance ; and Ave hence obtain an explanation of the variety of ema- ciation before us. Thus far we have contemplated the animal frame in a firm and healthy constitution : and have supposed a general harmony of ac- tion pervading every link of the extensive chain of nutrition from the digestive organs to the assimilating powers. But we do not al- ways find it in this condition: and occasionally perceive, or think we perceive, that this necessary harmony is intercepted in some part or other of its tenor: that the digestive powers, or some of them, do not perform their trust as they should do, or that the assi- milating powers, or some of them, exhibit a like default; or that the blood is not sufficiently elaborated in its course, or becomes loaded with some peculiar acrimony. And hence another cause, or rather an assemblage of other causes, competent to the disease before us. It is from the one or the other of these sources that Ave are in most, perhaps in all, cases to derive the third modification of this disease, which is here distinguished, for want of a better term, by that of atrophy of debility. The disease under this form is often very complex, and it is difficult to trace out what link in the great GE. HI.—SP. I.] SANGUINEOUS FUNCTION. 477 chain of action has first given way. Most probably, indeed, it is sometimes one link, and sometimes another. But from the sympa- thy which so strikingly pervades the Avhole, Ave see at once how easy it is for an unsoundness in one quarter to extend its influence to another, till the disease becomes general to the system. Yet I am much disposed to think that the atrophy so conspicuous in feeble habits, and the feeblest periods of life, as infancy and old age, com- mences most usually at the one or the other end of the chain, and immediately operates by sympathy on its opposite. This remark is in consonance with a very common law of life, by which impres- sions are more powerfully and more readily communicated from one extreme of an organ to another, than they are to any of the in- termediate points. It is hence the will operates instantly on the fingers, the stomach on the capillaries of the skin; and that the irri- tation produced by a stone in the bladder is felt chiefly in the glans penis. And hence the close correspondence which we have already seen prevail between these two extremities of the nutritive function in the case of want and hunger. Where atrophy is connected with a morbid state of the digestive organs, we have a little light thrown on the nature of the disease, but not much. For first, this indigestion does not necessarily pro- duce this effect, since it is no uncommon thing for dyspeptic patients to become plethoric, and gain, instead of lose, in bulk of body. And next, the morbid state of these organs may be a secondary in- stead of a primary affection, and be dependent upon a general hebe- tude or some other unsound condition of the assimilating powers, constituting the other end of the chain; and hence exercising a stronger sympathy over them than over any intermediate organs whatever: as the digestive organs themselves, if the disease should have originated in them, may exercise a like sympathy over the assimilating powers, and hence produce that general extenuation which, as we have just observed, is not a necessary consequence of dyspepsy. It is at least put, I think, beyond a doubt, that more than one set of organs is connected in the atrophy of debility. Where this atrophy takes place in infants at the breast or young children, it is ushered in by a flaccidity of the flesh, a paleness of the countenance, sometimes alternating with flushes, a bloated promi- nence of the belly, irregularity of the boAvels, pendulousness of the lower limbs, general sluggishness, and debility, and, where walking has been acquired, a disinclination to motion, with fretfulness in the day, and restlessness at night. There is at first no perceptible fever, no cough or difficulty of breathing: but if the disease continue, all these will appear as the result of general irritation, and the skin will become dry and heated, and be covered over with ecthyma, impetigo, or some other squalid eruption. The breath is generally offensive, the urine varies in colour and quantity; and in infants at the breast, the stools are often ash-coloured or lienteric, or greenish, loose and griping. The ap - petite varies j in some cases it fails, in others it is insatiable. 478 H.EMAT1CA. [CL. LA.—OR. IV. Where these symptoms, or the greater part of them occur to an infant at the breast, it becomes us, in the first place, to be particu- larly attentive to the manner in which it has been nursed, in respect to cleanliness, purity of air, warmth, and exercise: we have next to turn our attention to the nurse's milk; and afterwards to an ex- amination whether the infant is breeding teeth, or has worms, or there be any scrophulous taint in the blood. For the last Ave have no immediate remedy; the rest we must correct as we find occasion. And if we have no reason to be satisfied upon any of these points, it may still be advisable to change the milk. It is not easy to de- tect all the peculiarities of milk that may render it incapable of affording full nutrition: and there is reason to believe that one in- fant may pine away on Avhat proves a healthy breast to another. I have given this advice in some dilemmas, and have often found a wonderful improvement on its being followed. In children on their feet, who are confined to the filth and suffo- cating air of a narrow cell, the common habitation of a crowding family, from Sunday morning till Saturday night; or who are pressed into the service of a large manufactory, and have learnt to become a part of its machinery before they have learnt their mother-tongue; there is no difficulty in accounting for the atrophy that so often pre- vails amongst them. The appetite does not here so much fail as the general strength; their meals are, perhaps doled out at the allotted hours by weight and measure; but still they are falling vic- tims to emaciation; and are affording proof that air and exercise are of as much importance as food itself; that there are other or- gans than those of digestion upon which the emaciation must depend: and that, unless the supply furnished by the food to the blood-ves- sels be sufficiently oxygenized by ventilation, and coagulated by ex- ercise, the blood itself, however pure from all incidental acrimony or hereditary taint, will never stimulate the secernents of the vari- ous organs to which it travels, to a proper separation of its consti- tuent principles, and a conversion to their own substance. In all these cases, therefore, the proximate cause seems to be lodged principally in the assimilating powers of the system; and whenever the digestive organs groAv infirm also, it is rather by sym- pathy with the former than by any primary affection of their own. There is a singular case of atrophy quoted by Sauvages, to which he has given the name of lateralis, and which unquestionably be- longs to this variety. It occurred in a young child, and took posses- sion of just one half the body; the left side, from the axilla to the heel, being so completely wasted that the bones seemed only to be covered with skin, while the right side was fat. Under the influ- ence of topical antispasmodics, and sudorifics continued for seven years, the writer of the account tells us that, he began to get better —" melius habere ccepit."* • Nos. Med. CI. X. Ord. I. Ex. Collect. Acad. Tom. HI. p. 69S, GE. ni.—SP. I.] SANGUINEOUS FUNCTION. 479 In the atrophy of debility common to old age, the cellular mem- brane, that is the containing as Avell as the parts contained, seems rather to shrivel away, in many cases to be carried away by absorp- tion, and the muscular fibres to become dried up and rigid rather than loose and flabby. In this case the assimilating powers seem to have done their duty to the last, and like an empty stomach when loaded with gastric juice in a moment of sudden death, to have preyed upon and devoured themselves: for it is probable that more than half the bulk of the muscles and of the parenchyma of many of the organs is carried off in the same manner. Hence therefore we are to look for the proximate cause of the disease towards the other end of the chain, or among the chylific viscera. And we shall not in general look in vain. Not, indeed, that we shall always, or even commonly, find it in the stomach or in the liver, for the appetite may not fail, though its demand is but small and it is easily satisfied ; and probably digests what is introduced into it. Yet here the greater part of the food rests ; or rather it passes through the intestines and very little into lacteals, insomuch that many of our most cele- brated anatomists have thought, as I have already had occasion tc> observe,* that the mesenteric glands of old people become oblite- rated; while Ruysch contended that mankind pass the latter part of their lives Avithout lacteals, and that he himself was doing so at the time of writing. The mode of treatment needs not detain us. Where the disease depends upon a want of wholesome food, or of food of any kind, the cure is obvious : Avhere upon profuse evacuations, it falls within the precincts of some other disease, and is to be governed by its remedies. And where the cause is an infirm condition of any part of the chain of nutritive functions, from the chylific to the assimilat- ing organs, the same tonic course of medicine that may be advisa- ble in the one case will be equally advisable in the other. The bowels should be kept in a state of regularity; mercurial alterants may sometimes be required, though less frequently than under one or two varieties of tabes; the bitters and astringents enumerated under dyspepsy may be had recourse to, according to the peculiarity of the case; and cleanliness, fresh air, exercise, and cold-bathmg will complete the rest. The atrophy of old age is to be met by the richest foods, wine, and the warmth of another person sleeping in the same bed. * Vol. I. p. 282. Parabysma Mesentericum. 480 RflEMATICA. [CL. III.—OR. IV. SPECIES II. MARASMUS GLIMACTERICUS. ©eras of Mature. (Elfmacterfc Mutant. general decline of bulk and strength, with occasional reno- vation, AT THE AGE OF SENESCENCE, WITHOUT ANY MANIFEST CAUSE. For the ground-work of this species of marasmus I am entirely in- debted to Sir Henry Halford's elegant and perspicuous description of it in the Medical Transactions. The disease has hitherto never appeared in any nosological arrangement, but it has characters suf- ficiently distinct and striking for a separate species. In several of its features it bears a strong resemblance to the marasmus or atro- phy of old age described under the preceding species : but it differs essentially in the instances which it affords of a complete rally and recovery : and if the train of reasoning about to be employed in de- veloping its physiology prove correct, it will be found to differ also in its chief seat and proximate cause. The ordinary duration of life seems to have undergone little or no change from the Mosaic age, in Avhichas in the present day it vari- ed from threescore-and-ten to fourscore years. In passing through this term, however, we meet with particular epochs at which the body is peculiarly affected, and suffers a considerable alteration. These epochs the Greek physiologists contemplated as five ; and, from the word climax, (xAujt**!) which signifies a gradation, they de- nominated them climacterics. They begin with the seventh year, which forms the first climacteric ; and are afterwards regulated by a multiplication of the figures three, seven and nine, into each other ; as, the twenty-first year being the result of three times seven ; the forty-ninth, produced by seven times seven ; the sixty-third, or nine times seven; and the eighty-first, or nine times nine. A more per- fect scale might perhaps have been laid down ; but the general principle is well founded ; and it is not worth while to correct it. The two last were called grand climacterics, or climacterics empha- tically so denominated, as being those in which the life of man was supposed to have consummated itself; and beyond which nothing is to be accomplished, but a preparation for the grave. With the changes that occur on or about the first three of these periods Ave have no concern at present; and shall hence proceed to that Avhich frequently strikes our attention as taking place about the fourth, or in the interval between the fourth and fifth. This change is of two distinct and opposite kinds ; and it is necessary to notice each. We sometimes find the system at the period before us exhibiting all of a sudden a very extraordinary renovation of powers. The GE. III.—SP. II.] SANGUINEOUS FUNCTION. 481 author has seen persons who have been deaf for tAventy years abruptly recover their hearing, so as in some cases to hear very acutely : he has seen others as abruptly recover their sight, and throw away their spectacles, which had been in habitual employ- ment for as long a period ; and he has also seen others return to the process of dentition, and reproduce a smaller or larger number of teeth to supply vacuities progressively produced in earlier life. Under the genus Odontia, in the first class and first order of the present system, several of these singular facts have been already noticed, and examples given of entire sets of teeth cut at this period. That the hair should evince a similar regeneration, of which instances are also adduced in the same place, and of which Forestus affords other examples,* is perhaps less surprising; since this has been known to grow again, and even to change its colour after death.t But I have occasionally seen several of these singu- larities, and especially the reneAval of the sight and hearing, or of the sight and teeth, occur simultaneously. And hence Glanville spoke correctly when he affirmed that " the restoration of grey hairs to juvenility, and renewing exhausted marrow, may be effected without a miracle." On the other hand, instead of a renovation of powers at the period before us, Ave sometimes perceive as sudden and extraor- dinary a decline. We behold a man apparently in good health, Avithout any perceptible cause, abruptly sinking into a general decay. His strength, his spirits, his appetite, his sleep fail equally; his flesh falls aAvay; and his constitution appears to be breaking up. In many instances this is perhaps the real fact; and no human wisdom or vigilance can save him from the tomb. But in many instances also it is an actual disease, in which medical aid and kindly attention may be of essential service; and upon an applica- tion of which Ave behold the powers of life, as in other diseases, rally; the general strength return; the flesh grow fuller and firmer, the complexion brighten; the muscles become once more broad and elastic; and the whole occasionally succeeded by some of those extraordinary renovations of lost poAvers or even lost organs to which I have just adverted. The subject is obscure ; and it is as difficult perhaps to account for either of these extremes—for the sudden and unexpected decline, as for the sudden and singular restoration. That the de- cline however is a veal malady, and not a natural or constitutional decay, is perfectly obvious from the recovery. And hence, Sir Henry Halford, in reference to the period in which it occurs, and by Avhich, no doubt, it is influenced, has emphatically denominat- ed it the Climacteric Disease. Under the last species the author observed that the great chain of the organs of nutrition extends from the chylific viscera to the * Lib. XXXI. Obs. 6. f Eph. Nat. Cur.passim. vol. II.—61. 482 H.EMAT1CA. [CL. HI.—OR. IV. assimilating secernents; that these form the ends of the chain ; that a poAverful sympathetic action runs through the whole; but that this action is more powerful between the one end of the chain and the other, than between any of its intermediate links. He observed further that in the atrophy of old age the failure of action seems to commence and to be chiefly seated at the chylific or chyliferous end, and that the assimilating secernents exhibit the same failure only afterwards and by sympathy : that the lacteals become generally, and sometimes altogether obliterated, while the assimilating process is supported by an absorption, first of the animal oil deposited in the cellular membrane, then of this mem- brane itself, and, lastly, of much of the muscular and parenchyma- tous structure of the general frame. In the disease before us the reverse of all this seems to take place; and for its origin we must look to the assimilating powers constituting the other end of the chain. The patient falls away in flesh and strength before he com- plains of any loss of appetite, or has any dyspeptic symptoms; which only appear to take place afterwards by sympathy. And that the mesentery and lacteals are not paralyzed and obliterated, as in the atrophy of old age, is incontrovertible from the renovation of power and reproduction of bulk that form an occasional termination of the disease. In watching carefully the symptoms of this malady, when totally unconnected with any concomitant source of irritation either mental or bodily, we shall often perceive that it creeps on so gradually and insensibly that the patient himself is hardly aware of its commence- ment. " He perceives," to adopt the language of Sir Henry Hal- ford, " that he is tired sooner than usual, and that he is thinner than he was; but yet he has nothing material to complain of. In pro- cess of time his appetite becomes seriously impaired ; his nights are sleepless, or, if he get sleep, he is not refreshed by it. His face becomes visibly extenuated, or perhaps acquires a bloated look. His tongue is white, and he suspects that he has fever. If he ask advice, his pulse is found quicker than it should be, and he ac- knowledges that he has felt pains in his head and chest; and that his legs are disposed to swell; yet there is no deficiency in the quantity of his urine, nor any other sensible failure in the action of the abdominal viscera, except that the bowels are more sluggish than they used to be." Sometimes he feels pains shooting over different parts of the body, conceived to be rheumatic, but without the proper character of rheumatism ; and sometimes the head-ache is accompanied with vertigo. Towards the close of the disease, when it terminates fatally, the stomach seems to lose all its powers: the frame becomes more and more emaciated; the cellular membrane in the lower limbs is laden with fluid; there is an insurmountable restlessness by day, and a total want of sleep at night; the mind grows torpid and indifferent to what formerly interested it; and the patient sinks at last; seeming rather to cease to live, than to die of a mortal distemper. GE. HI.—SP. HI.] SANGUINEOUS FUNCTION. 483 Such is the ordinary course of this disorder in its simplest form when it proves fatal; and the poAvers of the constitution are incapable of coping with its influence. Yet it is seldom that we can have an opportunity of observing it in this simple form, and never perhaps but in a patient whose previous life has been entirely healthy, and whose mind is unruffled by anxiety. For if this complaint, whatever be its cause, should show itself in a person Avho is already a prey to grief, or care, or mental distress of any kind, or in whom some one or more of the larger and more important organs of the body, as the liver, the lungs, or the heart, has been weakened or otherwise injured by accident or irregularity, or is influenced by a gouty or other morbid diathesis, the symp- toms will assume a mixed character, and the disease be greatly ag- gravated. It is these accidents indeed that for the most part con- stitute the exciting cause, as well as the most fearful auxiliary of the disease; for, without such, it is highly probable that the predis- position might remain dormant; and that many a patient who falls a sacrifice to it Avould be enabled to glide quietly through the sequestered vale of age to the remotest limit of natural life, and at length quit the scene around him without any violent struggle or protracted suffering, with an euthanasia sometimes though rarely attained, but ardently desired by us all. Sir Henry Halford has remarked that the disease, according to his experience, is less common to women than to men. The author's own experience coincides with this observation. And we can be at no loss to account for the difference, when Ave reflect on the greater exposure of the latter than of the former to those contingencies which so frequently become occasional causes or auxiliaries, and which, at the period now alluded to, strike deeper and produce a much more lasting effect than in the heigh-day and ebulliency of life. There are some events, however, that apply equally to both sexes, and which very frequently lead to this affection; and that is, the loss of a long-tried and confidential friend; of a beloved or only child ; or of a wife or husband assimilated to each other in habits, disposition, general views and sentiments by an intercourse of perhaps thirty or forty years standing. This last, as it has occurred to me, is a more marked and more frequent cause of excitement than any other. I have seen it in some instances operate very rapidly : and have my eye at this moment directed to the melan- choly fate of a very excellent clergyman, between fifty and sixty years of age, the father of ten children, who were all dependent upon him, and whose benefice would have enabled him, in all probability, to provide for them respectably had he lived ; but who, having lost the beloved mother of his family while lying-in of her tenth living child, was never able to recover from the blow, and followed her to the grave in less than three months. I have at other times seen the same effect produced as clearly and decidedly, though with a much tardier step, and unaccompanied 4&1 Il&MATICA. [CL. III.—OR. IV with any sudden shock. I attended not long since a lady in Edgc- ware-Road, who died of a consumption at the age of fifty-four. Her husband, though not a man of keen sensibility, had attentively nursed her through the Avhole of her lingering illness, and had lived happily with her from an early period of life. He was aware of her approaching end, and prepared for it: and, in a few Aveeks after her disease, seemed to have recovered his usual serenity. Not long afterwards, however, he applied to me on his own account. I found him dispirited and losing flesh ; his appetite was diminish- ing, and his nights restless, with little fever, and altogether Avithout any manifest local disorder. The emaciation Avith its accompany- ing evils, nevertheless, increased, the general disease became con- firmed, and in about five months he fell a sacrifice to it. Occasionally, however, Avhere the climacteric temperament, if I may so express myself, is lurking, a very trivial accidental excite* ment proves sufficient to rouse it into action. " I have known," says Sir Henry Halford, " an act of intemperance, where intempe- rance Avas not habitual, the first apparent cause of it. A fall, which did not appear of consequence at the moment, and Avhich Avould not have been so at any other time, has sometimes jarred the frame into this disordered action. A marriage contracted late in life has also afforded the first occasion to this change." It has in some instances followed upon a cutaneous eruption, of Avhich the folloAving case will afford a very striking example, and show in the clearest colours the general want of tone Avhich under this morbid influence prevails throughout the system. Most of my readers of this metropolis have heard of, and many of them have perhaps had the pleasure of being personally acquainted with the late James Cobb, Esq. Secretary to the East India Company, the history of whose life, from his intimate and extensive connexion and correspondence Avith the most brilliant and distin- guished characters of the age that have figured either in political or fashionable life, and more especially from his own fine taste and commanding talents, and his umvearied efforts to patronise merit in whatever rank it Avas to be found, ought not to have been withheld from the Avorld. In November 1816 this gentleman, then in his sixty-first year, and blest with one of the firmest and most vigorous constitutions that I have ever knoAvn, applied to me for an erysipe- latous affection of the face. It was troublesome, and for nearly a fortnight accompanied Avith a slight fever, and a good deal of irri- tation. It subsided at length, but left a degree of debility Avhich called for a change of air, and relaxation from public duty. He made a short excursion to France, and returned much improved, but evidently not quite restored to all the strength and elasticity he formerly enjoyed. Insensibly, and Avithout any ostensible cause, he became emaciated, Avalked from Russel-Square to the East India House with less freedom than usual, and found his carriage a relief to him in returning home. His appetite diminished, his nights were less quiet, and his pulse a little quickened. At one time he GE. III.—SP. II.] SANGUINEOUS FUNCTION. 485 complained of an inextinguishable thirst, and voided an unusual quantity of urine, so as to excite some apprehension of paruria mellita. The urine, hoAvever, evinced no sweetness, and both these symptoms rapidly disappeared under the medical treatment laid down for him. The general Avaste, and debility, hoAvever, con- tinued to increase ; his natural cheerfulness began to flag occasion- ally, and exertion was a weariness. At this period an inflammation commenced suddenly on the left side of the nates, which soon pro- duced a tumour somewhat larger than a goose's egg, and suppurated very kindly. Sir Gilbert Blane and Sir Walter Farquhar Avere now engaged in consultation with myself, as was Dr. Hooper afterwards. It was a doubtful question, Avhat would be the result of this abscess ? It might be regarded as an effort of nature to re-invi- gorate the system by a critical excitement; and in this vieAv of the case there Avas reason for congratulation. But it Avas at the same time obvious, that if the strength of the system should not be found equal to this new source of exhaustion, and could not be stimulated to meet it, the abscess might prove highly unfavourable. The tumour was opened, and about a quarter of a pint of well-formed pus discharged: but the morbid symptoms remained without altera- tion, and the cavity seemed rather disposed to run into a sinus along the perinaeum than to fill up. The opening was enlarged, but no advantage folloAved: it was evident there Avas too little vigour in the system to excite healthy action. The abscess was alternately stimulated with tincture of myrrh, a solution of nitrate of silver, and red precipitate; but the surface continued glassy with a display of pale and flabby granulations, that vanished soon after they made their appearance. Mr. Cline was now united in consul- tation, and concurred in opinion that the Avound was of subordinate importance, and Avould follow the fortune of the general frame. The issue was still doubtful, for the constitution resisted pertina- ciously, though upon the whole the disorder Avas gaining ground. Yet even at this time there was not a single organ we could pitch upon, with the exception of the abscess, that gave indication of the slightest structural disease. The lungs were perfectly sound and unaffected ; the heart without palpitation; the mind in the fullest possession of all its powers; the head at all times free from pain or stupor, even after very large doses of opium and other narcotics : the bile Avas duly secreted; the urine in sufficient abundance ; and the bladder capable of retaining it without inconvenience through the whole night. The pulse, however, was quick, the stomach fastidious, and the bowels irregular, sometimes costive, and at others suddenly attacked with a diarrhoea that required instant and active attention to prevent a fatal deliquium. The wound continued on a balance: there was energy enough to prevent gangrene, but too little for incarnation. A clearer example of the disease before us cannot be Avished for or conceived. Unfortunately its progress, though retarded by the arms of medicine, was retarded alone. One of the last recommen- 486 1LEMATICA. [CL. HI.—OR. IV. dations was a removal into the country : but Mr. Cobb was now be- come so debilitated and infirm, that this was found a work of some difficulty, and required contrivance. His Royal Highness the Duke of Sussex, however, being kind enough to accommodate our patient with the use of his easy and convenient sofa-carriage, for as long a period as he might chuse, he proceeded without much fatigue to a house provided for him on the borders of Windsor Forest. The distance was now become too considerable for me to attend him statedly, and I visited him but once or twice afterwards. He con- tinued, however, to decline gradually, and, in about a month from the time of his going to Windsor, sunk suddenly under a return of the diarrhoea. In the progress of this disease medicine will generally be found to accomplish but little. The constitutional debility must be met by tonics, cordials, and a generous diet: and a scrupulous attention should be paid to such contingencies of body or mind as may form an exciting cause, or aggravate the morbid diathesis if already in a state of activity. Congestions must be removed where they exist, and every organ have room for the little play that the rigidity of advanced life allows to it: and where aperients are necessary, they should consist principally of the Avarm and bitter roots of resins, as rhubarb, guaiacum, and spike aloes. In many instances the Bath water, and in a few that of Cheltenham, will be also found of colla- teral use: and especially where we have reason to hope that a be- neficial impression has been made on the disease, and that the sys- tem is about to recover itself. The last remark I shall beg leave to offer, I must give in the words of Sir Henry Halford himself. If not strictly medical, it is of more than medical importance; and I have very great pleasure in seeing it put forth from so high an authority, and finding its way into a professional volume. " For the rest," says he, "the patient must minister to himself. To be able to contemplate with compla- cency either issue of a disorder Avhich the great Author of our being may, in his kindness, have intended as a warning to us to pre- pare for a better existence, is of prodigious advantage to recovery, as well as to comfort; and the retrospect of a well-spent life is a cordial of infinitely more efficacy than all the resources of the me- dical art." GE. III.—SP. in.] SANGUINEOUS FUNCTION. 487 SPECIES III. MARASMUS TABES. JBttlint. •ENERAL LANGUOR; DEPRESSION OF STRENGTH, AND, MOSTLY, OF SPIRITS ; HECTIC FEVER. Tabes is a Latin term of doubtful origin. The lexicographers de- rive it from the Greek t»jx«, " macero," varied in the Doric dialect to Txx.a,—whence Scaliger makes a compound of rxxoS<«$, " mace- rans vita," " a consuming life, or life of consumption ;" and sup- poses that such a word existed formerly, and that tabes is a deriva- tive from it. This is ingenious, but nothing more. Tab-eo, or tab-es, is most probably derived from the HebreAv axn (tab), lite- rally " to pine away or consume ;" which is the exact meaning of the Latin terms. Tabes is sufficiently distinguished from atrophy by the presence of hectic fever; from climacteric decay, by the tendency to de- pressed spirits, as Avell as its appearing at any age; and from con- sumption, by the local symptoms of the latter. Its ordinary causes are commonly supposed to be an acrimony in the blood from an absorption of pus, or the introduction of some poi- sonous substance, as quicksilver or arsenic ; or a scrophulous taint; or an irritation produced by excess in libidinous indulgences: thus laying a ground-work for the four following varieties : « Purulenta. Purulent decline. C Venenata. Decline from poison. y Strumosa. Scrophulous decline. ^ Dorsalis. Decline of intemperance. In the first of these varieties the absorbed pus may be con- templated as acting the part of a foreign and irritating substance,* and as acting upon a peculiarity of constitution : but unless the latter be present, pus will rarely, if ever, be found to produce a tabid frame: for, as already observed under hectic fever, if absorbed pus be capable, independently of idiosyncrasy, of inducing a decline in one instance, it ought to do so in every instance ; yet this we know is not the case, since buboes, empyemas, and other apostems and abscesses of large extent, have been removed by absorption, and yet no tabes has accompanied the process. It is said to occur more frequently where an abscess or a vomica is open ; in consequence of pus becoming more acrimonious by the action of the air. But * Armstrong, Diss, de Tabe purulenta. Edin, 1782. Lentiliu»,Jatromnemata, p. 384. Stuttg. 1712. 8vo- 488 ILEMATICA. [CL. III.—OR. IV. this supposition is altogether gratuitous: and Avhere hectic fever accompanies a sore or open abscess, it is more probably from in- creased irritation on the edges or internal surface of the cavity, as already observed when treating on psoas abscess. In tabes venenata, Dr. Cullen conceives that one cause of ema- ciation is produced by an absorption of oil from the cells of the cel- lular membrane into the blood, for the purpose of inviscating the acrimonious spiculae of the poisonous substance. This may perhaps be true in some instances : but by far the greater number of poi- sons that enter the blood, Avhether by deglutition or inhalation, act by a chemical rather than by a mechanical power. Let them, how- ever, act as they may, the hypothesis is not necessary to account for the emaciation : for the acrimony Avith Avhich the blood is here- by contaminated, is alone sufficient to excite and maintain the hec- tic ; as the hectic is alone sufficient to Avear aAvay the strength and substance of the system, and produce the Avaste. It is a disease, as Scheffler hasobserved, chiefly common to miners and mineralogists :* and, next to these, is to be found, perhaps, most frequently among the labourers in chemical laboratories. There are other poisonous irritants which are altogether ingene- rate or hereditary, that, by their perpetual stimulation, ultimately produce the same effect; as those of chronic syphilis, cancer, and scurvy. A more common cause, however, than any of these, is to be found in a state of the system which has apparently a very near relation to that of scrophula, though it is difficult precisely to identify them. The variety from this cause is, hence, frequently treated of under the head of scrophula or struma; but as it is peculiarly connected with a morbid condition of one or more of the organs of nutrition, including those of digestion and assimilation, and is uniformly ac- companied with emaciation, irritation, and some degree of hectic fever, it more properly falls within the range of the genus ma- rasmus than that of struma, and constitutes a peculiar variety of decline. Of all the contaminations that lurk in the blood, and are propaga- ble in a dormant state, that of scrophula, consisting, as for the pre- sent we must allow it to do, in the acrimony before us, shows itself sooner than any of the rest. It is curious, indeed, to observe the different periods of time that hereditary diatheses of a morbid kind demand for their maturity, unless quickened into development by some incidental cause. Scrophula very generally shows itself in infancy ; phthisis, rarely till at the age of puberty ; gout, in mature life; mania, some years later; and cancer still later than mania. Scrophula runs its course first, and becomes dormant, though rarely extinct; phthisis travels through a term of ten or twelve years, and if it do not destroy its victim by the age of thirty-five, generally consents to a truce, and is sometimes completely subjugated. All • Von der Gesundheit der Berglente. Chemnitz, 1770. GE. HI.—SP. HI.] SANGUINEOUS FUNCTION. 489 the rest persevere throughout the journey of life: they may indeed hide their heads for a longer or a shorter interval, but they com- monly continue their harassings till the close of the scene. When the strumous taint is excited into action in infant life, it ge- nerally fixes itself upon the chylific or chyliferous glands, especial- ly when they are in a Aveakly state ; most commonly upon the me- sentery, and to this quarter it often confines itself; insomuch that " I have frequently," says Dr. Cullen, "found the case occurring in persons who did not show any external appearance of scrophula; but in whom the mesenteric obstruction was afterwards discovered by dissection."* It is supposed by Dr. Cullen, and by most patho- logists, that the emaciation is in this case produced invariably by an obstruction of the conglobulate or lymphatic glands of the mesen- tery, through Avhich the chyle must necessarily pass to the thoracic duct. That an obstruction thus total may occur, is not to be alto- gether disputed, because the lymph has been found stagnated in its course by such an obstruction of lymphatic glands in other parts: but I have already observed that it is an interruption of very rare occur- rence ,t so rare, that Mr. Cruickshank affirms he never saw such a stagnation on the dissection of any mysenteric case whatever. And that a scrophulous enlargement of the glands of the mesentery does hot necessarily produce a total obstruction, is certain, because chil- dren, in whom mesenteric enlargement can be felt in the form of knots protuberating in the abdomen, have lived for a considerable number of years, sometimes ten or twelve, and have at last died of some other disease. And hence, it is perhaps more frequently the hectic fever kept up by the local irritation of the mesentery, and the general acrimony of the scrophulous taint in the blood, that pro- duces the emaciation in this case, than the pressure of a scrophu- lous infarction. " The mesenteric decline," says Dr. Young, "is generally pre- ceded by more or less of a head-ache, languor, and want of appe- tite. It is more immediately distinguished by acute pain in the back and loins, by fulness, and, as the disease advances, pain and tenderness of the abdomen. These symptoms are accompanied or succeeded by a chalky appearance, and want of consistency in the alvine evacuations, as if the chyle were rejected by the absorbents, and left in the form of a milky fluid in the intestines, and the func- tions of the liver were at the same time impaired, the natural tinge of the bile being wanting. The evacuations are also sometimes mixed with mucus and blood ; and are attended by pain, irritation, and tenesmus, somewhat resembling those that occur in a true dy- sentery. Occasionally also there are symptoms of dropsy, and es- pecially of ascites; as if the absorption of the fluid, poured into the cavity of the abdomen, were prevented by local obstacles : the ab- sorbent glands, which are enlarged, being rendered impervious, and * Pract. of Phys. Part HI. Book I. § MDCVI. f Vol. I. p. 282. CI. I. Ord. II. Parabysma Mesentericum. VOL. n.—62 190 HJEMATICA. [CL.III.—OR. IV. pressing also on the lacteals and lymphatics which enter them and pass by them." The appetite is generally good and often raven- ous ; probably produced by some remote irritation acting sympathe- tically on the stomach ; as that of the mesentery, or more likely that of the assimilating poAvers that constitute the opposite end of the chain of nutrient organs, and Avhich from their morbid excite- ment produce a morbid Avaste, and demand a larger supply than they receive. As Avorms are easily generated, and multiply in the digestive organs when in a state of debility, they have often been found in a considerable number in this disease, and have sometimes been mistaken for the cause of the malady instead of the effect.* Balme gives a case in which they were equally discharged by the mouth and anus.f In the strumous enlargements are occasionally found calcareous concretions, such as often appear in the joints Avhen weakened by arthritic affections,! or in other weak organs : and hence similar concretions are sometimes discovered in the lac- teals and the liver.§ The decline from an intemperate indulgence in libidinous plea- sures has been denominated tabes dorsalis, from the weakness which it introduces into the back, or rather into the loins. It is a disease of considerable antiquity ; for we find traces of it in the old- est historical records that have reached our own day: and it is par- ticularly described by Hippocrates under the name of 4»©ISIS NOTIAS,|| literally " humid tabes," from the frequent and involun- tary secretion of a gleety matter or rather of a dilute and imperfect seminal fluid. He explains it to be, as a disorder of the spinal mar- roAv, incident to persons of a salacious disposition, or who are new- ly married, and have too largely indulged in conjugal pleasures. He represents the patient as complaining of a sense of formication or a feeling like that of ants creeping from the upper part of his body, as his head, into the spine of his back ; and tells us that when he discharges his urine or excrements there is at the same time a co- pious evacuation of semen in consequence of which he is incapable of propagating his species, or answering the purpose of marriage. He is generally short-breathed and weak, especially after exercise: he is sensible of a weight in his head, his memory is inconstant and is affected with a failure of sight and a ringing in his ears. Though Avithout fever at first, he at length becomes severely feverish, and dies of that variety of remittent which the Greeks called leipyria, a sort of causus or ardent fever attended with great coldness of the extremities, but with a burning fire and intolerable heat within, an insupportable anxiety and unconquerable dryness of the tongue. • Chesneau, Lib. V. Obs. 27. f Journ. de Medicine, 1790. Sept. N. 1. $ Douin, Journ. des Sgavans, 1690.—Monro, Med. Trans. II. Art. 18. § Histoire de l'Academie des Sciences, &c. 1684. J ntps t»v ufos n«0w, Opp. p. 539. as also Ity< Neww, H. Opp. p. 479 GE. m—SP. HI.] SANGUINEOUS FUNCTION. 491 Dr. Cullen does not think that the quantity of seminal fluid dis- charged by undue indulgence can ever be so considerable as to ac- count for this general deficiency of fluids in the body, and the debi- lity that accompanies it, and adds that we must therefore seek for another explanation of these evils. " And whether," says he, " the effects of this evacuation may be accounted for either from the quality of the fluid evacuated, or from the singularly enervating pleasure attending the evacuation, or from the evacuation's taking off the tension of parts, the tension of Avhich has a singular poAver in supporting the tension and vigour of the whole body, I cannot po- sitively determine; but I apprehend that upon one or other of these suppositions the emaciation attending the tabes dorsalis mus tbe ac- counted for."* It is not difficult to trace this result in a less doubtful and more direct way. The sexual organs, both in males and females, have a close and striking sympathy with the organ of the brain; and the fluid they secrete with the nervous fluid. Whence Willis conceived that the fluids of both organs are the same, and hence expressly accounts for the debility.t Morbid salacity is no uncommon cause of madness, as we shall have occasion to observe hereafter. Irrita- tion of the uterus shortly after child-birth, is a still more frequent cause of the same mental affection. The testes are not capable of secreting their proper fluid till the sensorial organ has acquired, or is on the point of acquiring, maturity, so that both become perfect nearly at the same time; the mere apprehension of failure when in the act of embracing has at once, in a variety of instances, unnerv- ed the orgasm, and prevented the seminal flow so effectually, that the unhappy individual has often required many weeks or even months before he could recover a sufficient confidence to render the operation complete; while as Dr. Cullen has correctly observed the evacuation itself, even when conducted naturally, produces a plea- sure of a singularly enervating kind. It is in truth a shock that thrills through all the senses; and hence in persons of an epileptic temperament, has been known, as we shall have occasion to observe more fully hereafter, to bring on a paroxysm while in the act of in- terunion. It is hence easy to see that an immoderate excitement of the gene- ric organs, and secretion of seminal fluid must weaken the sen- sorial powers even at their fountain; and consequently that the nervous and muscular fibres throughout the entire frame, and even the mind itself, must be influenced by the debility of the sensorium. This we might suppose if there were no chronic flux from the se- minal vessels. But when we consider the effect often produced on the general frame by the discharge, or rather the irritation of a sin- gle blister; or, which is perhaps more to the purpose, of a small seton or issue, we can be at no loss to account for all the evils that * Pract. of Phys. Part III. B. I. § MDCX. f Pharm. Rationalis de Medicament. Operat. Pars. 2. 1675. 492 IIJEMATICA. [CL. HI—OR. IV. haunt the Avorn-out debauchee, and especially the self-abuser, from involuntary emissions of a seminal fluid hoAvever dilute and spirit- less, in connexion with the dreadful debility we have just noticed, and which is the cause of this emission. The nervous irritation which results from this debility is the source of the hectic by which the miserable being is devoured: and hence the heavy terrors and insupportable anxiety, corporeal as well as mental, the sense of for- mication and other phantasms, the flaccidity of the back and loins, the withering of the entire body, the constant desire of erection with an utter inability of accomplishing it, Avhich haunt him by day and by night, and throw him into a state of despondency. A fearful pic- ture, which cannot be too frequently before the eyes of a young man in this licentious metropolis in order to deter him from plung- ing into evils to which he is so often exposed.* Much of the medical treatment it may be proper to pursue has been anticipated in several of the preceding species. The first variety in Avhich the decline is dependent on the stimu- lus of an abscess or sore, or the introduction of pus into the circula- tion, can only be cured by a cure of the local affection. The strength may in the mean Avhile be supported by a course of inirri- tant tonics, as cinchona and the mineral acids, nutritious diet, gentle exercise and pure air. And, if stimulants be at any time employed with a view of acting more directly on the morbid irritation and changing its nature, they should be limited to the milder resins, as myrrh, or the milder terebinthinates, as camphor, and balsam of copaiva. In decline from the inhalation of metallic or other acrimonious vapours, if Dr. Cullen's hypothesis were established, that the ema- ciation is a mere result of the vis medicatrix naturae, and produced by an absorption of oil from the cellular membrane for the purpose of sheathing the minute goads of the poison, it Avould be our duty to follow up this indication and employ inviscating demulcents, both oils and mucilages. But this practice has rarely been productive of any success : and we have much more reason to expect benefit from a use of the alkalies, Avhich, by uniting with the metallic salts, if they still exist in the circulation, may disengage their acid princi- ples, reduce the metallic base to a harmless regulus, and, by the new combination hereby produced, form a cooling, perhaps a seda- tive neutral. The first step, however, is to remove the patient from the deleterious scene to an atmosphere of fresh air, then to purify the blood, whether Ave employ the alkalies or not, with alter- ant diluents, as the decoction of sarsaparilla, and afterwards to have recourse to bitters, astringents, and the chalybeate mineral waters. In strumous decline the mode of treatment should run precisely parallel Avith that for most of the species of parabysma, or visceral turgescence, already laid down under their respective heads, and • LeAvis's Essay upon the Tabes Dorsalis. Lond. 1758.—Brendal, Diss, de Tabe Horeali, Goett. 1748 GE. III.—SP. HI.] SANGUINEOUS FUNCTION. 493 particularly with that for mesenteric parabysma, to which the reader may turn.* In the treatment of tabes dorsalis, or decline from intemperate in- dulgence, our attention must be directed to the mind as Avell as to the body ; for it is a mixed complaint, and each suffers equally. A summer's excursion with a cheerful and steady friend, into some un- tried and picturesque country, where the beauty and novelty of the surrounding scenery may by degrees attract the eye, and afford food for conversation, will be the most effectual step to be pursued if the symptoms be not very severe. The hours should be regular, with early rising in the morning, the diet light, nutritive, and invigorat- ing, and a little wine may be allowed after dinner; since it will al- most always be found that the patient has too freely indulged in wine formerly; and he must be let down to the proper point of abstinence by degrees.! The metallic tonics will commonly be found of more use than the vegetable, with the exception of iron, which is generally too heating; though the chalybeate waters may be drunk, if sufficiently combined with neutral salts. The local cold bath of a bidet should be used from the first, and afterwards bath ing in the open sea. If the disease have made such an inroad on the constitution that travelling cannot be accomplished : if the mind be overwhelmed, the back perpetually harassed with pain and feebleness, and the night sleepless with hectic sweats and a frequent involuntary dis- charge, two grains of opium, or more if needful, should be taken constantly on going to bed; diluted acids, vegetable or mineral, should form the usual beverage, and a caustic be applied to the loins on each side. Hippocrates recommends the actual cautery, and that it should descend on each side of the back, from the neck to the sacrum. Savine bougies have been prescribed by some wri- ters as a topical stimulus ; but a bidet of cold Avater is preferable; with injections of zinc or copper, at first not rendered very astrin- gent, but gradually increased in power. * Vol. 282. p. 8. CI. I. Ord. U. t See Wichmann, De Pollutione diurna, frequentiori, sed rarius observata, Tabescentix causa, Goett. 1782. HJEMATICA. [CL. III.—OR. IV. SPECIES IV. MARASMUS PHTHISIS. i&onmmption. cough: pain or uneasiness in the OHEST, CHIEFLY ON DECUMBI' TURE : HECTIC FEVER : DELUSIVE HOPE OF RECOVERY. Consumption, or phthisic as it is sometimes called by old medical writers, is by Dr. Cullen contemplated as nothing more than a sequel of haemoptysis, instead of being regarded as an idiopathic affection ; and his species, which are two, can only be viewed, and so appear to have been by Dr. Cullen himself, as separate stages in the progress of the complaint; his first species being denominated phthisis incifiiens, and characterized by an absence of purulent ex- pectoration; and his second, phthisis confirmata, distinguished by the presence of this last symptom. This, however, is a very unsatisfactory, as well as a very unscien- tific view of the subject, and evidently betrays the trammels of Dr. Cullen's classification ; since he seems to have placed the disease in this position only because he could find no other to receive it: for he admits in his First Lines that, " phthisis arises also from other causes besides haemoptysis."* It is highly probable, indeed, that phthisis occurs, or at least commences, more frequently without hemorrhage from the lungs than with it, and consequently that haemoptysis ought much rather to be regarded as a symptom or sequel of phthisis, than phthisis of haemoptysis. " Haemoptysis," observes Dr. Young, in a work that has the rare advantage of combining great research and learning, comprehen- sive judgment, and a study of the present disease in his own per- son, " is usually enumerated among the exciting, or even among the more remote causes of consumption ; but in a healthy constitu- tion, haemoptysis is not materially formidable; and it is conjectured that Avhen it appears to produce consumption it has itself been oc- casioned by an incipient obstruction of a different kind.""I- So that on the concurrence of the two we may commonly adopt the opinion of Desault, and call it an haemoptysis from consumption, rather than a consumption from haemoptysis.^ Of the three varieties we are about to describe, we shall find haemoptysis a frequent cause of the second, but rarely of either of the others. These varieties I have taken from Dr. Duncan's very valuable " Observations" on consumption : they are evidently drawn • Part I. Book IV. Ch. I. Sect. DCCCLII. f Treatise on Consumptive Diseases, p. 45. t Sur les Maladies Veneriennes, la Rage, et la Phthisic, &c. 12 Bord. 1733. GE. HI.—SP. IV.] SANGUINEOUS FUNCTION. 495 from a close and practical attention to the disease, and are as fol- low: <* Catarrhalis. Catarrhal consumption. C Apostematosa. Apostematous consumption. y Tubercularis. Tubercular consumption. In the first variety, the cough is frequent and violent, with a copious excretion of a thin, offensive, purulent mucous, rarely mix- ed with blood ; generally soreness in the chest, and transitory pains shifting from side to side. It is chiefly produced by catching cold, or the neglect of a common catarrh. In theAPOSTEMATous variety, the cough returns in fits but is dry: there is a fixed, obtuse, circumscribed pain in the chest, sometimes pulsatory ; with a strikingly difficult decumbiture on one side; the dry cough at length terminates in a sudden and copious discharge of purulent matter, occasionally threatening suffocation ; the other symptoms being temporarily, in a feAv rare instances perhaps per- manently, relieved. When haemoptysis is the cause, the disease generally appears under this form. In the tubercular variety, the cough is short and tickling; and there is an excretion of the watery, whey-like sanies, sometimes tinged Avith blood; the pain in the chest is slight; and there is mostly an habitual elevation of spirits. Usually the result of a scrophulous diathesis. In Dr. Duncan's observations, consumption or phthisis is intro- duced as a genus, and consequently the varieties now offered as so many species; yet as the tubercular may run into the apostematous variety, and the catarrhal into both, according to the peculiarity of the constitution, and other concurrent circumstances, and more especially as a common cause may produce all of them in different idiosyncrasies, the present subdivision will perhaps be found the most correct. Dr. Wilson Philip, has formed another variety (Avith him species) of consumption, to Avhich he has given the name of Dysfiefitic Phthisis, and which he supposes to be produced by a previously diseased state of the digestive organs in which the lungs ultimately participate. " Drunkards," says he, " at that time of life which disposes to phthisis, frequently fall a sacrifice to this form of the disease; and those who have been long subject to severe attacks of dyspepsia, and Avhat are called bilious complaints, are liable to it— What is the nature of the relation observed between the affection of the lungs, and that of the digestive organs in this species of phthisis ? is the one a consequence of the other, or are they simultaneous af- fections, arising from a common cause? they are not simultaneous affections, for the one always precedes the other. In by far the majority of cases in which both the lungs and digestive organs are affected, the affection of the digestive organ precedes that of the lungs. In some instances, Ave find the affection of the lungs the primary disease: but in these the case does not assume the form 496 H22MATICA. [CL. HI.—OR. IV. above described, but that of simple phthisis ; and the hepatic affec- tion, which is always the most prominent feature of this derange- ment in the digestive organs, does not show itself till a late period of the disease, and then little, if at all influences the essential symp- toms."* These remarks show clearly that phthisis in this form is a sequel of a prior disorder, rather than an idiophatic affection; and, as such, needs not be pursued further in describing the present species. It would however be tedious and of no practical use, to notice the different ramifications into which consumption has been follow- ed up by many of the most approved pathologists that have touched upon it. Among modern writers, more especially, it has been very unnecessarily subdivided: thus Bayle gives us six species, derived from supposed organic causes ;f of most of which we can knoAV no- thing till the death of the patient; Portal fourteen,^ the first two of which, the scrophulous and plethoric, are peculiarly entitled to attention, Avhile the rest are drawn from other diseases with Avhich it is often complicated, or of Avhich it is a sequel. In Morton and Sauvages the divisions and subdivisions are almost innumerable. The Greek pathologists are not chargeable Avith the same error; for in general they treat of the disease, under two branches alone, phthisis, and phthoe; the first importing abscess of the lungs, or the apostematous variety of the present classification, and the se- cond ulceration of the lungs, embracing perhaps the greater part of the other two. The terms are those of Hippocrates, and they are thus interpreted by Aretaeus.§ Phthisis, as sufficiently appears from the last paragraph, is a dis- ease of high antiquity as well a8 of most alarming frequency and fatality. So frequent, indeed, is it as to carry off prematurely, ac- cording to Dr. Young's estimate, and the calculation is by no means overcharged, one-fourth part of the inhabitants of Europe :|| and so fatal that M. Bayle will not allow it possible for any one to recover Avho suffers from it in its genuine form.! I can distinctly aver, how- ever, that I have seen it terminate favourably in one or two in- stances when the patient has appeared to be in the last stage of the disease, with a pint and half of pus and purulent mucus expecto- rated daily, exhausting night-sweats and anasarca; but whether from the treatment pursued or a remedial exertion of nature I will not undertake to say. Dr. Parr affirms that he has witnessed six cases of decided phthisis recovered from spontaneously. The ordinary period of the consumptive diathesis is from the age of eighteen to * Trans, of Medico-Chirurg. Soc. Vol. VTI. p. 499. j- Recherches sur la Phthisis pulmonaire. Par. 1810. * Observations sur la Nature et la Traitement de la Phthisie pulmonaire, 2 torn. 8vo. Paris, 1809. § Morb. Chron. I. 10. || On Consumptive Diseases, Ch. HI. p. 20. 1 Recherches sur la Phthisie pulmonaire. Par. 1810. GE. HI.—SP. IV.] SANGUINEOUS FUNCTION. 497 that of thirty-five, though it occasionally anticipates the first, and overpasses the second, of these limits; the mean term of its prov- ing fatal is about thirty ; and the annual victims to its ravages in Great Britain, Dr. Woolcombe has calculated at fifty-five thousand.* The only causes of phthisis we are acquainted with are predis- ponent, and those that excite the predisposition into action. Of the nature of the predisponent cause, we know little more than that it appears to appertain to a peculiarity of constitution which aviII be noticed presently. The exciting or occasional causes are very nume- rous, as mechanical irritation of the lungb from swallowing a piece of bone; the dust of metallic or other hard substances perpetually inhaled; frequent and sudden changes of temperature or exposure of the body to cold when in a heated state and unprepared for it; overaction in speaking, singing, or playing on a wind-instrument; the irritation of various other diseases, as worms, scrophula, syphi- lis or measles; the sudden suppression of a cutaneous disease that nas continued long and formed a part of the habit, as itch ; or of any habitual discharge, as that of menstruation, or blood from the he- morrhoidal vessels, Avhen the discharge has become periodical: the irritation of a too rapid growth of the body, and that of various pas- sions perpetually preying upon the individual ; as mortified ambi- tion, disappointed love, home-longing,t Avhen at remote distance from one's friends and country. Examples of consumption from a mechanical irritation of the lungs are peculiarly numerous, and they furuish cases of every va- riety of the disease according to the habit or idiosyncrasy, though the apostematous is less frequent than the rest. So common is this complaint among persons employed in dry-grinding, or pointing needles in needle-manufactories, that Dr. Johnstone of Worcester informs us they seldom lived to be forty, from the accumulaiion of the dust of the grind-stones in the air-cells ot the lungs, and the ir- ritation and suppuration which follows.| It appears to be little less common among knife and scythe-grinders ; whence, accoraing to Dr. Simmons, the disease thus originating is called the grinders' rot,§ and Wepfer gives an account of its proving endemic ac Wald- shut, on the Rhine, where there is a cavern in which mill-stones are dug and wrought, the air is always hot even in the winter, and a very fine dust floats in it, which penetrates leathern bags, and discolours money contained in them. " All the workmen," says he, " become consumptive if they remain there for a year, and some even in a shorter time ; and they all die unless they apply early * Remarks on the frequency and fatality of different diseases, &c. 8vo. Lond. 1808. f R. Hamilton, in Duncan's Med. Com. XI. p. 343. t Mem. Med. Soc. V. 1799. p. 89. § Pract. Obs. on the Treatment of Consumptions, 8vo. 1780, vol. II.—63 198 1LEMATICA. ICL. HI.—OR. IV. for assistance."* And, hence, Dr. Fordyce had much reason for regarding the dust of the streets of London, as a serious cause of pulmonic disorders;! though it is a cause that has been much di- minished since the introduction of paving and watering. A lodgement of some fragment of a bone in the oesophagus has, in like manner, been a frequent cause of phthisis, which has often been protracted through a long period of time. Thus Claubry gives a case of this kind which had continued for fourteen years, and the patient seemed to be in the last stage of a consumption Avhen he was fortunate enough to bring up the piece of bone spon- taneously, in consequence of Avhich he recovered, though for the preceding four years he had laboured under an haemoptysis.I Mr. Holman describes a similar case that had run on for fifteen years, accompanied with cough, haemoptysis, and hectic diarrhoea; and Avhich was also speedily relieved in consequence of the bony frag- ment three quarters of an inch in length, and apparently carious, being suddenly coughed up after the discharge of a pint of blood.§ A moderate use of the vocal organs, as of any other, tends to strengthen them, and to enable public speakers, singers, and per- formers on Avind-instruments to go through great exertion without in- convenience, which would be extremely fatiguing to those who are but little practised in any of these branches; but the labour is often carried too far, and the lungs become habitually irritated, and hae- moptysis succeeds. I have knoAvn this terminate fatally among clergymen; who have lamented, when too late, that in the earlier part of life they spent their strength unsparingly in the duties of the pulpit. Hence, Dr. Young observes from Rammazini,|| that public speakers, readers, and singers, are most liable to pulmonary diseases, and that Morgagni and Valsalva have confirmed the ob- servation. Cicero himself felt it necessary, as he tells us in his book on orators, to retire from the forum for two years, during which he travelled into Asia, and afterwards returned with renewed vigour to the duties of his profession; and Moliere died of haemoptysis, immediately after performing, for the fourth time, his Malade lma- ginaire.^f There are many diseases that have a peculiar tendency to excite phthisis from their close connexion with the lungs, or affinity to hec- tic fever, which is one of its most prominent symptoms. Thus, ne- glected catarrhs form a frequent foundation, and measles for the same reason. Whether the tubercles found in the substance of the * Observationes de affect. Capitis. 4to. Schaff. 1727-8, quoted by Young on Consumptive diseases, p. 206. f Trans, of Soc. for the Improvement of Med. and Chir. Knowledge, Vol. I. 252. * Sedill. Journ. Gen. Med. XXXIV. p. 13. 1809. § Lond. Med. Journ. VII. p. 120. H On Consumptive Diseases, p. 264. 1 Van Swieten, Aph. IV. § 1201. p. 49, GE. HI.—SP. IV.] SANGUINEOUS FUNCTION. 499 lungs in the tubercular variety of consumption, be, in every in- stance, strictly scrophulous, may admit of a doubt; that they are so in many cases is unquestionable ; and hence scrophula becomes very generally an exciting, and not unfrequently, perhaps, a primary cause, of this disease. There is a case by Lissardet, of a fatal con- sumption which succeeded to a psora, supposed to have been too hastily cured ; and another by Coeuvet of a more favourable termi- nation, under similar circumstances, the dartre having re-appeared. It has occurred more than once to myself, that the lungs have been attacked during the cure of cutaneous affections, and, in one instance fatally, even where no hasty mode of treatment had been pursued.* The tendency of the syphilitic poison to produce phthisis has been noticed by almost every writer from the time of Bennet, who particularly dwells upon it ;t but whether this Avould be adequate to such a purpose without an hereditary predisposition is uncertain. And the same remark may be made respecting worms, which Mor- gagni has stated to be a very common cause.| Indeed any habitual irritation, in any part of the alimentary canal seems capable of ex- citing a sympathetic action in the lungs ; and hence Wilson in Dr. Duncan's Annals, gives a case of hectic in a child produced by swallowing a nail two inches long, which remained in the stomach fifteen months, and was then thrown up, and succeeded by a reco- very of health.§ Rapid groAvth is always attended with debility and consequent ir- ritability of the entire system ; and, where there is a predisposition to consumption, this also becomes often its harbinger, unless great caution is observed on the occasion. Richerand relates a case of this kind that terminated fatally, the individual having grown more than an English foot in a year.|| I have known a still more rapid growth without any other inconvenience than that of languor ; but in this case there was no phthisical predisposition. Where the chest labours under any misformation we can readily trace another cause of excitement, and are prepared to meet the examples that from this source so frequently occur to us in prac- tice. But it is less easy to explain by what means persons other- wise deformed, and particularly those who have had limbs ampu- tated, should be more liable to consumption than others ; yet this also is a remark that has been made by Bennet,! though I do not know that it has been supported by a concurrent observation. Of all the occasional or accidental causes of phthisis, however, frequent and sudden vicissitudes of temperature are probably the * On Consumptive Diseases, p. 269. f Vestibulum Tabidorum, 8vo. 1654. Leyd. t De Morb. Thoracis. Lib. II. Ep. Anat XXI. 43. § Vol. I. 1796. H Sedill. Journ. Gen. Med. XX. p. 255. t Tabid. Theatr. p. 99. 500 H^MATICA. [CL. HI.—OR. IV. most common; so common indeed, and at the same time so active, as often to be a cause of consumption in constitutions where we can- not trace any peculiar taint or predisposition whatever. Several hundred cases of phthisis from this cause, among which were many fatal ones, occurred in the channel fleet that blockaded the port of Brest in April 1800, as is particularly noticed by Dr. Trotter. The summer Avas hot and dry, the duty very severe ; and the sailors, wet with SAveat, were frequently exposed to currents of air at the port holes; and little time was allowed for refitting.* Hence the most frequent examples of consumption are to be found in those countries Avhich are most subject to changes of temperature. In Great Britain, it is calculated that the disease carries off usually about one-fourth of its inhabitants; at Paris, about one-fifth : and at Vienna, one-sixth : Avhile it is by no means common in Russia, and still less so in the West Indies; for it is checked in both regions by the greater uniformity of the atmos- phere Avhethcr hotter or colder.t It is a singular fact, and not well accounted for, that of all places which have hitherto been compared, the proportional mortality from consumption appears to have been the greatest at Bristol; and this, not among its occasional visitors, but its permanent inhabitants ; and yet, as though in defiance of experience, this very place has been chosen as the great resort of consumptive persons.}: Nor does its mineral watei seem entitled to any higher compliment than its atmosphere. Dr. Beddoes affirms in direct terms that it is of no manner of use;§ and Dr. Thomas, in more measured language, speaks nearly to the same effect; " In my humble opinion," says he, " the waters of the hot-Avells are by no means deserving of the credit ascribed to them; as, during a residence of some time at and near these wells, I cannot charge my memory with a single instance where any person, labouring under a confirmed phthisis, experienced much relief from their use alone."% Where a consumptive diathesis has once originated, it is often very evidently transmitted to succeeding generations ; and there is great reason to believe that the disease is in a certain degree contagious. M. Portal, and a few other pathologists of distinction, have doubted or denied that it possesses any such property; but the apparent instances of communication among near relations and close attentive nurses, and especially between husbands and wives, who have fallen victims to it in succession, are so frequent, that its contagious power has been admitted by most practitioners and in most ages. Aristotle appeals to it as a matter of general belief * Medicina Nautica. Vol III. p. 325. + Woolcombe (Dr. W.) Remarks on the frequency and fatality of Diseases, 8vo. Lond. 1808.—Southey (Dr. H. H.) Observations on Pulmonary Consump- tion, 8vo. Lond. 1814. \ Young ut supra, p. 42. § Manual of Health, &c 12mo. Lond. 1806. 1 Practice of Physic, p. 508, sixth edit. GE. HI.—SP. IV.] SANGUINEOUS FUNCTION. 501 among the Greeks in his day :* and it has since been assented to in succession by Galen, Morton, Hoffman, Vogel, Desault, Danvin, and most modern writers. I have myself been witness to various cases which could not be ascribed to any other cause ; and Dr. Rush has given an account of a consumption manifestly contagious, which spread from the pro- prietors of an estate among the negroes, who were neither related to the first victims, nor had been subjected to fatigue or anxiety on their account, and amongst whom it scarcely ever makes its appear- ance, f The disease, however, is but slightly contagious, admitting it to be so at all; and seems to demand a long and intimate com- munion, as, for instance, that of sleeping or constantly living in the same room, to render the miasm effective. Yet, in the present state of the question, most judicious practitioners from the time of Galen have thought it right to follow his advice, and to caution attendants upon consumptive patients against the danger of being constantly about their persons through the whole course of the disease. The diathesis strictly consumptive is usually associated, in the language of Hippocrates,! ana" Aretaeus,$ with a smooth, fair, and ruddy complexion, light or reddish hair, blue eyes, a long neck, a narrow chest, slender form, and high shoulders, or, in the words of Hippocrates, shoulders projecting like wings, and a sanguine dispo- sition. In some instances, however, the skin is dark, and the hair almost black. According to Dr. Withering and Dr. Darwin, the most constant of a consumptive habit is an unusual magnitude of the pupil, to which some have added long and dark eye-lashes; but this last character seems loose and unestablished. Itis a remark far better supported that the teeth are peculiarly clear, and the eyes peculiarly bright; and that both become more so Avhen the disease has once commenced its inroad; the former assuming a milky whiteness, and the latter a pearly lustre: showing how completely the animal oil is absorbed and carried off, not merely from the surface, and from the interstices of the muscles by which the form chiefly becomes emaciated, but from every organ what- ever : and, in the appearance of the teeth, affording an additional proof to those already offered when treating of odontia,|| that these peculiar bones are not extraneous bodies, destitute of vascularity, but possessing the same organization as other bones; rendered yellow by a deposit of animal oil, and blanched by its removal. Professor Camper, and most physicians with him, affirm that this appearance accompanies all the varieties of the disease ; but Dr. Foart Simmons limits it to the tubercular alone ; and conceives it to * Problem, Sect. I. 7. \ Medical Inquiries and Observations, &c. Vol. I. 8ro. Phil. 1789. t Epidem. v. p. 1142. $ Chron. Dis. i. 10. 12. B CI. I. Ord. I. Vol. I. p. 33. 502 HiEMATICA. [CL. HI.—OR. IV. be a distinguishing characteristic of this form of the disease or of a predisposition to it. And he remarks further, that of those who are carried off by tubercular phthisis, the greater number will be found never to have had a carious tooth.* The earliest symptoms of phthisis, in whatever manner excited, are insidious and show themselves obscurely. The patient is, perhaps, sensible of an unusual languor, and breathes with less freedom than formerly, so that his respirations are shorter and increased in number. He coughs occasionally, but does not com- plain of its being troublesome, and rarely expectorates at the same time : yet if he make a deep inspiration he is sensible of some degree of uneasiness in a particular part of the chest. These symptoms gradually increase, and at length the pulse is found quicker than usual, particularly toAvards the evening; a more than ordinary perspiration takes place in the course of the night; and if the sleep be not disturbed by coughing, a considerable paroxysm of coughing takes place in the morning, and the patient feels relaxed and enfeebled. This may be said to form the first stage of the disease : and it is the only hopeful season for the interposition of medical aid. The malady is noAv decidedly established ; the cough increases in frequency, and from being dry is accompanied Avith a purulent mucus, varying, according to the peculiar modification of the disease, from a watery Avhey-like sanies occasionally tinged Avith blood, to a sputum of nearly genuine pus. It may, as Aretaeus has well observed, be livid, deep-black, light-brown,or light-green; flatten- ed or round; hard or soft; fetid or without a smell. In many cases it is very scanty ; and we may also add with Aretaeus that in some consumptions there is no expectoration at all; for in the apostema- tous variety the sufferer has sometimes died before the vomica has broken. The uneasiness in the chest, only perceived at first on making a deep inspiration, is now permanent and attended with a sense of weight: the hectic fever has assumed its full character : the patient can lie with comfort only one side, which is usually the side affected; and the breathing, as Bennet has remarked, is frequently accompanied by a sound like the ticking of a watch. The strength noAv fails apace; the pulse varies from about a hundred to a hundred and twenty or thirty ; the teeth, from a cause just pointed out, increase in transparency, and the sclerotica of the eye is pearly-white ; " the fingers, to continue the elegant descrip- tion of Aretaeus as given by Dr. Young, are shrunk, except at the joints, which become prominent; the nails are bent for want of support, and become painful; the nose is sharp, the cheeks are red, the eyes sunk, but bright, the countenance as if smiling ; the Avhole body is shrivelled; the spine projects, instead of sinking, from the decay of the muscles; and the shoulder-blades stand out like the wings of birds." * Practical Observations on the treatment of Consumptions. By Samuel Foart Simmons, M. D. 8vo. London, 1779. GE. HI.—SP. IV.] SANGUINEOUS FUNCTION. 503 The third stage is melancholy and distressing, but usually of short duration. It commences Avith a depressing and colliquative diarrhoea; but till this period, and occasionally indeed through it, the patient supports his spirits and flatters himself with ultimate success, while all his friends about him are in despondency, and find it difficult to suppress their feelings. The voice becomes hoarse, the fauces aphthous, or the throat ulcerated, Avith a difficulty of swallowing. Dropsy, in various forms, now makes its approach; the limbs are anasarcous, the belly tumid, or the chest fluctuating; and the oppression is only relieved by an augmentation of the night-sweats or of the diarrhoea; for it is generally to be found that the one set of symptoms is less as the other is greater. " A few days before the patient's death, he is frequently unable to expecto- rate from apparent weakness, and sometimes dies absolutely suffo- cated : but much more commonly the secretion of pus, as well as the expectoration, has ceased; as if the capillary arteries had lost their power, or the fluids of the system were exhausted. There is also sometimes a degree of languid delirium for some days, and occasionally a total imbecility for a week or two: though, in gene- ral, the faculties are entire, and the senses acute, the patient being perfectly alive to the danger and distress of his situation, and retain- ing, even when his extremities are becoming cold, a considerable quickness of hearing and feeling. The closing scene is often painful, but it sometimes consists in the gradual and almost imper- ceptible approach of a sleep which is the actual commencement of death."* Such is the common progress and termination of the disease; but it varies considerably in the character and combination of its symptoms, and particularly in the tardiness or rapidity of its march, according to the habit or idiosyncrasy of the individual, or the variety of the disease itself. Where the constitution is firm, and the hereditary predisposition striking, it commonly assumes the apostematous form, and runs on to the fatal goal with prodigious speed, constituting what among the vulgar is called, with great force of expression, a galloping consumption. In this case, the activity of the absorbent, and, indeed, of every other part of the general system is wonderful: the whole frame is in a state of esluation and greedily preying upon itself. The animal spirits are more than ordinarily recruited, and all is hope and ardent imagina- tion; the secernents play with equal vigour, and the skin is drench- ed with moisture, the bronchial vessels are overloaded with mucus, vomica after vomica becomes distended with pus, and the bowels are a mere channel of looseness. The absorbents drink greedily ; and animal oil, cellular membrane, parenchyma, and muscle, are all swalloAved up and carried away, till every organ is rapidly reduced to half its proper weight and bulk, and the entire figure becomes a shrivelled skeleton. So swift Avas the progress of the disease in the * Young, On Consumptive Diseases, p. 28. 504 1LEMATICA. [CL. HI.—OR. IV. case of the Duchess de Pienne, that M. Portal informs us she died in ten or tAvelve days from the first alarm. On other occasions, the march of the consumption is as remarka- ble for its tardiness. This is particularly the case with the tuber- cular variety when not quickened in its pace by returns of haemop- tysis. Hoffman gives instances of two or three who lived under the disease for thirty years: and in the Edinburgh communications is the case of an individual who passed nearly the Avhole of a long life under its influence, who was consumptive from eighteen to seven- ty-two, and died of the complaint at last. Of two hundred cases, however, selected by M. Bayle, a hundred and four died within nine months, which may hence be regarded as the mean term. Dissections seem to prove that the most frequent variety of con- sumption is the tubercular: the tubercles consisting of circumscribed nodules or indurations, by Weffer called grandines,* found indis- criminately in all parts of the cellular texture, but more abundantly at the upper and posterior parts. They are at first very minute, whitish and opake, like small absorbent glands, but sometimes more transparent, like cartilage, with black dots in their substance. They augment by degrees till they are half an inch or more in diameter; but in general when they have acquired the size of large peas they begin to soften in the centre, and then open by one or more small apertures into the neighbouring bronchiae, or remain for a longer time closed, and constitute small vomicae, containing a curdy half- formed pus. Occasionally they unite into large abscesses.f Now as we have before observed from Dr. Baillie that nothing like a gland is to be found in the cellular membrane of the lungs in a sound state, constituting the seat of these tubercles, and as scrophula se- lects for its abode a glandular structure, tubercular consumption cannot perhaps with strict propriety be called a scrophulous dis- ease : yet as the untempered fluid contained in the tubercles resem- bles that of scrophula, and, more especially as this variety of con- sumption is very generally found in constitutions distinctly scrophu- lous, the analogy between the two is extremely close, and has often led to a similar mode of treatment. In some cases, proper abscesses or larger vomicae are found with- out any trace of tubercles; and especially Avhen the disease has fol- loAved rapidly upon peripneumony, or taken place in persons of ro- bust habits or entonic plethora. And, Avhere the catarrhal symp- toms have been striking, and, in the increasing hoarseness and free discharge of muculent pus, have evinced extensive inflammation on the surface of the trachea, M. Portal has found the whole extent of the tube lined by a crust resembling bone. In some instances, the lungs, from the accretion of new matter, have weighed not less than five or six pounds, which is nearly four times their ordinary * Sepulchr. Boneti per Marget. II. vii. f Young, ut supra.—Portal, Observations sur la nature et la traitement de la Phthisie.—Bayle, Recherches sur la Phthisie Pulmonaire. Par. 1810. GE. III.—SP. IV.] SANGUINEOUS FUNCTION. 505 weight; but in others, they have been so reduced as in the lan- guage of the same writer to leave " a vacant space," in the chest; or, in that of M. Bayle, to be shrivelled into leather. On this ac- count, breathing would be impossible if it were not that the lungs in a state of health are capable of containing ten times as much air as is received by an ordinary act of inspiration : and hence are ca- pable of losing a very large portion of their capacity without suffo- cation. In some cases, one lung has been entirely destroyed, and the office of respiration maintained by the remaining lung alone for" many years.* Many ingenious experiments have been invented to distinguish between pus and mucus, in order to determine the actual nature of the disease. Such trials may gratify the curiosity of the patholo- gist, but from the variable, and frequently complicated nature of the expectoration, as well in the most dangerous as in the earlier stages/ of the complaint, we can derive little assistance from this distinc- tion. Mr. Hunter, as a test, employed muriate of ammonia, having observed that a drop of pus united Avith a drop of this fluid is ren- dered soapy, while neither blood nor mucus is affected by it.f Mr* Charles Darwin Heu miserande puer ! si pua fata aspera rumpas Tu Marcellus eris— proposed a double test of sulphuric acid, and a solution of pure po- tass. If, on the addition of water to pus dissolved in each of these* separately, there be a powerful precipitation, the matter made use of is determined to be pus: if there be no precipitation in either, it is mucus. But the simplest and truest character of pus, as was first observed and described by Sir Everard Home is, that it is a whitish fluid composed of globules contained in a transparent liquid: that it does not coagulate by heat; and is only condensed by alco- hol. The presence of the globules, as remarked by Dr. Young, may be easily determined by putting a small quantity of the liquid between two pieces of plate-glass. If it be pus, we shall perceive, on looking through it towards a candle placed a little Avay off, the appearance, even in the day-time, of a bright circular corona of co- lours, of which the candle will be the centre; a red area sur- rounded by a circle of green, and this again by another of red; the colours being so much the brighter, as the globules are the more numerous and the more equable. If the substance be simply mu- cous, there will be no rings of colours; though a confused coloured halo may sometimes be perceived by the mixture of mucus with blood or some other material. Such is the general history of phthisis. The pathology and prac- tice are in a most unsatisfactory and unsettled state : nor can any • Boneti Sepulchr. Lib. I. Sect. U. Obs. 167.—Parotti, Raccolti d'OpuscoU scientificiXlVI. p. 275. f See Apostema commune of the present Volume, p. 169. VOL. II.—64 50C 1LKMATICA. [CL- IU__OR. IV. thing be conceived more contradictory than the writings upon both these subjects. Boerhaave regarded consumption as a local disease, or conversion of all the blood and chyle into pus by means of an erosive ulcer seated in the lungs: Stahl as a general disease unaf- fected by pus or any other acrimony. The latter ascribed consump- tion to the very abundant use of bark which was then prevailing in Europe: Avhile Morton regarded bark as his sheet-anchor in effect- ing a cure. Consumption, according to Brillouet and many other writers, is identic with scrophula, and is only to be cured by alka- lies, corrosive sublimate, or other mercurial alterants, employed for the cure of scrophulous affections.* According to Cullen, though it has an apparent connexion Avith scrophula, the analogy affords us no assistance in the treatment, and the remedies for the one are of no avail in the other. Dr. Rush contemplated it for the most part as an entonic or in- flammatory disease, and particularly in its first stage, though it is sometimes accompanied with a hectic or even a typhous fever. And hence his principal remedies Avere salivation, or bleeding Avhich he sometimes prescribed fifteen limes in six weeks, emetics, nitre in large doses, a milk and vegetable diet, Avalking in cold air even during an haemoptysis, and afterwards severe exercise. The hardships of a military life, says he, have effected cures in a multi- tude of cases of confirmed consumption; and a riding post-man has been relieved more than once by the pursuit of his occupation.! This bold practice excited many followers, and was tried Avith va- riable success upon a large scale. But a practice of an opposite kind equally bold, and which soon became equally popular, Avas pro- posed at the same time by M. Salvadori of Trent.| Consumption, in the vieAvof this pathologist, is an atonic instead of an entonic disorder from the beginning, a disease of direct debility and not of inflamma- tion ; and hence is only to be cured by an active plan of stimulants and roborants from the first. The patient's diet is to consist of co- pious meals of meat and wine, and his chief regimen to be that of climbing hills, or precipitous steeps in the morning as quickly as he is able, till he is out of breath and bathed in sweat, and then aug- menting the perspiration by placing himself near a large fire. Mr. May, who adopted the same general principle, seems to have post- poned the gymnastic part of the process till the symptoms were al- leviated, and to have called in the aid of medicines which Salvadori regarded as superfluous. May's medicinal means were emetics, bark, and laudanum, night and morning; and for diet, he prescrib- ed soup, meat, Avine, porter, brandy and water, eggs, oysters, with proper condiments. Swinging was interposed twice a-day ; and horse-exercise was to complete the cure.§ * Journ. de Med. 1777. f Med. Inquir. and Observ. I. 8vo. Phil. 1789. H. 1793. V. 1802. t Del Morbo Tiwco, 2 Vol. 8vo. Trent. 1787. §Lond. Med. Journ. IX. 1788. GE. HI.—SP. IV.] SANGUINEOUS FUNCTION. 507 Many later writers believe consumption to be very generally pro- duced by a habit of drinking vinegar daily to improve the figure: and Desault relates a case in which this effect Avas produced in the course of a month.* Galen recommends vinegar as the best refri- gerant we can employ: and Dr. Gregory, in 1794, gave the case of a patient who recovered by using three dozen lemons daily. Dr. Beddoes felt justified in declaring fox-glove a cure for consumption as certain as bark for agues :t Dr. Barton affirms he has never known but one case cured by it, though others may have been pal- liated :1 and Dr. Parr asserts roundly that it is more injurious than beneficial.§ Contradictory, however, as are these statements with each other, they are chiefly so, as being either too highly coloured or too in- discriminate. We have already considered phthisis under three va- rieties or modifications, chiefly in respect to it being deeper seated or more superficial; the apostematous lying lowermost, the tuber- cular somewhat higher, and the catarrhal on the surface. But each of these, as it occurs in different constitutions, or under different circumstances, may exhibit very different symptoms and demand a very different, and perhaps an opposite mode of treatment. And hence most of the principles on which the preceding opinions and modes of practice are founded, may derive authority from particu- lar examples of success; and are so far correct, though, perhaps, none of them will apply to the whole. So considerable, indeed, are the shades of distinction from this multiplicity of causes that every separate case of consumption should be allowed to speak for itself, and must call for much deviation from the widest line of treat- ment we can ever propose to ourselves under the form of general rules. The continuance of the disease when once produced may depend, as we took occasion to observe when discussing the nature of hectic fever,|| on the state of the constitution, or on the local irritation; for the hectic may be kept up by either, and so long as this conti- nues we can have no expectation of a recovery. In the first place, the local irritation may be small, while the constitution itself is bad and does not dispose the parts to a healing condition. And, se- condly, the constitution may be good while the local irritation is so considerable that there is not remedial power enough in the former to subdue it. How far both these principles have been kept in view by pathologists at large in their treatment of phthisis it is difficult to determine, though they ought never to be lost sight of: yet the ge- neral intentions by which they seem to have been guided, in the * Sur les Maladies Veneriennes, la Rage, et la Phthisie, 12. Bord. 1739. ■\ Essay on the causes, early signs, and prevention of Pulmonary Consump- tion, 1799. 4= Collections for a Materia Medica, 8vo. Philadel. 1798. § Med. Diet, in verb. Phthisis, Vol. II. p. 401. Epanetus Hectica. Vol. 11. p. 115. 5(jg HiEMATICA. [CL. HI.—OR. IV midst of all the contrariety of practice Ave have just noticed, are the follow ii ^ :— I. To take off inflammatory action. II. To correct the specific acrimony. III. To support under debility. IV. To subdue the local irritation and improve the secretion. V. To excite a change of action. I. If the patient be of a robust habit and in the prime and vigour of life, and if the symptoms indicate considerable inflammation, whether in ire lungs or bronchiae, such as, in the former case, fixed pain and weight in the chest, increased by lying on one side, with a dry but troublesome cough; and in the latter, a general soreness rather than pain in the chest, frequent and violent cough with a copious excretion of a thin, offensive, and purulent mucus; and, in both cases, with, a full and strong pulse, the fever, though remissive, making ai approach towards a cauma, constituting the plethoric species of M. Portal, and the inflammatory of Dr. Rush, there can he no question that our object in both these cases should be to di- minish the vascular action by every mean in our poAver. Copious bleeding by venesection should be had recourse to with all speed: and though we shall seldom be called upon so closely to folloAV the steps of Dr. Dover as to repeat the operation fifty times in succes- sion* before Ave desist, it may be necessary to follow it up rapidly to the third, fourth, or fifth time. M. Portal, in the catarrhal varie- ty, bled a man, seventy-eight years old, three times with the happi- est effect. Immediately after the use of the lancet, we should em- ploy small doses of ipecacuan or antimonial powder, so as to main- tain a nausea till the pulse is lowered. Where the symptoms approach to peripneumony, the latter is to be preferred; where they lean to an inflammation of the mucous membrane of the bron- chiae the former, of Avhich three or four grains may be given three or four times a-day, and will often prove expectorant, and unload the mucous pellicles of the air-cells. The boAvels should, in the mean time, be thoroughly opened by neutral salts or uniting three or four grains of calomel with the nauseating powder: and after this the fox-glove may be had recourse to with a considerable pro- mise of success. Von Helmont first employed this last medicine as a specific for scrophula: but the only specific influence Ave know it to possess is on the kidneys, and on the action of the heart and arteries. It is for this last effect we look to it in the present in- stance ; the only effect in all probability that renders it of any ad- vantage in consumption. In catarrhal phthisis it seems sometimes, however, to improve the character of the exspuition, and to render it less thin and acrid: but this is, perhaps, a collateral result of the diminished action of the arterial system : for an increased Aoav of genuine mucus, like that of genuine pus, depends upon only a small » Ancient Physician's Legacy to his Country, 8vo. Lond. GE. m.—SP. IV.] SANGUINEOUS FUNCTION. 509 augmentation of vascular energy: since, if the vessels be urged be- yond this, the secretion is hot, watery and acrimonious. If sudorifics be ever advisable in any modification of phthisis, it is here we may expect to find them of use. Bennet indulged the hectic morning sweats as a mean of abating the symptoms, and Morton observes that nothing is gained by checking them. But it is perfectly clear that they very greatly add to the debility, and never prove critical. It has been proposed by others, however, to overcome the morbid sweats by exciting a sAveat of a different kind : " for it is as practicable," says Mr. Watt, " to cure sweating by sudorifics, as diarrhoea by cathartics."* There is something plausible in this remark, and the experiment might, perhaps, be allowed to form a part of the reducent plan before us. But the au- thor has never tried it, and even in the state of the disease we are now contemplating, he would prefer mild diaphoretics or relaxants to drastic sudorifics. When a sufficient inroad has thus been made upon the inflamma- tory diathesis, we may content ourselves with an administration of the cooling neutrals, of which nitre is one of the best. It may be given in almond emulsion in the proportion of a scruple to half a pint; and, if the cough be still troublesome, may be conveniently united with some light narcotic, as the extract of hyoscyamus or white-poppy. The diet and general regimen are points of great im- portance ; but upon these we shall have to speak presently. It is not often, however, that phthisis commences with the inflam- matory action we have thus far contemplated.! Its ordinary march is unostentatious and insidious ; and it takes possession of the fair and delicate, rather than of the firm and athletic frame, and chiefly in those possessing this figure who can trace it in their ancestors and have hence reason to apprehend an hereditary taint. • II. Of the proximate cause of this predisponent diathesis we know nothing: it is generally supposed to have a near analogy to that of scrophula; and when called into action it commonly shows itself in the form of the tubercular variety: the tubercles themselves, though not occurring in a structure strictly glandular, bearing a con- siderable resemblance to scrophulous indurations. And, on this account, as there are various medicines, and a particular regimen that seems to have a beneficial effect upon a scrophulous habit, the same have been often resorted to for the cure of consumption. Thus, sea-water, the alkalies, almost all the metallic salts, and es- pecially those of mercury, have been repeatedly tried, but apparent- ly with very doubtful success. Mr. Spalding, in the American Medi- cal Repository, gives the case of a patient who had taken nearly tAVO pounds of potash and soda, intermixed like common salt with his ordinary food, and, he states, with considerable benefit after fox- glove, sulphuric acid and bitters had been successively found to disa- * Cases of Diabetes, Consumption, &c. 8vo. Paisley, 1808. f See Epanetus Hectica. Vol. II. p. 115. 510 HJEMATICA. [CL. HI.—OR. IV. gree ;* and Dr. Trotter affirms that among seamen in scrophulous consumption, as he calls the tubercular, salt and salt diet have proved of eminent service, but that the most effectual remedy is cinchona with sulphur.f Yet, however serviceable such medicines may have been found in the particular cases recorded, they have not succeeded in ordi- nary practice. " In scrophula," says Dr. Cullen, " the remedies that are seemingly of most power are sea-water and certain mineral waters, but these have generally proved hurtful in the case of tuber- cles of the lungs. I have known," he adds, " several instances of mercury very fully employed for certain diseases in persons who were supposed at the time to have tubercles formed, or forming in their lungs : but though the mercury proved a cure for those other diseases, it was of no service in preventing phthisis, and in some cases seemed to hurry it on."| Nor have any other metallic salts been of more use than those of mercury. Dr. Roberts has had the spirit and perseverance to run through the whole range of such of them as can in any way be thought applicable to this complaint; and has also had the candour, after a sufficient scale of trial in St. Bartholomew's, a candour how seldom to be met with, to confess that none of them were adminis- tered with success. The experimented list consisted of silver in its nitrate; lead in its superacetate, combined with opium for counter- acting its deleterious effects; zinc, in its sulphate and oxyde ; and the precipitate from the sulphate of potash, combined with myrrh; arsenic in the neutral salt formed by a combination with potash ; manganese in its white oxyde, in doses of ten grains every six hours ; cobalt in its black oxyde, in doses of from one grain to four; am- moniated copper; and muriate of barytes. And Avith a like want of success, he tells us in addition, Avere employed the vegetable narco- tics, aconite, hyoscyamus, stramonium, belladonna,as also toxicoden- dron^ We may hence, I think, fairly conclude with Dr. Cullen that, " the analogy of scrophula gives no assistance in this matter."|| This part of our subject, however, ought not to be closed without briefly adverting to the practice which has lately been adopted by some pathologists, of giving very small doses of antimony in the form of tartar emetic dissolved in a large body of some simple men- struum and continuing it for an almost indefinite period of time : but whether this be recommended with a view of destroying any specific acrimony, or of allaying general irritation, I cannot deter- mine. Dr. Balfour dissolves two grains of the emetic tartar in six ounces of water, and prescribes an ounce of this mixture, that is, a * Vol. V. p. 220. f Medicina Nautica. Vol. III. p. 359. t Pract. of Phys. Vol. II. Sect. DCCCCVH. § Med. Trans. Vol. IV. p. 129. II Pract. of Phys. Vol. II. Sect. DCCCCVH. GE. Ill—SP. IV.] SANGUINEOUS FUNCTION. 511 third part of a grain of the tartarized antimony, to be taken every hour, and a smaller quantity where this is found to nauseate. M. Lenthois, in his Methode Preservatif, apparently with a view of im- itating the great processes of nature in her manufacture of those metallic and other mineral waters which have been taken with most success, gives it in a far more divided state, and consequently with a much larger quantity of menstruum. He first dissolves a grain of tartarized antimony in eight table spoonfuls of distilled water, and then adds to the entire mixture six or eight pints of water in addition, and sometimes not less than twelve. The solution thus weakened is employed by the patient for common drink in every case and stage of consumption, either alone or with some other drink at meals, or occasionally with wine; it is taken without limitation at all sea- sons and hours. How far this method may answer I cannot say from personal practice : but the success of M. Lenthois is rendered suspicious from its pretended extent ; for he hereby prevents the disease, as he tells us, if it be not begun, and cures three out of four Avhere it is. III. But though in consumptions we can avail ourselves but little of the treatment that applies to scrophula, and know nothing what- ever of the nature of its specific acrimony or miasm, we see enough to convince us that consumption, in its general character is, like scrophula, a disease of debility: and that wherever it exhibits an excess of vascular action, it is merely in consequence of being plant- ed upon a plethoric or entonic temperament. And hence another principle, conspicuous in most of the remedial plans to Avhichit has given birth, is that of supporting the system while labouring under its influence. This principle is well founded but of difficult application ; and, like the opposite principle of reduction, has been often carried to an extreme. In its ordinary course, the disease is not only pecu- liarly prodigal of animal strength, but peculiarly protracted in its duration, while the fever, though remissive, rarely subsides alto- gether, or allows any interval of Avhich we can avail ourselves. In some instances, however, it does allow such interval, and espe- cially Avhere it has continued for a long period, and has broken down the general vigour of the frame; in which case Moreton occa- sionally found the inflammatory form with which it commenced con- verted into a low intermittent, sometimes assuming the quotidian, but more generally the tertian type; beginning with cold fits, and succeeded by intense heat and profuse sweats which exhausted the patient, though they left him in high spirits during the inter- missions.* And in such cases, it is possible that the tonic and stimu- lant plan of bark, wine, and even high-seasoned dishes, with cold air, cold bathing, and active exercise, so warmly eulogized by many Avriters, may occasionally prove successful, and particularly where the disease is of the apostematous or catarrhal variety, and there is no constitutional taint to oppose at the same time. * See Epanetus Hectica. Vol. H. p. 115, 512 REMATICA. [CL. HI.—OR. IV But this is a plan which cannot be brought into general practice; and, in supporting the strength of the system, we are ordinarily compelled to pursue a very different course. The first means by which we are to aim at accomplishing this is of a negative kind ; and consists in saving the frame as much as pos- sible from the profuse exhaustion it is daily sustaining, by calming the febrile irritation, and checking the colliquative sweats, which, as already observed, are never of a critical kind. " I have sometimes succeeded very decidedly," says Dr. Young in a note to the author, while the present sheet was printing, " in checking the sweats by Dover's powder : but I do not know that the progress of the disease has been much retarded by this pallia- tion." Bleeding, however plausible, and even advantageous when the pulse is full and strong, and the pain in the side acute, can rarely be allowed when the frame is delicate and irritable, and the pulse small and weak. Where the local distress is considerable, it may- be had recourse to as a palliative, but never carried beyond a few ounces, nor repeated without great hesitation. To emetics there is less objection, but vomiting is here to be preferred to nauseating. The latter, though it lowers the pulse, produces considerable fatigue and distress. The former emulges the bronchial glands, and diminishes the local irritation by transfer- ring it through the means of a general glow and moisture over the system at large. The dose may be repeated three or four times a week, and should have its poAver limited as nearly as may be to a single inversion of the stomach. In the selection of emetics some judgment is required, for those should be carefully avoided, which, like the antimonial prepara- tions, produce loose evacuations, and excite considerable sweating. The ipecacuan is perhaps one of the simplest and the best. Dr. Simmons, however, preferred the sulphate of copper, giving first of all half a pint of water to the patient, and then the blue vitriol from two grains to twenty, according to his age and strength, dis- solved in an additional cup-full of water. In general, he found that the moment the emetic reached the stomach -it was thrown up again, upon which the patient was ordered to swallow another half pint of water : which was sufficient to take off the nausea.* The reason that prohibits nauseating, prohibits also the use of fox-glove : for, though the pulse may be diminished, nothing more is obtained, and even this is obtained at loo great an expense of sensorial power in the degree of debility we are now contemplating : and the remark will apply to most of the narcotics, whether of the umbellate or solanaceous orders. The neutral salts answer better, and especially nitre ; and there is no modification of the disease in which this may not be given, and will not prove an excellent re- frigerant as well as sedative. The general error, however, has * Practical Observations on the Treatment of Consumption, &c. GE. III.— SP. IV.] SANGUINEOUS FUNCTION. 513 been in administering it too freely, as in doses of fifteen grains or a scruple; in Avhich case, it becomes a direct irritant, and does much more harm than good. Seven or eight grains at a time, as already prescribed, is a far better proportion, and even in this quantity it will answer best if considerably diluted. It is often united Avith narcotics ; but these are never found of use unless to palliate the cough or local distress ; for otherwise they increase the heat, and quicken the pulse. Most of the acids may also be employed for the same purpose, and Arith equally good effect. They may, indeed, be regarded in the joint character of sedatives, refrigerants, and astringent tonics ; and have hence every claim to attention. The mineral have been most commonly in use; but, from their erosive quality, they cannot be thrown in sufficient abundance into the circulating fluids: and on this account the vegetable are to be preferred; and, of the vege- table, the fermented acids, which, though someAvhat less grateful than the native, seem to be more effectual as tonics. The acetous acid Avas employed freely by Galen, diluted with Avater, who re- garded it as the best refrigerant Ave can select. It is continued to the present day among the Moorish physicians at Tunis, and, ac- cording to the late M. Orban, with decided success. He observed its effects, during three months, upon one patient who appeared to be labouring under a confirmed phthisis from a neglected catarrh. The quantity of vinegar drunk in the course of every twenty-four hours Avas seven fluid-ounces intermixed with seven times as much rain-water, and sweetened with two ounces of refined sugar. This apozem was accompanied with astringent and tonic pills composed chiefly of alum and sulphate of iron, of each of which two grains and a half were taken daily. The diet allowed Avas very slender, and consisted of nothing more than vermicelli or millet, boiled in water, and seasoned with a little oil and salt. Of this, only two meals in the four and twenty hours were allowed for several weeks. And, on the patient's becoming very costive under its use, the Moorish physician paid no attention to the symptom, but told M. Orban, that a constipated state of the bowels was the best symptom that could occur, and that the more strikingly this prevailed the more certain he was of a cure. M. Orban left this patient in a state of convalescence bordering on perfect health; and on his return to France, pursued the same plan, with the exception of the iron, which he omitted as too stimulant, and found it, in many cases, eminently successful, though not in all.* It has since been tried in our own country and has often proved equally advantageous. Dr. Roberts has paid particular attention to its effects; and, upon a pretty extensive scale, has been satisfied with them. One of his cases Avas of a very unpromising aspect; and consisted of a young gentleman, seventeen years of age, whose elder brother had died of phthisis two years before. The cough, which, in the morning * Med. Trans. Vol. V. Art, XVIII. VOL, !!•—65 514 HJEMATICA. [CL. III.—OR. IV was very considerable, Avas accompanied Avith expectoration some- times streaked with blood; a confirmed hectic preyed upon him, and the night sAveat Avas so profuse that his hair was drenched with it. " My patient," says Dr. Roberts, " was at once relieved by the use of the acid, and, in a short time, so lost his complaints, that, by my advice he discontinued the remedy.'"* The acetic and acetous acid seem to have been employed indiscriminately; over which the citric, Avhich was also tried, did not seem to have any advantage. The acetous was usually given in half ounce doses with an onuce of infusion of cascarilla, and a little mucilaginous powder or syrup, the dose being repeated three or four times a day. From these facts, as Avell as from a host of others of the same kind that might be adduced, the acetous acid appears to be a power- ful sedative. It diminishes action generally, checks night sweats, restrains haemoptysis, retards the pulse, and produces costiveness. It becomes, hence, necessarily a refrigerant; and it is probable that its refrigerant depends entirely upon its sedative power. That it is also an active astringent is knoAvn to every one ; but this seems to be a distinct quality ; for simple astringents, as bistort and catechu, have no pretensions to be sedative ; and the metallic salts with the exception of those of lead, are directly stimulant. On account of this sedative quality, vinegar, Avhen drunk in abundance, where there is no morbid excitement to suppress, becomes often highly mischievous: for, by unduly taking off the action of the assimi- lating poAvers, it prevents the secretion both of flesh and animal oil, and hence produces emaciation or a slender form; and is at times expressly resorted to for this very purpose by young and thought- less females who are afraid of becoming too corpulent. This effect also is often ascribed to its astringent quality, yet improperly; for it is the character of astringents to increase the solid content* of the frame, and give breadth as Avell as firmness to the muscles. In haemoptysis, I have carried the use of acetous acid much farther than Avas prescribed by Dr. Roberts, and with manifest and unmix- ed advantage. The proper astringents have also not unfrequently been employ- ed in phthisis for the same negative purpose of producing strength by checking the exhausting discharges of sweat, pus, or mucus, blood, and often diarrhoea ; but they have rarely proved successful. Some degree of benefit seems occasionally to have been derived from the use of oak-bark, several of the agaricst given in the form of lozenges, and the superacetate of lead ;| but they have far more generally been employed Avithout success or with more mischief than advantage. The most direct means of supporting the system Avould be by * Med. Trans, ut supra. f De Haen, Rat. Med. Tom. H. 567. Dufresnoy, in Corvisart, Journ. Med. Cent. VII. 531. 1804. * Ewell in Sedile. Journ, Gen. Med. XLIV. Hildebrand, id. XXXVI. GE. m.—SP. IV.] SANGUINEOUS FUNCTIO*. 515 those tonics that unite an astringent with a bitter principle; but we have already observed that the system is usually, and particularly in the beginning and at the height of the disease, in too high a de- gree of irritation for a convenient use of any medicines of this kind : though where the complaint has lasted for many months, and appears to be rather of the tubercular, or catarrhal, than of the apostematous variety, these may sometimes be employed with great success. The Angustura bark generally agrees better than the cinchona, and to this myrrh and iron may at such times be added in increasing doses, and particularly as prepared in the mistura ferri composita of the London College. In the tubercular variety, the cinchona seldom agrees in any stage: Dr. Cullen conceives never; and tells us that even where the disease has assumed something of an intermittent character, quotidian or tertian, and he has, on this account, been tempted to try it in free doses, he has in no instances succeeded so as to establish a complete cure. " For in spite," says he, " of large exhibitions of the bark, the paroxysms in less than a fortnight or three weeks after they had been stopped, always returned, and with greater violence, and proved fatal. In the latter stages of the apos- tematous variety, and especially when the vomicae are small and in perpetual succession, he thinks, however, it may be of service, in restoring a healthy action, and promoting a secretion of genuine pus. In this last case, and here perhaps only, we may venture with success on the use of the cold bath. In a more irritable state or stage of the complaint, the tepid bath may occasionally prove ser- viceable; and, where it does so, should be repeated three or four times a week, or even oftener. Of the effect of the banos de tierra of the once celebrated Solano de Luque I cannot speak from per- sonal knowledge. It consists in burying the patient up to the chin in fresh mould. It would be most obvious to suppose that this was designed to act as a tonic, and check the undue tendency to perspi- ration by a protracted chill, but that Van Swieten tells us the smell of fresh earth is serviceable, and approves of it on this account. It has since been recommended by Dr. Simmons and M. Ponteau. Before, however, the hectic, or the general irritability of the system has so far subsided as to render tonics advisable, our chief dependence for giving support to the system must be upon diet and regimen. The diet should be of the lightest kinds, and in very small pro- portion, or with long intervals of rest; for some degree of exacer- bation, in the stage of the disease we are now contemplating, is al- ways produced by the process of digestion. Under limosis exfiers we have already seen how very small a portion of food is necessary for the support of life, when neither mental nor muscular exercise are made use of; and, though hectic fever itself is a source of very great exhaustion, this exhaustion will be less in proportion as we produce less excitement, whether from eating or any other cause. And hence the most cautious physicians, from the time of the Greeks 516 HJEMATICA. [CL. m.—OR. IV. to our OAvn day, have concurred in recommending food in small quantity as well as of the lightest materials. It is not merely the stomach and its collatitious organs that are hereby put at rest, but the circulating system, the assimilating powers, the brain, and the intestines. And hence there Avas much judgment in the remark of the Moorish physician to M. Orban in the case just adverted to, in which the diet was peculiarly reduced and slender, that costiveness, so far from being an evil, was one of the most promising symptoms that could occur, and which rarely required any attention. It gives proof in reality, that the secernents of the larger intestines are quiescent, that the lacteals have absorbed nearly the whole of the materials introduced into the stomach, and that there is scarcely any refuse matter to irritate aftenvards, or be carried off in the form of feces. The food itself should consist principally of milk and the farina- ceous parts of plants, if it be not limited entirely to these: and upon a diet of this kind, in conjunction with temperate air and exer- cise, the Greek physicians placed their only hopes of a cure. Whe- ther it be necessary to pay that strict attention to the different kinds of milk which we find in many writers of established reputation I cannot fully determine. Galeii recommends woman's milk, as lightest of all, then ass's, next goat's or ewe's, and lastly cow's;* and Van Swieten adopts the recommendation of Galen.f Mare's milk has since been proposed as preferable to all these: but the analyses published by different chemists vary so much from each other, that it is difficult to come to a conclusion. If the experi- ments of Stipriaan may be depended upon, mare's milk contains most sugar and least cream, butter or caseous matter; and woman's milk most sugar and least butter and caseous matter next to mare's, with most cream next to sheep's.:}: Whence mare's milk should be the lightest of the whole, but less nutritive than woman's. Accord- ing to Parmentier, however, ass's milk contains a less proportion of caseous matter than any of the rest. Peculiar properties may sometimes be given to milk by the food fed upon; and hence Galen endeavoured to render it more astrin- gent by placing the animal, that was to furnish it, in pasturage, en- riched for the purpose with agrostis, lotus, polygonum, and melys- sophyllum. And as the patient became convalescent, and could bear a richer nutriment, he was allowed to sail down the Tiber and use the cow's milk of Stabiae, Avhich was peculiarly celebrated for its excellence. When ass's milk cannot conveniently be obtained, its place may be supplied with what has been called artificial ass's milk, which is a mixture of cow's milk and animal mucilage, diluted in a farina- ceous apozem, rendered slightly sweetish and aromatic by eryngo. • Opp. Tom. VI. 130,131. edit. Basil. 1542. f Comment. Tom. IV Sect. 1211. edit. Lugd. Bat. 1764. * See Crell's Chemische Annates, § VIH. p. 138. 1794.' GE.m.—SP.IV.] SANGUINEOUS FUNCTION. 517 The ordinary form consists in boiling eighteen contused snails Avith an ounce of hartshorn-shavings, of eryngo-root and peail-barley, in six pints of water to half its quantity, and then adding an ounce and a half of syrup of Tolu. Four ounces of this are usually taken morning and evening with an equal quantity of fresh milk from the cow.* The chief foods which have been allowed in the general treat- ment of consumption in its earlier and middle stages, in conjunction with milk and the farinacea, are the vegetable and animal mucilages, but particularly the former. And of these, that obtained from the Iceland liverwort, has been held, and deservedly so, in the highest degree of estimation; for to an aliment of sufficient nourishment it adds a tonic poAvcr by its bitterness ; yet a power that so far from increasing vascular action seems rather to quiet it; as though the bitter principle were itself in possession of something of the seda- tive quality of the hop, Ignatius's bear, or some other plant that decisively unites the two. Were it not, however, that every thing seems to be valued in proportion to the distance of its growth and the difficulty and ex- pense of acquiring it, it would not be necessary for us to go the Arctic circle in quest of Liverworts, as there are several species indigenous to our own country that have all the good qualities of that of Iceland, and in an equal degree : particularly the lichen cocciferus or fiyxidatus, commonly known by the name of cup-moss. This was long ago recommended in hooping-cough by Willis ; as it has since been employed in hectic affections by Strack ; and by Van Woensel in both phthisis and hooping-cough, and apparently with considerable success.! The lichen fiulmonarius, lungwort or lung- moss, common to most parts of Europe, and our own country among the rest, has also occasionally been made use of for the same pur- poses. It is, hoAvever, less mucilaginous than several other spe- cies, and so bitter as to be disagreeable to the palate, and in some places, and especially in the Siberian variety, to be employed as a substitute for hops. It requires on this account a longer maceration in water for extracting the bitter principle before it is used. In supporting or recruiting the strength, a due attention to air and exercise is also of high importance. The advantages offered by the first are those of a mild, dry, and equable atmosphere; and probably these are the whole. If the patient's own country give him these, he need not wander from home. If it do not he must create an artificial atmosphere in his oAvn chamber, or set of cham- bers, by keeping the thermometer at from 60° to 65° of Farenheit, and confining himself, to this temperature; or he must seek the atmosphere he stands in need of in a foreign climate. The disad- vantage of the former is that though he may support the requisite temperature, he cannot conveniently obtain a sufficient change of * Med. Trans. Vol. II. p. 341. f Hist, de la Societe" Hoyale de Medicine. II. 295, 5I& ILEMATICA. [CL. in.—OR. IV air, nor so Avell avail himself of the various exercises that might be useful to him, as if he Avere at liberty to go abroad. Hence a change of abode has been recommended in all ages to those Avhose native soil is subject to considerable and sudden atmos- pherical variations, though pathologists have by no means agreed upon a meteorological standard. For the patient's residence in our own country, the south-Avestern boundary of the Cornish coast, and particularly Penzance, seems to offer the best asylum ; and where a foreign climate is recommended it should lie between thirty and forty degrees of latitude; if lower than this, the disease, and es- pecially where ulceration has taken place, seems to be exacerbated instead of diminished ; and consequently its fatal issue to be quick- ened;* notwithstanding that to the natives consumption is little known within the tropics. Generally speaking, a change of climate or of local situation has been determined upon too late; and hence has not been attended with all the benefit that might otherwise have been reasonably hoped for. On which account, many pathologists have considered it as of little importance, if not more injurious than staying at home, though the most celebrated spots should be selected. Thus Dr. Carmichael Smyth asserts that Madeira is unfavourable to the consumptive when the lungs are materially injured, notwith- standing the mildness and equability of its climate.f Nice and Na- ples are said to be equally unfriendly from the neighbourhood of mountains ; and Dr. Southey's inquiry has led him to conclude that in Malta, Sicily, and other islands in the Mediterranean, phthisis, though a rare disease among the natives, does not appear to be re- tarded in those who visit them for a cure.:}: M. Portal dissuades from all such trials by affirming that there is no dependence to be placed upon them, since he has seen the disease accelerated in Eng- lishmen, or those of other northern nations, by a visit in quest of milder air to the south of France ; whilst in the natives of Langue- doc or Provence it has been restrained by a removal to Paris.§ The whole of this, however, only shows us that very great care is necessary in determining concerning the state and stage of the disease, the patient's constitution, and the local features of the situa- tion that may be proposed for his residence. Where, in the com- mencement of the disease, there is great irritability, or an inflam- matory diathesis ; or in its advance the strength of the constitution is greatly reduced ; and especially where an obstinate diarrhoea has supervened, the fatigues of journeying and of a sea-voyage, and the necessary relinquishment of many of those minuter, but still import- ant conveniencies, to which the patient has been accustomed at • Sir G. Blane, Observations on the Diseases of Seamen, 8vo. 1785. f Account of the effects of Swinging in pulmonary Consumption, &c. 8vo. 1787. i Observations on Pulmonary Consumption, 8vo. 1814. § Observations sur la nature et la traitement de la Phthisie pulmonaire, IT. p. 358. GE. HI.—SP. VI.] SANGUINEOUS FUNCTION. 519 home will more than counterbalance for all the advantages he might derive from the possession of a milder and more equable at- mosphere. The topography of the situation about to be chosen is of equal importance; for if it be strongly marked by lofty cliffs or mountains, the air will seldom circulate freely, but rush in currents in some parts, and be obstructed and become stagnant in others. Such is the state of Hastings on the Sussex coast of our own country, which would otherAvise form an excellent asylnm for those who are subject to pulmonary affections, and cannot remove far from their native abodes. The shore is skirted by two enormous cliffs of sand- stone that rise between two and three hundred feet in perpendicu- lar height. The old toAvn is built in a deep ravine opening towards the north-east, that lies between them, and the new toAvn imme- diately under the cliffs, fronting south and west; and hence, while the air is rushing in a perpetual current through the former, it becomes stagnant, heated and suffocated in the latter. On this ac- count, it has uniformly been found that small islands without any great boldness of feature, enjoy the most equable temperature, and, Avhen within the range already pointed out, form the most favoura- ble situations for consumptive cases. Madeira is, upon the whole, the best foreign station in the winter season; but from its mountain- ous face, catarrhal affections, and even genuine consumption itself, are, according to Dr. Gourlay, not uncommon to the natives; and in removing to it, therefore, it will be necessary to select a spot of sufficient elevation, and equally sheltered from the meteorological evils of currents, tempests, and suffocative heat. For the reasons just stated, the most equable of all temperatures is that of the sea itself: and hence many patients, Avho feel incon- venience from a residence on the sea-side, are almost instantly re- lieved by sailing at a few miles distant from it. This has often been resolved into the exercise of sailing, or the sea-sickness which in many instances is hereby excited. It is, nevertheless, a distinct advantage from either, and resolvable into the explanation just stated. Sea-sickness, however, is of unquestionable service in many cases: and particularly in those in which a protracted nausea by other means has already been recommended. The exercise of sailing is useful on another and a very different account. All motion without exertion, or with no more exertion than gives a pleasurable feeling to the system, which the Greeks expressed by the term aeora, in- stead of exhausting, tranquillizes, and proves sedative. It retards the pulse, calms the irregularities of the heart, produces sleep, and even costiveness. Hence sailing on the Tiber was a common pre- scription among the Roman physicians; and many consumptive pa- tients have found great benefit from long voyages, in which they have suffered no sea-sickness, and have been exposed to many varie- ties of atmospherical temperature. Hence, too, the well-known ad- vantage of exercise in a swing, or in a carriage, on horseback, or even on foot, as soon as these can be engaged in with comfort: the 520 HiEMATICA. '[CL. m.—OR. IV, organs of respiration, like those of every other kind, deriving strength, instead of weakness, from a temperate use of them. Gymnastic medicine, however, seems by many pathologists to have been carried to an extreme; and especially by Sydenham, Avho employed horse-exercise in all stages of the disease, and roundly affirms that neither mercury in syphilis, nor bark in intermittents, is more effectual than riding in consumptions.* Nor is carriage- exercise, says he, by any means to be despised though not equal to that of the saddle. Hoffman, and Baglivi adopted the same opinion, and laid it down in terms nearly as unqualified. Where phthisis is a secondary disease, and dependent upon some obstruction of the digestive viscera, exercise of this kind may, in many instances, be employed as an important co-operation with other means even from the beginning; and to such cases of consumption Desault judicious- ly limits it. In the present day it has been revived by Mr. Stewart under a variety of ingenious modifications, and appears in many cases to have afforded relief: but the constitutions of mankind must strangely have altered since the days of Sydenham, if the severity of horse exercise could at that period have been employed as a specific remedy in consumption of every kind. Stoll did not find it so in the middle of the last century; for he tells us that if a con- sumptive patient mount his horse he will ride to the banks of the Styx as surely as if he were in a pleurisy.f And Stoerck died con- sumptive though in the habit of riding, killed by an haemoptysis ap- parently produced by this exercise.}: IV. Another part of the curative process in the disease before us, has consisted in endeavouring to subdue the local irritation, and im- prove the secretion from the lungs. This has been chiefly at- tempted by fumigations, medicated airs, and expectorants. Bennet whs strongly attached to the first of these, and thought they proved peculiarly detergent, and enabled the patient to throw up a more laudable discbarge with increased facility. He some- times employed aroma lie herbs which were immersed in hot AVater, over which the patient held his head surrounded with clothes to confine the vapour, which was thus inhaled with every inspiration. But he seems to have placed more dependence on an inhalation of the fumes of various terebinthinate resins, as frankincence, styrax, and turpentine itself, mixed into a powder or troche with a few other ingredients, and burnt on coals : to which he sometimes added a considerable proportion of orpiment. And such was the success ascribed to this practice, that Willis, not many years after, resolved the greater exemption of certain parts of England and Holland, from coughs and consumptions, to the turf and peat fires which the in- habitants were in the habit of using, and the arsenical principle which was intermixed with the material. In our own day, terebin- • Opp. p. 629. f Nat. Med. I. *Quarin, pp.lS2,lQ3. 6E. ni.—SP. IV.] SANGUINEOUS FUNCTION. 521 thinate fumigations have been very extensively tried in consequence of the warm recommendation of Dr. now Sir Alexander Crichton, who thought he had perceived great and decisive advantage from the aroma of pitch' and tar diffused through rope manufactories, ships, and other places were these articles are in perpetual use. I have tried this repeatedly by heating a tin vessel of tar over an oil or spirit lamp, and thus impregnating the atmosphere of the chamber with the powerful vapour that arises. In doing this, how- ever, we must be careful not to burn the tar; for in such case the room Avill be filled with an empyreumatic smoke that will greatly add to the patient's cough instead of diminishing it. In those states of the disease in which terebinthinates, as myrrh, benzoin, or co- paiba, imy be taken internally Avith a prospect of success, this kind of fumigation will sometimes prove useful also: and it is hence far better adapted to the tubercular and catarrhal than to the aposte- matous variety. In a chronic state of both the first, I have some- times thought it serviceable ; but I have more frequently used it without any avail. Pneumatic medicine, which, about thirty years ago, was in the highest popularity, does not appear, Avhen candidly examined, to have been more successful. Oxygene gas has, in almost every in- stance, proved so stimulant, and so much increased the signs of in- flammatory action, that though it has seemed occasionally to afford a momentary relief in a few cases, it has rarely been persevered in more than a fortnight, by which time it has often suppressed the usual expectoration, and produced an haemoptysis.* There was much more reason and ingenuity in recommending an inhalation of hydrogene intermixed with common air than of oxy- gene : since the effect of this gas in destroying the irritability of the living fibre is known to every one ; and it was hence a plausible conjecture that by being applied immediately to the seat of disease it might sufficiently subdue the inflammatory impetus, change the action of the ulcerated surface, improve the secretion, and annihi- late the hectic. The experiment has been tried at home and abroad upon a pretty extensive scale, by employing different proportions of hydrogene, so that the patient has twice a-day breathed from a pint to a quart of the gass at a time, diluted Avith from twelve to six times its measure of common air ; and making every allowance for an exaggeration of statement in those who have most warmly en- gaged in the practice, it seems difficult not to concede that it has proved serviceable in various cases. A combination of hydrogene with common air seems, indeed, to be beneficial in various other modes of application ; but whether by lowering the ordinary stimulus of common air or by directly decom- posing and exhausting the nervous fluid communicated to the lungs it is not easy to determine. In either way, however, it has an equal tendency to indispose them to inflammatory action. Thus Clapier, * Fourcroy, Annales Chirur. IV. p. 83. 1790. vol. II.—66 5^2 HJEMATICA. [CL. IH.—OR. IV in the Journal de Medicine, relates a case of confirmed consumption cured by an habitual residence in a coal-mine ;* and expressly states that the matter expectorated soon began to assume a more healthy appearance, and Avas excreted more freely. It is, in like manner, a common remark that the miners in Cormvall are more generally exempt from phthisis than most other persons:! and that butchers, who are perpetually engaged in slaughter-houses, and surrounded by a vapour impregnated with hydrogene, possess an equal emanci- pation. It is probably to this cause, if to any, Ave are to ascribe the benefit which Bergius found consumptive patients derive from a re- sidence in coAv-houses,!: and Avhich was not long since a fashionable mode of practice in our own country. Expectorants and demulcents have, also, very generally been em- ployed for the same purpose ; that of subduing the disease by ex- citing a healing action in the tubercles or ulcerations, indicated by an improvement in the expuition. Of the general nature and mode of action of these classes of medi- cines, we have already spoken at large in discussing the treatment of cough and asthma ;§ and our remarks, therefore, upon the present occasion will be but feAV. Where the irritation is considerable, and accompanied Avith much increase of vascular action as in the commencement of the aposte- matous and catarrhal varieties, the best demulcents, and, indeed, the only medicines of this kind we can employ as palliatives, are the vegetable mucilages, as of tragacanth, quince seeds or gum Arabic. Where itis necessary to diminish the general action, these may be united with small doses of ipecacuan, or of squills ; which have the double power of exciting nausea, and unloading the mu- cous follicles of the bronchia as expectorants. And, where the cough is very troublesome, and the pain acute, they should be uni- ted with narcotics, as opium or hyoscyamus. In a more advanced stage of the disease, and through the entire course of the tubercular variety, except where haemoptysis is present, the expectorants more properly so called have often been employed with advantage. One of the oldest of these is sulphur, and perhaps one of the best; from its not readily dissolving in the first passages, it is carried to the rectum, and the skin sometimes, with little alte- ration ; and hence gently stimulates both extremities, loosens the bowels, and excites a pleasing diapnoe on the surface. It is in this Avay it appears to be serviceable in an inflammatory or tubercular state of the lungs. It was in high repute among the Greek and Ro- man physicians, who, when employing it as an expectorant, usually combined it with yolk of egg ; and it has maintained its character to the present day. In the tubercular, or scrophulous variety, as it is * Journ. Med. XVIII. 59. ■j- Southey, Observations on Pulmonary Consumption, 8vo. 1814. $ Neue Schwed. Abhandl. 1782. P. HI. p. 298. § Vol. 1. pp. 252. 382, GE. III.—SP. IV.] SANGUINEOUS FUNCTION. 523 often called, it has frequently been united with some other prepara- tion, as diaphoretic antimony, with which it was joined by Hoffman, dulcamara by Videt,* and cinchona by Dr. Trotter, t The vulnerary balsams and resins, hoAvever, have been more ge- nerally had recourse to; but ought rarely, perhaps never, to be em- ployed in an early stage of the disease. Their action is common, and depends upon their possession of a terebinthinate principle; and hence they might be used indiscriminately, but that some of them are less stimulant and heating than the rest. Myrrh and camphor are among the least irritant, and may often be employed when we dare not trust to any other. Copaiba, though of somewhat greater balsamic pungency, has often been found essentially useful. Marry- att was peculiarly attached to it: he gave twenty drops of it night and morning upon sugar; and asserts that, when an ulcer has been formed, it ought never to be omitted :J and Dr. Simmonds appears to hold it in nearly as high an estimation.§ V. The last part of the general therapeutic process which has been attempted in most ages, has consisted in endeavouring to di- minish or carry off the local affection by a transfer of action. Blisters have very generally been applied for this purpose to the back or the chest. Their service is temporary, but often very ef- ficacious, and they ought never to be neglected. It was formerly the custom to render them perpetual by the use of savine ointment, or some other escharotic. But it is equally less painful and more beneficial to let the skin heal, and renew them after short inter- vals. Setons, issues, and caustics, however, where the constitution is not very delicate, nor the habit very irritable, have proved far more powerful revellents, on account of their more violent stimulus and greater permanency of action. The actual cautery, though much abstained from in modern practice from its apparent, rather than real severity, was in almost universal use in ancient times ; and, in the mode described by Celsus, was undoubtedly a very formidable operation. When the disease, says he, has taken a deep root, the cautery must be applied under the chin, in the throat, twice on each breast, and under the shoulder-blades; and the ulcers must not be healed as long as the cough continues. Dr. Mudge pursued this plan to a very considerable extent on his own person, and ascribes his cure to the use of it. He applied a large caustic between the shoulders, which produced an eschar of nearly three inches in dia- meter and held fifty peas : but he confined himself at the same time to milk and a vegetable diet.|| Bennet exchanged the caustic for * Medicine Expectante, Tom. Ill p. 237. 8vo. Lyons, 1803. f Medicina Nautica, Vol. HI. p. 325. 8vo. Lond. 1814. $ Therapeutica, Lond. 1738. § Practical Observations on the Treatment of Consumptions. Lond. 1780. I| Radical Cure for a recent Catarrhous Cough, p. 78. 8vo. Lond. 1779. 524 HJEMAT1CA. LCL. III.—OR. IV. issues, Avhich he placed in the groins and hams, under the arms, and between the shoulders, and kept sweet by peas of orris root; and asserts that he found the use of these highly beneficial. Yet setons are said by those Avho have employed them to be still more serviceable than issues. The obvious intention is to produce a revulsion ; and hence by transferring the morbid action to a part of less importance, to alloAv the lungs to return to a healthy condition. Such transfer may, by these means, in some cases, be rendered to- tal, though, in general, the morbid irritation is only partially, in- stead of entirely, carried off. There are other means, however, by Avhich it seems to be removed altogether, although they are means that are seldom put into our hands. Thus M. Bayle's fifty-third case is that of a medical man who was fully prepared to meet his fate, and resolved to take no medicine whatever. At this time a severe rigor from an unknown cause at- tacked him, succeeded by a sweating fit so profuse that his linen was changed two-and-tAventy times in a night, and even this was not sufficient. The paroxysm proved critical; and the disease Avas thus carried off by an ephemera.* Sir Gilbert Blane gives an account of a like singular and salutary change excited by a hurricane at Barbadoes, in 1780; which pro- duced such an effect upon the air, or on the nerves of the sick, that some who Avere labouring under incipient consumption were cured by it; while others, who had reached a more advanced stage, were decidedly relieved, and freed for a time from many of their symptoms.f Bennet relates a case of consumption which was suspended for tAvo days in all its symptoms, except the emaciation, by a severe tooth-ache.f. In Hautesierck's collection, we have an account of a recovery from a purulent expectoration, by the formation of a fistu- lous abscess in another part of the body, which was itself cured by an operation.§ And we have numerons instances of consumption produced by a sudden cure of some chronic cutaneous eruption, and especially itch ; and of its ceasing upon a restoration of the pri- mary complaint. There is, however, no affection that seems to keep a consumptive diathesis in so complete a state of subjugation as that of pregnancy. Most practitioners have seen cases in which a female has dropped all the symptoms of phthisis upon conception, and has continued free from the disease till her delivery. Suckling does not seem to continue the truce; but if v she conceive again shortly afterAvards, she renews it: and there have been instances, in Avhich from a rapid succession of pregnancies, the suspension has * Recherches sur la Phthisie, &c. ut supra. f Observations on the Diseases of Seamen, 8vo. Lond. 1785. t Vestibul. Tabid, ut supra. *s Recueil d'Observations de Medicine, 8cc. Part II. p. 286. Paris 1772. GE. III.—SP. IV.] SANGUINEOUS FUNCTION. 525 been so long protracted that the morbid diathesis has run through its course, and entirely subsided, leaving the patient in possession of firm and established health. As one disease therefore, or state of body, is Avell known to have a frequent influence upon another, and consumption is found to be thus influenced by various affections, it is a question well Avorth in- quiring into whether there be any malady of less importance, which, like coAV-pox over small-pox, by forestalling an influence on the con- stitution, may render it insusceptible of an attack of phthisis ? Dr. Wells, not many years ago, very ingeniously engaged in an inquiry of this kind ; and rinding that it was common for the consumptive in Flanders to remove to the marshy parts of the country where agues were frequent, he began to think, not indeed that agues might give an exemption from consumptions, but that the situation which pro- duced the former might prove a guard against the latter. And so far as his topographical investigations have been carried, and they have extended over some part or other of all the quarters of the globe, this opinion has been countenanced : for he has discovered that wherever intermittents are endemic, consumption is rarely to be met with; Avhile the latter has become frequent in proportion as draining has been introduced.* The later inquiries of Mr. Southey do not support this hypothesis; but the question is yet unsettled, and well Avorth pursuing; and Mr. Mansford who practices in the in- terior of Somersetshire, has still more lately published a work which, though not written as a defence of Dr. Wells's opinion, in- directly confirms it, by endeavouring to prove that a low, inland situation, like the vales of his own country, are far better calculated as a residence for consumptive patients than the air of mountains or of the sea-coast.f GENUS IV. STRUMA. Scroplmla. INDOLENT, GLANDULAR TUMOURS, CHIEFLY IN THE NECK ; SUPPURATINfc SLOWLY, AND IMPERFECTLY, AND HEALING AVITH DIFFICULTY J UPPER LIP THICKENED ; SKIN SMOOTH; COUNTENANCE USUALLY FLORID. The Greeks denominated this disease XOIPA'S, the nosologists of recent times, scrophula, thus literally translating the Greek, and * Tras. Medico-chir. Soc. Vol. HI. p. 471. f Inquiry into the influence of Situation on Pulmonary Consumption. By T. G. Mansford, &c. 8vo. 1818. 526 HJEMAT1CA. [CL. HI.—OK. IV. importing swine-evil, swine-swellings, or morbid tumours to which swine are subject. Celsus employs struma, which was common in his own day, and has well described the complaint under this name, Avhich is therefore selected on the present occasion. It is probably derived from », " solvo, dissolvo"—. "to macerate, dissolve or corrupt;" and agreeably to the common rule of expressing the power of the Greek v by a Roman y, should be written lyes, as in the case of Lyssa, and Paralysis, both of which are derived from the same root; but lues has been employed so long and so generally, that it would be little less than affectation to attempt a change: and in allucinatio, or hallucinatio, from the Greek xXvtt or xXvnf, we are supported by a similar example of de- viation from the common rule. It appears to have been known to the world from an early age, as I have remarked on the running comment to the volume of No- sology, that acrimonious and poisonous materials are, at times, secreted by the genitals, capable of exciting local, and perhaps con- stitutional affections, in those who expose themselves to such poi- sons by incontinent sexual intercourse. Celsus enumerates vari- ous diseases of the sexual organs, most of which are only referable to this source of impure contact; but the hideous and alarming malady Avhich was first noticed as proceeding from the same source towards the close of the fifteenth century, and which has since been called almost exclusively venereal disease, has suppressed, till of late, all attention to these minor evils, in the fearful contemplation of so new and monstrous a pestilence; to various modifications of which most of the anterior and slighter diseases of the same organs seem to have been loosely and generally referred ; as though there were but one specific poison issuing from this fountain, and conse- quently but one specific malady. On which account, much confusion has arisen in the history and description of this disease; and syphi- lis, its most striking species, though commonly admitted, as we shall see presently, to be comparatively of recent origin, is by Plenck,* * Beobachtungen, &c. II. 548 HiEMATICA. [CL. HI.—OR. IV Richter,* Stoll,t and other Avriters of considerable eminence, re- garded as of far higher antiquity; asserted by Lefevre de Ville- brunef to have existed eight centuries before the expedition of Co- lumbus to America, and by De Blaguy§ to have been extant in the Mosaic rge. The keen and comprehensive mind of Mr. John Hunter first call- ed the attention of practitioners to the idea of different poisons and dif- ferent maladies; and the subject has since been pursued by Mr. Aber- nethy with a force of argument, and illustrated by a range of exam- ples, that seem to have put the question at rest. Mr. Abernethy has sufficiently established that, independently of the specific disease noAv generally recognized by the name of syphilis, there are nume- rous varieties of some other disease, perhaps other specific diseases, which originate from a distinct poison, possibly from several distinct poisons secreted in the same region from peculiarity of constitution, or causes riitherto undiscovered; and Avhich are accompanied with primary and secondary symptoms that often vary in their mode of origin, succession, and termination, from those of genuine syphilis, though in many instances they make a striking approach to it; and to which, therefore, Mr. Abernethy has given the name of pseudo- syphilitic diseases. Whether these really constitute distinct species, issuing from dis- tinct sorts of infection, or are mere varieties or modifications of one common species produced by one common morbid secretion, has not yet been sufficiently determined. In this ignorance upon the subject, it is better, for the present, to regard them in the latter, as being the more simple view; and with this preliminary explana- tion the expediency of allotting the two following distinct species to the genus lues will I think be obvious to every one. 1. lues syphilis. pox. 2. --- syphilodes. bastard pox. * Chir. Bibl. Band. I. Sect. ii. p. 163. f Praelect. p. 94. * Retz Annales, IV. § L'Art de guerin les Maladies Veneriennes, &c. GE. VI—SP. I.] SANGUINEOUS FUNCTION. 549 SPECIES I. LUES SYPHILIS. JLCERS ON THE GENITALS CIRCULAR, UNGRANULATING, THICKENED AT THE EDGE; THOSE OF THE THROAT DEEP AND RAGGED; SYMPTOMS UNIFORM IN THEIR PROGRESS J YIELDING TO A COURSE OF MERCU- RY ; NOT KNOAVN TO YIELD SPONTANEOUSLY. The vulgar term for the ulcers is Chancres, and the vulgar name for the disease is Pox, formerly Great-Fox* as contradistinguished from variola or small-pox, on account of the larger size of its blotches. It Avas also very generally called French Pox, as being supposed to be a gift to Europe from the French nation. There is some uncertainty concerning the origin of the specific term syphilis, which was probably however invented by Fracastorio about the close of the fifteenth century, from the Greek o-v and Callosum. The edges indurated and retracted. Callous ulcer. £ Spongiosum. With fungous or spongy excrescences. Fungous ulcer. y Cancrosum. With a hard, livid, lancinating irregu- Cancerous ulcer. lar, and frequently bleeding tumour at its base. The causes in each of these may be constitutional or local; and, in managing the ulcer, it is of great importance to determine this point; for the patient may otherwise be put very needlessly upon a long course of alterants, or may omit such a course when absolutely necessary. If there be a cancerous, a scrophulous, a scorbutic, a venereal, or any other taint in the blood, it will be imperative upon us to pursue the respective modes of treatment already laid down for these several complaints, since otherwise no topical applications can be of the least avail. There may be also a considerable degree of constitutional debi- lity and relaxation, to which the depraved state of the ulcer is owing; and in truth this is the most common of all the constitutional causes, and one which demands quite as much attention as any of the rest. In treating of abscess, we endeavoured to show that one of the uses of pus is to produce healthy granulations; and in treat- ing of inflammation we observed that a certain degree of vigorous and entonic, as well as inflammatory, action is necessary for the se- cretion of pus. And hence if the system be without this condition, GE. XII.—SP. H.] SANGUINEOUS FUNCTION. 617 the ulcer cannot heal; and, instead of genuine pus and healthy gra- nulations, we shall find a watery, ichorous fluid poured forth, of no advantage whatever, and often of an acrimonious quality, that irri- tates and thickens, and sometimes erodes and extends the edges of the ulcer; or a thin imperfect pus which gives rise to flabby and fungous granulations, that sprout up, indeed, rapidly and luxuriantly, but want firmness of texture, show a weak and morbid sensibility, and bleed and die away almost as soon as they are formed. Where this is the case, the ulcer, whatever modification it assumes, can be brought into a healing train only by increasing the health and vigour of the constitution. This, however, it is often difficult to accomplish; for, in very numerous instances of obstinate ulcers, we find the constitution has been exhausted and worn out by hard labour, hard drinking, or a long exposure to a tropical sun, and is labouring under a long train of dyspeptic, hepatic, or podagral symptoms. It is not necessary to repeat the plan it will be incum- bent upon us to pursue under these circumstances, as Ave have already detailed it under the constitutional affections themselves. And if, by persevering in such general treatment, we can give to the constitution a sufficient degree of vigour, the only difficulty we shall have to encounter is the vitiated state, and perhaps habit, to which the ulcer has been reduced in consequence of the consti- tutional affection. We hence come to the local treatment of ulcers; which forms a direct branch of surgical, and even manual attention. And I shall hence only farther observe, that the principles Avhich seem to have been productive of the best success, are those of changing the nature of the vitiated action by a local application of irritants; and increasing the tone of the vessels by warm suppuratives and astrin- gents, and the pressure of elastic bandages, which should be made of calico or the finest flannel. Mr. Baynton preferred the former on every occasion, as less cumbrous and more cleanly, and as being " a better conductor of that morbid heat which so constantly affects inflamed parts." In many cases, however, and particularly in cold, edematous limbs, it is rather desirable to accumulate than to carry off heat; and here the use of flannel will be preferable to that of calico; it possesses, moreover, more elasticity, and Avhen thin and fine is neither more cumbrous nor more uncleanly. When the edges or intersections of an ulcer have acquired a cal- lous thickness, or scirrhosity, the actual cautery has often been ap- plied with success, and especially in the manner recommended by M. Maunoir, who has given an instructive history of his practice in the ninth volume of the Medico-Chirurgical Transactions. The in- strument he employs, he calls, from the form of its bulb, an iron olive. It is, in effect, an iron rod with a bulb at the end, of the size of a tonquin-bean. For the sake of rapid execution he heats several of these at the same time in a fierce fire, and uses them at a white heat, passing each in succession with great speed over the morbid part, so as to make a considerable rut or groove as he pro- ceeds. The pain endured seems to be far less than might be expected. vol. 11.—78 618 HALMATICA. [CL. HI.—OR. IV. The cautery thus prepared and applied, has been frequently found the most effectual as Avell as the shortest means of extirpating can- cerous scirrhosities about the lips, and other parts of the surface. And it is peculiarly calculated for radically destroying many of those irregular and spongy excrescences which, from their readiness to bleed freely, have been distinguished by the name of fungus hjema- TODES. The nature and origin of these parasitic substances have not been very satisfactorily explained. By some writers, and especially by M. Roux, they are regarded as soft and fungous cancers, but they seem to be without any of the pathognomic signs by which cancers are distinguished. They are not known to be hereditary, nor to become scirrhous in any stage, nor do they chiefly affect a glandular situation. They are found in every part of the body, appearing at first like a small sarcomatous tumour, with a soft or medullary feel: the tumour enlarges, and secretes an acrimonious fluid Avhich con- taminates the parts adjoining, Avhether gland, muscle, cellular mem- brane or periosteum, and converts them into its oAvn nature. At the same time it erodes the skin and soon sprouts above it in a loose, luxuriant and caulifloAver form, of a dark red, or purple hue, loaded with blood-vessels, and bleeding profusely upon a slight puncture or even pressure. This singular fungus has often sprung up in in- ternal cavities, as the ball of the eye, the lungs, the testicles and the uterus : and has occasionally appeared in the breast, the spleen, and the liver. In these situations it is apt to ravage without re- straint, and there is great difficulty in destroying it Avithout destroy- ing the organ from Avhich it issues. But wherever the hand can follow them they are often repressed, and have been sometimes ex- tirpated by caustics, and particularly by being sprinkled with a mixture of poAvder of arsenic and opium ; and sometimes, where it is seated on a narrow peduncle, by a ligature. The actual cautery, however, wherever it can be applied, seems to afford the quickest and most effectual cure, and in the peduncular variety offers the best means of preventing a profuse hemorrhage, by being applied to the stump after the body of the tumour has been removed by the knife. SPECIES HI. ULCUS SINUOSUM. Sinuous Q&lctv. COMMUNICATING WITH THE NEIGHBOURING PARTS BY ONE OR MORE CHANNELS. We have alaeady seen, that inflammations of every kind propagate themselves by continuous sympathy; and hence one cause of the spread of those that are ulcerative. But ulcerative inflammations do not spread equally; for those parts are most subject to their ac- tion, and consequently give way soonest where the living principle is weakest, or the structure is most loose and cavernous. And hence GE. XII.—SP. III.] SANGUINEOUS FUNCTION. 619 a more frequent origin of hollows and sinuses in the cellular sub- stance, particularly in the more dependent parts, as about the rec- tum, and the urethra. These sinuses or hollows are soon filled Avith lymph or some other fluid, and this fluid, in a vitiated state of the ulcer, soon becomes acrimonious and erosive; and we have hence a chemical cause of extension or elongation added to that of a structural. And to this cause we are chiefly to ascribe the origin of the fistula lachrymalis. When these sinuosities are first formed or scooped out, their walls are soft, irritable, and of the common cellular web; but when they have remained for a considerable period of time they become cal- lous and insensible ; forming the two following varieties noticed in the volume of Nosology. « Recens. The channel fresh and yielding. Recent Sinus. Q Fistulosum. The channel chronic and indurated. Fistulous or Pipy-sinus. The form assumed by a sinus is determined by the'course of the probe; its capacity by the quantity of water or any other fluid it will contain when injected by a syringe. Three modes of cure have been attempted, that of incarnation or filling up the hollow by sound granulations issuing from the bottom ; that of coalition or an union of the walls of the sinus, and that of destroying it by an opening down its entire length. The first is sometimes accomplished by warm detergent balsams or lotions where the sinus is shallow. The second is more usually had recourse to where it is deeper; and attempted first by irritant and even erosive injections, so as to excite a new inflammation down the whole course of the canal; and afterwards by pressure applied at first to its lowest part, and advanced gradually to its mouth ; or, which is better, by a seton passed from the orifice of the ulcer to the utmost depth of the sinus, leaving here an opening sufficiently large for the escape of whatever matter might otherwise collect and become stagnant. The third mode of cure is effected by the knife, and where unaccompanied with danger or inconvenience from the vicinity of large blood-vessels ©r nerves, is by far the speediest and most decisive of the whole. SPECIES IV. ULCUS TUBERCULOSUM. ffiarartg Excrescent ©tlcer, WITH TUBERCULOUS EXCRESCENCES, LOBED BY RAGGED AND SPREAD- ING EXULCERATIONS. This is the noli me tangere of many writers, and the lupus of others; evidently referring to the caustic acrimony of the discharge which flows from it, and affects the fingers or whatever other parts .m^-rp'^ 620 HJEMATICA. [CL. EH.—OR. IV. come in contact with it; and the ravenous, or wolf-like voracity with which it preys on the neighbouring organs, spreading in rag- ged and fungous lobes or with cracking and callous edges, and de- stroying the skin through an extensive range, and the muscles to a considerable depth. A valuable practical paper upon this disease is to be found in the Philosophical Transactions,* addressed to the Royal Society by M. Daviel, surgeon to Lewis XV. of France ; who describes it as a cancer, to which, indeed, from its tendency to ramify, and the viru- lence of its discharge it has some resemblance; and whence Sauvages denominates it cancer Lufius. It commences in the subjacent peri- osteum or perichondrium from a diseased condition of the organ; at first assumes externally the form of a tubercle or wart; and though found over the body generally, is most common to the eye- lids, nostrils, cheeks, and other parts of the face. It is highly irri- table; and when the tubercle has acquired the size of a fig or a filbert, it ulcerates the cuticle, shows a callous edge, and spreads with a most offensive ichor in every direction: often throwing forth fungous excrescences from the bottom. Occasionally before it opens externally, from the acrimony secreted below, an herpetic vesication is formed on the surface. If partially extirpated, it grows again with rapidity and to a greater extent; caustics always exacerbate it; and the only radical cure con- sists in dissecting the diseased part, and removing the whole of the periosteous or cartilaginous base as far as it appears to be affected. SPECIES V. ULCUS CARIOSUM. Various 2£lcer. the ulcer extending into the substance of the subjacent bone. When a portion of a bone is killed by an ulcerative process com- mencing in itself, it forms, as Ave have already observed, a caries properly so called. Wnen it is destroyed by the spread of a sore commencing in the imeguments or muscles above it, the disease is called a carious ulcer. And Avhen the ulceration extends to the medulla of the bone it is often denominated an arthrocace. Upon this subject, however, it is not necessary to enlarge in the present place; as we have already discussed the general nature and the ordinary forms of ulceration under the first species of the Genus before us, and the mode by which the death and separation of one portion of bone from another are effected, under the fourth species of the preceding Genus. ___ ... -----------■-----------------------------------T:. w^', • Vol. XLIX, year 1755. A END OF VOL. II. ' - ^ A-,. JvOX 7V\/^% NLM032779172